Comparative analysis of portal hepatic infiltrating leucocytes in acute drug-induced liver injury, idiopathic autoimmune and viral hepatitis.

Drug-induced liver injury (DILI) is often caused by innate and adaptive host immune responses. Characterization of inflammatory infiltrates in the liver may improve understanding of the underlying pathogenesis of DILI. This study aimed to enumerate and characterize leucocytes infiltrating liver tissue from subjects with acute DILI (n = 32) versus non-DILI causes of acute liver injury (n = 25). Immunostains for CD11b/CD4 (Kupffer and T helper cells), CD3/CD20 (T and B cells) and CD8/CD56 [T cytotoxic and natural killer (NK) cells] were evaluated in biopsies from subjects with acute DILI, either immunoallergic (IAD) or autoimmune (AID) and idiopathic autoimmune (AIH) and viral hepatitis (VH) and correlated with clinical and pathological features. All biopsies showed numerous CD8(+) T cells and macrophages. DILI cases had significantly fewer B lymphocytes than AIH and VH and significantly fewer NK cells than VH. Prominent plasma cells were unusual in IAD (three of 10 cases), but were associated strongly with AIH (eight of nine) and also observed in most with AID (six of nine). They were also found in five of 10 cases with VH. Liver biopsies from subjects with DILI were characterized by low counts of mature B cells and NK cells in portal triads in contrast to VH. NK cells were found only in cases of VH, whereas AIH and VH both showed higher counts of B cells than DILI. Plasma cells were associated most strongly with AIH and less so with AID, but were uncommon in IAD.

Anticipation of the difficult airway: preoperative airway assessment, an educational and quality improvement tool.

BACKGROUND: Assessment of the potentially difficult airway (DA) is a critical aspect of resident education. We investigated the impact of a new assessment form on airway prediction and management by anaesthesia residents. We hypothesized that residents would demonstrate improvement in evaluation of DAs over the study duration. METHODS: After IRB approval, anaesthesia residents were randomized into two groups: control (existing form) and experimental (new form). Data were collected prospectively from August 2008 to May 2010 on all non-obstetric adult patients undergoing non-emergent surgery. RESULTS: Eight thousand three hundred and sixty-four independent preoperative assessments were collected and 8075 were analysed. The experimental group had the higher completion rate than the control group (94.3% vs 84.3%, P=0.001). DA prediction was higher for the control group (71.2%) compared with the experimental group (69.1%; P=0.032). A significant improvement in prediction rates was found over time for the experimental group (likelihood estimate=0.00068, P=0.031). CONCLUSIONS: The use of a comprehensive airway assessment did not improve resident ability to predict a DA in an academic, tertiary-based hospital, anaesthesiology residency training programme.

A randomized clinical comparison of the Intersurgical i-gel and LMA Unique in non-obese adults during general surgery.

BACKGROUND: The i-gel is a cuffless, single-use supralaryngeal airway device designed to provide a more effective seal than the laryngeal mask airway (LMA). Although the superiority of the i-gel compared to the LMA Classic was determined in a previous study, no studies have been performed that compare it to the disposable LMA Unique. The aim of this study was to compare the Intersurgical i-gelTM against the LMA UniqueTM (uLMA) in terms of ease of placement, time of insertion, and adequacy of placement through a randomized, controlled clinical trial. METHODS: Following Institutional Review Board (IRB) approval and written informed consent, 50 adult patients were recruited for this study. All enrolled patients were ASA 1-2, Mallampati I-II, and scheduled to receive general anesthesia. Patients were randomized to have either the i-gel or the uLMA placed for airway management. After standardized induction techniques, the airway was secured with the assigned device. All patients were interviewed postoperatively for sore throat, hoarseness, and dysphagia. Standard vital signs, end-tidal CO2, tidal volumes, and peak pressures were recorded. Insertion time, leak pressures, and anatomic placement as assessed fiberoptically for the i-gel were recorded. Ease of placement and complications were also recorded. RESULTS: The insertion time was significantly less with the i-gel (21.04±12.6 s vs. 30.04±14.1 s, P=0.02). An inadequate seal was noted in three patients with the i-gel, and it was exchanged for the uLMA in all three cases. There were no significant differences in the ease of insertion, leak pressures, or fiberoptic view. Most of the fiberoptic views, as assessed through the drain tube, demonstrated esophageal mucosa (22/25). Patients receiving the i-gel were significantly more likely to require a second attempt at insertion by the anesthesiologist (OR 8.11, CI 1.1-58.6, P=0.03). Finally, patients receiving the size 5 i-gel were significantly more likely to complain of immediate postoperative symptoms, such as sore throat and dysphagia (OR 29.32, CI 1.4-613.1, P=0.03). CONCLUSION: Although the i-gel had a faster insertion time in comparison to the uLMA, there was a greater need for repeat insertions. The weight criteria established by the manufacturer may need to be readjusted to recommend a larger size device in some patients less than 90 kg because all of the repeat insertions were in patients weighing more than 80 kg. In all other aspects of its use, the i-gel performed similarly to the uLMA.