Laparoscopic management of transcervical fallopian tube prolapse.

INTRODUCTION: Fallopian tube prolapse (FTP) is a rare but increasingly recognized postoperative complication of total hysterectomy, but few reports relate FTP to supracervical hysterectomy. CASE: A 35-year-old, G2P2, patient with a history of recurrent fibroid prolapse received a supracervical hysterectomy. One week postoperatively, she was treated for infection, and 1 month later a scheduled Pap smear returned benign results and noted a rare cluster of glandular cells. Two months after the hysterectomy, the patient presented to the outpatient clinic with vaginal discharge and dyspareunia. The patient was diagnosed with FTP and was treated with total salpingectomy using a combined vaginal and laparoscopic approach. CONCLUSION: Transcervical FTP is a rare complication following supracervical hysterectomy. Increasing awareness of the condition will allow for fewer delays in diagnosis and treatment. A laparoscopic total salpingectomy provides effective treatment with minimal invasiveness.

Retrospective audit of the air-Q intubating laryngeal airway as a conduit for tracheal intubation in pediatric patients with a difficult airway.

OBJECTIVES: To assess the efficacy of the ILA as a conduit for tracheal intubation in pediatric patients with a difficult airway. AIM: The primary goals of this retrospective audit were to assess the clinical performance of the ILA in pediatric patients with a difficult airway, expand on our initial favorable experience with this device, and collect pilot data for future prospective and comparison studies. METHODS: The charts of patients with a difficult airway in whom the ILA was used during a period of 1 year in a freestanding pediatric institution were reviewed following a practice change in the authors' institution favoring the ILA over the laryngeal mask airway as a conduit for tracheal intubation. RESULTS: Thirty-four pediatric patients had an ILA placed during the course of their airway management. Eight of the 34 patients in this cohort required emergent airway management. The median age was 47.1 (0.3-202.2) months and the median weight was 16.3 (3.9-86.0) kilograms. Three of the cases were unanticipated difficult airways and the remaining were anticipated difficult airways as a result of craniofacial syndromes (n = 21), cervical spine instability or immobility (n = 7), or airway hemorrhage (n = 3). Thirty-three of the 34 patients (97%) were intubated on the first attempt through the ILA, with the aid of a fiberoptic bronchoscope (n = 25), a Shikani Optical Stylet (n = 7), or blindly (n = 2). In one patient, blind tracheal intubation required a second attempt for successful intubation, making the overall success rate 100%. Oxygen desaturation was noted in 6 of the 34 cases. CONCLUSIONS: In a series of pediatric patients with difficult airways, the ILA was successfully used as a conduit for tracheal intubation in all patients. Visualization techniques may offer a greater degree of success in intubations through the ILA due to the potential for epiglottic down-folding in children.

A clinical evaluation of the intubating laryngeal airway as a conduit for tracheal intubation in children.

BACKGROUND: The air-Q Intubating Laryngeal Airway (ILA) (Cookgas LLC, Mercury Medical, Clearwater, FL) is a supraglottic airway device available in pediatric sizes, with design features to facilitate passage of cuffed tracheal tubes when used to guide tracheal intubation. We designed this prospective observational study of the ILA to assess the ease of its placement in paralyzed pediatric patients, determine its position and alignment to the larynx using a fiberoptic bronchoscope, gauge its efficacy as a conduit for fiberoptic intubation with cuffed tracheal tubes, and evaluate the ability to remove the ILA without dislodgement of the tracheal tube after successful tracheal intubation. METHODS: One hundred healthy children, aged 6 months to 8 years, ASA physical status I to II, and scheduled for elective surgery requiring general endotracheal anesthesia were enrolled in this prospective study. Based on the manufacturer's guidelines, each patient received either a size 1.5 or 2.0 ILA according to their weight. The number of attempts for successful insertion, leak pressures, fiberoptic grade of view, number of attempts and time for tracheal intubation, time for ILA removal, and complications were recorded. RESULTS: ILA placement, fiberoptic tracheal intubation, and ILA removal were successful in all patients. The size 1.5 ILA cohort had significantly higher rates of epiglottic downfolding compared with the size 2.0 ILA cohort (P < 0.001), despite adequate ventilation variables. When comparing fiberoptic grade of view to weight, a moderate negative correlation was found (r = -0.41, P < 0.001), indicating that larger patients tended to have better fiberoptic grades of view. The size 1.5 ILA cohort had a significantly longer time to intubation (P = 0.04) compared with the size 2.0 ILA cohort. However, this difference may not be clinically significant because there was a large overlap of confidence bounds in the average times of the size 1.5 ILA (27.0 ± 13.0 seconds) and size 2.0 ILA cohorts (22.7 ± 6.9 seconds). When comparing weight to time to tracheal intubation, a weak correlation that was not statistically significant was found (r = -0.17, P = 0.09), showing that time to intubation did not differ significantly according to weight, despite higher fiberoptic grades in smaller patients. CONCLUSIONS: The ILA was easy to place and provided an effective conduit for tracheal intubation with cuffed tracheal tubes in children with normal airways. Additionally, removal of the ILA after successful intubation could be achieved quickly and without dislodgement of the tracheal tube. Because of the higher incidence of epiglottic downfolding in smaller patients, the use of fiberoptic bronchoscopy is recommended to assist with tracheal intubation through this device.

The pore-forming protein Cry5B elicits the pathogenicity of Bacillus sp. against Caenorhabditis elegans.

The soil bacterium Bacillus thuringiensis is a pathogen of insects and nematodes and is very closely related to, if not the same species as, Bacillus cereus and Bacillus anthracis. The defining characteristic of B. thuringiensis that sets it apart from B. cereus and B. anthracis is the production of crystal (Cry) proteins, which are pore-forming toxins or pore-forming proteins (PFPs). Although it is known that PFPs are important virulence factors since their elimination results in reduced virulence of many pathogenic bacteria, the functions by which PFPs promote virulence are incompletely understood. Here we study the effect of Cry proteins in B. thuringiensis pathogenesis of the nematode Caenorhabditis elegans. We find that whereas B. thuringiensis on its own is not able to infect C. elegans, the addition of the PFP Cry protein, Cry5B, results in a robust lethal infection that consumes the nematode host in 1-2 days, leading to a "Bob" or bag-of-bacteria phenotype. Unlike other infections of C. elegans characterized to date, the infection by B. thuringiensis shows dose-dependency based on bacterial inoculum size and based on PFP concentration. Although the infection process takes 1-2 days, the PFP-instigated infection process is irreversibly established within 15 minutes of initial exposure. Remarkably, treatment of C. elegans with Cry5B PFP is able to instigate many other Bacillus species, including B. anthracis and even "non-pathogenic" Bacillus subtilis, to become lethal and infectious agents to C. elegans. Co-culturing of Cry5B-expressing B. thuringiensis with B. anthracis can result in lethal infection of C. elegans by B. anthracis. Our data demonstrate that one potential property of PFPs is to sensitize the host to bacterial infection and further that C. elegans and probably other roundworms can be common hosts for B. cereus-group bacteria, findings with important ecological and research implications.

NOx and ADMA changes with focal ischemia, amelioration with the chaperonin GroEL.

Both nitric oxide and asymmetric dimethylarginine (ADMA) play a critical role in the regulation of cerebral blood flow, though their neuroprotective and cytotoxic effects are still under investigation. In this study, we found that nitrate/nitrite (NOx) levels in plasma, ischemic brain tissue, and cerebrospinal fluid (CSF) increased significantly 24h after 2h transient middle cerebral artery occlusion (MCAO) in rats. ADMA levels were unchanged in plasma, but decreased significantly in CSF 24h following MCAO. The CSF ADMA/NOx ratio decreased markedly following ischemia. Rats protected by expression of the chaperonin GroEL or its folding deficient mutant D87K had lower plasma NOx levels at 24h reperfusion. ADMA, NO, and their ratio in CSF merit further study as biomarkers for ischemic brain injury.