Building consensus on critical thinking assessment tool for undergraduate nursing students in a socialist low-middle income country: A delphi study.

Aim: We aimed to build consensus on a holistic critical thinking (CT) assessment tool involving cognitive skills and disposition for undergraduate nursing students in a socialist low-middle income country, Lao People's Democratic Republic (Lao PDR). Background: University degree nursing education program in Lao PDR has been started since 2011 to strengthen the ability to think as professional nurse, and nursing regulations have progressively developed last decade. However, there are still few studies assessing the CT ability of nursing students in Lao PDR. Design: Delphi study. Methods: We conducted three rounds of Delphi survey of 14 panel members consisting of nursing faculty members and clinical supervisors. The first and second survey rounds involved a combination of a series of questionnaires and face-to-face interviews to obtain ideas or opinions about descriptions of the CT assessment tool. The third round was the meeting with 13 panel members to reach a consensus on the descriptions of the CT assessment tool. Results: The number of descriptions changed from 29 to 30 under seven assessment criteria of the cognitive skills and from 34 to 32 under 10 assessment criteria of the habits of mind as disposition. The panel provided active comments on the descriptions in terms of social, cultural, and educational backgrounds. Especially the descriptions of criteria applying standards and creativity were discussed from practical viewpoints such as the hierarchical social structure in hospital, limited educational resources, and the cultural value of harmony. Conclusions: The holistic CT assessment tool that resulted from the consensus is anticipated to help Laotian nursing educators to assess undergraduate nursing students' CT ability more efficiently with confidence at both the university and hospitals continuously. Subsequent implementation of the CT assessment tool in a socialist low-middle income country is warranted.

3M microfoam™ surgical tape prevents nasal pressure injury associated with nasotracheal intubation: A randomized double-blind trial.

BACKGROUND: 3M microfoam™ surgical tape (3ST: 3M Japan Limited) is used for pressure wound control of medical equipment. It is cushioned and can be fitted to any body part. Here we investigated whether 3ST prevents nasal pressure injury associated with nasotracheal intubation (NTI). METHODS: We conducted a prospective, randomized double-blind study, enrolling 63 patients aged 20 to 70 years, who underwent general anesthesia with NTI. They were divided into 2 groups; those treated with 3ST (group S; n = 31) and control (group C; n = 31). After NTI and before securing the nasotracheal tube, a 35 × 25 mm 3ST was used to protect the nasal wing in group S, and the nasotracheal tube was fixed in place after NTI without protection in group C. The primary outcome was the presence or absence of nasal pressure injury after extubation. The Chi-Square test was used to assess the association between the 2 categorical variables. RESULTS: Nasal pressure injury was observed in 7 and 19 patients from groups S and C, respectively, representing a significant difference between the 2 groups (24.1% vs 67.8%, P = .001). Remarkably, none of the patients developed ulcers. CONCLUSION: 3ST prevents nasal pressure injury associated with NTI.

Comparison of Emergence Agitation Scale Scores and Creatine Kinase Levels After General Anesthesia in Children: A Prospective Cohort Study.

Introduction A simple indicator of muscle damage is creatine kinase (CK). Although CK elevation is informative for malignant hyperthermia, no study has examined the relationship between the anesthetically awake state and CK in children. We aimed to prospectively examine the relationship between the awakening state and CK on the day after surgery in children who have undergone anesthesia with volatile inhalation anesthetics. Methods The study included 119 patients aged 0-15 years and scheduled to undergo general anesthesia for cleft lip and palate-related surgery. Emergence agitation (EA) was assessed after completion of general anesthesia using the five-point EA scale, and patients were divided into the following five groups according to the EA score: EA1, EA2, EA3, EA4, and EA5. The primary outcome was ΔCK (comparison of CK values one week prior to surgery to CK values on the day after surgery) in each EA group. The secondary outcome was ΔCK when the EA score was divided into the following two groups: EA ≤2 (EA score of 1 or 2) and EA ≥3 (EA score of 3, 4, or 5). Results The median ΔCK values in the EA1 to EA5 groups were 3 (quartile -19~9), 5 (-32~88), 99.5 (-18~190.5), 121 (29~219.5), and 144 (41~340.5), respectively, indicating a statistically significant difference overall. Statistically significant differences were also observed between the EA1 and EA4 groups and between the EA2 and EA4 groups. The median ΔCK values in the EA ≤2 and EA ≥3 groups were 3 (quartile -27~85) and 108 (23.5~206.7), respectively, indicating a statistically significant difference. Conclusion The results of this study revealed that a higher EA score at the time of anesthesia awakening is associated with a larger ΔCK, indicating that a high CK level on the day after surgery is highly related to the state of the patient upon awakening.

Perioperative Management of a Patient With von Recklinghausen's Disease With Anticipated Difficult Airway Management: A Case Report.

Von Recklinghausen's disease is characterized by skin pigmentation, multiple neurofibromatosis, and osseous changes. In the anesthetic management of patients with von Willebrand's disease, it is important to provide appropriate airway management, taking into account the cutaneous laxity caused by neurofibromatosis of Recklinghausen's disease. This case describes the perioperative management of a patient with Recklinghausen's disease with suspected difficulty in airway management.

Comparison of hemostatic effect and safety between epinephrine and tramazoline during nasotracheal intubation: a double-blind randomized trial.

BACKGROUND: Nasal bleeding is the most common complication during nasotracheal intubation (NTI). To reduce nasal bleeding, the nasal mucosa is treated with vasoconstrictors (epinephrine [E] or tramazoline [T]) prior to NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI. METHODS: This study was preregistered on UMIN-CTR after being approved by the IRB of the School of Dentistry at Aichi Gakuin University. Written consent was received from all the patients. Total 206 patients aged 20-70 years and classified as 1-2 on American Society of Anesthesiologists-physical status were scheduled to undergo general anesthesia with NTI. At last, 197 patients were randomly divided into two groups and treated with either E (n = 99; 3 patients were discontinued) or T (n = 98; 2 patient were discontinued). After induction of general anesthesia, each patient's nasal mucosa was treated using either E or T. The E used in this study was BOSMIN® SOLUTION 0.1% (Daiichi-Sankyo Co., Ltd., Tokyo), and the T used in this study was TRAMAZOLIN Nasal Solution 0.118% AFP, (Alfresa Pharma Corporation, Osaka). E was diluted five times according to the package insert (final concentration of E = 0.02%), and T was used in its original solution. After 2 min, NTI was performed via the right nostril. Primary outcome were the presence of nasal bleeding (if bleeding was recognized at the posterior pharyngeal wall via nasal cavity during intubation, it was defined as bleeding) and the degree of bleeding (classified as none, mild, moderate, or severe). Secondary outcomes were arrhythmia, and hemodynamic (mean atrial pressure and heart rate) changes associated with vasoconstrictors. RESULTS: The presence of bleeding was comparable in both groups (12.5%, E; 14.5%, T; P = 0.63). No significant difference between the groups regarding the degree of bleeding (P = 0.78) was observed, with most patients having no bleeding (n = 84, E; n = 82, T). No severe bleeding and no arrhythmias induced by vasoconstrictor were observed in the two groups. CONCLUSIONS: Nasal treatment with E or T shows no difference in nasal bleeding during NTI. Although no arrhythmia associated with E was observed in this study, it has been reported in literature. Therefore, as frequency and degree of nasal bleeding were comparable, nasal treatment with T could reduce the risk of NTI. TRIAL REGISTRATION: UMIN-CTR (Registration No. UMIN000037907 ). Registered (05/09/2019).

A Case of Childhood-Onset Basedow-Graves' Disease Diagnosed as a Result of the Fourth Time of General Anesthesia for Oral and Maxillofacial Surgery.

The incidence of childhood-onset Basedow's (Graves') disease is approximately 5% of all cases. Herein, we report a teenage female patient diagnosed with childhood-onset Graves' disease immediately following general anesthesia. Her signs and symptoms included tachycardia immediately prior to general anesthesia, delirium upon emerging from anesthesia, persistent postoperative tachycardia and anxiety, and prolonged nausea and vomiting.

Two Cases of Rocuronium-Induced Anaphylaxis/Anaphylactic Shock Successfully Treated With Sugammadex.

While anaphylaxis can occur at any time during general anesthesia, 90% of cases occur at induction of anesthesia. As several drugs are administered simultaneously at this time, it is difficult to identify the causative agent. However, it has been found that rocuronium is the most common drug associated with perioperative anaphylaxis. We treated 2 cases of patients who were administered sugammadex for anaphylactic symptoms thought to be caused by rocuronium, after which the anaphylactic symptoms disappeared. One of the most important aspects of treating anaphylactic shock is improving hemodynamics. If signs indicating circulatory collapse are observed, epinephrine should be administered immediately. However, because rocuronium was suspected of being the causative agent, and taking the patients' clinical course over time into consideration, sugammadex was initially administered. As a result, symptoms improved. Therefore, we believe that the administration of sugammadex may be effective for treating anaphylaxis caused by rocuronium and also help in identifying the causative agent.

The effect of various dilute administration of rocuronium bromide on both vascular pain and pharmacologic onset: a randomized controlled trial.

BACKGROUND: Rocuronium bromide (RB) is known to cause vascular pain. Although there have been a few reports that diluted administration causes less vascular pain, there have been no studies investigating diluted administration and the onset time of muscle relaxation. Therefore, we examined the influence of diluted administration of RB on the onset time of muscle relaxation and vascular pain. METHODS: 39 patients were randomly assigned to three groups: RB stock solution 10 mg/ml (Group 1), two-fold dilution 5 mg/ml (Group 2), or three-fold dilution 3.3 mg/ml (Group 3). After the largest vein of the forearm was secured, anesthesia was induced by propofol and 0.6 mg/kg of RB was administered. The evaluation method devised by Shevchenko et al. was used to evaluate the degree of vascular pain. The time from RB administration until the maximum blocking of T1 by TOF stimulation was measured. RESULTS: There was no significant difference in escape behaviors of vascular pain among the three groups, and the onset time of muscle relaxation was significantly slower in Group 3 than in Group 1 (p = 0.033). CONCLUSION: Our results suggested that it is unnecessary to dilute RB before administration if a large vein in the forearm is used. TRIAL REGISTRATION: UMINCTR Registration number UMIN000026737 . Registered 29 Mar 2017.

Usefulness of Airway Scope for intubation of infants with cleft lip and palate-comparison with Macintosh laryngoscope: a randomized controlled trial.

BACKGROUND: Airway Scope (AWS) with its plastic blade does not require a head-tilt or separate laryngoscopy to guide intubations. Therefore, we hypothesized that its use would reduce the intubation time (IT) and the frequency of airway complication events when compared with the use of Macintosh Laryngoscope (ML) for infants with cleft lip and palate (CLP). METHODS: The parents of all patients provided written consents; we enrolled 40 infants with CLP (ASA-PS 1). After inducing general anesthesia using sevoflurane and rocuronium, we performed orotracheal intubations using either AWS (n = 20) or ML (n = 20), randomly. We define the duration between manual manipulation using cross finger for maximum mouth opening and the first raising motion of the chest following intubation by artificial ventilation as "IT;" further, the measured IT as primary outcomes. Airway complications were considered secondary outcomes. Moreover, we looked for associations between IT and the patient's characteristics: extensive clefts, age, height, and weight. We used the Mann-Whitney test and Fisher's exact probability test for statistical analysis; p < 0.05 was considered as statistically significant. RESULTS: The mean IT was 31.5 ± 8.3 s in AWS group and 26.4 ± 8.9 s in ML group. Statistical significant difference was not found in IT between the two groups. The IT of AWS group was statistically related to extensive clefts. Airway complications were detected in ML group. CONCLUSION: AWS could be useful for intubation of infants with CLP; it required IT similar to that required using ML, with a lower rate of airway complications. TRIAL REGISTRATION: UMIN-CTR Registration number UMIN000024763 . Registered 8 November 2016.

The usefulness of the McGrath MAC laryngoscope in comparison with Airwayscope and Macintosh laryngoscope during routine nasotracheal intubation: a randomaized controlled trial.

BACKGROUND: McGrath MAC video laryngoscope offers excellent laryngosopic views and increases the success rate of orotracheal intubation in some cases. The aim of this study was to determine the usefulness of McGrath MAC for routine nasotracheal intubation by comparing McGrath MAC with Airway scope and Macintosh laryngoscope. METHODS: A total of 60 adult patients with ASA physical status class 1 or 2, aged 20-70 years were enrolled in this study. Patients were scheduled for elective oral surgery under general anesthesia with nasotracheal intubation. Exclusion criteria included lack of consent and expected difficult airway. Patients were randomly allocated to three groups: McGrath MAC (n = 20), Airway scope (n = 20), and Macintosh laryngoscope (n = 20). After induction, nasotracheal intubation was performed by six expert anesthesiologists with more than 6 years of experience. RESULTS: There were no significant differences in preoperative airway assessment among the three groups. Successful tracheal intubation time was 26.8 ± 5.7 (mean ± standard deviation) s for McGrath MAC, 36.4 ± 11.0 s for Airway scope, and 36.5 ± 8.9 s for Macintosh laryngoscope groups. The time for successful tracheal intubation for McGrath MAC group was significantly shorter than that for Airway scope and Macintosh laryngoscope (p < 0.01). McGrath MAC significantly improved the Cormack Lehane grade for nasotracheal intubation compared with Macintosh laryngoscope (p < 0.05). CONCLUSION: McGrath MAC significantly facilitates routine nasotracheal intubation compared with Airwayscope and Macintosh laryngoscope by shortening the tracheal intubation time and improving the Cormack Lehane grade. TRIAL REGISTRATION: UMINCTR Registration number UMIN000023506 . Registered 5 Aug 2016.

Regulation of cell migration by sphingomyelin synthases: sphingomyelin in lipid rafts decreases responsiveness to signaling by the CXCL12/CXCR4 pathway.

Sphingomyelin synthase (SMS) catalyzes the formation of sphingomyelin, a major component of the plasma membrane and lipid rafts. To investigate the role of SMS in cell signaling and migration induced by binding of the chemokine CXCL12 to CXCR4, we used mouse embryonic fibroblasts deficient in SMS1 and/or SMS2 and examined the effects of SMS deficiency on cell migration. SMS deficiency promoted cell migration through a CXCL12/CXCR4-dependent signaling pathway involving extracellular signal-regulated kinase (ERK) activation. In addition, SMS1/SMS2 double-knockout cells had heightened sensitivity to CXCL12, which was significantly suppressed upon transfection with the SMS1 or SMS2 gene or when they were treated with exogenous sphingomyelin but not when they were treated with the SMS substrate ceramide. Notably, SMS deficiency facilitated relocalization of CXCR4 to lipid rafts, which form platforms for the regulation and transduction of receptor-mediated signaling. Furthermore, we found that SMS deficiency potentiated CXCR4 dimerization, which is required for signal transduction. This dimerization was significantly repressed by sphingomyelin treatment. Collectively, our data indicate that SMS-derived sphingomyelin lowers responsiveness to CXCL12, thereby reducing migration induced by this chemokine. Our findings provide the first direct evidence for an involvement of SMS-generated sphingomyelin in the regulation of cell migration.

Sphingomyelin synthase 1-generated sphingomyelin plays an important role in transferrin trafficking and cell proliferation.

Transferrin (Tf) endocytosis and recycling are essential for iron uptake and the regulation of cell proliferation. Tf and Tf receptor (TfR) complexes are internalized via clathrin-coated pits composed of a variety of proteins and lipids and pass through early endosomes to recycling endosomes. We investigated the role of sphingomyelin (SM) synthases (SMS1 and SMS2) in clathrin-dependent trafficking of Tf and cell proliferation. We employed SM-deficient lymphoma cells that lacked SMSs and that failed to proliferate in response to Tf. Transfection of SMS1, but not SMS2, enabled these cells to incorporate SM into the plasma membrane, restoring Tf-mediated proliferation. SM-deficient cells showed a significant reduction in clathrin-dependent Tf uptake compared with the parental SM-producing cells. Both SMS1 gene transfection and exogenous short-chain SM treatment increased clathrin-dependent Tf uptake in SM-deficient cells, with the Tf being subsequently sorted to Rab11-positive recycling endosomes. We observed trafficking of the internalized Tf to late/endolysosomal compartments, and this was not dependent on the clathrin pathway in SM-deficient cells. Thus, SMS1-mediated SM synthesis directs Tf-TfR to undergo clathrin-dependent endocytosis and recycling, promoting the proliferation of lymphoma cells.

S Phase-preferential Cre-recombination in mammalian cells revealed by HIV-TAT-PTD-mediated protein transduction.

The Cre recombinase of bacteriophage P1 is a powerful tool for artificial modification of genomic function in mammalian cells. To date, many researchers have studied the enzymatic biochemistry of Cre recombinase in loxP site-specific cleavage and rearrangement, as well as its use in gene technology. However, the intricate mechanisms of Cre-mediated recombination are still poorly understood. For example, more knowledge is needed in order to understand Cre recombinase's dependency on cell cycle, the necessity of other factors for recombination, and the exact nuclear environment that's required at the target locus, in order for recombination to take place in eukaryotic cells. In this study, we showed that P1 Cre-mediated recombination occurred frequently during S-phase of the cell cycle. HeLa cells were synchronized in cell cycle with the thymidine-hydroxyurea block method, and recombinant Cre proteins were fused with HIV-1 TAT protein transduction domains (PTD) in every phase of the cell cycle. Results showed that the transduction of PTD-Cre gave rise to genomic recombination preferentially during the S-phase of cell cycle. These findings will contribute significantly to the development of the Cre/loxP recombination system in vivo.

CCAAT/enhancer binding protein-beta (C/EBP-beta), a pivotal regulator of the TATA-less promoter in the rat catalase gene.

The rat catalase gene carries a TATA-less promoter and its transcriptional mechanism is interesting because of downregulation in liver injury. We characterized the core element in the promoter and found that C/EBP-beta binding downstream of the transcription initiation site plays a crucial role for transcription. The multiple complexes binding to the promoter were composed of homodimers and heterodimers of C/EBP-beta isoforms. Transduction of the C/EBP-beta gene showed complete reconstitution of multiple binding complexes in HeLa cells, similar to normal liver. Furthermore, C/EBP-beta was observed to bind to the endogenous catalase promoter. These data suggest that multiple complex formation of C/EBP-beta regulates transcription in the TATA-less catalase promoter.