Assessing Appearance, Speech, and Hearing (dis)Satisfaction in Individuals with Cleft Lip and/or Palate: A Contribution to General Population Norms.

BACKGROUND: Individuals with cleft lip and/or palate (CL/P) may grow up with a visible facial difference, alongside speech and/or hearing challenges. Self-perceptions are stronger predictors of psychosocial adjustment than objective assessments, highlighting the importance of patient-reported outcome measures. Previously titled the Satisfaction with Appearance (SwA) questionnaire, the Cleft Hearing, Appearance and Speech Questionnaire (CHASQ) has been used in several countries to assess patient satisfaction, guide clinical decision-making, and conduct craniofacial research, but has lacked general population norms from which to draw comparisons. The aim of this study was to contribute to the development of norms by utilising existing data collected in the United Kingdom (UK) in 2004 using the original SwA. METHODS: SwA data collected from school pupils (n = 761) aged 10-16 years were analysed across age and gender. RESULTS: Hair, Eyes and Ears received the highest ratings, while Teeth received the lowest ratings. Those who were younger, and those who were male, generally rated their appearance more favourably. Thresholds are proposed to identify young people in need of clinical monitoring (10%) and intervention (5%). DISCUSSION: This study supports the potential of the CHASQ as a clinically useful outcome measure and research tool with the ability to identify appearance concerns in relation to specific facial features, as well as overall appearance satisfaction in young people with and without CL/P. Further validation of its use in the CL/P population and other patient groups, as well as countries outside the UK would add additional weight to the CHASQ's utility.

Biodegradable, Drug-Loaded Nanovectors via Direct Hydration as a New Platform for Cancer Therapeutics.

The stabilization and transport of low-solubility drugs, by encapsulation in nanoscopic delivery vectors (nanovectors), is a key paradigm in nanomedicine. However, the problems of carrier toxicity, specificity, and producibility create a bottleneck in the development of new nanomedical technologies. Copolymeric nanoparticles are an excellent platform for nanovector engineering due to their structural versatility; however, conventional fabrication processes rely upon harmful chemicals that necessitate purification. In engineering a more robust (copolymeric) nanovector platform, it is necessary to reconsider the entire process from copolymer synthesis through self-assembly and functionalization. To this end, a process is developed whereby biodegradable copolymers of poly(ethylene glycol)-block-poly(trimethylene carbonate), synthesized via organocatalyzed ring-opening polymerization, undergo assembly into highly uniform, drug-loaded micelles without the use of harmful solvents or the need for purification. The direct hydration methodology, employing oligo(ethylene glycol) as a nontoxic dispersant, facilitates rapid preparation of pristine, drug-loaded nanovectors that require no further processing. This method is robust, fast, and scalable. Utilizing parthenolide, an exciting candidate for treatment of acute lymphoblastic leukemia (ALL), discrete nanovectors are generated that show strikingly low carrier toxicity and high levels of specific therapeutic efficacy against primary ALL cells (as compared to normal hematopoietic cells).

Redox-Sensitive Stomatocyte Nanomotors: Destruction and Drug Release in the Presence of Glutathione.

The development of artificial nanomotor systems that are stimuli-responsive is still posing many challenges. Herein, we demonstrate the self-assembly of a redox-responsive stomatocyte nanomotor system, which can be used for triggered drug release under biological reducing conditions. The redox sensitivity was introduced by incorporating a disulfide bridge between the hydrophilic poly(ethylene glycol) block and the hydrophobic polystyrene block. When incubated with the endogenous reducing agent glutathione at a concentration comparable to that within cells, the external PEG shells of these stimuli-responsive nanomotors are cleaved. The specific bowl-shaped stomatocytes aggregate after the treatment with glutathione, leading to the loss of motion and triggered drug release. These novel redox-responsive nanomotors can not only be used for remote transport but also for drug delivery, which is promising for future biomedical applications.

Automated tracking of dolphin whistles using Gaussian mixture probability hypothesis density filters.

This work considers automated multi target tracking of odontocete whistle contours. An adaptation of the Gaussian mixture probability hypothesis density (GM-PHD) filter is described and applied to the acoustic recordings from six odontocete species. From the raw data, spectral peaks are first identified and then the GM-PHD filter is used to simultaneously track the whistles' frequency contours. Overall over 9000 whistles are tracked with a precision of 85% and recall of 71.8%. The proposed filter is shown to track whistles precisely (with mean deviation of 104 Hz, about one frequency bin, from the annotated whistle path) and 80% coverage. The filter is computationally efficient, suitable for real-time implementation, and is widely applicable to different odontocete species.

Water-polysaccharide interactions in the primary cell wall of Arabidopsis thaliana from polarization transfer solid-state NMR.

Polysaccharide-rich plant cell walls are hydrated under functional conditions, but the molecular interactions between water and polysaccharides in the wall have not been investigated. In this work, we employ polarization transfer solid-state NMR techniques to study the hydration of primary-wall polysaccharides of the model plant, Arabidopsis thaliana. By transferring water (1)H polarization to polysaccharides through distance- and mobility-dependent (1)H-(1)H dipolar couplings and detecting it through polysaccharide (13)C signals, we obtain information about water proximity to cellulose, hemicellulose, and pectins as well as water mobility. Both intact and partially extracted cell wall samples are studied. Our results show that water-pectin polarization transfer is much faster than water-cellulose polarization transfer in all samples, but the extent of extraction has a profound impact on the water-polysaccharide spin diffusion. Removal of calcium ions and the consequent extraction of homogalacturonan (HG) significantly slowed down spin diffusion, while further extraction of matrix polysaccharides restored the spin diffusion rate. These trends are observed in cell walls with similar water content, thus they reflect inherent differences in the mobility and spatial distribution of water. Combined with quantitative analysis of the polysaccharide contents, our results indicate that calcium ions and HG gelation increase the amount of bound water, which facilitates spin diffusion, while calcium removal disrupts the gel and gives rise to highly dynamic water, which slows down spin diffusion. The recovery of spin diffusion rates after more extensive extraction is attributed to increased water-exposed surface areas of the polysaccharides. Water-pectin spin diffusion precedes water-cellulose spin diffusion, lending support to the single-network model of plant primary walls in which a substantial fraction of the cellulose surface is surrounded by pectins.

Automatic detection and classification of odontocete whistles.

Methods for the fully automatic detection and species classification of odontocete whistles are described. The detector applies a number of noise cancellation techniques to a spectrogram of sound data and then searches for connected regions of data which rise above a pre-determined threshold. When tested on a dataset of recordings which had been carefully annotated by a human operator, the detector was able to detect (recall) 79.6% of human identified sounds that had a signal-to-noise ratio above 10 dB, with 88% of the detections being valid. A significant problem with automatic detectors is that they tend to partially detect whistles or break whistles into several parts. A classifier has been developed specifically to work with fragmented whistle detections. By accumulating statistics over many whistle fragments, correct classification rates of over 94% have been achieved for four species. The success rate is, however, heavily dependent on the number of species included in the classifier mix, with the mean correct classification rate dropping to 58.5% when 12 species were included.

Nasointestinal tube placement: Techniques that increase success.

Background: Delayed gastric emptying (DGE) is a major cause of undernutrition that can be overcome using nasointestinal (NI) feeding, but tube placement often fails. We analyse which techniques enable successful NI tube placement. Methods: Efficacy of tube technique was determined at each of six anatomical points: Nose, nasopharynx-oesophagus, stomach-upper and -lower, duodenum part-1 and intestine. Results: In 913 first NI tube placements, significant associations with tube advancement were found in the pharynx (head tilt, jaw thrust, laryngoscopy), stomach_upper (air insufflation, 10 cm or 20-30 cm flexible tube tip ± reverse Seldinger manoeuvre), stomach_lower (air insufflation, possibly flexible tip and wire stiffener) and duodenum part-1 and beyond part-2 (flexible tip and combinations of micro-advance, slack removal, wire stiffener or prokinetic drugs). Conclusion: This is the first study to show what techniques are associated with tube advancement and the alimentary tract level they are specific to.

The internal structure of gadolinium and perfluorocarbon-loaded polymer nanoparticles affects 19F MRI relaxation times.

19F magnetic resonance imaging (19F MRI) is an emerging technique for quantitative imaging in novel therapies, such as cellular therapies and theranostic nanocarriers. Nanocarriers loaded with liquid perfluorocarbon (PFC) typically have a (single) core-shell structure with PFC in the core due to the poor miscibility of PFC with organic and inorganic solvents. Paramagnetic relaxation enhancement acts only at a distance of a few angstroms. Thus, efficient modulation of the 19F signal is possible only with fluorophilic PFC-soluble chelates. However, these chelates cannot interact with the surrounding environment and they might result in image artifacts. Conversely, chelates bound to the nanoparticle shell typically have a minimal effect on the 19F signal and a strong impact on the aqueous environment. We show that the confinement of PFC in biodegradable polymeric nanoparticles (NPs) with a multicore structure enables the modulation of longitudinal (T1) and transverse (T2) 19F relaxation, as well as proton (1H) signals, using non-fluorophilic paramagnetic chelates. We compared multicore NPs versus a conventional single core structure, where the PFC is encapsulated in the core(s) and the chelate in the surrounding polymeric matrix. This modulated relaxation also makes multicore NPs sensitive to various acidic pH environments, while preserving their stability. This effect was not observed with single core nanocapsules (NCs). Importantly, paramagnetic chelates affected both T1 and T219F relaxation in multicore NPs, but not in single core NCs. Both relaxation times of the 19F nucleus were enhanced with an increasing concentration of the paramagnetic chelate. Moreover, as the polymeric matrix remained water permeable, proton enhancement additionally was observed in MRI.

Airborne respiratory aerosol transport and deposition in a two-person office using a novel diffusion-based numerical model.

BACKGROUND: The COVID-19 pandemic was caused by the SARS-CoV-2 coronaviruses transmitted mainly through exposure to airborne respiratory droplets and aerosols carrying the virus. OBJECTIVE: To assess the transport and dispersion of respiratory aerosols containing the SARS-CoV-2 virus and other viruses in a small office space using a diffusion-based computational modeling approach. METHODS: A 3-D computational model was used to simulate the airflow inside the 70.2 m3 ventilated office. A novel diffusion model accounting for turbulence dispersion and gravitational sedimentation was utilized to predict droplet concentration transport and deposition. The numerical model was validated and used to investigate the influences of partition height and different ventilation rates on the concentration of respiratory aerosols of various sizes (1, 10, 20, and 50 µm) emitted by continuous speaking. RESULTS: An increase in the hourly air change rate (ACH) from 2.0 to 5.6 decreased the 1 µm droplet concentration inside the office by a factor of 2.8 and in the breathing zone of the receptor occupant by a factor of 3.2. The concentration at the receptor breathing zone is estimated by the area-weighted average of a 1 m diameter circular disk, with its centroid at the center of the receptor mannequin mouth. While all aerosols were dispersed by airflow turbulence, the gravitational sedimentation significantly influenced the transport of larger aerosols in the room. The 1 and 10 µm aerosols remained suspended in the air and dispersed throughout the room. In contrast, the larger 20 and 50 µm aerosols deposited on the floor quickly due to the gravitational sedimentation. Increasing the partition between cubicles by 0.254 m (10") has little effect on the smaller aerosols and overall exposure. IMPACT: This paper provides an efficient computational model for analyzing the concentration of different respiratory droplets and aerosols in an indoor environment. Thus, the approach could be used for assessing the influence of the spatial concentration variations on exposure for which the fully mixed model cannot be used.

Paramagnetic relaxation enhancement NMR as a tool to probe guest binding and exchange in metallohosts.

Paramagnetic metallohost systems can bind guest molecules and find application as biomimetic catalysts. Due to the presence of the paramagnetic metal center, rigorous characterization of these systems by NMR spectroscopy can be very difficult. We report here that metallohost-guest systems can be studied by using the paramagnetic relaxation enhancement (PRE) effect. Manganese(III) porphyrin cage compounds are shown through their PRE to thread and bind viologen guests, including a polymeric one. The binding constants and dethreading activation parameters are lower than those of the metal-free porphyrin cage compounds, which is proposed to be a result of charge repulsion of the trivalent metal center and dicationic viologen guest. The threading rate of the manganese(III) porphyrin cage onto the polymer is more than 10 times faster than that of the non-metallated one, which is ascribed to initial binding of the cage to the polymer chain prior to threading, and to an entron effect.

Poly(ethylene imine) nanocarriers do not induce mutations nor oxidative DNA damage in vitro in MutaMouse FE1 cells.

Genotoxicity information on polymers used for gene delivery is scant, but of great concern, especially when developing polymeric nanocarriers as nonviral vector systems for cancer treatment. The genotoxicity of some engineered nanomaterials, e.g., metal oxides like ZnO, TiO2, and CuO but also carbon based materials like carbon black or nanotubes, has commonly been related to oxidative stress, and subsequent inflammation. Recent studies of poly(ethylene imine) (PEI)-based polymers, important nonviral vector systems for pDNA and siRNA, might raise concerns because of their toxic effects dominated by cellular oxidative stress and inflammatory responses, similar to the mentioned effects of engineered nanoparticles. In this study, we employed a FE1-MutaMouse lung epithelial cell line based mutation assay to determine the genotoxicity of three PEI-based polymers and nanosized zinc oxide particles (NZO), all of which have previously been shown to trigger oxidative stress and inflammation. In addition, oxidative DNA damage (8-OH-dG) in FE1 cells was assessed by ELISA. The well-known carcinogen benzo[a]pyrene (B[a]P) was used as positive control. FE1 lung epithelial cells were exposed for eight sequential 72 h incubations, and reporter-gene mutation frequency or 8-OH-dG formation was determined to assess mutagenicity and oxidative DNA damage, respectively. No cytotoxic effects were detected at the exposure levels examined, which are representative of PEI concentrations normally used in in vitro transfection studies. In contrast to B[a]P, neither PEI-polymers nor NZO showed any significant mutagenic activity or oxidative DNA damage in the exposed cells, although PEI-based polymers have been shown to generate significant levels of cellular stress and inflammatory responses. We suggest that the lack of any detectable mutagenic/genotoxic activity of the PEI-based polymers studied here is a crucial step toward a safe use of such nanocarriers in clinical trials.

Fixed bearing, all-polyethylene tibia, lateral unicompartmental arthroplasty - A final outcome study with up to 28 year follow-up of a single implant.

BACKGROUND: Lateral unicompartmental arthroplasty (UKA) constitutes only 5-10% of all unicompartmental replacements performed. Whilst the short and medium term benefits are well documented, there remains concern regarding the higher revision rate when compared with total knee replacement. We report the long term clinical outcome and survivorship of a large series of lateral UKA. PATIENTS AND METHODS: Between 1974 and 1994, 71 patients (82 knees) underwent a lateral fixed-bearing St Georg Sled UKA. Prospective data was collected pre-operatively and at regular intervals post-operatively using the Bristol Knee Score (BKS), with later introduction of the Oxford Knee (OKS) and Western Ontario MacMaster (WOMAC) scores. Kaplan Meier survival analysis was used, with revision, or need for revision, as end point. 85% of the patients were female. No patients were lost to follow-up. RESULTS: Functional knee scores improved post-operatively up to 10 years, at which point they demonstrated a steady decline. Survivorship was 72% at 15 years, and 68% at 20 and 25 years. Nineteen knees were revised, with progression of disease in another compartment the commonest reason. There were two revisions due to implant fracture. In patients aged over 70 years at time of index procedure, 81% died with a functioning prosthesis in situ. CONCLUSION: This represents the longest follow-up of a large series of lateral UKA. Results of this early design of fixed bearing UKA demonstrate satisfactory long term survivorship. In elderly patients, further intervention is rarely required. More contemporary designs or techniques may show improved long term survivorship in time.

The role of membrane destabilisation and protein dynamics in BAM catalysed OMP folding.

The folding of ß-barrel outer membrane proteins (OMPs) in Gram-negative bacteria is catalysed by the ß-barrel assembly machinery (BAM). How lateral opening in the ß-barrel of the major subunit BamA assists in OMP folding, and the contribution of membrane disruption to BAM catalysis remain unresolved. Here, we use an anti-BamA monoclonal antibody fragment (Fab1) and two disulphide-crosslinked BAM variants (lid-locked (LL), and POTRA-5-locked (P5L)) to dissect these roles. Despite being lethal in vivo, we show that all complexes catalyse folding in vitro, albeit less efficiently than wild-type BAM. CryoEM reveals that while Fab1 and BAM-P5L trap an open-barrel state, BAM-LL contains a mixture of closed and contorted, partially-open structures. Finally, all three complexes globally destabilise the lipid bilayer, while BamA does not, revealing that the BAM lipoproteins are required for this function. Together the results provide insights into the role of BAM structure and lipid dynamics in OMP folding.

De novo design of transmembrane ß barrels.

Transmembrane ß-barrel proteins (TMBs) are of great interest for single-molecule analytical technologies because they can spontaneously fold and insert into membranes and form stable pores, but the range of pore properties that can be achieved by repurposing natural TMBs is limited. We leverage the power of de novo computational design coupled with a "hypothesis, design, and test" approach to determine TMB design principles, notably, the importance of negative design to slow ß-sheet assembly. We design new eight-stranded TMBs, with no homology to known TMBs, that insert and fold reversibly into synthetic lipid membranes and have nuclear magnetic resonance and x-ray crystal structures very similar to the computational models. These advances should enable the custom design of pores for a wide range of applications.

Continuous-Flow Production of Perfluorocarbon-Loaded Polymeric Nanoparticles: From the Bench to Clinic.

Perfluorocarbon-loaded nanoparticles are powerful theranostic agents, which are used in the therapy of cancer and stroke and as imaging agents for ultrasound and 19F magnetic resonance imaging (MRI). Scaling up the production of perfluorocarbon-loaded nanoparticles is essential for clinical translation. However, it represents a major challenge as perfluorocarbons are hydrophobic and lipophobic. We developed a method for continuous-flow production of perfluorocarbon-loaded poly(lactic-co-glycolic acid) (PLGA) nanoparticles using a modular microfluidic system, with sufficient yields for clinical use. We combined two slit interdigital micromixers with a sonication flow cell to achieve efficient mixing of three phases: liquid perfluorocarbon, PLGA in organic solvent, and aqueous surfactant solution. The production rate was at least 30 times higher than with the conventional formulation. The characteristics of nanoparticles can be adjusted by changing the flow rates and type of solvent, resulting in a high PFC loading of 20-60 wt % and radii below 200 nm. The nanoparticles are nontoxic, suitable for 19F MRI and ultrasound imaging, and can dissolve oxygen. In vivo 19F MRI with perfluoro-15-crown-5 ether-loaded nanoparticles showed similar biodistribution as nanoparticles made with the conventional method and a fast clearance from the organs. Overall, we developed a continuous, modular method for scaled-up production of perfluorocarbon-loaded nanoparticles that can be potentially adapted for the production of other multiphase systems. Thus, it will facilitate the clinical translation of theranostic agents in the future.

Anatomy and Functional Morphology of the Mysticete Rorqual Whale Larynx: Phonation Positions of the U-Fold.

Many Mysticetes (baleen whales) are acoustically active marine mammals. This is epitomized by rorquals, and specifically male humpback whales (Megaptera novaeangliae) whose complex songs comprise a wide range of vocalizations. The sound production mechanism of odontocetes (toothed whales, including dolphins and porpoises) is well described, in contrast to that of mysticetes whose vocalization mechanism remains a subject of active scientific investigation. Anatomical observations and acoustic signal processing have led to divergent hypotheses under the framework of a production-based approach. We attempt to unify these hypotheses by broadening existing data with our new anatomical investigation, interpreted in light of known acoustical properties of mysticete vocalizations. We examined 15 specimens of four rorqual species: sei whale (Baleanoptera borealis), fin whale (Baleanoptera physalus), minke whale (Baleanoptera acutorostrata), and humpback whale (Megaptera novaeangliae). Based on these data and on previous literature, we propose a description of three functional positions (rest, breathing, and recirculation), unidirectional egressive airflow for sound production (from lungs to laryngeal sac), and new nomenclature for different parts of the U-fold (distal section, midsection, and corniculate flaps). Each of these sections has specific morphological and acoustical properties that support the concept of "mode variation" in baleen whale vocalizations. Anat Rec, 2018. © 2018 Wiley Periodicals, Inc. Anat Rec, 302:703-717, 2019. © 2018 Wiley Periodicals, Inc.

Acupuncture analgesia: II. Clinical considerations.

BACKGROUND: Acupuncture and related percutaneous neuromodulation therapies can be used to treat patients with both acute and chronic pain. In this review, we critically examined peer-reviewed clinical studies evaluating the analgesic properties of acupuncture modalities. METHODS: Using Ovid and published medical databases, we examined prospective, randomized, sham-controlled clinical investigations involving the use of acupuncture and related forms of acustimulation for the management of pain. Case reports, case series, and cohort studies were not included in this analysis. RESULTS: Peer-reviewed literature suggests that acupuncture and other forms of acustimulation are effective in the short-term management of low back pain, neck pain, and osteoarthritis involving the knee. However, the literature also suggests that short-term treatment with acupuncture does not result in long-term benefits. Data regarding the efficacy of acupuncture for dental pain, colonoscopy pain, and intraoperative analgesia are inconclusive. Studies describing the use of acupuncture during labor suggest that it may be useful during the early stages, but not throughout the entire course of labor. Finally, the effects of acupuncture on postoperative pain are inconclusive and are dependent on the timing of the intervention and the patient's level of consciousness. CONCLUSIONS: Current data regarding the clinical efficacy of acupuncture and related techniques suggest that the benefits are short-lasting. There remains a need for well designed, sham-controlled clinical trials to evaluate the effect of these modalities on clinically relevant outcome measures such as resumption of daily normal activities when used in the management of acute and chronic pain syndromes.

Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine.

BACKGROUND: Sugammadex is a modified [gamma] cyclodextrin compound, which encapsulates rocuronium to provide for a rapid reversal of residual neuromuscular blockade. We tested the hypothesis that sugammadex would provide for a more rapid reversal of a moderately profound residual rocuronium-induced blockade than the commonly used cholinesterase inhibitors, edrophonium and neostigmine. METHODS: Sixty patients undergoing elective surgery procedures with a standardized desflurane-remifentanil-rocuronium anesthetic technique received either sugammadex, 4 mg/kg IV (n = 20), edrophonium, 1 mg/kg IV and atropine, 10 microg/kg IV (n = 20), or neostigmine, 70 microg/kg IV and glycopyrrolate, 14 microg/kg IV (n = 20) for reversal of neuromuscular blockade at 15 min or longer after the last dose of rocuronium using acceleromyography to record the train-of-four (TOF) responses. Mean arterial blood pressure and heart rate values were recorded immediately before and for 30 min after reversal drug administration. Side effects were noted at discharge from the postanesthesia care unit. RESULTS: The three groups were similar with respect to their demographic characteristics and total dosages of rocuronium prior to administering the study medication. Although the initial twitch heights (T1) at the time of reversal were similar in all three groups, the time to achieve TOF ratios of 0.7 and 0.9 were significantly shorter with sugammadex (71 +/- 25 and 107 +/- 61 s) than edrophonium (202 +/- 171 and 331 +/- 27 s) or neostigmine (625 +/- 341 and 1044 +/- 590 s). All patients in the sugammadex group achieved a TOF ratio of 0.9 < or =5 min after reversal administration compared with none and 5% in the edrophonium and neostigmine groups, respectively. Heart rate values at 2 and 5 min after reversal were significantly higher in the neostigmine-glycopyrrolate group compared with that in sugammadex. Finally, the incidence of dry mouth was significantly reduced in the sugammadex group (5% vs 85% and 95% in the neostigmine and edrophonium groups, respectively). CONCLUSION: Sugammadex, 4 mg/kg IV, more rapidly and effectively reversed residual neuromuscular blockade when compared with neostigmine (70 microg/kg IV) and edrophonium (1 mg/kg IV). Use of sugammadex was associated with less frequent dry mouth than that with the currently used reversal drug combinations.

Transdermal scopolamine: an alternative to ondansetron and droperidol for the prevention of postoperative and postdischarge emetic symptoms.

BACKGROUND: Given the controversy regarding the use of droperidol and the high cost of the 5-HT3 antagonists, a cost-effective alternative for routine use as a prophylactic antiemetic would be desirable. We designed two parallel, randomized, double-blind sham and placebo-controlled studies to compare the early and late antiemetic efficacy and adverse event profile of transdermal scopolamine (TDS) 1.5 mg, to ondansetron 4 mg IV, and droperidol 1.25 mg IV for antiemetic prophylaxis as part of a multimodal regimen in "at risk" surgical populations. METHODS: A total of 150 patients undergoing major laparoscopic (n = 80) or plastic (n = 70) surgery procedures received either an active TDS patch (containing scopolamine 1.5 mg) or a similar appearing sham patch 60 min before entering the operating room. All patients received a standardized general anesthetic technique. A second study medication was administered in a 2-mL numbered syringe containing either saline (for the two active TDS groups), droperidol, 1.25 mg, or ondansetron, 4 mg (for the sham patch groups), and was administered IV near the end of the procedure. The occurrence of postoperative nausea and vomiting/retching, need for rescue antiemetics, and the complete response rates (i.e., absence of protracted nausea or repeated episodes of emesis requiring antiemetic rescue medication) was reported. In addition, complaints of visual disturbances, dry mouth, drowsiness, and restlessness were noted up to 72 h after surgery. RESULTS: There were no significant differences in any of the emetic outcomes or need for rescue antiemetics among the TDS, droperidol, and ondansetron groups in the first 72 h after surgery. The complete response rates varied from 41% to 51%, and did not significantly differ among the treatment groups. The overall incidence of dry mouth was significantly more frequent in the TDS groups than in the droperidol and ondansetron groups (21% vs 3%). CONCLUSIONS: Premedication with TDS was as effective as droperidol (1.25 mg) or ondansetron (4 mg) in preventing nausea and vomiting in the early and late postoperative periods. However, the use of a TDS patch is more likely to produce a dry mouth.

Comparison of three video laryngoscopy devices to direct laryngoscopy for intubating obese patients: a randomized controlled trial.

STUDY OBJECTIVE: To compare three different video laryngoscope devices (VL) to standard direct laryngoscopy (DL) for tracheal intubation of obese patients undergoing bariatric surgery. HYPOTHESIS: VL (vs DL) would reduce the time required to achieve successful tracheal intubation and improve the glottic view. DESIGN: Prospective, randomized and controlled. SETTING: Preoperative/operating rooms and postanesthesia care unit. PATIENTS: One hundred twenty-one obese patients (ASA physical status I-III), aged 18 to 80 years, body mass index (BMI) >30 kg/m(2) undergoing elective bariatric surgery. INTERVENTION: Patients were prospectively randomized assigned to one of 4 different airway devices for tracheal intubation: standard Macintosh (Mac) blade (DL); Video-Mac VL; Glide Scope VL; or McGrath VL. MEASUREMENTS: After performing a preoperative airway evaluation, patients underwent a standardized induction sequence. The glottic view was graded using the Cormack Lehane and percentage of glottic opening (POGO) scoring systems at the time of tracheal intubation. Times from the blade entering the patient's mouth to obtaining a glottic view, placement of the tracheal tube, and confirmation of an end-tidal CO2 waveform were recorded. In addition, intubation attempts, adjuvant airway devices, hemodynamic changes, adverse events, and any airway-related trauma were recorded. MAIN RESULTS: All three VL devices provided improved glottic views compared to standard DL (p < 0.05). Video-Mac VL and McGrath also significantly reduced the time required to obtain the glottic view. Video-Mac VL significantly reduced the time required for successful placement of the tracheal tube (vs DL and the others VL device groups). The Video-Mac and GlideScope required fewer intubation attempts (P< .05) and less frequent use of ancillary intubating devices compared to DL and the McGrath VL. CONCLUSION: Video-Mac and GlideScope required fewer intubation attempts than standard DL and the McGrath device. The Video-Mac also significantly reduced the time needed to secure the airway and improved the glottic view compared to standard DL.