Managing magnets: An audit of introduction of the Royal College of Emergency Medicine Best Practice Guideline.

AIM: To evaluate management of children and young people presenting to the Emergency Department (ED) with magnet ingestion before and after new guidance. METHODS: In May 2021, a National Patient Safety Agency and Royal College of Emergency Medicine (RCEM) Best Practice Guideline about management of ingested magnets was published. This was implemented in our department. Children and young people presenting after magnet ingestion were identified from SNOMED (coded routinely collected data) and X-ray requests between January 2016 and March 2022. Management was compared to national guidance. RESULTS: There were 138 patient episodes of magnet ingestion, with a rising incidence over the 5-year period. Following introduction of the guideline, there was a higher incidence of admission (36% vs. 20%) and operative intervention (15.7% vs. 8%). Use of follow-up X-ray increased from 56% to 90%. There was substantial variation in the management prior to guidance which reduced after introduction of the RCEM guidance. CONCLUSION: Management of magnet ingestion has become more standardised since introduction of the National RCEM Best Practice Guideline, but there is still room for improvement.

The Sheen Paajanen grOin Recommended Treatment 'SPoRT' score for groin pain.

INTRODUCTION: Evaluating groin pain still evades many clinicians at times as they have difficulty determining the cause of pain when no true hernia exists. This study's aim was to evaluate a simple and novel scoring system which is reproducible, to help determine whether conservative measures or surgery is recommended for the management of groin pain attributable to inguinal disruption. MATERIAL & METHODS: A retrospective analysis of all patients from 2018 to 2020 that underwent surgery or conservative management for inguinal disruption with at least a 1-year follow-up were evaluated. The scoring system is based on MRI and ultrasound imaging as well as clinical findings, with scores given from - 2 to + 2 based on the defined findings listed. A maximum total of four points scored for each assessment was used. Sensitivity and specificity analysis was conducted for each potential score cut off point. RESULTS: A total of 172 patients were evaluated with 33 patients (19%) undergoing conservative management and 139 patients (81%) undergoing surgery. The median SPoRT score for the surgery group was 2.0 (1.0, 3.0), and - 1.0 (- 3.0, 0.0) in the physiotherapy group which was a significant difference (p < 0.001). An optimal cut off of ≤ 0 for physio and ≥ 1 for surgery was established, yielding a sensitivity of 90.9% (95% CI 75.7%-98.1%), a specificity of 89.2% (95% CI 82.8%-93.8%) and an area under the curve (AUC) of 0.936 (95% CI 0.874-0.997). DISCUSSION: SPoRT score of ≤ 0 can recommend a patient should undergo conservative measures or physiotherapy as a mainstay of treatment with a score of ≥ 1 recommending surgery. Further validation of the score is necessary.

'Socialised care futility' in the care of older people in hospital who call out repetitively: An ethnographic study.

BACKGROUND: People living with dementia may call out repetitively, sometimes called disruptive vocalisation, or verbal agitation. In literature and policy, patients who call out repetitively are assumed to be expressing an unmet need, which should be met. Yet there has been little systematic study of this patient group in an acute hospital setting. OBJECTIVES: To better understand patients who call out repetitively and to identify what care looks like in an acute hospital setting. DESIGN: Ethnography. SETTINGS: Ten acute geriatric medical wards in two hospitals. PARTICIPANTS: 30 cognitively impaired patients who were calling out repetitively, and 15 members of hospital staff. METHODS: Semi-structured interviews with hospital staff, 150 h of ward observations and informal conversations with staff, scrutiny of medical and nursing documentation, and measures of patient health status. RESULTS: Patients who called out were moderately or severely cognitively impaired, often had delirium, were very physically disabled, and many were approaching the end of life. Most hospital staff were found to hold contradictory views: that calling out represents distress or unmet need, but that nothing can be done to alleviate the calling out. During informal conversations, most staff also tended to say that they intuitively recognised when intervening was likely to alleviate calling out. During observations, many staff appeared to and spoke of the ability to 'block' calling out. As a result we argue that social, emotional and physical needs may get overlooked. We argue that some calling out is due to a need that is unmeetable. We also found that while staff would talk about strategies for identifying need, observations and hospital documentation did not support evidence of systematic attempts to identify potential need. CONCLUSION: Calling out repetitively within a hospital setting is difficult for staff to understand and to respond to. This is because many of these patients are severely cognitively impaired, often immobile and dependent on their professional carers. We argue that a form of socialised care futility is communicated between staff and is used to rationalise becoming unresponsive to calling-out. We explain this phenomenon as resulting from two protective mechanisms: defence of staff's professional identity as competent practitioners; and defence of staff as having personal morality. Socialised care futility risks good quality care, therefore systematic strategies to assess and manage possible need should be developed, even if calling out remains irresolvable in some cases.

Longitudinal dynamics of herd-level Mycobacterium bovis MLVA type surveillance in cattle in Northern Ireland 2003-2016.

Investigating genetically-structured diversity in pathogen populations over time is important to better understand disease maintenance and spread. Herd-level surveillance of Mycobacterium bovis genotypes (multi-locus VNTR analysis types, MLVA types) from all culture-confirmed bovine tuberculosis (TB) herd cases was undertaken in Northern Ireland (NI), generating an unparalleled, longitudinal, population-level 14-year survey for this pathogen. Across this population, 295 genetically-distinct M. bovis MLVA types were identified in the 19,717 M. bovis isolates surveyed. Of these, the most frequent was MLVA type 002 (23.0%); 151 MLVA types were represented more than once, in groups ranging from 2 to 4438 isolates. Only 23 MLVA types were isolated in all 14 years. Investigating inter-annual frequency of M. bovis MLVA types, examples of statistically-significant expansions (MLVA types 002, 004, 006, 009 and 027), contractions (MLVA types 001, 007 and 011) and maintenance (MLVA types 003 and 005) were disclosed, during a period of fluctuating bovine TB herd-level incidence at the NI scale. The fixed period frequency distribution of MLVA types remained highly right-skewed. Novel VNTR copy number variant MLVA types (N = 242; an average of 17 per annum) were identified throughout the survey. The MLVA type distribution in the landscape was not random; MLVA types showed statistically-significant geographical localization and strong spatial associations with Divisional Veterinary Office (DVO) regions. There was also evidence of differential risk of particular MLVA types across breeds (Holstein/Friesian vs. other), age-class, and sex and some evidence of an association between the number of animals testing positive for bovine TB during the disclosing test and particular MLVA types, although there was substantial variation.

Chair based exercise in community settings: a cluster randomised feasibility study.

BACKGROUND: Some older people who find standard exercise programmes too strenuous may be encouraged to exercise while remaining seated - chair based exercises (CBE). We previously developed a consensus CBE programme (CCBE) following a modified Delphi process. We firstly needed to test the feasibility and acceptability of this treatment approach and explore how best to evaluate it before undertaking a definitive trial. METHODS: A feasibility study with a cluster randomised controlled trial component was undertaken to 1. Examine the acceptability, feasibility and tolerability of the intervention and 2. Assess the feasibility of running a trial across 12 community settings (4 day centres, 4 care homes, 4 community groups). Centres were randomised to either CCBE, group reminiscence or usual care. Outcomes were collected to assess the feasibility of the trial parameters: level of recruitment interest and eligibility, randomisation, adverse events, retention, completion of health outcomes, missing data and delivery of the CCBE. Semi- structured interviews were conducted with participants and care staff following the intervention to explore acceptability. RESULTS: 48% (89 out of 184 contacted) of eligible centres were interested in participating with 12 recruited purposively. 73% (94) of the 128 older people screened consented to take part with 83 older people then randomised following mobility testing. Recruitment required greater staffing levels and resources due to 49% of participants requiring a consultee declaration. There was a high dropout rate (40%) primarily due to participants no longer attending the centres. The CCBE intervention was delivered once a week in day centres and community groups and twice a week in care homes. Older people and care staff found the CCBE intervention largely acceptable. CONCLUSION: There was a good level of interest from centres and older people and the CCBE intervention was largely welcomed. The trial design and governance procedures would need to be revised to maximise recruitment and retention. If the motivation for a future trial is physical health then this study has identified that further work to develop the CCBE delivery model is warranted to ensure it can be delivered at a frequency to elicit physiological change. If the motivation for a future trial is psychological outcomes then this study has identified that the current delivery model is feasible. TRIAL REGISTRATION: ISRCTN27271501 . Date registered: 30/01/2018.

How to deal with violent and aggressive patients in acute medical settings.

Dealing with violence and aggression is an area where health professionals often feel uncertain. Standing at the interface between medicine, psychiatry and law, the best actions may not be clear, and guidelines neither consistently applicable nor explicit. An aggressive, violent or abusive patient may be behaving anti-socially or criminally. But in acute medical settings it is more likely that a medical, mental health or emotional problem, or some combination thereof, is the explanation and usually we will not know the relative contribution of each element. We must assume that difficult behaviour represents the communication of distress or unmet need. We can prevent and de-escalate situations by understanding why they have arisen, identifying the need, and trying to anticipate or meet it. In these situations 'challenging behaviour' is much like any other presenting problem: the medical approach is to diagnose and treat, while trying to maintain safety and function. In addition, the person-centred approach of trying to understand and address psychological and emotional distress is required. Skilled communication, non-confrontation, relationship-building and negotiation represent the best way to manage situations and avoid harm. If an incident is becoming dangerous, doctors need to know how to act to defuse the situation, or make it safe. Doctors must know about de-escalation and non-drug approaches, but also be confident about when physical restraint and drug treatment are necessary, and how to go about using appropriate drugs, doses, monitoring and aftercare. There are necessary safeguards around using these approaches, from the perspectives of physical health, mental wellbeing, and human rights.

Assessment of concurrent infection with bovine viral diarrhoea virus (BVDV) and Mycobacterium bovis: A herd-level risk factor analysis from Northern Ireland.

Bovine viral diarrhoea virus (BVDV) is a significant pathogen of cattle, leading to severe economic and animal-welfare impacts. Furthermore, the pathogen has been associated with impacting the progression or spread of other pathogens (e.g. Mycobacterium bovis, the causative agent of bovine tuberculosis (bTB)). During this study we investigated (i) risk factors for BVDV at a herd-level and (ii) whether there was any association between BVDV and herd-level bTB risk. The data for this study were gathered from a voluntary BVDV control programme in Northern Ireland (2013-2015) based on the identification of virus positive animals through tissue tag testing of calves. We assigned a herd-level BVDV status to 2827 participating herds, where a herd was assumed "infected" if one or more animals tested positive for BVDV. Two model suites were developed. Firstly, we assessed risk factors for BVDV herd status using multivariable logit random-effects modelling, aggregating to the calendar year level (2013-2015; n=4828; model 1). Secondly, we aggregated data across the three years of the study to give an overall status for the whole study period (n=2827; logistic model 2). Risk factors included year, herd-type, herd size, number of births, inward trade moves, calf mortality, and region. Furthermore, the herd-level bovine tuberculosis status (based on the single intradermal comparative cervical tuberculin (SICCT) test outcomes, or confirmation at post-mortem), or the size of bTB breakdowns (number of SICCT test positive animals), of herds was also investigated to assess whether there was an association (co-infection) with herd BVDV status. The final models suggested that BVDV herd status was positively associated with increased levels of calf mortality, herd size, number of births, the number of BVDV tests undertaken and the number of animals introduced to the herd. There was a significant univariable positive association between BVDV status, and SICCT breakdown risk, breakdown size and confirmed bTB status in model 2. However, there was no evidence of significant associations between bTB status (using SICTT status, confirmed status or herd breakdown size) and BVDV status in final multivariable models when controlling for other significant confounders. These results provide information for action for the future control and eradication of BVDV in Northern Ireland, though these data provide little support for the hypothesised association between BVDV and bTB status at herd-level. Further animal-level analyses are necessary to investigate whether there is support for a BVD-bTB co-infection association, including the impact of co-infection on the severity of infection.

Feeding decisions in advanced dementia.

When close to death, people stop eating. In neurodegenerative conditions swallowing may become unsafe, and artificial nutrition and hydration (ANH) may be proposed or requested. But nutrition is surrounded by other considerations: opportunity, help, environment, enjoyment, mood, social being and symbolic importance. Poor care or deliberate attempts to end life might also result in poor nutrition and dehydration. Decisions about ANH are open to conventional ethical analysis and subject to mental capacity law. Most people with appetite or swallowing failure have advanced dementia and lack capacity. Determining someone's best interests means considering values and preferences, previous and current wishes, and requires consultation with families and other carers. Short-term prognosis is difficult to judge in non-malignant conditions. We often do not know the views of the individual. Moreover, we are unsure if ANH can achieve the goals intended of it - there is little evidence that tube feeding prolongs life, prevents aspiration or improves wellbeing. Palliative care and best practice dementia care have much in common. Open communication, good relationships with families and carers, skilled approaches to problems and respect for individuals and their diversity. Modified oral feeding will be appropriate for most; ANH is rarely appropriate, but some individuals and their families feel differently. Careful assessment for potentially treatable causes of swallowing and appetite problems, honest communication about uncertainties over prognosis and the impact of interventions and ascertainment of individuals' values and beliefs make for better care for people with dementia and better decisions about feeding.

Caring for cognitively impaired older patients in the general hospital: a qualitative analysis of similarities and differences between a specialist Medical and Mental Health Unit and standard care wards.

BACKGROUND: Around half of people aged over 70 years admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A Medical and Mental Health Unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random sub-sample of participants and the recording of field notes. OBJECTIVES: The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes. DESIGN: Field notes were analysed using the constant comparison method. SETTING: A large hospital within the East Midlands region of the United Kingdom. PARTICIPANTS: Patient participants were aged over 65, and identified by Admissions Unit physicians as being 'confused'. Most patients had delirium or dementia. RESULTS: Sixty observations (360 h) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients. CONCLUSION: Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward.

The evidence for treating hypertension in older people with dementia: a systematic review.

Hypertension and dementia commonly co-exist in older people, yet guidance is lacking on how to manage these co-existing conditions. The aim of this systematic review was to assess the evidence for the treatment of hypertension in older people with dementia. Medline, EMBASE, Cochrane Library and the national research register archives were searched. Inclusion criteria were: randomised controlled trial of hypertension treatment, included participants aged 65+ years, participants had a diagnosis of dementia (global cognitive decline for at least 6 months affecting daily function), and the study assessed cognitive outcomes using validated tools. Dementia prevention studies and poor quality studies were excluded. The initial search revealed 1178 papers of potential interest, of which 24 were selected for review and six met the full inclusion criteria. Trials included people with mild-to-moderate but not severe dementia; exclusion criteria for the trials were extensive. Four trials were placebo-controlled RCTs; the remaining two compared different antihypertensives. All trials reported MMSE scores at baseline and follow-up; four reported blood pressure changes at follow-up; and only three reported cardiovascular morbidity or mortality at follow-up. Only one of four placebo-controlled studies showed evidence of blood pressure reduction, but no clear evidence for benefit (or harm) from antihypertensives on cognition, physical function or other cardiovascular outcomes. We found no evidence to confirm or refute the hypothesis that treatment of hypertension in people with dementia leads to overall health benefit.

Epidemiology and management of a bovine brucellosis cluster in Northern Ireland.

An epidemiological investigation was undertaken of 41 bovine brucellosis outbreaks that occurred within a 10-month period, in a region where eradication measures appeared to be succeeding. The primary outbreak comprised three herds with significant within-herd spread and a high probability of multiple abortions. Direct contact between cattle at pasture was the most likely means of between-herd transmission for most (71%) outbreaks, with an attack rate of 28.1% in herds immediately neighbouring the primary outbreak herds and 11.3% in the next concentric ring of farms. Resolution of the incident was attributed to a rapid response by the veterinary authorities, detailed epidemiological investigations, repeated, prolonged testing of contact herds and employment of parallel testing.

Second-eye cataract surgery in elderly women: a cost-utility analysis conducted alongside a randomized controlled trial.

AIM: The aim of this study was to evaluate the cost-effectiveness of second-eye cataract surgery for older women with minimal visual dysfunction in the eye to be operated on from a Health and Personal Social Services perspective, compared to waiting list controls who had already undergone first-eye cataract surgery. METHODS: A cost-utility analysis was undertaken alongside a randomized controlled trial of second-eye cataract surgery in secondary care ophthalmology clinics. A total of 239 women over 70 years old with one unoperated cataract were randomized to cataract surgery (expedited, approximately 4 weeks) or control (routine surgery, 12 months wait). Outcomes were measured in terms of quality-adjusted life years (QALYs), with health-related quality of life estimated using the EuroQol EQ-5D. RESULTS: The operated group had costs which were, on average, pound646 more than the control group (95% confidence interval, pound16-1276, P<0.04) and had a mean QALY gain of 0.015 (95% confidence interval, -0.039 to 0.068, P=0.59) per patient over 1 year. Therefore, the incremental cost-utility ratio was pound44,263 over the 1-year trial period. In an analysis modelling costs and benefits over patients' expected lifetime, the incremental cost per QALY was pound17,299, under conservative assumptions. CONCLUSIONS: Second-eye cataract surgery is not likely to be cost-effective in the short term for those with mild visual dysfunction pre-operation. In the long term, second-eye cataract surgery appears to be cost-effective unless carer costs are included.

The SF-36: a simple, effective measure of mobility-disability for epidemiological studies.

BACKGROUND: Mobility disability is a major problem in older people. Numerous scales exist for the measurement of disability but often these do not permit comparisons between study groups. The physical functioning (PF) domain of the established and widely used Short Form-36 (SF-36) questionnaire asks about limitations on ten mobility activities. OBJECTIVES: To describe prevalence of mobility disability in an elderly population, investigate the validity of the SF-36 PF score as a measure of mobility disability, and to establish age and sex specific norms for the PF score. METHODS: We explored relationships between the SF-36 PF score and objectively measured physical performance variables among 349 men and 280 women, 59-72 years of age, who participated in the Hertfordshire Cohort Study (HCS). Normative data were derived from the Health Survey for England (HSE) 1996. RESULTS: 32% of men and 46% of women had at least some limitation in PF scale items. Poor SF-36 PF scores (lowest fifth of the gender-specific distribution) were related to: lower grip strength; longer timed-up-and-go, 3m walk, and chair rises test times in men and women; and lower quadriceps peak torque in women but not men. HSE normative data showed that median PF scores declined with increasing age in men and women. CONCLUSION: Our results are consistent with the SF-36 PF score being a valid measure of mobility disability in epidemiological studies. This approach might be a first step towards enabling simple comparisons of prevalence of mobility disability between different studies of older people. The SF-36 PF score could usefully complement existing detailed schemes for classification of disability and it now requires validation against them.

Complications of awake fibreoptic intubation without sedation in 200 healthy anaesthetists attending a training course.

BACKGROUND: Two hundred anaesthetists underwent airway endoscopy and attempted awake fibreoptic intubation (FOI) on a training course. Complications were recorded and each subject's response to the procedure was assessed. METHODS: Topical airway local anaesthesia was produced with up to 9 mg kg(-1) of lidocaine, sedation was not used. Complications during and after the procedure were noted. Later, the subjects completed an anonymous questionnaire about anxiety, pain, coughing, and side-effects of lidocaine. RESULTS: More than 1300 endoscopies were performed, 180 delegates were intubated, 175 by the nasal route and five orally. Intubation was abandoned in 20 (10%) subjects. Nasal bleeding occurred in 20 (10%) subjects. Symptoms that could be attributed to lidocaine were reported by 71 (36%) subjects. Afterwards, two (1%) subjects experienced rigors and one developed a lower respiratory tract infection. CONCLUSIONS: Nasendoscopy and FOI under local anaesthesia are associated with complications, notably those of infection and airway trauma. Side-effects potentially attributable to lidocaine administration were commonly reported.

Development of a new measure of health-related quality of life for people with dementia: DEMQOL.

BACKGROUND: We identified the need to develop a scientifically rigorous measure of health-related quality of life (HRQL) in dementia that would be appropriate for use at all stages of dementia severity and would be available in both self- and proxy-report versions. METHOD: We used standard psychometric methods to eliminate items with poor psychometric properties (item-reduction field test) and to assess the acceptability, reliability and validity of the item-reduced instruments (psychometric evaluation field test). We developed and validated two versions of DEMQOL: a 28-item interviewer-administered questionnaire that is self-reported by the person with dementia (DEMQOL) and a 31-item interviewer-administered questionnaire that is proxy-reported by a caregiver (DEMQOL-Proxy). RESULTS: DEMQOL shows high reliability (internal consistency and test-retest) and moderate validity in people with mild/moderate dementia. DEMQOL-Proxy shows good acceptability and internal consistency and moderate evidence of validity in people with mild/moderate and severe dementia. Test-retest reliability and performance in people with severe dementia need further testing. CONCLUSIONS: DEMQOL and DEMQOL-Proxy show psychometric properties that are comparable with the best available dementia-specific measures of HRQL. We recommend that DEMQOL and DEMQOL-Proxy are used together. Reliability and validity need to be confirmed in independent samples and responsiveness needs to be evaluated.

Quality of life in dementia: more than just cognition. An analysis of associations with quality of life in dementia.

OBJECTIVES: To explore the extent to which commonly used measures of specific outcomes in dementia are an appropriate proxy for quality of life in dementia. METHODS: This was a cross sectional study set in communities in London and Nottingham, comprising 101 people with dementia and their 99 main family caregivers. The main outcome measures were health related quality of life in dementia (measured by the DEMQOL-Proxy), cognition (Mini Mental State Examination), functional impairment (Barthel Index), behavioural and psychological symptoms in dementia (Neuropsychiatric Inventory; NPI), and carer mental health (General Health Questionnaire). RESULTS: On univariate analysis, decreased quality of life was statistically significantly correlated with higher levels of behavioural and psychological disturbance (NPI total score and its agitation, depression, anxiety, disinhibition, and irritability subscales); younger age of the person with dementia; and poorer mental health of the carer. Quality of life was not statistically significantly associated with cognition or carer age. In a multivariate model, psychological and behavioural disturbance and patient age remained statistically significantly associated with quality of life. Carer mental health was no longer statistically significantly associated, and cognition and functional limitation remained statistically insignificant. CONCLUSIONS: These data suggest that quality of life in dementia is complex, and that simple proxy substitutions of discrete measures such as cognition or function are likely to miss important factors.

Combined nebulization and spray-as-you-go topical local anaesthesia of the airway.

BACKGROUND: Twenty-five anaesthetists underwent awake fibreoptic intubation using a combination of nebulization and topical local anaesthesia. Plasma lidocaine concentrations were measured and the quality of the local anaesthesia was assessed. METHODS: After i.v. glycopyrrolate 3 microg kg(-1) and intranasal xylometolazone 0.1%, lidocaine 4% 200 mg was administered by nebulizer. Supplementary lidocaine to a maximum total of 9 mg kg(-1) was applied directly and via a fibreoptic endoscope. Nasotracheal intubation was performed once the vocal cords became unreactive. Heart rate, non-invasive blood pressure and oxygen saturation were recorded at 5-min intervals. Blood sampling commenced with a baseline sample and continued at 10 min intervals until 60 min after final administration of local anaesthetic. Subjects graded levels of anxiety, pain and coughing using written and visual analogue scales. RESULTS: Conditions for fibreoptic endoscopy and intubation were good. Seventeen received the maximum lidocaine dose of 9 mg kg(-1). The average dose used was 8.8 mg kg(-1). All plasma lidocaine concentrations assayed were below 5 mg litre(-1). Four volunteers reported feeling lightheaded after the procedure, despite normal blood pressure. Of these, two had the highest plasma lidocaine concentrations recorded: 3.5 and 4.5 mg litre(-1). Twenty-two of the 25 subjects found endoscopy and intubation acceptable, three found it enjoyable and no subject rated it as distressing. CONCLUSIONS: This method of airway anaesthesia was acceptable to this small group of unsedated subjects. It produced good conditions for fibreoptic intubation. A maximum calculated lidocaine dose of 9 mg kg(-1) did not produce toxic plasma concentrations of lidocaine.