Randomized equivalence trial of the King Vision aBlade videolaryngoscope with the Miller direct laryngoscope for routine tracheal intubation in children <2 yr of age.

BACKGROUND.: We conducted a randomized equivalence trial to compare direct laryngoscopy using a Miller blade (DL) with the King Vision videolaryngoscope (KVL) for routine tracheal intubation. We hypothesized that tracheal intubation times with DL would be equivalent to the KVL in children <2 yr of age. METHODS.: Two hundred children were randomly assigned to tracheal intubation using DL or KVL. The primary outcome was the median difference in the total time for successful tracheal intubation. Secondary outcomes assessed were tracheal intubation attempts, time to best glottic view, time for tracheal tube entry, percentage of glottic opening score, airway manoeuvres needed, and complications. RESULTS.: The median difference between the groups was 5.7 s, with an upper 95% confidence interval of 7.5 s, which was less than our defined equivalence time difference of 10 s. There were no differences in the number of tracheal intubation attempts and the time to best glottic view [DL median 5.3 (4.1-7.6) s vs KVL 5.0 (4.0-6.3) s; P =0.19]. The percentage of glottic opening score was better when using the KVL [median 100 (100-100) vs DL median 100 (90-100); P <0.0001]. Use of DL was associated with greater need for airway manoeuvres during tracheal intubation (33 vs 7%; P <0.001). Complications did not differ between devices. CONCLUSIONS.: In children <2 yr of age, the KVL was associated with equivalent times for routine tracheal intubation when compared with the Miller blade. CLINICAL TRIAL REGISTRATION: NCT02590237.

A randomised comparison of the Ambu® AuraGain™ and the LMA® supreme in infants and children.

We conducted a randomised trial in 100 children in order to compare the clinical performance of the Ambu(®) AuraGain(™) and the LMA(®) Supreme(*) for airway maintenance during mechanical ventilation. The primary outcomes were initial and 10-min airway leak pressures. Ease, time and success rates for device and gastric tube insertion, fibreoptic grades of view, airway quality during anaesthetic maintenance, and complications were also assessed. There were no differences in the initial and ten min airway leak pressures between the Ambu AuraGain and LMA Supreme, median (IQR [range]) initial: 19 (16-22 [10-34]) vs 18 (14-24 [8-40]) cmH2 O, p = 0.4; and ten min: 22 (18-26 [11-40]) vs 20 (16-26 [12-40]) cmH2 O, p = 0.08, respectively. Ease, time and success rates for device placement, gastric tube insertion and complications were also not significantly different. Children receiving the LMA Supreme required more airway manouevers (7 vs 1 patient, p = 0.06) to maintain a patent airway. Our results suggest that the Ambu AuraGain may be a useful alternative to the LMA Supreme, as demonstrated by comparable overall clinical performance in children.

Randomized comparison of experts and trainees with nasal and oral fibreoptic intubation in children less than 2 yr of age.

BACKGROUND: We hypothesized that the time to successful fibreoptic tracheal intubation through the nasal route would be faster than the oral route for both experts and trainees in children <2 yr of age. METHODS: One hundred children, 24 months and under in age, were randomized to an operator (expert or trainee), and route (nasal or oral) for fibreoptic tracheal intubation. Three separate times were then measured: (i) time to first glottic view, (ii) time to carinal view, and (iii) total time to successful tracheal intubation. The number of attempts made, manoeuvres needed to obtain an adequate laryngeal view, and manoeuvres for tracheal tube passage were also recorded. RESULTS: Time to successful tracheal intubation was significantly faster for experts than trainees. There was no difference in the time to tracheal intubation between the nasal and oral routes for experts. In trainees, intubation times were shorter for the nasal route-median (inter-quartile range) time (s) to carinal view was 35 (27-63) for the nasal route vs 59 (38-94) for the oral route (P=0.03), and the median time to successful tracheal intubation were 62 (49-122) vs 117 (61-224), P=0.05, for the nasal and oral routes, respectively. For trainees, the oral route required a greater number of airway manoeuvres for adequate laryngeal views and passage of the tracheal tube compared with the nasal route. CONCLUSIONS: For clinicians with less experience in using paediatric bronchoscopes, fibreoptic tracheal intubation through the nasal route may be a more straightforward process than the oral route in children <2 yr of age. CLINICAL TRIAL REGISTRATION: NCT02029300 (www.clinicaltrials.gov).

Elective use of supraglottic airway devices for primary airway management in children with difficult airways.

BACKGROUND: Supraglottic airways (SGAs) have an established role in airway management of difficult airways in both adults and children. However, there are limited data regarding the use of SGAs for primary airway management in children. The aim of this study is to assess the success rates and adverse events related to the use of SGAs for primary airway management during anaesthesia in children with difficult airways. METHODS: A retrospective analysis of SGA use for primary airway management in the difficult airway population in a single centre over a 4-yr period was performed. Difficult airway was defined as either a history of difficult direct laryngoscopy (a documented Cormack and Lehane Grade 3 or greater and the need for an alternate device to direct laryngoscopy for successful tracheal intubation), a history of difficult mask ventilation, or both. The difficult airway condition, patient characteristic data, type and length of procedure, type and size of SGA placed, number of attempts for successful device placement, success/failure associated with the device during anaesthetic maintenance, and complications were recorded. RESULTS: A total of 77,272 children received general anaesthesia in a free-standing paediatric institution. Four hundred and fifty-nine patients were reported to have a difficult airway. Of those, 109 received general anaesthesia and an SGA for primary management, meeting the inclusion criteria for this study during a 4-yr period. An SGA was successfully used in 96% of these patients. In four patients, an alternative airway was needed. CONCLUSIONS: SGAs can be effectively utilized for airway maintenance in the paediatric difficult airway population.

A randomised comparison of free-handed vs air-Q assisted fibreoptic-guided tracheal intubation in children < 2 years of age.

We prospectively compared free-handed and air-Q™ assisted fibreoptic-guided tracheal intubation in children < 2 years of age. Eighty healthy children were enrolled and randomly assigned to a technique (free-handed or air-Q assisted) and operator (trainee or attending). Time, number of attempts and manoeuvres required were assessed. There was no difference in median (IQR [range]) time to successful tracheal intubation between the free-handed (52.2 (34.8-67.7 [19.7-108.0]) s), and the air-Q assisted (60.3 (45.5-75.1 [28.1-129.0]) s; p = 0.13) groups, or the number of attempts needed. The air-Q assisted group required fewer manoeuvres to optimise the laryngeal view (median (IQR [range]) 0 (0-1 [0-2])) than the free-handed group (1 (1-1 [0-3]); p < 0.001). In conclusion, fibreoptic-guided tracheal intubation times were similar with and without the use of the air-Q, but supraglottic airway devices may be a consideration for their other practical advantages.

Use of the air-Q intubating laryngeal airway for rapid-sequence intubation in infants with severe airway obstruction: a case series.

We describe a four-step method for fibreoptic-guided, rapid-sequence tracheal intubation through the air-Q intubating laryngeal airway in infants with severe airway obstruction. Our step-wise process provides an organised and controlled approach to safely securing the airway.

A randomised comparison of the self-pressurised air-QTM intubating laryngeal airway with the LMA Unique™ in children.

We conducted a randomised trial comparing the self-pressurised air-Q™ intubating laryngeal airway (air-Q SP) with the LMA-Unique in 60 children undergoing surgery. Outcomes measured were airway leak pressure, ease and time for insertion, fibreoptic examination, incidence of gastric insufflation and complications. Median (IQR [range]) time to successful device placement was faster with the air-Q SP (12 (10-15 [5-18])) s than with the LMA-Unique (14 (12-17 [6-22]) s; p=0.05). There were no statistically significant differences between the air-Q SP and LMA-Unique in initial airway leak pressures (16 (14-18 [10-29]) compared with 18 (15-20 [10-30]) cmH2 O, p=0.12), an airway leak pressures at 10 min (19 (16-22 [12-30]) compared with 20 (16-22 [10-30]) cmH2 O, p=0.81); fibreoptic position, incidence of gastric insufflation, or complications. Both devices provided effective ventilation without the need for airway manipulation. The air-Q SP is an alternative to the LMA-Unique should the clinician prefer a device not requiring cuff monitoring during anaesthesia.

A randomised trial comparing the laryngeal mask airway Supreme™ with the laryngeal mask airway Unique™ in children.

We conducted a randomised controlled trial comparing the laryngeal mask airway Supreme(™) with the laryngeal mask airway Unique(™) in children. Fifty children presenting for elective surgery were randomly assigned to receive either the laryngeal mask airway Supreme or laryngeal mask airway Unique. The outcomes measured were airway leak pressure, ease and time for insertion, insertion success rate, fibreoptic examination, incidence of gastric insufflation, ease of gastric tube placement through the laryngeal mask airway Supreme, quality of airway during anaesthetic maintenance and complications. Median (IQR [range]) time to successful device placement was shorter with the laryngeal mask airway Unique, 14.5 [13.5-16.3 (10.0-23.6)] s than with the laryngeal mask airway Supreme, 17.4 [14.8-19.8 (11.5-29.2)] s; p = 0.007. Median (IQR [range]) airway leak pressures for the laryngeal mask airway Supreme and laryngeal mask airway Unique were 20 [16-21 (12-22)] cmH(2)O and 15 [14-18 (10-24)] cmH(2)O, respectively (p = 0.001). The incidence of gastric insufflation was lower with the laryngeal mask airway Supreme (zero vs six patients), p = 0.01. In conclusion, the laryngeal mask airway Supreme performed as well as the laryngeal mask airway Unique and is a useful alternative for airway maintenance, particularly in children who require evacuation of gastric contents during anaesthesia.

A randomised comparison of the LMA SupremeTM and LMAProSealTM in children.

We conducted a randomised trial comparing the size-2 LMA Supreme™ with the LMA ProSeal™ in 60 children undergoing surgery. The outcomes measured were airway leak pressure, ease and time for insertion, fibreoptic examination, incidence of gastric insufflation, ease of gastric tube placement, quality of the airway during anaesthetic maintenance and complications. There were no statistically significant differences between the LMA Supreme and LMA ProSeal in median (IQR [range]) insertion time (12 (10-15 [7-18]) s vs 12 (10-13 [8-25]) s; p = 0.90), airway leak pressures (19 (16-21 [12-30]) cmH(2) O vs 18 (16-24 [10-34]) cmH(2) O; p = 0.55), fibreoptic position of the airway or drain tube, ease of gastric access and complications. Both devices provided effective ventilation requiring minimal airway manipulation. The LMA Supreme can be a useful alternative to the LMA ProSeal when single-use supraglottic devices with gastric access capabilities are required.

A resistive-pulse sensor chip for multianalyte immunoassays.

MultiAnalyte immunoassays are often required to diagnose a pathologic condition. Here, we show how resistive-pulse sensing and multiple artificial pores can be integrated together on a single chip to detect different antigens rapidly and simultaneously. We use multiple pores on a single chip to detect the size change of latex colloids upon specific antigen-antibody binding on the colloid surface. As a proof-of-principle, we demonstrate our ability to detect simultaneously human G-CSF and GM-CSF antigens on a single chip. Our novel technique is a scalable technology that can lead to the sensing of at least N2 antigens simultaneously with an N N array of pores on a single chip.

A Microfluidic Method for the Selection of Undifferentiated Human Embryonic Stem Cells and in Situ Analysis.

Conventional cell-sorting methods such as fluorescence-activated cell sorting (FACS) or magnetic-activated cell sorting (MACS) can suffer from certain shortcomings such as lengthy sample preparation time, cell modification through antibody labeling, and cell damage due to exposure to high shear forces or to attachment of superparamagnetic Microbeads. In light of these drawbacks, we have recently developed a label-free, microfluidic platform that can not only select cells with minimal sample preparation but also enable analysis of cells in situ. We demonstrate the utility of our platform by successfully isolating undifferentiated human embryonic stem cells (hESCs) from a heterogeneous population based on the undifferentiated stem-cell marker SSEA-4. Importantly, we show that, in contrast to MACS or FACS, cells isolated by our method have very high viability (~90%). Overall, our platform technology could likely be applied to other cell types beyond hESCs and to a variety of heterogeneous cell populations in order to select and analyze cells of interest.

Radiologic diagnosis of cystic fibrosis in adults and children.

RATIONALE AND OBJECTIVES: Most radiologists are familiar with the classic chest radiographic findings of cystic fibrosis (CF) when these occur in children. We hypothesized that given the same findings, a diagnosis of CF would be less likely to be considered in an adult than in a child. METHODS: We compiled 30 pediatric and 28 adult CF chest radiographs and obtained two independent readings on each by different general radiologists among the eight who volunteered to participate as they performed their daily clinical work. The cases were presented to the readers so that they did not know which radiographs were part of the study. The association between the correct diagnosis of CF and whether the patient was an adult or a child was assessed using odds ratios and logistic regression, so that Brasfield score, Schwachman-Kulczycki score, and the patient's sex could also be considered as predictive of correct diagnosis. RESULTS: In 67% of the pediatric cases, at least one of the radiologists considered CF as a possible diagnosis, whereas they considered CF a possibility in only 50% of the adults. Both radiologists suggested the correct diagnosis in 40% of pediatric cases and only 14% of adult cases (p < .05). CONCLUSION: Because the radiographic findings were similar in the two groups of patients according to severity groupings, we believe CF was less commonly considered in the adult patient because of the traditional belief that CF is a childhood disease.

Narcissistic organization, projective identification, and the formation of the identificate.

Clinical examples are given, varying from what would appear to be self-sufficient normal people, to overtly psychotic cases, in order to illustrate the development of a narcissistic organization of varying intensity and permanence. That is to say, an identification via projective identification has taken place, which heightens intrinsic omnipotence, to allow what has been termed the identificate to believe that it has become the desired object--and thereby that within this spuriously organized ego-structure exist the characteristics and functions of the object or part object that has been taken over. Varying forms of such identificatory process are illustrated. The functions of these 'successful defence' manoeuvres are to obviate any feelings of an awareness of envy, although they may be overtly envious attacks within themselves, secondly they nullify any awareness of dependence, and also nullify awareness of need and illness, and thirdly they maintain the narcissistic organization by producing a successful identificate.

Unprovoked assaults--making sense of apparently random violence.

An unprovoked assault occurs when a total stranger assaults a totally innocent victim he has never met. Presenting findings from three such cases, representative of a series of ten seen as part of his work as a psychoanalyst at a special forensic hospital in the UK, the author attempts to tie together the victim and his attacker in the attacker's mind, setting out to explain how the victim fits the need of a psychotic man's fantasy, at a particular time. A provisional hypothesis about the internal situation of such patients and its diagnosis, treatment and management is put forward and discussed, in the context of the implications for the treatment of such offenders and the psychoanalytic theory of projection and symbolisation.

Nostalgia.

An attempt is made to differentiate between true and false nostalgia, with clinical illustrations from the analyses of a chronic psychotic patient, and a far less disturbed young woman, whose main symptom of vagueness clouded the analytic work, and her own perceptions and capacities. The significance of the differentiation for psychoanalytic work is stressed.

Radiology/pathology conference at Robert Wood Johnson Medical School. Benign mediastinal teratoma.

The authors review the findings for a 15-month-old female after a left thoracotomy was performed. Radiographs demonstrated a large mass involving the majority of the left hemithorax. Pathologic findings yielded a well-encapsulated, red and white, soft tissue mass.

Label-free resistive-pulse cytometry.

Numerous methods have recently been developed to characterize cells for size, shape, and specific cell-surface markers. Most of these methods rely upon exogenous labeling of the cells and are better suited for large cell populations (>10,000). Here, we review a label-free method of characterizing and screening cells based on the Coulter-counter technique of particle sizing: an individual cell transiting a microchannel (or "pore") causes a downward pulse in the measured DC current across that "pore". Pulse magnitude corresponds to the cell size, pulse width to the transit time needed for the cell to pass through the pore, and pulse shape to how the cell traverses across the pore (i.e., rolling or tumbling). When the pore is functionalized with an antibody that is specific to a surface-epitope of interest, label-free screening of a specific marker is possible, as transient binding between the two results in longer time duration than when the pore is unfunctionalized or functionalized with a nonspecific antibody. While this method cannot currently compete with traditional technology in terms of throughput, there are a number of applications for which this technology is better suited than current commercial cytometry systems. Applications include the rapid and nondestructive analysis of small cell populations (<100), which is not possible with current technology, and a platform for providing true point-of-care clinical diagnostics, due to the simplicity of the device, low manufacturing costs, and ease of use.

Biological sensing with an on-chip resistive pulse analyzer.

Resistive pulse sensors (or Coulter counters) detect the conductance change caused by single fluid-borne particles transiting a pore. Their simplicity in design and use, along with their capability for single-molecule sensitivity, make them well-suited to the analysis of biological particles. Here, we use standard methods of micro- and nanolithography to construct resistive-pulse devices that combine microfluidics with electronic sensing. We use the devices to detect single latex colloids, single DNA molecules, and specific antibody/antigen binding. We discuss the advantages of our design, and prospects for future applications.