Institutional preparedness to prevent and manage anaesthesia-related 'can't intubate, can't oxygenate' events in Australian and New Zealand teaching hospitals.

It is unclear how the recent local and international focus on systems issues and human factors in 'can't intubate, can't oxygenate' events has impacted institutional preparedness in Australia and New Zealand. This study attempts to capture a snapshot of current practices in Australian and New Zealand teaching hospitals with regard to preparedness to prevent and manage 'can't intubate, can't oxygenate' events. All Australian and New Zealand College of Anaesthetists' teaching hospitals were invited to complete an online survey consisting of 33 questions on terminology, equipment, cognitive aids, training and quality assurance. Follow-up was by both email and telephone. Responses were received from 129 (91%) of the 142 sites. The survey revealed both countries have largely moved to point-of-care 'can't intubate, can't oxygenate' equipment. There were regional differences reported, with Australia favouring equipment, cognitive aids and teaching that supports a combined cannula and scalpel approach to 'can't intubate, can't oxygenate', whilst New Zealand favours those promoting a scalpel-only approach. A lack of consistency with the terminology used around 'can't intubate, can't oxygenate' both within and between the two countries was also identified. This survey has revealed a generally reassuringly high degree of institutional preparedness to prevent and manage 'can't intubate, can't oxygenate' events across both countries but with strong regional differences in approaches. Little is known of the institutional practices outside these countries, making international comparison difficult.

The establishment of an anaesthetist-managed intraoperative neurophysiological monitoring service and initial outcome data.

Neurophysiological monitoring has been recommended to reduce the risk of neurological damage during a wide variety of surgeries. While the concept of an anaesthesia-led intraoperative neurophysiological monitoring (IONM) service is not new, the quality of this service provision has not been studied. In this article, we present our experience with the establishment of this service, and the results of our audit of 302 cases monitored over the initial four years. Our results identified that an anaesthesia-led IONM service was able to achieve a reliable signal in 95.4% of cases and capture significant alerts in 15.6% of these cases with sensitivity, specificity, false positive and negative rates consistent with published data. Our results indicate an anaesthesia-led IONM service is effective in identifying patients at an increased risk of an adverse outcome.

A cadaver study comparing three fibreoptic-assisted techniques for converting a supraglottic airway to a cuffed tracheal tube.

After rescuing an airway with a supraglottic airway device, a method to convert it to a cuffed tracheal tube is often needed. The best method to do this has never been directly studied. We compared three techniques for conversion of a standard LMA® Unique airway to a cuffed endotracheal tube using a fibrescope. The primary endpoint was time to intubation, with secondary endpoints of success rate, perceived difficulty and preferred technique. We also investigated the relationship between level of training and prior training and experience with the techniques on the primary outcome. The mean (95% CI) time to intubation using a direct tracheal tube technique of 37 (31-42) s was significantly shorter than either the Aintree intubation catheter technique at 70 (60-80) s, or a guidewire technique at 126 (110-141) s (p < 0.001). Most (13/24) participants rated the tracheal tube as their preferred technique, while 11/24 preferred the Aintree technique. In terms of perceived difficulty, 23/24, 21/24 and 9/24 participants rated the tracheal tube technique, Aintree technique and guidewire technique, respectively, as either very easy or easy. There was no relationship between prior training, prior experience or level of training on time to completion of any of the techniques. We conclude the tracheal tube and Aintree techniques both provide a rapid and easy method for conversion of a supraglottic airway device to a cuffed tracheal tube. The guidewire technique cannot be recommended.

The effects of right-hemisphere brain damage on patients' use of terms of personal reference.

Successful communication depends on social as well as linguistic factors. In conversation, for example, a speaker must often refer to another person. Choosing an appropriate term of personal reference requires a speaker to consider several features of the discourse context, including properties of the persons being referred to and what knowledge is shared between the speaker and his or her addressee. In a pair of similar studies, we examined how right-hemisphere brain-damaged (RHD) patients and nonbrain-damaged control subjects use these different kinds of information in choosing formal (e.g., "Mr. Harding") versus informal ("Oliver") terms of reference for an absent third person. Stimulus vignettes manipulated three variables: the occupational status of the referent, the speaker's familiarity with the referent (i.e., the degree to which the speaker and referent were personally acquainted), and the addressee's familiarity (i.e., the degree to which the addressee and referent were personally acquainted). Relative to the control subjects, the RHD patients showed decreased use of both familiarity variables when choosing formal over informal labels, but apparently preserved sensitivity to the status variable. These results suggest how decreased use of the knowledge shared between a speaker and addressee disrupts RHD patients' discourse and thus contributes to these patients' aberrant interpersonal behavior. In addition. In addition, the results from the second study demonstrated an asymmetry in how female versus male subjects responded to the status manipulation.

The use of pronoun anaphora and speaker mood in the interpretation of conversational utterances by right hemisphere brain-damaged patients.

Understanding utterances in conversations requires a listener to weigh the disparate pieces of information present in a discourse. In this study, we examined how right hemisphere brain-damaged (RHD) patients and non-brain-damaged control subjects interpreted responses to questions concerning the location of a person (e.g., "Where's Dad?"). Stimulus vignettes included variation on three factors relevant to discourse comprehension: the mood of a speaker, the plausibility of the answer to a question, and whether the answer contained an anaphoric pronoun linking the response to the preceding question. Relative to the control subjects, the RHD patients made greater than normal use of the presence/absence of an anaphoric pronoun in their utterance interpretations, less than normal use of the speaker's mood, and marginally less than normal use of a response's plausibility. These data show how RHD patients rely on their largely intact linguistic abilities when understanding discourse and how their comprehension goes awry due to their reduced appreciation of other essential aspects of natural communication. The discussion focuses on the variable roles of speaker mood, plausibility, and pronoun anaphora in supporting inferences about a speaker's intended meaning and on the selective nature of RHD patients' impairment in this domain.

Story processing in right-hemisphere brain-damaged patients.

The understanding of stories requires sensitivity to structural aspects of narrative, the emotional content conveyed by the narrative, and the interaction between structural and emotional facets of the story. Right-hemisphere-damaged (RHD) and normal control subjects performed a number of different analytic tasks which probed their competence at story comprehension. Results revealed that RHD subjects perform at a level comparable to that of normal controls with stories that follow a canonical form and that they show few difficulties with structural aspects of narrative. Contrary to expectation, they are strongly influenced by the "interest" level of a story and by other factors that tap emotional sensitivity. Findings are discussed in terms of the processing and arousal mechanisms which may give rise to the observed pattern of difficulties in RHD patients.

Sensitivity to conversational deviance in right-hemisphere-damaged patients.

To participate meaningfully in conversation, speakers must be sensitive to statements which advance and those which block the direction of a discourse. The effect of right-hemisphere damage (RHD) on sensitivity to conversational advancers and blockers was investigated by asking subjects to interpret normal conversations and conversations which were blocked by violations of Gricean maxims: specifically, tangential and redundant statements. Results indicate that RHD patients function normally in canonical, directed conversation. However, they have difficulty interpreting and judging the effect of blocking statements, particularly with regard to tangentiality. The results are discussed in terms of a mental model of directed conversation which incorporates both structural and affective components.

Familial continual skin peeling.

A clinical picture of familial continual peeling of the skin is described and discussed together with light and ultramicroscopic manifestations in one of the probands. The pattern of splitting distinguishes this condition from keratolysis exfoliativa. The ultramicroscopy exhibited mainly predominance of low-density keratocytes in the corneal layer, abnormalities in distribution of lamellar granules and disrupted coating of the cells in the intercellular spaces of the corneal layer.

Richner-Hanhart syndrome (tyrosinaemia-II) (report of four cases without ocular involvement).

Four cases of tyrosinaemia with cutaneous manifestations, but without ocular involvement, are reported in a family with consanguineous parents. The tyrosine levels in the serum and in the urine were normal in both parents, while in the offsprings the tyrosine levels were elevated 7 1/2-13 times in the serum and 3-13 times in the urine. Although the serum tyrosine levels in our cases were higher than most of the cases reported in the literature the eyes of all our patients were normal. The skin manifestations were very impressive, and varying degrees of mental retardation were present in all patients. The patients put on a low-protein diet improved considerably and have been kept symptom-free for 1 1/2 years. The possible implication of the discrepancy between the high serum levels and lack of ocular changes is discussed. Our results suggest that the Richner-Hanhart syndrome may include more than one distinct biochemical entity.

Angiolymphoid hyperplasia with eosinophilia. An electron microscopy study.

Ultrastructural investigation of a case of papular (dermal) lymphoid hyperplasia with eosinophilia revealed in the proliferating tissue rounded inclusion bodies made up of smaller particles which formed within the lysosomal vacuoles and sometimes occupied a large proportion of the cytoplasm. The bodies also occur in the extracellular spaces. Apart from this, groups of mosaic-like particles and concentric bodies with a central core suggesting viral provenance were demonstrated.