The videoscopic view may not be significantly superior to the directly sighted peroral view during Macintosh-style videolaryngoscopy: a randomized equivalence cadaver trial.

PURPOSE: Videolaryngoscopy is widely believed to give a superior view to that obtained by direct laryngoscopy. Published literature suggests this benefit extends to both hyper-angulated and Macintosh-style videolaryngoscopes. Notwithstanding, our clinical experience shows that the videoscopic view with a Macintosh-style videolaryngoscope is often no different or only marginally better than the directly sighted peroral view. METHODS: A human cadaver equivalence study was performed in which four experienced laryngoscopists obtained pre-assigned laryngeal views by direct sighting using the single-use Macintosh blades of the GlideScope® Spectrum™ (GS) DirectView Macintosh (DVM) and C-MAC®S videolaryngoscopes. Blinded to the laryngoscopist's view, two independent observers rated the videoscopic view presented on the proximal video monitor at the same time. Directly sighted and videoscopic views obtained by the laryngoscopist and video scorers were recorded on a visual analogue scale (VAS) for each device as the primary outcome measures and compared. RESULTS: On the VAS, the C-MAC®S videoscopic view revealed only approximately 0.9% more (99% confidence interval [CI], -2.5% to 4.3%) of the laryngeal inlet than the directly sighted view. Using GS DVM, the videoscopic view revealed 6.7% (99% CI, 2.3% to 11.0%) more of the laryngeal inlet than the directly sighted view. Although results for the GS DVM achieved statistical significance, neither device gave a clinically significantly improved videoscopic view compared with the directly sighted peroral view. CONCLUSION: This study failed to corroborate previously published findings of a clinically significantly improved videoscopic view compared with direct peroral sighting using Macintosh-style videolaryngoscopes. Further study of this class of device is warranted in human subjects.

RéSUMé: OBJECTIF: La vidéolaryngoscopie est considérée par beaucoup comme une modalité offrant une visualisation supérieure à celle obtenue par laryngoscopie directe. Selon la littérature publiée, cet avantage s'étendrait tant aux vidéolaryngoscopes hyper-angulés qu'aux vidéolaryngoscopes de style Macintosh. Ceci dit, notre expérience clinique montre que la visualisation par vidéoscopie obtenue à l'aide d'un vidéolaryngoscope de style Macintosh est souvent similaire ou seulement légèrement meilleure à une visualisation per-orale directe. MéTHODE: Une étude d'équivalence sur cadavre humain a été réalisée dans laquelle quatre opérateursexpérimentés en laryngoscopies ont obtenu des vues laryngées pré-assignées par visualisation directe à l'aide de lames de Macintosh à usage unique avec unDirectView Macintosh (DVM) GlideScope® Spectrum™ (GS) et un vidéolaryngoscope C-MAC®S. Sans avoir accès à la visualisation de l'opérateur, deux observateurs indépendants ont simultanémentévalué la visualisation vidéoscopique présentée sur le moniteur vidéo proximal. Les visualisations directes et vidéoscopiques obtenues par l'opérateur et les évaluateurs des vidéos ont été enregistrées sur une échelle visuelle analogique (EVA) pour chaque dispositif en tant que critère d'évaluation principal, puis comparées. RéSULTATS: Sur l'EVA, la visualisation vidéoscopique obtenue avec le C-MAC®S n'a montré qu'approximativement 0,9 % de plus (intervalle de confiance [IC] 99 %, -2,5 % à 4,3 %) de l'orifice laryngé que la visualisation directe. Avec le GS DVM, la visualisation vidéoscopique a révélé 6,7 % (IC 99 %, 2,3 % à 11,0 %) de plus de l'orifice laryngé que la visualisation directe. Bien que les résultats obtenus avec le GS DVM aient atteint une signification statistique, aucun dispositif n'a permis d'obtenir une visualisation vidéoscopique significativement améliorée d'un point de vue clinique par rapport à la visualisation per-orale directe. CONCLUSION: Cette étude n'est pas parvenue à corroborer les résultats précédemment publiés d'une visualisation vidéoscopique améliorée et cliniquement significative avec les vidéolaryngoscopes de style Macintosh par rapport à une visualisation per-orale directe. Des recherches supplémentaires sur cette classe de dispositifs sont nécessaires chez des sujets humains.

A New Framework for Practice-Academic Partnerships During the Pandemic-and into the Future.

ABSTRACT: During the COVID-19 pandemic, many health care facilities closed their doors to nursing students, depriving them of the experience of caring for patients, a foundation of nursing education. The purpose of this article is to report on how the National Council of State Boards of Nursing convened nurse leaders from around the country to explore this problem and develop possible solutions.Coming together virtually, these leaders recommended a national model, the practice-academic partnership, to provide nursing students with in-person clinical experiences during the pandemic. This model is unique in its recognition of the important role of nursing regulatory bodies in these partnerships. The practice-academic partnership model creates clinical education opportunities for students during a public health crisis, such as the COVID-19 pandemic. Further, the model could be applied to meet the chronic challenges nursing education programs have often faced in securing clinical sites, even in the absence of a global or national public health emergency. We provide the context in which the practice-academic partnership model was developed, along with keys to its successful implementation and suggestions for its evaluation. We also discuss the implications of using this model once the pandemic ends.

The Role of ECMO in the "At-Risk" Tracheal Extubation: A Case Report.

Tracheal extubation requires careful planning and preparation. We present the extubation of a patient with severe ankylosing spondylitis after cervical spine surgery. We discuss the use of extracorporeal membrane oxygenation (ECMO) in this "at-risk" extubation, where our ability to oxygenate was uncertain and reintubation was predicted to be difficult. To our knowledge, ECMO has not previously been used in this context. We suggest preparing ECMO for rescue oxygenation when all other fundamental oxygenation techniques are predicted to be difficult or impossible. ECMO could be included in airway management and extubation guidelines.

Leptin indirectly regulates gonadotropin-releasing hormone neuronal function.

The adipose-derived hormone leptin communicates information about metabolic status to the hypothalamic GnRH neuronal system. It is unclear whether leptin can act directly on GnRH neurons. To examine this, we used three approaches. First, the presence of leptin-induced signal transducer and activator of transcription-3 activation was examined in GnRH neurons in male and female rats. Intracerebroventricular treatment with 4 mug leptin-induced robust signal transducer and activator of transcription-3 expression within the anteroventral periventricular nucleus but not in GnRH neurons. Second, fertility was assessed in male and female CRE-loxP transgenic mice with conditional leptin receptor (Lepr) deletion from either all forebrain neurons or GnRH neurons only. Forebrain neuron LEPR deletion prevented the onset of puberty resulting in infertility in males and females and blocked estradiol-induced LH surge. However, mice with GnRH neuron-selective Lepr deletion exhibited normal fertility apart from a slight puberty delay in males. Lastly, the highly sensitive technique of single-cell nested PCR was used to test for Lepr transcript presence in individual GnRH neurons, identified in situ using GnRH-green fluorescent protein transgenics. Whereas 75% of positive control (proopiomelanocortin) neurons contained Lepr mRNA, no (none of 18) GnRH neurons were Lepr mRNA positive. Collectively, these results show that leptin does not act directly on GnRH neurons in rats and mice. Leptin appears to regulate GnRH function via forebrain neurons that are afferent to GnRH because forebrain neuronal LEPR deletion caused infertility. The location and phenotype of these leptin-responsive neurons remains to be elucidated.