Cadaveric study of movement of an unstable atlanto-axial (C1/C2) cervical segment during laryngoscopy and intubation using the Airtraq(®) , Macintosh and McCoy laryngoscopes.

Concern that laryngoscopy and intubation might create or exacerbate a spinal cord injury has generated extensive research into cervical spinal movement during laryngoscopy. We performed a randomised trial on six cadavers, using three different laryngoscopes, before and after creating a type-2 odontoid peg fracture. Our primary outcome measure was the change in the space available for the spinal cord at the C1/2 segment measured by cinefluoroscopy. Tracheal intubation was performed using a minimal view of the glottis, a bougie, and manual in-line stabilisation. In a cadaveric model of type-2 odontoid fracture, the space available for the cord was preserved in maximum flexion and extension, and changed little on laryngoscopy and intubation.

The dangerous gamble of heparinization within two weeks of nonoperative traumatic acute subdural hematoma in patients with increased stroke risk: a case series.

BACKGROUND: In traumatic acute subdural hematoma (aSDH) management, systemic anticoagulation is contraindicated, particularly during the first 2 weeks. We present two cases of patients with nonoperative aSDH whose stroke risk led to heparinization within 2 weeks of the initial hemorrhage and examine their outcomes to illustrate the risks and benefits associated with systemic anticoagulation. MATERIALS AND METHODS: Two elderly males, on warfarin at baseline who developed traumatic nonoperative aSDH were heparinized within 2 weeks of aSDH onset. RESULTS: One patient showed a decreased SDH volume on Day 19. The second patient developed sudden onset headache with fixed/dilated pupils on Day 5. In this patient, a CT scan of the brain revealed marked enlargement of the aSDH from 0.9 to 2.4 cm with midline shift of 1.5 cm, and uncal herniation that was incompatible with life. CONCLUSION: Heparinization within two weeks of aSDH may cause SDH enlargement resulting in rapidly fatal neurologic deterioration. Further study is needed to more definitively address this issue.

Pre-oxygenation and apnoea in pregnancy: changes during labour and with obstetric morbidity in a computational simulation.

Using the Nottingham Physiology Simulator, we investigated the effects on pre-oxygenation and apnoea during rapid sequence induction of labour, obesity, sepsis, pre-eclampsia, maternal haemorrhage and multiple pregnancy in term pregnancy. Pre-oxygenation with 100% oxygen was followed by simulated rapid sequence induction when end-tidal nitrogen tension was less than 1 kPa, and apnoea. Labour, morbid obesity and sepsis accelerated pre-oxygenation and de-oxygenation during apnoea. Fastest pre-oxygenation was in labour, with 95% of the maximum change in expired oxygen tension occurring in 47 s, compared to 97 s in a standard pregnant subject. The labouring subject with a body mass index of 50 kg x m(-2) demonstrated the fastest desaturation, the time taken to fall to an arterial saturation < 90% being 98 s, compared to 292 s in a standard pregnant subject. Pre-eclampsia prolonged pre-oxygenation and tolerance to apnoea. Maternal haemorrhage and multiple pregnancy had minor effects. Our results inform the risk-benefit comparison of the anaesthetic options for Caesarean section.

Pre-oxygenation in pregnancy: an investigation using physiological modelling.

Hypoxaemia during anaesthetic induction in obstetrics is hazardous for mother and baby, but the onset of desaturation can be delayed by pre-oxygenation. This study investigated pre-oxygenation during pregnancy using computer simulation. The Nottingham Physiology Simulator was configured to replicate normal pregnant physiology. Three pregnant and three non-pregnant subjects were created, representing population variation according to published physiological values. They underwent pre-oxygenation by tidal and vital capacity breathing of 100% oxygen. Pre-oxygenation during tidal breathing proceeded more rapidly in pregnancy, the median [range] time to achieve 95% of the maximum change in P(E)O2 being 1 min 37 s [1:23-1:52] in pregnant subjects, compared to 2 min 51 s [2:28-3:15] in non-pregnant subjects. Vital capacity pre-oxygenation required seven breaths [5-10] in pregnant subjects, compared to six breaths [4-9] in non-pregnant subjects, to achieve the same P(E)O2 as after 95% complete tidal pre-oxygenation. We recommend 2 min of tidal breathing for pre-oxygenation in pregnancy.

Apnoea in pregnancy: an investigation using physiological modelling.

Oxygen desaturation during apnoea following anaesthetic induction in obstetrics is hazardous for mother and baby. This study investigated apnoea during pregnancy using computer simulation. The Nottingham Physiology Simulator was configured to replicate normal pregnant physiology. Three pregnant and three non-pregnant subjects were created, representing population variation according to published physiological values. They each commenced apnoea from four levels of pre-oxygenation from none to 99% complete denitrogenation. During apnoea, the physiological changes of rapid sequence induction were simulated. We found reduced apnoea tolerance in pregnancy, the median [range] time taken to fall to S(a)O2 < 90% after 99% complete denitrogenation being 4 min 52 s [3:43-6:17] in the pregnant subjects, vs 7 min 25 s [5:49-9:42] in the non-pregnant subjects. The time taken to fall from S(a)O2 90% to 40% was 35 s [32-45] in the pregnant vs 45 s [38-56] in the non-pregnant subjects. Two minutes of pre-oxygenation by tidal breathing provides approximately 3.5-6 min before desaturation to < 90%.

Relationship of clinical efficacy to postmortem-determined anatomic subthalamic stimulation in Parkinson syndrome.

OBJECTIVE/BACKGROUND: Patients with medically refractory Parkinson's disease (PD) obtain significant clinical benefit from subthalamic nucleus (STN) stimulation. The degree to which a successful outcome relates to the anatomic location of the stimulating electrode has not yet been clearly established. Many studies have attempted to correlate the clinical result with the electrode location using postoperative magnetic resonance imaging (MRI) and there have been a few that used autopsy-determined locations. In this report, we describe long-term clinical follow-up in a patient with autopsy-determined electrode tip anatomic location. METHODS: A 67-year-old patient with a 27-year history of idiopathic PD complicated by disabling motor fluctuations and dopaminergic dyskinesias underwent bilateral STN deep brain stimulation (DBS). He was prospectively followed in a long-term clinical protocol until his death 40 months after electrode placement. Postoperative magnetic resonance (MR) imaging and postmortem studies of this patient's brain were performed to localize DBS tip locations. RESULTS: STN stimulation produced improvement of the patient's motor fluctuations, dyskinesias and clinical motor performance, especially appendicular tremors, rigidity and bradykinesia. MRI showed the electrode tips to be within 2 mm of the intended target. Postmortem brain analysis identified the right DBS tip location at the dorsomedial edge of the STN, with the left electrode in the vicinity (but not within) the STN. Chronic DBS elicited minor reactive changes were confined to the immediate vicinity of the electrode tracks. The pathological analysis demonstrated numerous cortical Lewy bodies and degenerative encephalopathy, establishing the diagnosis of transitional type diffuse Lewy body disease (DLBD) rather than simple PD. CONCLUSION: This patient obtained clinical benefit from STN stimulation typical of that seen for most PD patients. Both the MR analysis and the autopsy demonstrated electrode placement at or outside the boundaries of the STN, suggesting that that clinical efficacy may not depend on electrode location within the central region of the STN.

Operative techniques and morbidity with subthalamic nucleus deep brain stimulation in 100 consecutive patients with advanced Parkinson's disease.

OBJECTIVE: Subthalamic nucleus (STN) stimulation for patients with medically refractory Parkinson disease (PD) is expanding. Reported experience has provided some indication of techniques, efficacy, and morbidity, but few centres have reported more than 50 patients. To expand this knowledge, we reviewed our experience with a large series of consecutive patients. METHODS: From March 1999 to September 2003, 191 subthalamic stimulator devices (19 unilateral) were implanted in 100 patients with PD at New York Presbyterian Hospital/Columbia University Medical Center. Sixteen patients had undergone a prior surgery for PD (pallidotomy, thalamotomy, or fetal transplant). Microelectrode guided implantations were performed using techniques similar to those described previously. Electrode implantation occurred 1-2 weeks before outpatient pulse generator implantation. RESULTS: Reductions of dyskinesias and off severity/duration were similar to prior published reports. Morbidity included: 7 device infections (3.7%), 1 cerebral infarct, 1 intracerebral haematoma, 1 subdural haematoma, 1 air embolism, 2 wound haematomas requiring drainage (1.0%), 2 skin erosions over implanted hardware (1.0%), 3 periprocedural seizures (1.6%), 6 brain electrode revisions (3.1%), postoperative confusion in 13 patients (6.8%), and 16 battery failures (8.4%). Of the 100 patients, there were no surgical deaths or permanent new neurological deficits. The average hospital stay for all 100 patients was 3.1 days. CONCLUSION: Subthalamic stimulator implantation in a large consecutive series of patients with PD produced significant clinical improvement without mortality or major neurological morbidity. Morbidity primarily involved device infections and hardware/wound revisions.

The diagnostic acceptability of low-bandwidth transmission for tele-ultrasound.

Ultrasound recordings were made of 100 consecutive patients attending for obstetric examination in Peterhead and 100 patients attending for non-obstetric examination in Aberdeen. Two identical video-conferencing machines were used to transmit and receive the original ultrasound images at data rates of 384 kbit/s and 128 kbit/s, thus producing a total of three tapes for each case. Four experienced observers, who were blinded to the transmission bandwidth, each viewed 300 examinations and decided whether the images were acceptable or not for diagnosis. Almost 100% of the obstetric ultrasound images on the original recordings were considered diagnostically acceptable, compared with 93% of the 384 kbit/s transmissions and 44% of the 128 kbit/s transmissions. Similarly, 99% of the non-obstetric ultrasound images were considered acceptable, compared with 87% of the 384 kbit/s transmissions and 21% of the 128 kbit/s transmissions. For the obstetric ultrasound images the intra-observer diagnostic agreement was 93% (kappa = 0.89) between the original and the 384 kbit/s transmissions, and 78% (kappa = 0.63) between the original and the 128 kbit/s transmissions. For the non-obstetric ultrasound images the respective intra-observer diagnostic agreements were 77% (kappa = 0.62) and 78% (kappa = 0.63). The quality of dynamic ultrasound images transmitted at 384 kbit/s was diagnostically acceptable, but was unsatisfactory at 128 kbit/s.

From district general hospital to local general hospital.

Much debate has centred around the future of acute services in the NHS in the UK with particular reference to the role and function of the District General Hospital. This paper explores a new model of hospital development--the 'Local General Hospital' which lies somewhere between the DGH and the cottage or community hospital. The paper uses the case study of Neath General Hospital in South Wales which moved to a LGH model. The paper explores the functional content of the LGH balancing accessibility with cost and clinical effectiveness. The paper makes particular reference to the development of clinical networks which cross organisational boundaries and the support of GPs and consultant medical staff as key success factors in the transition from DGH to LGH.

Nuchal thickening in Jacobsen syndrome.

A routine detailed ultrasound examination performed at 20 weeks' gestation demonstrated the presence of nuchal thickening as an apparently isolated finding. The concentration of maternal alpha-fetoprotein was normal and the risk of Down's syndrome was 1 in 6800. Amniocentesis was performed and chromosome analysis showed the karyotype 46,XY, del(11)(q23) found in Jacobsen syndrome. Fetal autopsy performed following medical termination at 23 weeks confirmed the phenotype and internal abnormalities found in Jacobsen syndrome.

Risk and preventive factors for cot death in The Netherlands, a low-incidence country.

UNLABELLED: In the Netherlands an 18 months case control study into cot death was undertaken as part of the European Concerted Action (ECAS) on sudden infant death syndrome to determine the relative risk of prone sleeping and other sleep practices. Physicians in the Netherlands were asked to report to the study centre all sudden and unexpected deaths of children between 1 week and 2 years of age. Non cot death cases were deleted from further analysis after a consensus was reached by three pathologists, not primarily involved in the post mortem diagnosis. A positive response of families was achieved in 91% of cases registered in the Central Bureau of Statistics. The study comprised 73 cot deaths and 146 controls, two for each case and matched for date of birth. All families were visited at home for completion of a questionnaire. The cot death rate has dropped considerably over the past 10 years after the recommendations on supine sleeping to a low of 0.26 per 1000 live born infants. In addition to the ECAS objective, we wanted to establish whether previously found risk factors are still valid in the present situation or that new factors might have emerged, some of them possibly protective. CONCLUSION: Placing an infant prone or on side on last occasion, secondary prone position (not placed prone but turned to prone), inexperienced prone sleeping and use of a duvet, leading to head and body being covered, were shown to be risk factors. Preventive factors were using a cotton sleeping-sack and a dummy. Even in a low incidence country, such as the Netherlands, there are indications that further prevention is possible.

Management education for undergraduate doctors. A survey of medical schools.

Explores the extent to, and ways in which, doctors are prepared for their future role in management through the undergraduate medical curriculum. Surveys the colleges across the UK offering undergraduate medical education using both prospectuses and questionnaires to establish both inclusion of healthcare management/policy in curricula and the subject content offered. Establishes that the majority of colleges offer some teaching of health care management/policy although the areas of study included vary considerably. The emphasis in most institutions appears to be on introducing the structure and organization of the NHS together with decision making in respect of resource allocation often located within a public health programme. This leads to the tentative conclusion that the management education needs of future public health physicians are reasonably well served while those of hospital doctors and general practitioners need further investigation.

The removal of well-fixed porous ingrown femoral components.

It is now evident that some biologically well-fixed hip prostheses may require removal and/or revision much earlier than originally anticipated. The relatively atraumatic removal of porous ingrown but clinically unacceptable femoral components, while difficult, has become increasingly feasible because of accumulated clinical experience and advances in biomedical technology. Preoperative planning, adequate instrument armamentarium, and intraoperative patience are important keys to the successful removal of these implants.

Progressive diaphyseal dysplasia presenting as neuromuscular disease.

Two children with progressive diaphyseal dysplasia (Engelmann's disease) were initially diagnosed as having a neuromuscular disorder because of their clinical presentations of muscle weakness, a waddling gait, and limb pain. Radiographs revealed the characteristic radiographic changes.

Ipsilateral carpal, metacarpal, and ankle fractures resulting from an attempted basketball slam-dunk. A case report.

A 23-year-old male recreational basketball player sustained an open ankle fracture and ipsilateral carpal and metacarpal fractures as a result of a fall while attempting a slam-dunk. The wrist and hand fractures were treated nonoperatively. The open ankle fracture required irrigation, debridement, and open reduction/internal fixation. In addition to the prerequisite leaping ability, long-term success in "playing above the rim" requires experience, exceptional physical agility, and the mental discipline to anticipate and avoid slam-dunk opportunities with high risk for personal injury.

Drinking patterns and abstinence among the elderly.

For almost a decade the research literature has reflected both the scarcity of new knowledge regarding alcohol use or abuse among the elderly and the need to address the problem. Current theoretical perspectives on probable trends of alcohol-related problems among older persons include historical-cohort prediction, biological and clinical geriatric expectations, and sociocultural-economic expectations. These theoretical perspectives are frequently in opposition to each other and are largely untested with appropriate data. This paper introduces the principal theoretical perspectives of alcohol use among the elderly and presents recent data from a probability sample of noninstitutionalized elderly persons regarding alcohol consumption patterns, abstinence, and the influence of increasing chronological age and economic security on alcohol consumption.