Direct versus indirect laryngoscopy using a Macintosh video laryngoscope: a mannequin study comparing applied forces.

PURPOSE: Upper airway injury and sympathetic activation may be related to the forces applied during laryngoscopy. We compared the applied forces during laryngoscopy using direct and indirect visualization of a standardized mannequin glottis. METHODS: Force transducers were applied to the concave surface of a GlideScope T-MAC Macintosh-style video laryngoscope that can also be used as a conventional direct-view laryngoscope. Thirty-four anesthesiologists performed four laryngoscopies (two direct and two indirect views) on an Ambu mannequin in a randomized sequence. During each laryngoscopy, participants were instructed to obtain views corresponding to > 80% and 50% of the glottic opening aperture. Peak and impulse forces were measured for each view. RESULTS: To achieve a 50% glottic opening view, the top 10th percentile force was higher with direct vs indirect laryngoscopy in terms of peak (difference, 9.1 newton; 99% confidence interval [CI], 7.4 to 13.9) and impulse (difference, 56.4 newton·sec; 99% CI, 49.0 to 81.7) forces. To achieve >80% view of the glottic opening, median force was higher with direct vs indirect laryngoscopy in terms of peak (difference, 3.6 newton; 99% CI, 1.6 to 7.3) and impulse (difference, 20.4 newton·sec; 99% CI, 11.7 to 35.1) forces. CONCLUSIONS: In this mannequin study, lower forces applied during indirect vs direct laryngoscopy may reflect an advantage of video laryngoscopy, but additional studies using patients are required to confirm the clinical implications of these findings.

RéSUMé: OBJECTIF: Les lésions aux voies aériennes supérieures et l'activation du système sympathique pourraient être dues aux forces appliquées pendant la laryngoscopie. Nous avons comparé les forces appliquées pendant une laryngoscopie avec visualisation directe vs indirecte d'une glotte standardisée sur mannequin. MéTHODE: Des transducteurs ont été appliqués à la surface concave d'un vidéolaryngoscope de type Macintosh GlideScope T-MAC, un dispositif qui peut également être utilisé comme laryngoscope conventionnel avec visualisation directe. Trente-quatre anesthésiologistes ont chacun réalisé quatre laryngoscopies (deux visualisations directes et deux indirectes) sur un mannequin Ambu en suivant une séquence randomisée. Pendant chaque laryngoscopie, les participants avaient pour consigne d'obtenir des vues correspondant à > 80 % et 50 % de l'ouverture glottique. Les forces maximales et impulsions ont été mesurées pour chaque visualisation. RéSULTATS: Pour obtenir une visualisation à 50 % de l'ouverture glottique, le 10e percentile maximal était plus élevé en cas de laryngoscopie directe qu'en cas de laryngoscopie indirecte tant au maximum de la force (différence, 9,1 newton; intervalle de confiance [IC] 99 %, 7,4 à 13,9) qu'à l'impulsion (différence, 56,4 newton·sec; IC 99 %, 49,0 à 81,7). Pour obtenir une visualisation à > 80 % de l'ouverture glottique, la médiane était également plus élevée en cas de laryngoscopie directe qu'en cas de laryngoscopie indirecte, tant au maximum de la force (différence, 3,6 newton; intervalle de confiance [IC] 99 %, 1,6 à 7,3) qu'à l'impulsion (différence, 20,4 newton·sec; IC 99 %, 11,7 à 35,1). CONCLUSION: Dans cette étude sur mannequin, les forces et impulsions moins prononcées appliquées pendant la laryngoscopie indirecte plutôt que directe pourraient refléter un avantage de la vidéolaryngoscopie, mais des études supplémentaires sur patient sont nécessaires afin de confirmer les implications cliniques de ces résultats.

Supraglottic airway devices: indications, contraindications and management.

Supraglottic airway devices (SADs) have become an essential tool in airway management. Over the past three decades, these devices have been increasingly adopted as an alternative to face mask ventilation and/or endotracheal intubation. The range of proposed uses and features has increased significantly. They are used in pre- and in-hospital settings, elective and emergency anesthesia, in spontaneously breathing and ventilated patients, as conduits for intubation, as a bridge to extubation and for airway rescue. With SADs, serious complications such as aspiration and loss of airway are rare and largely preventable. Adequate operator experience, familiarity with the selected device, attention to details and careful patient selection are fundamental to safety and proficiency. In this review, we explore the increasing proposed uses for SADs and discuss possible complications and the management of these.

Perceptions of the health effects of stoves in Mongolia.

PURPOSE: The purpose of this paper is to evaluate the views of stove users in Ulaanbaatar, Mongolia on how stoves affect their health. DESIGN/METHODOLOGY/APPROACH: In this paper focus groups were conducted with improved stove users; traditional stove users; and a mix of traditional and improved stove users. Individual interviews were also held with various types of stove users. A translator moderated all discussions with a questioning route. All discussions were fully transcribed and translated. The transcripts were analysed by identifying common themes in responses to form an emerging theory. FINDINGS: The findings in the paper are that all stove users recognised respiratory symptoms caused by stove smoke and other health effects such as warmth, dirt and workload, which they perceived to be important. Stove users had a lack of knowledge about the diseases caused by the smoke. Public health was a key driver for the improved stove project, yet has been neglected in improved stove marketing. RESEARCH LIMITATIONS/IMPLICATIONS: The study used in this paper was limited by the language barrier. Some of the meanings of participants' responses may have been lost in translation. PRACTICAL IMPLICATIONS: This paper has highlighted the importance of the health effects of stove smoke to stove users. Uptake of the improved stoves has been low. Public health should be included in marketing strategies for improved stoves to increase their uptake. ORIGINALITY/VALUE: The paper shows that acute respiratory infections are a major cause of mortality world-wide. Indoor air pollution from burning biomass fuels in household stoves causes a significant proportion of respiratory infections. No qualitative research has been published exploring stove users' views on the health effects of stoves. This paper provides an insight into stove users' perceptions for those interested in people-centred approaches to tackling international health issues.

International health in medical education: students' experiences and views.

PURPOSE: The purpose of this paper is to describe the experiences and views of the first group of medical students to complete the intercalated International Health BSc in Leeds. DESIGN/METHODOLOGY/APPROACH: The paper draws on experiences of international health and draws parallels with those of other international health students. The paper also discusses how studying international health may benefit future doctors and considers how medical education can take a more international approach. FINDINGS: The paper finds that international health education can help future doctors acquire knowledge and skills in refugees' health, patients' cultural differences, the multifactoral influences on health, policymaking, the interests of various stakeholders, problem-solving skills and evidence-based medicine. PRACTICAL IMPLICATIONS: The paper shows that international health teaching is both relevant and valuable in medical education. The medical profession should give more recognition to its worth. ORIGINALITY/VALUE: This is the first paper to reflect on medical students' experiences of studying for an intercalated BSc at Leeds. It makes some important points about international health education for doctors and medical students world-wide.

In a randomized study of envelope and ink color, colored ink was found to increase the response rate to a postal questionnaire.

OBJECTIVE: To assess the effect of the colors of the envelope and ink on the response rate to a postal questionnaire in a study screening for undiagnosed parkinsonism in people aged 65 years and over in the community. STUDY DESIGN AND SETTING: A total of 2,524 people aged 65 years and over from five general practices in Aberdeen were randomized to receive a questionnaire about the symptoms of parkinsonism printed in either colored (green) or black ink, and sent out in either a brown or white envelope. RESULTS: The overall response rate was 63.5%. There was no significant interaction between envelope and ink color. The use of green ink compared to black significantly increased the response rate from 61.4% to 65.7% (OR 1.20, 95% confidence interval 1.02, 1.41). There was no overall effect of envelope color on response rate (62.3% brown and 64.8% white, OR 0.90, 95% confidence interval 0.76, 1.06) but there was significant heterogeneity between the general practices. When this general practice-envelope interaction was accounted for, brown envelopes had a significantly lower response rate than white ones (OR 0.49). CONCLUSION: This study, along with existing evidence, has shown that the use of certain ink colors in postal questionnaires is likely to increase response rates relative to black ink. The effect of envelope color was inconsistent both within this study and between previous studies.

Age-, and gender-specific incidence of vascular parkinsonism, progressive supranuclear palsy, and parkinsonian-type multiple system atrophy in North East Scotland: the PINE study.

INTRODUCTION: There have been few incidence studies of vascular parkinsonism (VP), progressive supranuclear palsy (PSP), and parkinsonian-type multiple system atrophy (MSA-P). We measured the age-, gender- and socioeconomic-specific incidence rates for these conditions in north-east Scotland. METHODS: Incident non drug-induced parkinsonian patients were identified prospectively over three years by several overlapping methods from a baseline primary care population of 311,357. Parkinsonism was diagnosed if patients had two or more cardinal motor signs. Patients had yearly follow-up to improve diagnostic accuracy. Incidence rates using the diagnosis by established research criteria at latest follow-up were calculated for each condition by age, gender, and socioeconomic status. RESULTS: Of 377 patients identified at baseline with possible or probable parkinsonism, 363 were confirmed as incident patients after median follow-up of 26 months (mean age 74.8 years, SD 9.8; 61% men). The crude annual incidence was 3.2 per 100,000 (95% confidence interval (CI) 2.2-4.3) for VP, 1.7 per 100,000 (95% CI 1.0-2.4) for PSP, and 1.4 per 100,000 (95% CI 0.8-2.1) for MSA-P. VP and MSA-P were more common in men (age-adjusted male to female ratios 2.58 (95% CI 1.65-3.83) and 8.65 (95% CI 4.73-14.5) respectively). Incidence did not vary with socioeconomic status. DISCUSSION: This is the first community-based, prospective study to report the incidence of vascular parkinsonism and the third to report the incidence of PSP and MSA-P. Further follow-up and comparison with similar studies in different populations will yield valuable prognostic and aetiological information on these conditions.

Age-, gender-, and socioeconomic status-specific incidence of Parkinson's disease and parkinsonism in northeast Scotland: the PINE study.

There have been few high quality incidence studies of Parkinson's disease (PD). We measured age-, gender- and socioeconomic-specific incidence rates for parkinsonism and PD in north-east Scotland, and compared our results with those of previous high quality studies. Incident patients were identified prospectively over three years by several overlapping methods from primary care practices (total population 311,357). Parkinsonism was diagnosed if patients had two or more cardinal motor signs. Drug-induced parkinsonism was excluded. Patients had yearly follow-up to improve diagnostic accuracy. Incidence rates using clinical diagnosis at latest follow-up were calculated for all parkinsonism and for PD by age, gender and socioeconomic status. Meta-analysis with similar studies was performed. Of 377 patients identified at baseline with possible or probable parkinsonism, 363 were confirmed as incident patients after median follow-up of 26 months (mean age 74.8 years, SD 9.8; 61% men). The crude annual incidence of parkinsonism was 28.7 per 100,000 (95% confidence interval (CI) 25.7-31.8) and PD 17.9 per 100,000 (95% CI 15.5-20.4). PD was more common in men (age-adjusted male to female ratio 1.87:1, 95% CI 1.55-2.23) but there was no difference by socioeconomic status. Meta-analysis of 12 studies showed an incidence of PD (adjusted to the 1990 Scottish population) of 14.6 per 100,000 (95% CI 12.2-17.3) with considerable heterogeneity (I(2) 95%), partially explained by population size and recruitment duration. The incidence of PD was similar to other high quality studies. The incidence of PD was not affected by socioeconomic status.

The mini-mental Parkinson's (MMP) as a cognitive screening tool in people with Parkinson's disease.

BACKGROUND: Cognitive decline is common in Parkinson's disease (PD) but may not be adequately identified by the mini-mental state examination (MMSE), which is better suited to Alzheimer's disease. The mini-mental Parkinson (MMP) examination is a cognitive screening tool designed in French specifically for PD. We aimed to establish the validity and reliability of the English language version of the MMP compared with the MMSE. METHODS: People with various stages of PD underwent testing with the MMP and MMSE, which was then compared with a reference standard battery of neuropsychological tests to identify those with significant cognitive impairment. RESULTS: Forty-nine patients were recruited. Both the MMP and MMSE were significantly correlated with scores on all the neuropsychological tests in the validation battery. The median MMP score was proportionally lower (80% of maximum) than the MMSE (90% of maximum) in PD patients with cognitive impairment and those with prior neuropsychiatric complications but there was no difference between the MMP and MMSE in areas under the curves (0.84) for detecting cognitive impairment. Test-retest reliability of the MMP was good (intra-class correlation coefficient 0.793). An MMP of 28 or lower out of 32 detected cognitive impairment with 87% sensitivity and 76% specificity. DISCUSSION: The English language version of the MMP has now been validated. It detects more cognitive deficits in PD patients than the MMSE and identifies significant cognitive impairment in those with PD at least as well as the MMSE.

Pilot study of the incidence and prognosis of degenerative Parkinsonian disorders in Aberdeen, United Kingdom: methods and preliminary results.

The objective of this study was to test the methods for a large study of the incidence and prognosis of Parkinson's disease and other degenerative parkinsonian disorders and provide provisional incidence figures. This was a community-based prospective study to identify patients with newly diagnosed non-drug-induced Parkinsonism (>or=2 of tremor, rigidity, bradykinesia, postural instability) from a population of 148,600 people in Aberdeen, Scotland, over 18 months. Multiple search strategies were used to identify patients, including some population screening. Incident patients and age/sex-matched controls had assessments of impairment, disability, quality of life, mood, and cognition and are being followed up yearly. Two hundred and two people with possible parkinsonian symptoms were assessed, and 82 incident patients were identified, 50 with probable Parkinson's disease. The crude incidences of probable Parkinsonism and probable Parkinson's disease were 31.4/100,000/year (95% CI: 24.5-39.7) and 22.4/100,000/year (95% CI: 16.6-29.6), respectively. The mean age of diagnosis of Parkinson's disease was 76.1 +/- 10.0 years and the incidence was greater in men. The methods were generally successful. Provisionally, we found a higher incidence of Parkinson's disease than other comparable studies, and our patients were considerably older. This may reflect better case ascertainment in the elderly. A larger study is planned.