Impacted fetal head at cesarean delivery.

PURPOSE: Impacted fetal head (IFH) can be defined as the deep engagement of the fetal head in the maternal pelvis at the time of cesarean delivery that leads to its difficult or impossible extraction with standard surgical maneuvers. In this narrative review, we aimed to ascertain its incidence, risk factors, management and complications from the perspective of the anesthesiologist as a multidisciplinary team member. METHODS: Databases were searched from inception to 24 January 2023 for keywords and subject headings associated with IFH and cesarean delivery. RESULTS: IFH has an incidence of 2.9-71.8 % in emergency cesarean section. Maternal risk factors are advanced cervical dilatation, second stage of labor and oxytocin augmentation. Anesthetic and obstetric risk factors include epidural analgesia and trial of instrumental delivery and junior obstetrician, respectively. Neonatal risk factors are fetal malposition, caput and molding. Current evidence indicates a lack of confidence in the management of IFH across the multidisciplinary team. Simple interventions in IFH include lowering the height or placing the operating table in the Trendelenburg position, providing a step for the obstetrician and administering pharmacological tocolysis. Maternal complications are postpartum hemorrhage and bladder injury while neonatal complications include hypoxic brain injury, skull fracture and death. Surgical complications are reviewed to remind the anesthesiologist to anticipate and prepare for potential problems and manage complications in a timely manner. CONCLUSION: The anesthesiologist has a fundamental role in the facilitation of delivery in IFH. We have proposed an evidence based management algorithm which may be referred to in this emergency situation.

A prospective, observational, cohort study of airway management of patients with COVID-19 by specialist tracheal intubation teams.

PURPOSE: Because of the anticipated surge in cases requiring intensive care unit admission, the high aerosol-generating risk of tracheal intubation, and the specific requirements in coronavirus disease (COVID-19) patients, a dedicated Mobile Endotracheal Rapid Intubation Team (MERIT) was formed to ensure that a highly skilled team would be deployed to manage the airways of this cohort of patients. Here, we report our intubation team experience and activity as well as patient outcomes during the COVID-19 pandemic. METHODS: The MERIT members followed a protocolized early tracheal intubation model. Over a seven-week period during the peak of the pandemic, prospective data were collected on MERIT activity, COVID-19 symptoms or diagnosis in the team members, and demographic, procedural, and clinical outcomes of patients. RESULTS: We analyzed data from 150 primary tracheal intubation episodes, with 101 (67.3%) of those occurring in men, and with a mean (standard deviation) age of 55.7 (13.8) yr. Black, Asian, and minority ethnic groups accounted for 55.7% of patients. 91.3% of tracheal intubations were performed with videolaryngoscopy, and the first pass success rate was 88.0%. The 30-day survival was 69.2%, and the median [interquartile range] length of critical care stay was 11 [6-20] days and of hospital stay was 12 [7-22] days. Seven (11.1%) MERIT healthcare professionals self-isolated because of COVID-19 symptoms, with a total 41 days of clinical work lost. There was one reported incident of a breach of personal protective equipment and multiple anecdotal reports of doffing breaches. CONCLUSION: We have shown that a highly skilled designated intubation team, following a protocolized, early tracheal intubation model may be beneficial in improving patient and staff safety, and could be considered by other institutions in future pandemic surges.

RéSUMé: OBJECTIF: En raison de l'augmentation anticipée du nombre de cas nécessitant une admission à l'unité de soins intensifs, du risque élevé de génération d'aérosols de l'intubation trachéale et des exigences spécifiques aux patients atteints du coronavirus (COVID-19), nous avons créé une équipe mobile dédiée pour l'intubation trachéale rapide (MERIT - Mobile Endotracheal Rapid Intubation Team) afin de garantir qu'une équipe hautement qualifiée puisse être déployée pour prendre en charge les voies aériennes de cette cohorte de patients. Notre objectif était de rapporter l'expérience et l'activité de notre équipe d'intubation ainsi que les devenirs des patients pendant la pandémie de COVID-19. MéTHODE: Les membres de l'équipe MERIT ont suivi un modèle d'intubation trachéale précoce basé sur un protocole. Pendant sept semaines autour du pic de la pandémie, des données prospectives ont été colligées concernant l'activité de la MERIT, les symptômes et diagnostics de COVID-19 parmi les membres de l'équipe, ainsi que les données démographiques, procédurales et les devenirs cliniques des patients. RéSULTATS: Nous avons analysé les données de 150 épisodes d'intubations trachéales initiales, dont 101 (67,3 %) survenus chez des hommes, avec un âge moyen (écart type) de 55,7 (13,8) ans. Les personnes noires, asiatiques et de minorités ethniques représentaient 55,7 % des patients. Au total, 91,3 % des intubations trachéales ont été réalisées par vidéolaryngoscopie, et le taux de réussite au premier essai était de 88,0 %. Le taux de survie à 30 jours était de 69,2 %, et la durée médiane (écart interquartile) de séjour aux soins intensifs était de 11 (6-20) jours et de 12 (7-22) jours à l'hôpital. Sept (11,1 %) professionnels de la santé de l'équipe MERIT se sont mis en auto-isolement en raison de symptômes de la COVID-19, pour un total de 41 jours de travail clinique perdus. Un incident de bris de stérilité de l'équipement de protection individuelle a été rapporté, et de multiples bris lors du déshabillage ont également été rapportés de façon anecdotique. CONCLUSION: Nous avons démontré qu'une équipe d'intubation désignée et hautement qualifiée, respectant un modèle d'intubation trachéale précoce basé sur un protocole, pourrait contribuer à améliorer la sécurité des patients et du personnel. La création d'une telle équipe est envisageable dans d'autres établissements lors de futurs épisodes pandémiques.

The Association between Metabolic Syndrome and Multiple Myeloma.

Multiple myeloma (MM) is a haematological malignancy arising from monoclonal proliferation of plasma cells in the bone marrow, resulting in the presence of paraproteins or M-protein in serum. The involvement of paraproteins produced by malignant plasma cells in the development of hyperlipidaemia and low-HDL cholesterol has been described, as has an association with MM and obesity, hypertension, and type 2 diabetes mellitus, and insulin resistance, that is, features of the metabolic syndrome (MS). There is an association between MS components, inflammatory cytokines, and the development of MM, and some drugs used in the treatment of MS such as statins and metformin may improve outcomes in MM.

Training final year medical students in telephone communication and prioritization skills: An evaluation in the simulated environment.

Introduction: Receiving clinical tasks via the telephone and correctly prioritizing job lists are integral to patient safety. However, structured training on these skills is currently lacking in many medical curriculums. This study evaluated the impact of telephone communication and prioritization training on the ability of final year medical students to carry out these skills during an on-call simulation. Methods: Twenty-five final year King's College London medical students underwent a training session focused on telephone communication and task prioritization (group A). The performance of group A students in an on-call simulation involving these tasks was compared with twenty-five untrained final year students (group B). All participants completed a questionnaire about their training and/or simulation experience. Results: Group A compared to B students asked for more task-related information during each simulated call and correctly prioritized the resultant job list on significantly more occasions. Significantly more group A students reported being confident in answering calls and prioritizing their lists. The majority of students supported the addition of telephone communication and prioritization training into the medical curriculum. Conclusions: This study demonstrates the educational benefit of structured teaching on the ability of final year medical students to receive telephone handovers and prioritize job lists.

Metabolic Syndrome in Long-Term Survivors of Hematopoietic Stem-Cell Transplantation.

Since its introduction more than 50 years ago, hematopoietic stem-cell transplantation (HSCT) has transformed from an inescapably fatal procedure to one where cure from malignant and other nonmalignant hematologic diseases is becoming increasingly common. Nevertheless, longevity is not entirely restored. New causes of mortality have emerged; of particular importance is that of increased cardiovascular disease (CVD), related to metabolic syndrome and its components. Controversy exists over whether the metabolic abnormalities induced are a direct effect of HSCT itself or a consequence of other therapies involved. Analysis of the mechanisms that promote the changes in metabolic components will give insight into future HSCT therapy as well as CVD pathogenesis and prevention.

Use of lipid-lowering medications in myasthenia gravis: a case report and literature review.

We present a patient with myasthenia gravis (MG) who developed worsening of his condition after starting ezetimibe. We review the literature concerning lipid-modifying medications and MG. The use of bile acid sequestrant agents may have a place in the lipid management of MG patients because they did not seem to cause muscle-related side effects or worsening of MG.