Experimental Analysis of the Efficiency and Usability of Tylke Versus Magill Forceps.

INTRODUCTION: The procedure of nasotracheal intubation (NI) has long been performed utilizing the Magill forceps as developed by Sir Ivan Magill in the 1920s. While used for nearly a century, several serious patient safety concerns remain including torn tube cuffs, vocal cord trauma, and inefficient tube placement. The Tylke forceps have been developed as a modification to the largely unchanged form of Magill forceps. METHODS: In the present investigation we compared the efficacy, number of clasps, and muscle activation involved in NI using the Tylke forceps versus the Magill forceps in previously untrained individuals. RESULTS: Tylke forceps showed faster successful NI over the standard Magill forceps at an average intubation time of 6.54s vs. 13.73s, respectively. Tylke forceps also had fewer clasps per intubation over the Magill. The trapezius, deltoid, and brachioradialis muscle activation was also compared in Tylke vs Magill forceps intubation trials. Tylke forceps required less lower muscle activation in the brachioradialis and trapezius over the Magill forceps with Tylke forceps resulting in higher deltoid muscle activation. CONCLUSION: Tylke forceps were more efficacious and reduced the number of clasps over the Magill forceps when used in successful NI with different muscle activation patterns.

Helping Patients Understand Their Dizziness: Assessment of a Three-Dimensional Printed Vestibular Model.

To assess the improvement in patient understanding with use of a three-dimensional printed vestibular model as a teaching tool and to evaluate the effects of educational approach on dizziness-related disabilities. Single center randomized controlled trial set in the Otolaryngology ambulatory care clinic located at a tertiary care, teaching institution in Shreveport, Louisiana. Patients with a current or suspected diagnosis of benign paroxysmal positional vertigo who met inclusion criteria were randomized to either the three-dimensional model group or the control group. Each group received the same education session about dizziness, with the three-dimensional model being used as a visual aid in the experimental group. The control group received only verbal education. Outcome measures included patient understanding of benign paroxysmal positional vertigo etiology, comfort level with symptom prevention, anxiety related to vertigo symptoms, and how likely the patient was to recommend the teaching session to another individual suffering from vertigo. Pre-session and post-session surveys were administered to all patients to assess outcome measures. Eight patients were enrolled in the experimental group, and eight patients were enrolled in the control group. On post-survey data, the experimental group reported increased understanding of symptom etiology (p = 0.0289), increased comfort level with preventing symptoms (p = 0.2999), a larger decrease in symptom related anxiety (p = 0.0453) and were more likely to recommend the education session (p = 0.2807) compared to the control group. Three-dimensional printed vestibular model demonstrates promise for patient education and reducing related anxiety. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03325-5.

Safety, Efficacy, and Ease of Insertion of Gnana Laryngeal Airway (GLA-4): A Prospective Clinical Study Utilizing the Unique Laryngeal Mask Airway With a Suction Tubing.

INTRODUCTION: Utilizing laryngeal mask airways to maintain patients' airways is advantageous because it enables the anesthesiologist to keep the patient spontaneously inhaling and is less traumatic to the airway than intubation. Newer designs such as the Gnana laryngeal mask airway design permit real-time suctioning while the mask is on a patient. METHODS: This is a prospective observational study of the efficacy of Gnana laryngeal airway 4 (GLA-4) in 50 patients undergoing colonoscopy. Induction and maintenance of anesthesia were provided with propofol; GLA-4 was applied to secure the airway; and correct placement was verified. RESULTS: Fifty patients were included in the study (44% female, 56% male, mean age: 56.5 years, mean BMI: 33.3). Twelve patients were assigned American Society of Anesthesiologists (ASA) class 2, and 38 were assigned ASA class 3. The first attempt of GLA-4 insertion was successful in 47 patients, and two attempts were required for the successful placement of the GLA-4 in two patients. The successful placement was not achieved in one patient. The average time to successful insertion was 27.1 ± 3.9s. The average volume of oropharyngeal secretions suctioned through the suction catheter was 9.96 ± 2.31 mL. No intraoperative or postoperative complications occurred in the 50 patients. There were no reports of sore throat, hoarseness, dysphagia, or cough immediately postop. CONCLUSION: GLA-4 can be inserted safely with adequate periglottic occlusion. This laryngeal mask is unique and desirable due to its ability to evacuate oropharyngeal secretions while in place to prevent laryngospasm. To establish the role of GLA-4 in broader clinical situations, additional clinical trials and studies are required.

Untangling social-ecological interactions: A methods portfolio approach to tackling contemporary sustainability challenges in fisheries.

Meeting the objectives of sustainable fisheries management requires attention to the complex interactions between humans, institutions and ecosystems that give rise to fishery outcomes. Traditional approaches to studying fisheries often do not fully capture, nor focus on these complex interactions between people and ecosystems. Despite advances in the scope and scale of interactions encompassed by more holistic methods, for example ecosystem-based fisheries management approaches, no single method can adequately capture the complexity of human-nature interactions. Approaches that combine quantitative and qualitative analytical approaches are necessary to generate a deeper understanding of these interactions and illuminate pathways to address fisheries sustainability challenges. However, combining methods is inherently challenging and requires understanding multiple methods from different, often disciplinarily distinct origins, demanding reflexivity of the researchers involved. Social-ecological systems' research has a history of utilising combinations of methods across the social and ecological realms to account for spatial and temporal dynamics, uncertainty and feedbacks that are key components of fisheries. We describe several categories of analytical methods (statistical modelling, network analysis, dynamic modelling, qualitative analysis and controlled behavioural experiments) and highlight their applications in fisheries research, strengths and limitations, data needs and overall objectives. We then discuss important considerations of a methods portfolio development process, including reflexivity, epistemological and ontological concerns and illustrate these considerations via three case studies. We show that, by expanding their methods portfolios, researchers will be better equipped to study the complex interactions shaping fisheries and contribute to solutions for sustainable fisheries management.

Fish, People, and Systems of Power: Understanding and Disrupting Feedback between Colonialism and Fisheries Science.

AbstractThis essay explores shifting scientific understandings of fish and the evolution of fisheries science, and it grapples with colonialism as a system of power. We trace the rise of fisheries science to a time when Western nation-states were industrializing fishing fleets and competing for access to distant fishing grounds. A theory of fishing called "maximum sustainable yield" (MSY) that understands fish species in aggregate was espoused. Although alternatives to MSY have been developed, decision-making continues to be informed by statistical models developed within fisheries science. A challenge for structured management systems now rests in attending to different systems of knowledge and addressing local objectives, values, and circumstances. To deepen and illustrate key points, we examine Pacific herring (Clupea pallasii) and the expansion of commercial herring fisheries and state-led management in British Columbia, Canada. A feedback between colonialism and fisheries science is evident: colonialism generated the initial conditions for expansion and has been reinforced through the implementation of approaches and tools from fisheries science that define and quantify conservation in particular ways. Some features may be unique to the herring illustration, but important aspects of the feedback are more broadly generalizable. We propose three interconnected goals: (a) transform the siloed institutions and practices of Western science, (b) reimagine and rebuild pathways between information (including diverse values and perspectives) and decision-making, and (c) devolve governance authority and broaden governance processes such that multiple ways of knowing share equal footing.

Conceptualizing ecosystem services using social-ecological networks.

Social-ecological networks (SENs) represent the complex relationships between ecological and social systems and are a useful tool for analyzing and managing ecosystem services. However, mainstreaming the application of SENs in ecosystem service research has been hindered by a lack of clarity about how to match research questions to ecosystem service conceptualizations in SEN (i.e., as nodes, links, attributes, or emergent properties). Building from different disciplines, we propose a typology to represent ecosystem service in SENs and identify opportunities and challenges of using SENs in ecosystem service research. Our typology provides guidance for this growing field to improve research design and increase the breadth of questions that can be addressed with SEN to understand human-nature interdependencies in a changing world.

Beamline K11 DIAD: a new instrument for dual imaging and diffraction at Diamond Light Source.

The Dual Imaging and Diffraction (DIAD) beamline at Diamond Light Source is a new dual-beam instrument for full-field imaging/tomography and powder diffraction. This instrument provides the user community with the capability to dynamically image 2D and 3D complex structures and perform phase identification and/or strain mapping using micro-diffraction. The aim is to enable in situ and in operando experiments that require spatially correlated results from both techniques, by providing measurements from the same specimen location quasi-simultaneously. Using an unusual optical layout, DIAD has two independent beams originating from one source that operate in the medium energy range (7-38 keV) and are combined at one sample position. Here, either radiography or tomography can be performed using monochromatic or pink beam, with a 1.4 mm × 1.2 mm field of view and a feature resolution of 1.2 µm. Micro-diffraction is possible with a variable beam size between 13 µm × 4 µm and 50 µm × 50 µm. One key functionality of the beamline is image-guided diffraction, a setup in which the micro-diffraction beam can be scanned over the complete area of the imaging field-of-view. This moving beam setup enables the collection of location-specific information about the phase composition and/or strains at any given position within the image/tomography field of view. The dual beam design allows fast switching between imaging and diffraction mode without the need of complicated and time-consuming mode switches. Real-time selection of areas of interest for diffraction measurements as well as the simultaneous collection of both imaging and diffraction data of (irreversible) in situ and in operando experiments are possible.

Cardiogenic Shock and Mitral Valve Chord Rupture: A Rare Presentation of Libman-Sacks Endocarditis.

Distinguishing Libman-Sacks endocarditis from other valvular heart disease etiologies has important implications for management. We present a case of a 23-year-old man who presented in extremis with fever and cardiogenic shock caused by Libman-Sacks endocarditis with associated mitral valve chord rupture. (Level of Difficulty: Beginner.).

Two infants with bilateral renal agenesis who were bridged by chronic peritoneal dialysis to kidney transplantation.

Bilateral renal agenesis is associated with severe oligohydramnios and was considered incompatible with postnatal life due to severe pulmonary hypoplasia. The use of renal replacement therapy was limited by significant morbidity and mortality associated with dialysis in very young infants with major pulmonary pathology. In the United States, there is a tremendous controversy about whether or not the use of prenatal amniotic fluid infusions provides a benefit to fetuses with bilateral renal agenesis. One of the critical issues identified is that there are, as yet, no children reported who had achieved long-term survival. Previous reports all indicated these children died shortly after birth or after unsuccessful peritoneal dialysis. We present two infants with a prenatal diagnosis of bilateral renal agenesis whose mothers elected to undergo prenatal amnioinfusions. One was born at 28 weeks with a birthweight of 1230 g and the other born at 34 weeks with a birthweight of 1940 g. We present the details of both cases, with initial management on chronic peritoneal dialysis, which started shortly after birth, as a bridge to living related kidney transplants.

Efficacy and safety of standard and anti-reflux self-expanding metal stent: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Self-expanding metal stents are the main palliative treatment modality for unresectable esophageal cancer. Gastroesophageal reflux is a common adverse outcome after placement of esophageal stent for cancer involving the gastroesophageal junction and the gastric cardia. Anti-reflux stents with valve have been designed to prevent the acid reflux. The superiority of anti-reflux stent over standard stent in preventing gastroesophageal reflux has not been established well. This study compares the anti-reflux stent and the standard stent in terms of their efficacy to prevent acid reflux. AIM: To compare the standard and the anti-reflux stents in terms of their efficacy, safety, and complications. METHODS: The meta-analysis included 8 randomized clinical trials (RCTs) to compare pooled outcomes of total 395 patients. Primary outcomes include improvement in reflux symptoms and dysphagia score. Secondary outcomes include complications of stent migration, occlusion, and bleeding. RESULTS: A total of eight RCTs were included in the meta-analysis. Compared to the standard stent, the anti-reflux stent showed a trend towards reduction in the dysphagia score without reaching a statistical significance [Standardized mean difference (SMD): -0.33 (-0.71, 0.05); P = 0.09, I 2: 37%]. There was no statistical difference in the gastrointestinal reflux (GER) scores between the two types of stents [SMD: -0.17 (-0.78, 0.45); P = 0.008, I 2: 74%]. Compared to standard stent, anti-reflux stent showed no difference in the risk of stent migration [OR: 1.37 (0.66, 2.83); P = 0.40, I 2: 0 %], bleeding [OR: 1.43 (0.40, 5.13); P = 0.59, I 2: 0 %], and obstruction [OR: 1.66 (0.60, 4.60); P = 0.33, I 2: 0 %]. CONCLUSION: Traditional self-expanding standard esophageal stent and anti-reflux stent with valve are similar in terms of outcomes and complications.

Cross-discipline evidence principles for sustainability policy.

Evidence-based approaches to sustainability challenges must draw on knowledge from the environment, development and health communities. To be practicable, this requires an approach to evidence that is broader and less hierarchical than the standards often applied within disciplines.

Study on the comparative activity of echinocandins on murine gut colonization by Candida albicans.

Colonization of the gastrointestinal (GI) tract by Candida species is a principal pathogenetic event for development of invasive candidiasis. Importantly, the effect of echinocandins, the preferred antifungal agents for treatment of invasive candidiasis, on GI tract colonization by Candida spp. is currently unknown. Herein, we used an established model of persistent murine GI tract colonization by Candida albicans to test the ability of different echinocandins to eradicate the yeast from murine gut. Adult male Crl:CD1 (ICR) BR mice were fed with chow containing C. albicans and subsequently treated with different echinocandins or normal saline via daily intraperitoneal injections for 10 days. Quantitative stool cultures were performed immediately before (week one), and weekly for three months after discontinuation of treatment. Notably, treatment with all three echinocandins used (caspofungin, anidulafungin, and micafungin) resulted in eradication of Candida albicans from the stools, as evidenced by the significant reduction of yeast cells from a mean of 4.2 log10 CFU/g of stool before treatment (week one of colonization) to undetectable (<2 log10 CFU/g of stool) levels (week 12, P < 0.0001). In contrast, there was no significant reduction of Candida yeast cells in the stools of control mice. Collectively, the ability of echinocandins to eradicate C. albicans from the stools could have important implications in prophylaxis of high-risk patients for development of invasive candidiasis originating from the GI tract.

CRIT-LINE: a noninvasive tool to monitor hemoglobin levels in pediatric hemodialysis patients.

BACKGROUND: The national average for achieving the KDOQI-recommended hemoglobin (Hgb) target level of 11-12 g/dL is low with the current anemia management protocol of measuring Hgb levels every 2-4 weeks to guide intervention. The objective of this study was to correlate initial Hgb readings from the CRIT-LINE monitor with actual serum Hgb levels in pediatric patients on hemodialysis (HD). METHODS: Data were collected from pediatric HD patients who had Hgb tests ordered for routine and/or clinical reasons. Hgb concentrations were read with the CRIT-LINE after 0.5 or 1 L of blood had been processed by HD in patients with a body weight of ≤20 or >20 kg, respectively. Ultrafiltration was kept at a minimum until the CRIT-LINE Hgb was read. RESULTS: In total, 217 Hgb readings from 23 HD patients were analyzed. Results showed a statistically significant correlation between CRIT-LINE readings and laboratory Hgb measurements (r = 0.94, p < 0.0001) using Pearson correlation coefficients for well-distributed data. The mean Hgb levels measured by CRIT-LINE and the laboratory were 11.12 ± 1.63 and 11.31 ± 1.69 g/dL, respectively. CONCLUSIONS: The CRIT-LINE monitor is an accurate instrument for monitoring Hgb levels in HD patients. Further studies will be needed to evaluate whether using CRIT-LINE Hgb levels to guide anemia management will improve the percentage of children with Hgb levels within target.

Research participant-centered outcomes at NIH-supported clinical research centers.

BACKGROUND: Although research participation is essential for clinical investigation, few quantitative outcome measures exist to assess participants' experiences. To address this, we developed and deployed a survey at 15 NIH-supported clinical research centers to assess participant-centered outcomes; we report responses from 4,961 participants. METHODS: Survey questions addressed core aspects of the research participants' experience, including their overall rating, motivation, trust, and informed consent. We describe participant characteristics, responses to individual questions, and correlations among responses. RESULTS: Respondents broadly represented the research population in sex, race, and ethnicity. Seventy-three percent awarded top ratings to their overall research experience and 94% reported no pressure to enroll. Top ratings correlated with feeling treated with respect, listened to, and having access to the research team (R(2) = 0.80-0.96). White participants trusted researchers more (88%) than did nonwhite participants collectively (80%; p < 0.0001). Many participants felt fully prepared by the informed consent process (67%) and wanted to receive research results (72%). CONCLUSIONS: Our survey demonstrates that a majority of participants at NIH-supported clinical research centers rate their research experience very positively and that participant-centered outcome measures identify actionable items for improvement of participant's experiences, research protections, and the conduct of clinical investigation.

The prospective pediatric continuous renal replacement therapy (ppCRRT) registry: a critical appraisal.

Continuous renal replacement therapy (CRRT), which provides gradual, predictable clearance and fluid removal, is commonly used to manage acute kidney injury (AKI) and fluid overload in critically ill children. The Prospective Pediatric CRRT (ppCRRT) Registry, founded in 2001 and comprising 13 pediatric centers in the United States, represents the largest cohort of children receiving CRRT to date. Data from the ppCRRT has been used to describe pediatric CRRT demographics and epidemiology, improve technical aspects of CRRT provision for children, and identify novel or underappreciated risk factors affecting survival. Whereas the registry has successfully answered many questions, a number of questions remain unanswered and new ones have arisen. This article describes the ppCRRT Registry, including its major findings, the lessons learned, and the limitations inherent in its design. Additionally, using the registry as a framework, areas of future study are identified and potential methodologies examined.

Association between maintenance fluid tonicity and hospital-acquired hyponatremia.

OBJECTIVE: To evaluate whether the administration of hypotonic fluids compared with isotonic fluids is associated with a greater risk for hyponatremia in hospitalized children. STUDY DESIGN: Informatics-enabled cohort study of all hospitalizations at Lucile Packard Children's Hospital between April 2009 and March 2011. Extraction and analysis of electronic medical record data identified normonatremic hospitalized children who received either hypotonic or isotonic intravenous maintenance fluids upon admission. The primary exposure was the administration of hypotonic maintenance fluids, and the primary outcome was the development of hyponatremia (serum sodium <135 mEq/L). RESULTS: A total of 1048 normonatremic children received either hypotonic (n = 674) or isotonic (n = 374) maintenance fluids upon admission. Hyponatremia developed in 260 (38.6%) children who received hypotonic fluids and 104 (27.8%) of those who received isotonic fluids (unadjusted OR 1.63; 95% CI 1.24-2.15, P < .001). After we controlled for intergroup differences and potential confounders, patients receiving hypotonic fluids remained more likely to develop hyponatremia (aOR 1.37, 95% CI 1.03-1.84). Multivariable analysis identified additional factors associated with the development of hyponatremia, including surgical admission (aOR 1.44, 95% CI 1.09-1.91), cardiac admitting diagnosis (aOR 2.08, 95% CI 1.34-3.20), and hematology/oncology admitting diagnosis (aOR 2.37, 95% CI 1.74-3.25). CONCLUSIONS: Hyponatremia was common regardless of maintenance fluid tonicity; however, the administration of hypotonic maintenance fluids compared with isotonic fluids was associated with a greater risk of developing hospital-acquired hyponatremia. Additional clinical characteristics modified the hyponatremic effect of hypotonic fluid, and it is possible that optimal maintenance fluid therapy now requires a more individualized approach.

AKI in hospitalized children: epidemiology and clinical associations in a national cohort.

BACKGROUND AND OBJECTIVES: Although AKI is common among hospitalized children, comprehensive epidemiologic data are lacking. This study characterizes pediatric AKI across the United States and identifies AKI risk factors using high-content/high-throughput analytic techniques. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: For the cross-sectional analysis of the 2009 Kids Inpatient Database, AKI events were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Demographics, incident rates, and outcome data were analyzed and reported for the entire AKI cohort as well as AKI subsets. Statistical learning methods were applied to the highly imbalanced dataset to derive AKI-related risk factors. RESULTS: Of 2,644,263 children, 10,322 children developed AKI (3.9/1000 admissions). Although 19% of the AKI cohort was ≤ 1 month old, the highest incidence was seen in children 15-18 years old (6.6/1000 admissions); 49% of the AKI cohort was white, but AKI incidence was higher among African Americans (4.5 versus 3.8/1000 admissions). In-hospital mortality among patients with AKI was 15.3% but higher among children ≤ 1 month old (31.3% versus 10.1%, P<0.001) and children requiring critical care (32.8% versus 9.4%, P<0.001) or dialysis (27.1% versus 14.2%, P<0.001). Shock (odds ratio, 2.15; 95% confidence interval, 1.95 to 2.36), septicemia (odds ratio, 1.37; 95% confidence interval, 1.32 to 1.43), intubation/mechanical ventilation (odds ratio, 1.2; 95% confidence interval, 1.16 to 1.25), circulatory disease (odds ratio, 1.47; 95% confidence interval, 1.32 to 1.65), cardiac congenital anomalies (odds ratio, 1.2; 95% confidence interval, 1.13 to 1.23), and extracorporeal support (odds ratio, 2.58; 95% confidence interval, 2.04 to 3.26) were associated with AKI. CONCLUSIONS: AKI occurs in 3.9/1000 at-risk US pediatric hospitalizations. Mortality is highest among neonates and children requiring critical care or dialysis. Identified risk factors suggest that AKI occurs in association with systemic/multiorgan disease more commonly than primary renal disease.

A case study on development of an integrated, multidisciplinary dental curriculum.

Calls for fundamental reform of dental education were made twice in the twentieth century. More recently, spurred by the work of the American Dental Education Association's Commission on Change and Innovation in Dental Education (ADEA CCI), North American dental educators have again begun advocating for major curriculum reform in order to develop in students the higher order thinking skills required for the contemporary practice of dentistry. This case study describes the process of curricular reform at one school designed to move from a traditional siloed curriculum to one that uses case-based, integrated multidisciplinary courses to improve teaching and learning. The process was broad-based and comprehensive and included a schoolwide values clarification exercise and agreement on desired characteristics of an ideal graduate. Stakeholders agreed that the reform curriculum should incorporate inter- and multidisciplinary courses, case-based and active learning strategies, and concepts from adult learning theory. The new curriculum model is comprised of five unique but related curriculum "strands," each managed by a small group of interdisciplinary faculty content experts. Challenges in the development and implementation of the reform curriculum are discussed, and an assessment plan is presented.