Coronary Artery Embolism: Two Case Reports and a Review of the Literature

Coronary embolism (CE) is an uncommon and unique cause of acute myocardial infarction. In this report, we review 216 cases of CE including 2 new cases from our institution. The mean patient age was 52.5 years and 62% of the patients were males. Chest pain was the most common presenting symptom followed by dyspnea, and the most commonly affected vessel was the left anterior descending artery. Leading etiologies of the embolus were atrial fibrillation, septic emboli, and iatrogenic causes. Treatment approaches varied with thrombus aspiration being used in 30% of cases. In-hospital mortality rate was 36% and 13% of the cases were complicated by cerebrovascular accident. CE is a unique pathology that leads to acute myocardial infarction. It portends a high mortality rate and requires a high level of suspicion as symptoms may be misleading. Further research is needed in order to improve recognition and management and to lower associated mortality.     

Human preferences for sexually dimorphic faces may be evolutionarily novel

A large literature proposes that preferences for exaggerated sex typicality in human faces (masculinity/femininity) reflect a long evolutionary history of sexual and social selection. This proposal implies that dimorphism was important to judgments of attractiveness and personality in ancestral environments. It is difficult to evaluate, however, because most available data come from large-scale, industrialized, urban populations. Here, we report the results for 12 populations with very diverse levels of economic development. Surprisingly, preferences for exaggerated sex-specific traits are only found in the novel, highly developed environments. Similarly, perceptions that masculine males look aggressive increase strongly with development and, specifically, urbanization. These data challenge the hypothesis that facial dimorphism was an important ancestral signal of heritable mate value. One possibility is that highly developed environments provide novel opportunities to discern relationships between facial traits and behavior by exposing individuals to large numbers of unfamiliar faces, revealing patterns too subtle to detect with smaller samples.Inspired by evidence from nonhuman species indicating that exaggerated sex-typical traits (e.g., large antlers, peacock tails) are often attractive to mates or intimidating to rivals (1, 2), morphological sex typicality in humans (masculinity in men and femininity in women) has been the focus of considerable research into attractiveness judgments (3, 4). Facial attractiveness research has been revolutionized by this explanatory framework from the biological sciences, which proposes that attractive human faces honestly signaled mate value within ancestral environments.An influential proposal is that facial femininity is a signal of fertility in human female faces (4–9) because, within same-age women, it is associated with estrogens (10), which, in turn, are related to measures of reproductive health (11). Like ovarian function, facial femininity declines with age in adulthood (12, 13). The proposal that fertile women should be attractive to men is seemingly uncontroversial because males who discriminatively mate with fertile females should achieve a straightforward reproductive advantage over those males who do not, with all other factors being equal (6). Although direct associations between facial femininity and fertility have not been demonstrated, the consensus from Western preferences, and from the limited cross-cultural data available, is that femininity is attractive, as predicted by the fertility hypothesis (14–17). In environments where fertility is high and variable, this relationship should be even more apparent.In male faces, masculinity has been variously proposed to signal heritable disease resistance (“good genes” or “immunocompetence”) (4, 15, 18–22) and/or perceived as a cue of aggressiveness and, consequently, intrasexual competitiveness (22, 23). The “honesty” of face shape as an indicator of immunocompetence is proposed to be the result of an immunosuppressive effect of testosterone. Because testosterone influences the growth of sex-typical traits in many species (24, 25), masculine facial shape is proposed to be a costly, and thus honest, signal of male quality (22). The hypothesis that cues of heritable health should be attractive to females is widely accepted (26), although the evidence for a link between heritable health and masculinity in humans is tentative at best (22).Support for a link between masculinity and aggression is largely indirect, and it consists of an association between testosterone and both aggressive behavior (27, 28) and face shape (25), in addition to the fact that honest signaling of dominance is commonly observed in nonhuman species (3). Masculine faces are perceived as aggressive in those groups (i.e., urban, Western) where the relationship has been tested (29). Because masculinity may signal both (desirable) immunity and (potentially costly) aggression in humans, some authors have proposed that preferences for masculinity reflect women trading-off benefits of traits putatively associated with health against those traits associated with prosocial behaviors, such as parental investment (23, 30, 31).Consistent with both of these proposals, data indicate that preferences for masculinity are stronger in circumstances where indirect benefits (heritable quality) can be realized without accompanying direct costs (aggression and low paternal investment). Such circumstances include judging attractiveness in the context of a short-term (vs. a long-term) relationship (32) and in the follicular phase of the menstrual cycle when conception following intercourse is most likely (33). Masculinity is also reported to be more strongly preferred in environments with relatively high pathogen burdens (19, 30) and in environments with higher local homicide rates (23), which has been interpreted as a response to variation in the benefits of heritable disease resistance (19) and in the net benefits conferred by aggressive males under varying levels of male–male competition (23).All of this supporting evidence comes with a very important caveat; although there has been some cross-cultural work in this area (34), the majority of studies have been conducted in Western, often student, populations characterized by high levels of development and urbanization [Western, educated, industrialized, rich, and democratic; so-called WEIRD participants (35)]. Research on preferences in other groups is scant and methodologically inconsistent, using Internet-based designs or a limited cross-cultural component (7, 15–18). Because there are differences between Western/non-Western and industrial/small-scale societies in many behaviors, including aspects of visual perception and mate choice (35), this over-representation greatly limits generalizability. Perhaps most importantly, large-scale (post)industrial societies present inhabitants with large numbers of unfamiliar faces and provide venues for the efficient exchange of (visual) social information (e.g., posters, television, Internet); these factors may be instrumental in the acquisition and reinforcement of preferences (36–39). It is possible therefore that rather than being a legacy of ancestral selection pressures, preferences for dimorphism emerge in large urban groups as a byproduct of the information-processing strategies used to process large amounts of social information or in response to arbitrary cultural norms.Development also introduces an increased presence of highly differentiated social roles that arise from a greater division of labor, along with opportunities to acquire prestige without strength or aggression. Because partner preferences have been proposed to develop in response to sex-typical social roles (40, 41), it is possible that increasingly differentiated roles could influence masculinity preferences if desirable social roles not present in less developed groups are associated with facial appearance.We assessed preferences for, and trait attributions made to, faces varying in dimorphism in a cross-cultural sample of 12 groups, including non-Western, nonstudent, and small-scale societies (n = 962; Tables S1 and S2). We tested the predictions, derived from the immunocompetence handicapping hypothesis, that (i) preferences for dimorphism will be stronger in less developed groups and (ii) masculine faces would be perceived as aggressive in all populations, with perceptions in low-development groups at least as strong as in groups with high development. We estimated social development with the Human Development Index (HDI), which is a composite indicator compiled by the United Nations Development Program. To investigate which aspects of development were associated with variation in perception of our facial stimuli, we took the World Health Organization measures of years lost to disease and United Nations (UN) measures of homicide rates as proxy measures of disease burden and male intrasexual competition, respectively (both log-transformed), and UN measures of levels of urbanization. Using these national statistics almost certainly underestimates disease burden in the small-scale societies in our sample, which is a conservative estimate with regard to our hypotheses.

Table 1.

Summary information for the groups tested

“GIOSAT”: a tool to assess CanMEDS competencies during simulated crises

Purpose

Our objective was to develop and evaluate a Generic Integrated Objective Structured Assessment Tool (GIOSAT) to integrate Medical Expert and intrinsic (non-medical expert) CanMEDS competencies with non-technical skills for crisis simulation.

Methods

An assessment tool was designed and piloted using two pediatric anesthesia scenarios (laryngospasm and hyperkalemia). Following revision of the tool, we used previously recorded videos of anesthesia residents (n = 50) who managed one of two intraoperative advanced cardiac life support (ACLS) scenarios (ventricular tachycardia or ventricular fibrillation). Four independent trained raters, blinded to the residents’ level of training, analyzed the video recordings using the GIOSAT scale. Inter-rater reliability was calculated using intraclass correlations (ICCs) for single raters (single measure) and the average of the four raters (average measure), and construct validity was investigated by correlating GIOSAT scores with postgraduate year of residency (PGY).

Results

Total GIOSAT scores for the ACLS scenarios had single measure ICCs of 0.62 and average measure ICCs of 0.85. Inter-rater reliability was substantial for both Medical Expert and intrinsic competencies (single measure ICCs 0.69 and 0.62, respectively; average measure ICCs 0.90 and 0.82, respectively). We found significant correlations between PGY level and total GIOSAT score (r = 0.36; P = 0.011) and between PGY level and Medical Expert competencies (r = 0.42; P = 0.003); however, correlations were not found between PGY level and intrinsic CanMEDS competencies (r = 0.24; P = 0.09).

Conclusion

Inter-rater reliability of the total GIOSAT scores using four trained raters was substantial. Significant correlation between PGY and (i) total GIOSAT score and (ii) Medical Expert competencies supports construct validity. Evidence of validity was not obtained for intrinsic CanMEDS competencies.     

The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient

Background

Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.

Methods

Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.

Conclusions

The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.     

Pulsed holmium:yttrium-aluminum-garnet laser-induced liquid jet as a novel dissection device in neuroendoscopic surgery

OBJECT: A pressure-driven continuous jet of water has been reported to be a feasible tool for neuroendoscopic dissection owing to its superiority at selective tissue dissection in the absence of thermal effects. With respect to a safe, accurate dissection, however, continuous water flow may not be suitable for intraventricular use. The authors performed experiments aimed at solving problems associated with continuous flow by using a pulsed holmium:yttrium-aluminum-garnet (Ho:YAG) laser-induced liquid jet (LILJ). They present this candidate neuroendoscopic LILJ dissection system, having examined its mechanical characteristics and evaluated its controllability both in a tissue phantom and in a rabbit cadaveric ventricle wall. METHODS: The LILJ generator was incorporated into the tip of a No. 4 French catheter so that the LILJ could be delivered via a neuroendoscope. Briefly, the LILJ was generated by irradiating an internally supplied column of physiological saline with a pulsed Ho:YAG laser (pulse duration time 350 microsec; laser energy 250-700 mJ/pulse) within a No. 4 French catheter (internal diameter 1 mm) and ejecting it from a metal nozzle (internal diameter 100 microm). The Ho:YAG laser energy pulses were conveyed by an optical fiber (core diameter 400 microm) at 3 Hz, whereas physiological saline (4 degrees C) was supplied at a rate of 40 ml/hour. The mechanical characteristics of the pulsed LILJ were investigated using high-speed photography and pressure measurements; thermal effects and controllability were analyzed using an artificial tissue model (10% gelatin of 1 mm thickness). Finally, the ventricle wall of a rabbit cadaver was dissected using the LILJ. Jet pressure increased in accordance with laser energy from 0.1 to 2 bar; this translated into a penetration depth of 0.08 to 0.9 mm per shot in the ventricle wall of the rabbit cadaver. The gelatin phantom could be cut into the desired shape without significant thermal effects and in the intended manner, with a good surgical view. CONCLUSIONS: The present results show that the pulsed LILJ has the potential to become a safe and reliable dissecting method for endoscopic procedures.     

Vascular injuries in total hip replacement arthroplasty: a review of the problem

Considering the proximity of the major endopelvic and exopelvic vascular structures to the hip joint, we find that reported vascular complications of total hip replacement are relatively rare. We encountered 1 case of vascular injury after primary, and 2 cases after revision, total hip arthroplasty. This stimulated us to send a postal survey to the members of the British Hip Society inquiring about such vascular complications, with a view to evaluating their incidence, management, and final outcome. We received 42 valid replies of 82 questionnaires sent. A conservative estimate from this study is 1 vascular injury in 14 consultant life years of practice. A total of 26 vascular injuries were studied in detail, which included 3 of our index cases. There were 14 cases encountered in revision hip replacement, while the rest occurred in primary hip replacement surgery. Three patterns of presentation of vascular injuries were recognized--immediate, early, and late, all of which require prompt recognition and appropriate treatment. The potential of vascular injury seems to be underestimated in primary total hip replacements, leading to late recognition and poor outcome.