[Comparative study of the KingVision videolaryngoscope and Airwayscope using manikins].

BACKGROUND: KingVision (KV) is a new videolaryngoscope. In this study, we compared the ease of use of the KV with the Airwayscope (AWS) by experienced personnel in a simulated manikin. METHODS: Twenty-eight anesthesiologists participated in this study. We used an advanced patient simulator (AIRSIM) to simulate normal manikin and difficult airway scenarios including cervical spine rigidity and limited mouth opening. We compared the time required for visualization of the glottis (Tv) and tracheal intubation (Ti), and analyzed the percentage of glottic opening (POGO) score and the success rates for tracheal intubation. RESULTS: In normal manikin, the Tv and Ti with the KV were significantly shorter than with the AWS (P < 0.05). The POGO score with the KV was higher than with the AWS (P < 0.05). In difficult airway scenarios including both cervical spine rigidity and limited mouth opening, the Tv and Ti with the KV were shorter than with only the AWS (P < 0.05). There is not much difference between KV and AWS regarding the POGO score in difficult airway. CONCLUSIONS: KV may be a suitable device for routine anesthesia care and difficult airway intubation. Further studies in a clinical setting are necessary to confirm these findings.

[Intubation training survey using four types of laryngoscopes among medical students: a comparison of the Macintosh laryngoscopes, Miller laryngoscopes, Airtraq, and Pentax-AWS Airwayscope].

BACKGROUND: Recently, rigid indirect laryngoscopes with integrated tube guidance such as Pentax-AWS (AWS) and Airtraq (ATQ) are clinically available. They are known to improve the laryngeal view and facilitate intubation compared to the Macintosh laryngoscope (MAC). However, whether these new devices are easy to learn for novice laryngoscopists is not well understood. We surveyed medical students regarding their usefulness in intubation procedure on mannequin. METHODS: Sixty-six medical students with no intubation experience were enrolled. A short instruction including practice for four devices (MAC, Miller laryngoscope (MIL), AWS, and ATQ) was given. Four intubation procedures (one for each device) to the mannequin (Laerdal airway trainer) were performed. The time to place the tube, percentage of glottic opening (POGO), incidence of esophageal intubation and teeth click were recorded. Participants were asked to choose the best device for their use. For statistical analyses, ANOVA and Chi-square tests were used where appropriate, and P < 0.01 considered significant. RESULTS: Time for intubation was significantly longer in ATQ (P < 0.01). POGO was significantly higher in AWS, but lower in MAC (P < 0.01). Complications were fewer in AWS (P < 0.01), and 70% of the participants chose AWS as the best device. CONCLUSION: With minimal instruction including practice, the AWS seemed to achieve safer intubation with better laryngeal view for novice laryngoscopists.

Body weight variation predicts disease progression after invasive ventilation in amyotrophic lateral sclerosis.

Weight loss is an independent predictor of survival in the early stages of amyotrophic lateral sclerosis (ALS). However, the effects of weight variations on the functional prognosis after tracheostomy and invasive ventilation (TIV) in ALS remain unknown. This prospective cohort study aimed to investigate the relationship between weight loss before TIV and disease progression after TIV in ALS patients. Sixty ALS patients with TIV were enrolled and classified into subgroups based on the rate of decline in body mass index, from onset to TIV utilization (ΔBMI). During follow-up, we assessed the patients for presence of communication impairments, ophthalmoplegia, total quadriplegia, mouth opening disability, and dysuria. We analyzed the relationship between ΔBMI and the communication stage or motor disabilities. The log-rank test showed that patients with a ΔBMI ≥ 1.7 kg/m2/year showed a shorter period of preserved communication ability (p = 0.0001), shorter time to develop ophthalmoplegia (p = 0.0001), total quadriplegia (p < 0.0001), mouth opening disability (p < 0.0001), and dysuria (p = 0.0455). Cox multivariate analyses showed that a larger ΔBMI was an independent prognostic factor for the early development of ophthalmoplegia (p = 0.0400) and total quadriplegia (p = 0.0445). Weight loss in the early stages of ALS predicts disease progression in patients with advanced stages of ALS using TIV.

[Case of specific MRI T2* weighted image associated with bacterial endocarditis].

We report a case of multiple signal loss lesions detected by T2* weighted image associated with bacterial endocarditis. A 23 year-old woman, who had undergone surgical closure of ventricular septal defect at age 2, suffered headache and general fatigue after dental treatment. She was admitted to another institution, and examinations revealed bacterial endcarditis. She was transferred to our hospital, and underwent aortic valve replacement. After the valve replacement, CT revealed parenchymal hematoma in the left frontal lobe. CT angiography (CTA) and cerebral angiography (CAG) demonstrated an aneurysm at the distal branch of the left middle cerebral artery. T2* weighted image demonstrated multiple signal loss lesions, which were not revealed by CAG and CTA. We speculated that these signal loss lesions were thrombosed mycotic intracranial aneurysms. She underwent left frontotemporal craniotomy, and the aneurysm was resected. Mycotic aneurysms are rare neurovascular lesions but their mortality and morbidity are high, so careful follow-up examinations are required. T2* weighted image was useful to detect mycotic aneurysms and plan the surgical strategy.

Transvenous extraction of advisory implantable cardioverter defibrillator leads with a relatively long implant duration.

BACKGROUND: Optimal management of advisory implantable cardioverter defibrillator (ICD) leads has not been established. Several studies were reported concerning the lead extraction of advisory ICD leads, but the implant duration of those studies was short. We estimated the efficacy of lead extractions of advisory ICD leads with a relatively longer duration in Japanese patients. METHODS: We retrospectively analyzed 28 patients who underwent a lead extraction at Kokura Memorial Hospital and Tokyo Medical and Dental University Hospital [Fidelis (Medtronic, Minneapolis, MN, USA): n=19, Riata (St. Jude Medical, Sylmar, CA, USA): n=8, Isoline (SORIN CRM SAS, Clamart, France): n=1]. The mean implant duration was 63.3±19.3 months. The indications were device related infections in 3, electrical lead failures in 18, electrical lead failures and venous obstructions in 3, and prophylactic reasons in 4 patients. Inappropriate shocks because of electrical lead failures were observed in 9 patients. RESULTS: Complete removals were achieved of all 28 advisory leads. In 23 out of 28 patients, new ICD leads were implanted during the same procedure. In one patient, open chest surgery was performed for a hemothorax that occurred during a new ICD lead implantation just after successfully removing the advisory ICD lead. There were no other major or minor complications. CONCLUSION: Transvenous extractions of advisory ICD leads with relatively long implant duration were performed with a high success rate and low complication and mortality rate in Japanese patients.

Preparation of stem cell aggregates with gelatin microspheres to enhance biological functions.

The objective of this study is to improve the viability and osteogenic differentiation of cultured rat bone marrow-derived mesenchymal stem cells (MSC) by the use of gelatin hydrogel microspheres. Gelatin was dehydrothermally crosslinked at 140° C for 48 h in a water in oil emulsion state. When cultured with the gelatin hydrogel microspheres in round, U-bottomed wells of 96-well plates coated with poly(vinyl alcohol) MSC formed aggregates homogeneously incorporating the microspheres. The viability of the cell aggregates was significantly higher compared with that of aggregates formed without microspheres. MSC proliferation in the aggregates depended on the number and diameter of the incorporated microspheres. Higher MSC proliferation was observed for aggregates incorporating a greater number of larger gelatin microspheres. When evaluated as a measure of aerobic glycolysis the ratio of l-lactic acid production/glucose consumption in MSC was significantly lower for MSC cultured with gelatin microspheres than those without microspheres. MSC production of alkaline phosphatase (ALP) and sulfated glycosaminaglycan (sGAG) was examined to evaluate their potential osteogenic and chondrogenic differentiation. The amount of ALP produced was significantly higher for MSC aggregates cultured with gelatin microspheres than that of MSC cultured without microspheres. On the other hand, the amount of sGAG produced was significantly lower for MSC aggregates containing microspheres. It is concluded that the incorporation of gelatin hydrogel microspheres prevents the aggregated MSC suffering from a lack of oxygen, resulting in enhanced MSC aggregation and cell proliferation and osteogenic differentiation.

Observation of the embolus protection filter for Carotid Artery Stenting.

BACKGROUND: Carotid artery stenting in patients with high surgical risk is considered as an effective alternative to carotid endarterectomy. Because the occurrence of distal embolization with CAS is still a major concern, an embolus protection device is usually used during the procedure. We developed a technique for observation of embolus protection filter and evaluated the debris or thrombus microscopically, and the pathologic findings were compared with preoperative imaging studies. METHODS: After completing CAS, the filter membrane was stained with HE solution and removed from filter strut. Mounting onto a glass slide, the filter was evaluated under a microscope. Plaque debris and appearance of filter membrane were evaluated, and the covered area was measured. The pathologic findings were compared with preoperative imaging studies. RESULTS: Microscopic observation of the slide revealed atheromatous debris as well as thrombotic material to the filter membrane. Hematoxylin-eosin stain facilitates the characterization of the debris composition, namely, thrombotic debris, calcified debris, organized debris, fibrous debris, and lipid-rich debris. The subtypes of debris were consistent with preoperative imaging studies. Thus, in cases of intraprocedural flow impairment, more than 50% of the filter area was covered with debris or thrombotic material. CONCLUSION: Carotid plaque debris captured during carotid stenting with protection filter can be visualized with HE stain on the glass side. This simple method allows us to better understand the plaque debris and appearance of embolus protection filter.