Failed tracheostomy under local anaesthesia...plan B?

Severe stridor of recent onset is a challenge to deal with because of the lack of investigations on which to base the management plan. We describe a case of an elderly lady who presented to us with a short history of severe stridor. We encountered unanticipated difficulties with tracheostomy under local anaesthesia as the thyroid was replaced by a diffuse mass and the airway had to be secured by an awake fibre-optic intubation. Awake fibre-optic intubation is thought to be a relative contraindication in acute upper airway obstruction, but occasionally tracheostomy under local anaesthesia may not be possible and in experienced hands an awake fibre-optic intubation is a reasonable alternative.

Awake insertion of the laryngeal mask airway using topical lidocaine and intravenous remifentanil.

We assessed the use of intravenous remifentanil for the insertion of the laryngeal mask airway in 10 healthy awake volunteers, a technique primarily developed to facilitate functional magnetic resonance imaging studies of anaesthesia. Each volunteer received 200 microg glycopyrronium intravenously. Topical airway anaesthesia was effected by 4 ml nebulised lidocaine 4%, followed by 12 sprays of lidocaine 10%. Remifentanil was subsequently infused to achieve an initial target effect-site concentration of 2 ng.ml(-1); increments of 1 ng.ml(-1) were allowed with the maximum effect-site concentration limited to 6 ng.ml(-1). Insertion of the laryngeal mask airway was successful on the first attempt in all cases. The median (IQR [range]) target effect-site remifentanil concentration at insertion was 2.5 (2-3 [2-4]) ng.ml(-1). All volunteers were co-operative during the procedure and only one reported discomfort. Sore throat was a complication in all volunteers. We conclude that the technique allows successful insertion of the laryngeal mask airway in healthy awake volunteers under conditions that were safe and reproducible.

Inhibitors of the lipoxygenase pathway block development of Brugia malayi L3 in vitro.

Brugia malayi L3 molt to the L4 stage in serum-free cultures supplemented with arachidonic, linoleic, or linolenic acids and the basidiomycetous yeast Rhodotorula minuta. These fatty acids are capable of entering the eicosanoid pathway of arachidonate metabolism, the pathway responsible for generating a number of biologically active mediators, including prostaglandins, leukotrienes, and lipoxins. To determine whether this pathway was required for L3 development, we added dual inhibitors of cyclooxygenase and lipoxygenase to in vitro cultures containing B. malayi L3. These compounds significantly inhibited L3 molting. To evaluate whether 1 or both of these pathways of arachidonate metabolism were involved in molting, we tested drugs inhibiting either cyclooxygenase or lipoxygenase. Lipoxygenase inhibitors blocked L3 molting, whereas cyclooxygenase inhibitors did not. To assess whether enzymes operating downstream of lipoxygenase were also involved in L3 molting, we added inhibitors of enzymes involved in leukotriene synthesis and found they were also capable of preventing development. We tested the same inhibitor panel on Dirofilaria immitis L3. A single lipoxygenase inhibitor and inhibitors of 2 different enzymes operating downstream of lipoxygenase disrupted D. immitis development. These results demonstrate that a lipoxygenase pathway product is required for molting of the infective stage larvae of filarial parasites.

Development of a serum-free system for the in vitro cultivation of Brugia malayi infective-stage larvae.

Over the past several years, numerous attempts have been made to culture the infective-stage (L3) larvae of the human filarial parasite Brugia malayi in an in vitro system that promotes molting to the fourth larval stage (L4). Although there have been reports in the literature of successful L3 to L4 development in vitro, all of these systems have required serum supplementation. The complexity of serum as a culture supplement has made reproducibility of results and identification of specific factors necessary for L3 development problematic. We have developed a serum-free in vitro system consisting of RPMI 1640 supplemented with one of three fatty acids (arachidonic, linoleic, or linolenic) that supports consistent and reproducible molting to the fourth larval stage in the presence of a basidiomycetous yeast, Rhodotorula minuta. Coculture with this yeast, initially isolated as a culture contaminant, is required for successful molting. In serum-free cultures lacking R. minuta, L3 larvae survive for upward of 2 weeks, but do not molt successfully. The L4 larvae generated in cultures containing R. minuta are well formed, as seen by light and electron microscopy, and are capable of further development upon transfer to a permissive host. This culture system is inexpensive and easily reproducible, thus making it a useful tool for studying the requirements for the development of B. malayi L3.

Medical groups and the metaphor of manufacturing.

Medical groups are vitally interested in achieving better operating margins in view of diminishing revenues and cost increases. The answer to this dilemma is heightened productivity. However, raising the productivity of medical care providers does not just automatically happen. It requires innovative thinking and the courage to instill change in the face of resistance. This article examines several medical manufacturing strategies that might be used by medical groups to improve productivity. These strategies are based on proven approaches in business that have been translated for the health care context.

Pharmacology and neurochemistry of nefazodone, a novel antidepressant drug.

Nefazodone is a new antidepressant drug with a pharmacologic profile distinct from that of the tricyclic, monoamine oxidase inhibitor, and serotonin selective reuptake inhibitor antidepressants. Nefazodone was initially discovered for its ability to block 5-HT2A receptors and its reduced potency as an alpha 1-adrenergic blocker. It was later shown to inhibit both serotonin and norepinephrine uptake in vitro, attributes which most likely impart its clinical efficacy and which differentiate nefazodone from its chemical predecessor trazodone. The combination of these two mechanisms may ultimately result in a facilitation of 5-HT1A-mediated neurotransmission, which may be beneficial for treating symptoms of depression as evidenced by recent clinical findings. In addition, the preclinical profile of nefazodone demonstrates that it has decreased anticholinergic and antihistaminic activity relative to traditional agents. Clinical findings to date are consistent with these observations.

The effects of a pectin-supplemented elemental diet in a boy with short gut syndrome.

The effect of a pectin-supplemented diet in short gut syndrome was investigated in a 3-year-old boy. Nitrogen absorption was higher and stomach-to-anus transit time was prolonged during pectin supplementation of the enteral feed. Pectin supplementation had no adverse effects on electrolyte balance or glucose absorption. These data indicate that pectin supplementation of enteral feed may enhance nitrogen absorption and seems not to adversely affect absorption in short gut syndrome.