Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries.

Importance: Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events. Objective: To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. Design, Setting, and Participants: The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. Exposures: Tracheal intubation. Main Outcomes and Measures: The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. Results: Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. Conclusions and Relevance: In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.

C1-C2 instability with severe occipital headache in the setting of vertebral artery facet complex erosion.

PURPOSE: An exact understanding of patient vertebral artery anatomy is essential to safely place screws at the atlanto-axial level in posterior arthrodesis. We aim to report a case of erosion of the left vertebral artery into the C1-C2 facet complex with resultant rotatory and lateral listhesis presenting with severe occipital headache. This represents a novel etiology for this diagnosis and our report illustrates technical considerations when instrumenting the C1-C2 segment. METHODS: We report a case of severe occipital headache due to C1-C2 instability with resultant left C2 nerve compression in the setting of erosion of the vertebral artery into the C1-C2 facet complex. RESULTS: A 68-year-old woman presented with a 12-month history of progressively debilitating headache and neck pain with atlanto-axial instability. Computed tomography (CT) angiography demonstrated erosion of the left vertebral artery into the left C1-C2 facet complex. In addition, the tortuous vertebral arteries had eroded into the C2 pedicles, eliminating the possibility for posterior pedicle screw placement. The patient underwent posterior arthrodesis of C1-C2 utilizing bilateral lateral mass fixation into C1 and bilateral trans-laminar fixation into C2 with resolution of all preoperative complaints. CONCLUSIONS: This study constitutes the first report of a tortuous vertebral artery causing the partial destruction of a C1-C2 facet complex, as well as instability, with the clinical presentation of severe occipital headache. It hereby presents a novel etiology for both the development of C1-C2 segment instability as well as the development of occipital headache. Careful evaluation of such lesions utilizing CT angiography is important when formulating a surgical plan.

Prostate cancer trends in Latvia during 1990-2012: incidence, prevalence, mortality, and survival rates.

BACKGROUND AND OBJECTIVE: Prostate cancer (PCa) is one of the most common form of cancer in males worldwide. One of the highest PCa-related mortality rates in the world is observed in Latvia. MATERIALS AND METHODS: Our study included male patients diagnosed with PCa between 1990 and 2012. We analyzed incidence, prevalence and mortality trends using joinpoint analysis. Kaplan-Meier analysis was performed for 5-, 10-, 15- and 20-year overall survival and cancer-specific survival rates. RESULTS: A total of 14,083PCa patients with a mean age of initial PCa diagnosis being 70.1 (SD 8.6) was registered. The standardized incidence rates (per 100,000) increased from 18.9 in 1990 to 74.7 in 2012, while the standardized prevalence rates (per 100,000) increased from 69.9 in 1990 to 437.6 in 2012. Standardized PCa mortality rates (per 100,000) also rose from 13.2 in 1990 to 27.2 in 2006 followed by statistically insignificant decrease continuing up to 2012. The mean 5-year cancer-specific survival rates increased from 43.6% in 1990 to 70.7% in 2007, and the mean 10-year cancer-specific survival rates from 32.9% in 1990 to 40.5% in 2001. CONCLUSIONS: This study revealed that the incidence, prevalence and mortality rates increased between 1990 and 2012, and although the 5- and 10-year overall and cancer-specific survival rates improved over the reviewed period they still needed to get better.