From not knowing to doing: An interprofessional approach to clinician training in use of Goal Attainment Scaling (GAS) as a recovery-oriented outcome measure in a rural mental health service.

Outcome measurement and feedback are key to quality improvement in healthcare. Goal attainment scaling (GAS) is a tool that could be used to measure outcomes of mental health services delivering recovery-oriented care. The objective of this prospective study was to evaluate the effectiveness of tailored, interprofessional, multilevel and adaptable GAS training on clinician views, learning, competence, performance and confidence in the use of GAS. Thematic analysis of eight clinician participant views was done using the method proposed by Braun and Clarke (Thematic analysis: a practical guide to understanding and doing, 2022). Four main themes were generated: clinicians found that this type of training is useful, GAS influenced the way they thought about their roles in goal setting and recovery-oriented care and COVID-19 pandemic impacts. Furthermore, clinicians' skills to set scalable GAS goals with consumers and clinician confidence in using GAS improved. The results of this study show a positive impact of tailored, interprofessional, multilevel and adaptable training supporting development of clinician skills in the GAS process. The training design had a favourable effect on clinician views, learning, competence, performance and confidence of GAS as a recovery-oriented outcome measure. The approach to GAS training and use of GAS as a recovery-oriented outcome measure should be considered in response to mental health service reform.

Predicting current and future climate suitability for arecanut (Areca catechu L.) in India using ensemble model.

Climate change has the potential to influence plant development, physiology, and distribution. Arecanut (Areca catechu L.), with its long life span of 60-70 years, thrives in a tropical habitat remains exposed to various abiotic and biotic factors. It is pertinent to comprehend the adaptation strategies of this crop towards climate change over time. The Biomod2 ensemble platform for species distribution modeling was utilized to predict the potential impact of climate change on the adaptability of the crop. The extracted study region of India was used for prediction, and the final run of 6 models ensemble includes 894 occurrence points and 9 climate variables with 80%-20% of training and validation sets. The model's outputs had area under curve (AUC) values of 0.943 and true skills statistics (TSS) of 0.741, which are regarded as accurate. The research area was categorized into five groups: very high, high, moderate, low, and very low. The examination involved assessing the shift in each category from the present to two prospective scenarios (shared socio-economic pathways; SSP 2-4.5 and SSP 5-8.5) projected for the 2050s and 2070s. A shift in the climate suitability area from 'very high' and 'high' categories to 'moderate' or 'very low' categories was observed suggesting the need for adaptive strategies to sustain the current yield levels. Amongst the regions, Karnataka state, which at present has more than 50% area under cultivation, is highly vulnerable and more area is coming under 'very low' and 'low' categories from eastern side. Meanwhile, in north eastern part of the country a shift in high suitable region from northwest to southwest is observed. Overall, the model prediction suggests that some parts of west and south interior regions of the country warrant immediate consideration in order to adapt to future climate change, whereas some part of north east can be considered for future cultivation.

What accounts for turnover intention in the Australian public mental health workforce?

High staff turnover is common within the Australian public mental health workforce, contributing to workforce shortages and ultimately impacting the ability to provide stable efficient, effective, and ongoing optimal care to the community. In this study, we aimed to (a) establish the most pertinent factors associated with increased turnover intention in the public mental health workforce in Australia, and (b) establish whether such factors differ between metropolitan and rural services. We used a cross-sectional, correlational design using an online survey method. In total, 235 mental health service staff of various disciplines and levels, from four public hospitals in Victoria, Australia participated in the study. We used three feed-forward multiple regression analyses to assess the study aims. We found that job satisfaction, occupational burnout, and understaffing may be the most pertinent factors to consider regarding turnover intention. Job satisfaction and occupational burnout were factors endorsed across the entire sample, as well as specifically within both the metropolitan and rural services, while understaffing was a pertinent factor regarding turnover intention across the entire sample and for rural services, but not metropolitan services. Our findings regarding the pertinence of job satisfaction, occupational burnout, and understaffing in turnover intention provide key information that may be used to inform interventional targets aimed at reducing attrition from the public mental health workforce in Australia.

Investigating Attraction and Retention of Staff Within Public Mental Health Services in Victoria, Australia: Protocol for a Mixed Methods Study.

BACKGROUND: A large proportion of Australians are affected by mental illness each year, and treatment gaps are well known. To meet current and future demands and enable access to treatment that is safe, effective, and acceptable, a robust and sustainable mental health workforce is required. Factors reported to attract people to work within the mental health sector include aspiring to help others, having an interest in mental health and human behavior, the desire to make a difference and do something worthwhile, personal lived experience, recognition, and value of discipline-specific roles. However, despite the various reasons people enter the public mental health workforce, recruitment and retention continue to be ongoing challenges. To date, there has been limited investigation into understanding which factors are most relevant to the current Victorian workforce. Furthermore, a comparison to health care workers outside of mental health is also needed to better understand the specific needs of staff within the mental health sector. OBJECTIVE: This study aims to explore factors related to attraction, recruitment, and retention of the public mental health workforce in Victoria, Australia. METHODS: The study is a multisite, mixed methods cross-sectional study to be conducted at 4 public hospital services within Victoria, Australia: 2 in metropolitan and 2 in regional or rural locations. Current, previous, and nonmental health workers will be asked to complete a 20-25-minute web-based survey, which is developed based on previous research and offered participation in an optional 30-60-minute semistructured interview to examine personal experiences and perceptions. Both aspects of the project will examine factors related to attraction, recruitment, and retention in the public mental health workforce. Differences between groups (ie, current, past, and nonmental health workers), as well as location, discipline, and health setting will be examined. Regression analyses will be performed to determine the factors most strongly associated with retention (ie, job satisfaction) and turnover intention. Qualitative data will be transcribed verbatim and thematically analyzed to identify common themes. RESULTS: As of May 2023, we enrolled 539 participants in the web-based survey and 27 participants in the qualitative interview. CONCLUSIONS: This project seeks to build on current knowledge from within Australia and internationally to understand role and service/system-related issues of attraction, recruitment, and retention specifically within Victoria, Australia. Seeking up-to-date information from across the health workforce may provide factors specific to mental health by illuminating any differences between mental health workers and health care workers outside of mental health. Furthermore, exploring motivators across health care disciplines and locations to enter, stay in, or leave a role in public mental health settings will provide valuable information to support how the sector plans and develops strategies that are fit for purpose. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48855.

Prevalence and factors associated with mental health problems of psychological distress and depression among rural Victorians - analysis of cross-sectional data (Crossroads II).

BACKGROUND: Research suggests that rates of mental illness are similar in rural and urban Australia, although there are significant workforce shortages in rural regions along with higher rates of chronic disease and obesity and lower levels of socioeconomic status. However, there are variations across rural Australia and limited local data on mental health prevalence, risk, service use and protective factors. This study describes the prevalence of self-reported mental health problems of psychological distress and depression, in a rural region in Australia and aims to identify the factors associated with these problems. METHODS: The Crossroads II study was a large-scale cross-sectional study undertaken in the Goulburn Valley region of Victoria, Australia in 2016-18. Data were collected from randomly selected households across four rural and regional towns and then screening clinics from individuals from these households. The main outcome measures were self-reported mental health problems of psychological distress assessed by the Kessler 10 and depression assessed by Patient Health Questionnaire-9. Unadjusted odd ratios and 95% confidence intervals of factors associated with the two mental health problems were calculated using simple logistic regression with multiple logistic regression using hierarchical modelling to adjust for the potential confounders. RESULTS: Of the 741 adult participants (55.6% females), 67.4% were aged ≥ 55 years. Based on the questionnaires, 16.2% and 13.6% had threshold-level psychological distress and depression, respectively. Of those with threshold-level K-10 scores, 19.0% and 10.5% had seen a psychologist or a psychiatrist respectively while 24.2% and 9.5% of those experiencing depression had seen a psychologist or a psychiatrist, respectively in the past year. Factors such as being unmarried, current smoker, obesity, were significantly associated with a higher prevalence of mental health problems whereas physical activity, and community participation reduced the risk of mental health problems. Compared to rural towns, the regional town had higher risk of depression which was non-significant after adjusting for community participation and health conditions. CONCLUSIONS: The high prevalence of psychological distress and depression in this rural population was consistent with other rural studies. Personal and lifestyle factors were more relevant to mental health problems than degree of rurality in Victoria. Targeted lifestyle interventions could assist in reducing mental illness risk and preventing further distress.

The impact of COVID-19 on the mental health workforce: A rapid review.

The COVID-19 pandemic led to significant adaptations to healthcare. Provision of mental healthcare in a changing environment presented healthcare workers with unique challenges and demands, including changes in workload and expectations. To inform current and future healthcare service responses, and adaptations, the current review aimed to collate and examine the impact of the pandemic on mental healthcare workers (MHWs). We conducted a rapid systematic review to examine the overall impact of the COVID-19 pandemic on MHWs. Searches were conducted in Ovid Medline and PsycInfo and restricted to articles published from 2020. Inclusion criteria specified articles written in English, published in peer-reviewed journals, and that examined any outcome of the impact of COVID-19 on MHWs; 55 articles fulfilled these criteria. Outcomes were categorized into 'work-related outcomes' and 'personal outcomes'. Mental healthcare workers worldwide experienced a range of work-related and personal adversities during the pandemic. Key work-related outcomes included increased workload, changed roles, burnout, decreased job satisfaction, telehealth challenges, difficulties with work-life balance, altered job performance, vicarious trauma and increased workplace violence. Personal outcomes included decreased well-being, increased psychological distress and psychosocial difficulties. These outcomes differed between inpatient, outpatient and remote settings. The COVID-19 pandemic significantly altered the delivery of mental healthcare and MHWs experienced both work-related and personal adversities during the COVID-19 pandemic. With the continuation of changes introduced to healthcare in the initial stages of the pandemic, it will be important to maintain efforts to monitor negative outcomes and ensure supports for MHWs, going forward.

Levosulpiride and Ramosetron for the Prevention of Postoperative Nausea and Vomiting in Laparoscopic Surgery: A Prospective Randomized Double-blind Study.

Background: Postoperative nausea and vomiting (PONV) continues to be common complication of anesthesia and surgery in spite of availability of so many antiemetic drugs and regimens for prevention. This study compared Ramosetron and Levosulpiride in terms of efficacy for PONV prevention after laparoscopic surgery. Aim: To compare the efficacy of intravenous (i.v.) Levosulpiride 25 mg with i.v. Ramosetron 0.3 mg in preventing PONV. Setting: S. D. M. College of Medical Sciences and Hospital, Sattur, Dharwad from November 2018 to June 2020. Design: It is a prospective randomized double-blind study. Statistical Analysis: All the data were collected, tabulated, and expressed as mean ± standard deviation. Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS 22.0 Evaluation version). Unpaired sample t-test and Chi-square test have been used for the quantitative and qualitative data, respectively. A P value of 0.05 was considered statistically insignificant. Materials and Methods: This prospective randomized, double-blind study was conducted in 200 patients undergoing laparoscopic surgery falling under the inclusion criteria are numbered and every nth patient selected by systemic random sampling procedure and allocated into two groups of 100 each, group Levosulpiride (Group L) and group Ramosetron (group R) study drugs givenwithin 30 min induction of anesthesia. Group L will receive LEVOSULPIRIDE 25 mg i.v. Group R will receive RAMOSETRON 0.3 mg i.v. Results: The incidence of vomiting in the Levosulpiride group and in the Ramosetron groupduring 0-4 h (20% vs. 30%, P = 0.1110), 4-8 h (4% vs. 5%, P = 0.7450), 8-12 h (5% vs. 4% P = 0.7210) and 12-24 h (0% vs. 0%). The incidence of nausea and overall PONV and the use of rescue antiemetic was not significantly different during all time intervals. The severity of nausea was not different between the two groups. Difference in the efficacy of Levosulpiride and Ramosetron was statistically insignificant (P > 0.05) in the prevention of PONV. Conclusion: Levosulpiride 25 mg or Ramosetron 0.3 mg given intravenously to prevent PONV inpatients undergoing elective laparoscopic surgery under general anesthesia are equally effective in controlling PONV.

Data of 16S rRNA gene amplicon-based metagenomic signatures of arecanut rhizosphere soils in Yellow Leaf Disease (YLD) endemic region of India.

Arecanut (Areca catechu L.) is an important plantation crop cultivated predominantly in the Indian states of Karnataka, Kerala, Assam, West Bengal, and Maharashtra in an area of 5.19 lakh ha, with Karnataka State alone accounting for about 68.41% of the area and 79.97% of production. Arecanut production has recently been hampered due to environmental and disease pressures, especially the escalating incidence of Yellow Leaf Disease (YLD). The involvement of phytoplasma as the etiological agent of YLD has been reported. Symptoms include yellowing at the tip of leaflets of two or three fronds of the outer most whorl which gradually spreads to the inner whorl of leaves. As the disease progresses, the entire crown becomes yellow leaving only the spear leaf green. In severe cases, the affected leaves often show necrosis from their tips. In advanced stages, the leaves are reduced in size and become stiff and pointed and the crown ultimately falls off. Degeneration of cortex is commonly observed in the diseased roots. The kernel of affected nuts shows discolouration and later turns blackish. The reduction in yield over a period of three years, immediately after the incidence of the disease, has been estimated to be around 50%. Harnessing the arecanut-microbiome interactions to address the biotic and abiotic stresses of the host plant offers immense opportunity to increase arecanut production sustainably. Here, we report a comprehensive analysis of the structural composition of the arecanut rhizosphere bacterial diversity utilizing next-generation sequencing (NGS) technology. We have used amplicon sequencing (V3-V4 regions of the 16S rRNA gene) of bulk soil and rhizosphere samples collected from YLD endemic regions of Aranthodu, Sullia Taluk, Dakshina Kannada District, Karnataka State, India, to assess the microbial diversity. The results revealed that while there is a great diversity of bacterial communities, relatively few bacterial phyla predominate with higher relative abundance. The phyla viz., Proteobacteria, Bacteroidetes, Firmicutes, Acidobacteria, Planctomycetes, Patescibacteria, Chloroflexi, Actinobacteria, Fusobacteria, and Verrucomicrobia were found to be dominant in the rhizosphere of the arecanut.

Practical approach for safe anesthesia in a COVID-19 patient scheduled for emergency laparotomy.

COVID-19 patients presenting for emergency laparotomy require evaluation of surgical illness and viral disease. As these patients are likely to have a wide spectrum of deranged physiology and organ dysfunction, optimization should start preoperatively and continue through intraoperative and postoperative recovery periods along with appropriate antimicrobial cover. The goal should be not to delay damage control surgery in favor of evaluation and optimization. When a COVID-19 positive or suspected patient is to be operated for laparotomy, the situation often demands general anesthesia with invasive monitoring and analgesia complemented by regional anesthesia to minimize postoperative opioid requirements to facilitate early recovery. This particular article addresses the issues related to emergency laparotomy management in relation to COVID-19 patient. Healthcare workers should diligently use effective PPE and practice disinfection to prevent spread. Video-communication is an effective means of evaluation. Information expected from investigations should be weighed against risk of exposure to healthcare workers/laypersons. Simulation and memory aids should be used to familiarize team members with roles and techniques of management while in PPE. Step-wise detailed planning for patient transfer, anesthesia induction, maintenance and emergence, aid in enhancing HCW safety without compromising patient care.

Longitudinal study of health, disease and access to care in rural Victoria: the Crossroads-II study: methods.

BACKGROUND: High quality, contemporary data regarding patterns of chronic disease is essential for planning by health services, policy makers and local governments, but surprisingly scarce, including in rural Australia. This dearth of data occurs despite the recognition that rural Australians live with high rates of ill health, poor health behaviours and restricted access to health services. Crossroads-II is set in the Goulburn Valley, a rural region of Victoria, Australia 100-300 km north of metropolitan Melbourne. It is primarily an irrigated agricultural area. The aim of the study is to identify changes in the prevalence of key chronic health conditions including the extent of undiagnosed and undermanaged disease, and association with access to care, over a 15 year period. METHODS/DESIGN: This study is a 15 year follow up from the 2000-2003 Crossroads-I study (2376 households participated). Crossroads-II includes a similar face to face household survey of 3600 randomly selected households across four towns of sizes 6300 to 49,800 (50% sampled in the larger town with the remainder sampled equally from the three smaller towns). Self-reported health, health behaviour and health service usage information is verified and supplemented in a nested sub-study of 900 randomly selected adult participants in 'clinics' involving a range of additional questionnaires and biophysical measurements. The study is expected to run from October 2016 to December 2018. DISCUSSION: Besides providing epidemiological and health service utilisation information relating to different diseases and their risk factors in towns of different sizes, the results will be used to develop a composite measure of health service access. The importance of access to health services will be investigated by assessing the correlation of this measure with rates of undiagnosed and undermanaged disease at the mesh block level. Results will be shared with partner organisations to inform service planning and interventions to improve health outcomes for local people.

Commentary on Richardson et al. detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure.

Consciousness consists of two components: arousal and awareness of the environment and self. Arousal refers to the behavioral continuum that occurs between sleep and wakefulness, while awareness to the content of consciousness (Laureys, 2014). In normal physiological states, with the exception of REM sleep, the level of arousal is positively correlated with awareness (Laureys, 2014) such that arousal is graded and measured by the degree to which it is diminished. This conceptualization appears to have led experts, including the DSM-5, to consider delirium as a condition to not associated with impairments in arousal (Schiff and Plum, 2000, American Psychiatric Association, 2013). However, arousal can be both diminished and heightened, not unlike the performance of an old-fashioned incandescent bulb at different voltages, giving barely sufficient light at low voltages and brightening up unbearably at high voltages (MacIsaac et al., 1999). Delirium is associated with both hypo-arousal and hyper-arousal (Han et al., 2017). A small but significant proportion of delirious older patients (10%; n = 155) in the emergency department in this study had normal arousal at the time of the short arousal assessment (Han et al., 2014).

The role of diagnosis in delirium.

Delirium is common and is commonly misdiagnosed, chiefly in being missed (Bhat and Rockwood, 2007). The consequences of misdiagnosis are often severe and wide ranging, affecting patients, caregivers, health professionals, and hospitals (Inouye et al., 2014). Many an older hospitalized person with delirium is trapped in the interface between psychiatry and the rest of medicine, and can too easily be caught in the tendentious battles between treating teams. Both researchers and policymakers have sought to improve this unacceptable state of affairs (Young et al., 2010; Tieges et al., 2015).

Ultrabrief Electroconvulsive Therapy for Mania: Data From 11 Acute Treatment Courses.

Electroconvulsive therapy (ECT) is an effective treatment of mania. Ultrabrief ECT is a novel modality that is associated with fewer cognitive adverse effects than the standard pulse width brief pulse ECT. It has been well studied in depression. However, its use in mania is not yet known. Following a retrospective chart view, we report a small sample of patients who had Right Unilateral Ultrabrief ECT (RUB-ECT) for mania. Eleven RUB-ECTs were identified for 9 patients; 72.8% remission rate was observed with RUB-ECT. Two patients required switch into bitemporal ECT in view of minimal clinical response and 1 patient to right unilateral brief pulse ECT because of poor seizure parameters. All patients achieved remission eventually. The possible mechanisms of ECT in mania and clinical implications of ultrabrief ECT are discussed.

Comparison of intranasal dexmedetomidine and dexmedetomidine-ketamine for premedication in pediatrics patients: A randomized double-blind study.

BACKGROUND: Goal of premedication in pediatric anesthesia are relieving pre and postoperative anxiety, good parental separation, and smooth induction of anesthesia. Anxiety can produce aggressive reactions, increased distress, increased postoperative pain and postoperative agitation. The benzodiazepine, midazolam, is the most frequently used premedication in pediatric anesthesia. Midazolam has a number of beneficial effects when used as premedication in children: Sedation, fast onset, and limited duration of action. Though midazolam has a number of beneficial effects, it is far from an ideal premedicant having untoward side effects such as paradoxical reaction, respiratory depression, cognitive impairment, amnesia, and restlessness. Dexmedetomidine is a newer α-2-agonist, which can be used as premedicant. AIMS: To compare the level of sedation, parental separation, mask acceptance, postoperative recovery of intranasal premedication with dexmedetomidine and dexmedetomidine-ketamine combination in pediatric patients. SETTINGS AND DESIGN: Prospective randomized double-blind study. SUBJECTS AND METHODS: After written informed consent from the patient's parents or legal guardian, 54 children of American Society of Anesthesiologists physical status I or II, aged between 1 and 6 years, scheduled to undergo elective minor surgery were enrolled. In group D patient received 1 µg/kg dexmedetomidine intranasally and in group DK received 1 µg/kg dexmedetomidine and 2 mg/kg ketamine intranasally. Patients were assessed every 10 min for the level of sedation, parenteral separation, heart rate, and oxygen saturation by an independent observer. Mask acceptance and postoperative agitation were noted using an appropriate scale. STATISTICAL ANALYSIS USED: Pearson Chi-square analysis to determine differences between two groups with respect to separation anxiety and acceptance of the anesthesia mask. Percentages used to represent frequencies. The level of significance was set at P< 0.05. RESULTS: Acceptable parenteral separation was achieved in 90% of patients 30 min after premedication. Sedation was acceptable in 80% of patients at induction. Good mask acceptance was seen in 60% of patients. The incidence of emergence agitation (EA) was 2%. None of the above parameters was statistically significant between the two groups. CONCLUSIONS: Dexmedetomidine, as premedicant in children provides acceptable parenteral separation. However, mask acceptance in operation room is poor. Combination of dexmedetomidine and ketamine does not increase the success of premedication. Use of dexmedetomidine is associated with decreased EA.

Suicide rates in five-year age-bands after the age of 60 years: the international landscape.

BACKGROUND: There is paucity of studies examining suicide rates in narrow five-year age-bands after the age of 60 years. This study examined suicide rates in eight five-year age-bands between the age of 60 and 99 years because this will allow more precise comparison between the young old (60-79 years) and the oldest old (80+ years) age groups. METHODS: Data on the number of suicides (International Classification of Diseases - ICD-10 codes, X60-84) in each of the eight five-year age-bands between the age-bands 60-64 years and 95-99 years in both gender for as many years as possible from 2000 were ascertained from three sources: colleagues with access to national data, national statisics office websites and email contact with the national statistics offices. The population size for the corresponding years and age-bands was estimated for each country using data provided by the United Nations website. RESULTS: In men, suicide rates continued to increase for each of the seven five-year age-bands from 60-64 years to 90-94 years age-band, and then declined slightly for the 95-99 year age-band. In women, suicide rates continued to increase for each of the six five-year age-bands from 60-64 years to 85-89 years age-bands, and then declined slightly for the 90-94 years and 95-99 years age-bands. CONCLUSIONS: The overall global suicide rates for each of the eight five-year age-bands are sufficiently large for them to constitute a public health concern. This is especially important given the ongoing rise in the elderly population size and the paucity of data on risk and protective factors for suicide in the five-year age-bands after the age of 60 years.

Retrospective comparison of effectiveness of right unilateral ultra-brief pulse with brief pulse ECT in older adults (over 65) with depression.

BACKGROUND: To compare response, remission and switch (to other pulse width and/or electrode placement) rates and number of treatments between groups receiving right unilateral ultra-brief (RUL-UB), Bitemporal brief (BT), Bifrontal Brief (BF) and Right unilateral brief (RUL-B). METHOD: Data was collected from case notes in three centers. There were 133 in total, grouped as RUL-UB (50), BT (43), BF (23), RUL-B (17). Two of the three centers had a preferred electrode placement and pulse width. RESULTS: Apart from age, the groups did not differ significantly on sex distribution, proportion of bipolar depression and psychotic symptoms. 56% of patients in RUL-UB switched compared to 12.5% in RUL-B, 4.9% in BT and none in BF (p value < 0.0001). When we considered patients who switched as treatment failures, remission rates were significantly different (p value < 0.0001) 40% in RUL-UB, 81.3% in RUL-B, 73.9% in BF and 78.0% in BT. Mean number of treatments in each group was significantly different (p value < 0.0001); 12.02 in RUL-UB, 10.2 in RUL-B, 7 in BF and 7.5 in BT. Post-hoc analysis indicated that RUL-UB differed significantly from BT and BF. Final response and remission rates including patients who switched were 98% and 82% in RUL-UB, 100% and 93.8% in RUL-B, 100% and 73.9% in BF and 97.7% and 83.7% in BT. CONCLUSION: Majority commencing RUL-UB switched and received 4-5 more treatments compared to bilateral placements. RUL-UB ECT appears less effective and might not be appropriate as first line for all older adults as some patients at higher anaesthetic risk would benefit from having reduced number of treatments.

Comparison of Macintosh laryngoscope and C-MAC video laryngoscope for intubation in lateral position.

BACKGROUND AND AIMS: Endotracheal intubation is conventionally performed when the patient is in supine position. It may be required to secure airway in laterally positioned patient. Tracheal intubation in lateral position seems to be difficult because the laryngeal view is compromised. Hence, C-MAC video laryngoscope (Karl Storz, Germany), a newer device using a modified macintosh blade may be useful for intubation in lateral position. MATERIAL AND METHODS: A total of 100 American Society of Anesthesiologists Grade I and II patients, randomly allotted to C-MAC or direct laryngoscopy group. Patients with difficult airway were excluded. After induction of anesthesia, patient was put in right-lateral position and intubation was carried out by consultant who is well-versed in using C-MAC laryngoscope. Time for intubation, number of attempts, Modified Cormack - Lehane grade, mucosal injury, and external laryngeal manipulation applied were noted. STATISTICAL ANALYSIS: Demographics and baseline airway assessments were analyzed using summary statistics. Unpaired t-test was used to assess intubation time. Number of attempts, esophageal intubation, dental injury, mucosal injury, use of stylet, and application of external laryngeal manipulation were analyzed using Chi-square test. RESULTS: Overall intubation success rate was 100%. The time taken in C-MAC group was 24.8 ± 8.5 s and in direct group was 33.8 ± 9.12 s. The number of intubation attempts was not significant. Cormack - Lehane grade was better with C-MAC laryngoscope. Mucosal injury and use of external laryngeal manipulation was more in direct group. CONCLUSION: C-MAC is better than Macintosh laryngoscope for intubation in lateral position.

Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome.

The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel's deformity (wherein the scapulae ride high on the back), synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA). After intubation, we used second smaller endotracheal tube (ETT) to stabilize and elongate the first ETT while removing the LMA.