Search

Copyright of Anaesthesist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: During a 'cannot intubate, cannot oxygenate' situation, asphyxia can lead to cardiac arrest. In this stressful situation, two complex algorithms facilitate decision-making to save a patient's life: difficult airway management and cardiopulmonary resuscitation. However, the extent to which competition between the two algorithms causes conflicts in the execution of pivotal treatment remains unknown. Due to the rare incidence of this situation and the very low feasibility of such an evaluation in clinical reality, we decided to perform a randomised crossover simulation research study. We propose that even experienced healthcare providers delay cricothyrotomy, a lifesaving approach, due to concurrent cardiopulmonary resuscitation in a 'cannot intubate, cannot oxygenate' situation., Design: Due to the rare incidence and dynamics of such a situation, we conducted a randomised crossover simulation research study., Setting: We collected data in our institutional simulation centre between November 2016 and November 2017., Participants: We included 40 experienced staff anaesthesiologists at our tertiary university hospital centre., Intervention: The participants treated two simulated patients, both requiring cricothyrotomy: one patient required cardiopulmonary resuscitation due to asphyxia, and one patient did not require cardiopulmonary resuscitation. Cardiopulmonary resuscitation was the intervention. Participants were evaluated by video records., Primary Outcome Measures: The difference in 'time to ventilation through cricothyrotomy' between the two situations was the primary outcome measure., Results: The results of 40 participants were analysed. No carry-over effects were detected in the crossover design. During cardiopulmonary resuscitation, the median time to ventilation was 22 s (IQR 3-40.5) longer than that without cardiopulmonary resuscitation (p=0.028), including the decision-making time., Conclusion: Cricothyrotomy, which is the most crucial treatment for cardiac arrest in a 'cannot intubate, cannot oxygenate' situation, was delayed by concurrent cardiopulmonary resuscitation. If cardiopulmonary resuscitation delays cricothyrotomy, it should be interrupted to first focus on cricothyrotomy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Critical incidents in difficult airway management are still a main contributory factor for perioperative morbidity and mortality. Many national associations have developed algorithms for management of these time critical events. For implementation of these algorithms the provision of technical requirements and procedure-related training are essential. Severe airway incidents are rare events and clinical experience of the individual operators is limited; therefore, simulation is an adequate instrument for training and evaluating difficult airway algorithms., Objective: The aim of this observational study was to evaluate the application of the institutional difficult airway algorithm among anesthetists., Material and Methods: After ethics committee approval, anesthetists were observed while treating a "cannot intubate" (CI) and a "cannot intubate, cannot ventilate" (CICV) situation in the institutional simulation center. As leader of a supportive team the participants had to deal with an unexpected difficult airway after induction of anesthesia in a patient simulator. The following data were recorded: sequence of the applied airway instruments, time to ventilation after establishing a secured airway using any instrument in the CI situation and time to ventilation via cricothyrotomy in the CICV situation. Conformity to the algorithm was defined by the sequence of the applied instruments. Analysis comprised conformity to the algorithm, non-parametric tests for time to ventilation and differences between junior and senior anesthetists., Results: Out of 50 participants 45 were analyzed in the CI situation. In this situation 93% of the participants acted in conformity with the algorithm. In 62% the airway was secured by flexible intubation endoscopy, in 38% with another device. Data from 46 participants were analyzed in the CICV situation. In this situation 91% acted in conformity with the algorithm. The last device used prior to the decision for cricothyrotomy was flexible intubation endoscopy in 39%, a laryngeal mask in 22% and other instruments in 39%. Of the 50 participants 38 had already been institutionally trained in difficult airway management during the previous 2 years. For cricothyrotomy the participants needed a median time of 63 s and there was no difference between junior and senior anesthetists (p = 0.46). The cricothyrotomy was performed faster using a surgical approach than a transtracheal puncture approach using a Melker emergency cricothyrotomy set (52 s vs. 73 s, p = 0.014)., Conclusion: The conformity to the algorithm of over 90% indicates a good training level of the participants concerning the difficult airway algorithm. In the observed sample flexible intubation endoscopy tended to be of high significance even in the unanticipated difficult airway. Cricothyrotomy was performed faster surgically than by the use of the transtracheal puncture approach, while no differences between junior and senior anesthetists were observed. For the successful management of an unexpected difficult airway, specific training of these special and rare events is crucial. A standardized provision of special airway instruments stored in a special trolley and frequent application of this trolley in the clinical routine is recommended.

Objective: To evaluate the impact on schistosomiasis of biennial treatment with praziquantel (PZQ) among school-age children in Burkina Faso, the first country that achieved full national coverage with treatment of more than 90% of the school-age population., Methods: A cohort of 1727 schoolchildren (6-14 years old) was monitored at yearly intervals through a longitudinal survey. Additional groups of schoolchildren were monitored in cross-sectional surveys. Parasitological examinations for Schistosoma haematobium and Schistosoma mansoni were performed, and prevalence and intensity of infection before and after treatment were analysed., Findings: Data from the longitudinal cohort show that a single round of PZQ treatment significantly reduced prevalence of S. haematobium infection by 87% (from 59.6% to 7.7%) and intensity of infection by 92.8% (from 94.2 to 6.8 eggs/10 ml of urine) 2 years post-treatment. The impact on infection was also confirmed by a cross-sectional survey 2 years post-treatment. Importantly, the proportion of school-age children with heavy S. haematobium infection decreased from around 25% before treatment to around 2-3% 2 years post-treatment. Cross-sectional comparison of S. haematobium infection in 7-year-old children in their first year at school, who received treatment through community-based drug delivery, also showed significant reduction in both prevalence (65.9%) and intensity of S. haematobium infection (78.4%) 2 years after single treatment. A significant reduction in S. mansoni infection was also achieved., Conclusion: Significant and sustained reduction in S. haematobium infection was achieved by biennial treatment in school-age children in Burkina Faso. This may provide a cost-effective treatment strategy for similar national schistosomiasis control programmes in sub-Saharan Africa.

Fourty-three cases of ileus in newborns are presented. Twenty-seven newborns received a Bishop-Koop anastomosis. In 19 cases, the Bishop-Koop anastomosis was performed primarily and in 8 cases as a second intervention. We consider the Bishop-Koop anastomosis to be a safer procedure than primary end-to-end or end-to-side anastomosis. Only one anastomotic leak occurred in our patients. We prefer the Bishop-Koop anastomosis not only in cases of meconium ileus, but also in other types of intestinal atresia and stenosis, especially for the management of greatly different intestinal diameters. In our experience, this method is also suitable for re-anastomosing a double-barrel anastomosis. The Bishop-Koop procedure minimizes the risks of primary anastomosis without enterostoma, and later extraperitoneal closure of the stoma is easy and safe.

This study explored the nature of patient advocacy among 40 institutionally employed registered nurses, nurse managers, clinical nurse specialists and nursing administrators. Participants were asked to define patient advocacy, to discuss their experiences with advocacy in institutions and their perceptions of risk associated with advocacy in institutional settings, and to identify one concept central to patient advocacy. The results delineated conceptual definitions of advocacy and numerous factors that influence nurses' decisions about acting as patient advocates in institutions. Additionally, they showed striking similarities between conceptual terms used to define advocacy and terms used to define caring.

De novo synthesis and excretion into perfusate and bile fluid of hepatic gangliosides were studied in isolated perfused rat livers. Addition of N-acetyl-[6-3H(n)]D-mannosamine to the perfusate resulted in radioactive synthesis of at least eight gangliosides labeled in their sialic acid residues. About 10% of total de novo synthesized gangliosides were excreted into the perfusate, less than 1% into the bile fluid. Labeled gangliosides were tentatively identified by cochromatography with known standards. All of them are known to occur in rat liver and sera. The results indicate that most, if not all, normal serum gangliosides are synthesized in the liver; excretion with bile fluid is negligible. They explain previous observations, and indicate clinical implications, which are discussed.

4-Hydroxyalkenals, natural cytotoxic products of lipid peroxidation, are substrates for human alcohol dehydrogenases (ADH). Class I and II ADHs reduce aliphatic 4-hydroxyalkenals with chain lengths of from 5 to 15 carbons at pH 7 with kcat and Km values comparable to simple aliphatic aldehydes of the same chain length. Class II is particularly effective in the reduction with kcat values as high as 3300 min-1 for 4-hydroxyundecenal. Class III ADH is essentially inactive toward all of these substrates. The class I and II isozymes also catalyze the oxidation of the 4-hydroxy group at pH 10. However, during the reaction, an NAD(+)-dependent irreversible partial inactivation of the alpha beta 1 isozyme is observed which is attributed, with the aid of computer graphics modeling, to selective modification of the alpha subunit. Both ethanol and 1,10-phenanthroline, known to compete with conventional substrates, instantaneously, reversibly, and competitively inhibit 4-hydroxyalkenal reduction and oxidation, indicating that 4-hydroxyalkenals bind at the same site as do conventional substates. The fact that the class II enzyme pi pi-ADH so far is found only in the liver and that the 4-hydroxyalkenals are the best substrates known for this isozyme suggest that it may play a significant role in cellular defenses in the conversion of the cytotoxic aldehydes to the less reactive alcohols.

Glyoxalase I from human erythrocytes was studied by use of the strong reversible competitive inhibitor S-p-bromobenzylglutathione. Replacements of cobalt, manganese and magnesium for the essential zinc in the enzyme were made by a new procedure involving 10% methanol as a stabilizer of the enzyme. The K(m) value for the adduct of methylglyoxal and glutathione was essentially unchanged by the metal substitutions, whereas the inhibition constant for S-p-bromobenzylglutathione increased from 0.08mum for the Zn-containing enzyme to 1.3, 1.7 and 2.4mum for Co-, Mn- and Mg-glyoxalase I respectively. Binding of the inhibitor to the enzyme caused quenching of the tryptophan fluorescence of the protein, from which the binding parameters could be determined by the use of non-linear regression analysis. The highest dissociation constant was obtained for apoenzyme (6.9mum). The identity of the corresponding kinetic and binding parameters of the native enzyme and the Zn(2+)-re-activated apoenzyme and the clear differences from the parameters of the other metal-substituted enzyme forms give strong support to the previous identification of zinc as the natural metal cofactor of glyoxalase I. Binding to apoenzyme was also shown by the use of S-p-bromobenzylglutathione as a ligand in affinity chromatography and as a protector in chemical modification experiments. The tryptophan-modifying reagent 2-hydroxy-5-nitrobenzyl bromide caused up to 85% inactivation of the enzyme. After blocking of the thiol groups (about 8 per enzyme molecule) 6.1 2-hydroxy-5-nitrobenzyl groups were incorporated. Inclusion of S-p-bromobenzylglutathione with the modifying reagent preserved the catalytic activity of the enzyme completely and decreased the number of modified residues to 4.4 per enzyme molecule. The findings indicate the presence of one tryptophan residue in the active centre of each of the two subunits of the enzyme. Thiol groups appear not to be essential for catalytic activity. The presence of at least two categories of tryptophan residues in the protein was also shown by quenching of the fluorescence by KI.

The apoenzyme of glyoxalase I (EC 4.4.1.5) from human erythrocytes was prepared by removal of Zn2+ with ethylenediaminetetraacetic acid (EDTA). Methanol was used as a stabilizing agent. Extended dialysis was required to remove EDTA from the resulting solution of apoenzyme. Reconstitution with Mn2+ was followed by measuring enzyme activity, electron paramagnetic resonance of free Mn2+ ions, and nuclear magnetic resonance of water protons. The holoenzyme contained two Mn2+ per protein dimer and had approximately 50% of the catalytic activity of the native enzyme. The binding of the cosubstrate glutathione (gamma-L-glutamyl-L-cysteinylglycine), the product S-D-lactoyl-glutathione, and the competitive inhibitor S-(p-bromo-benzyl)glutathione was monitored by the quenching of the intrinsic tryptophan fluorescence and by the proton relaxation enhancement of water bound to Mn2+ in the active site of the enzyme. The dissociation constants were 1.1 mM, 0.42 mM, and 0.54 microM for glutathione, S-D-lactoylglutathione, and S-(p-bromobenzyl)glutathione, respectively. The temperature and frequency dependences of the longitudinal and transverse paramagnetic relaxation rates, 1/T1p and 1/T2p, were studied for water. The results were analyzed in terms of correlation and exchange times. In addition proton and deuteron relaxation rates were measured in parallel at two different magnetic fields. Good agreement between the two approaches of analysis was noticed. The data show that two water molecules are bound in the first coordination sphere of Mn2+ in the active site of glyoxalase I. When S-(p-bromobenzyl)glutathione or S-D-lactoylglutathione is bound to the enzyme, only one exchangeable water molecule could be detected, indicating occlusion of the second water molecule. An enediol mechanism involving the metal-bound water is proposed for the catalysis effected by glyoxalase I.

Zn2+ in native glyoxalase I from human erythrocytes can be replaced by Cu2+, giving an inactive enzyme. Cu2+ was demonstrated to compete with the activating metals Zn2+ and Mn2+, indicating a common binding site on the enzyme for these metal ions. The electron paramagnetic resonance (EPR) spectra of 63Cu(II) glyoxalase I at 77 K and of its complexes with glutathione and some glutathione derivatives are characteristic of Cu2+ in an elongated octahedral coordination (g parallel = 2.34, g perpendicular = 2.09, and A parallel = 14.2 mT). The low-field bands of the free enzyme are asymmetric and become symmetrical upon addition of glutathione or S-(p-bromobenzyl)glutathione but not S-(D-lactoyl)glutathione. The results indicate the existence of two conformations of Cu(II) glyoxalase I, in agreement with the effects caused by these compounds on the protein fluorescence. The copper hyperfine line at low field in the EPR spectrum of the S-(p-bromobenzyl)glutathione complex of 63Cu(II) glyoxalase I shows a triplet structure, indicative of coupling to one nitrogen ligand in the equatorial plane. Similar results were obtained with the glutathione complex. By addition of the spectrum of the S-(p-bromobenzyl)glutathione complex and a spectrum corresponding to two nitrogen ligands with two different coupling constants, a good fit was obtained for the low-field region of the asymmetric spectrum of free 63Cu(II) glyoxalase I. The first two spectra are assumed to correspond to two separate conformational states of the enzyme. The results demonstrate that at least one nitrogen ligand is involved in the binding of Cu2+.(ABSTRACT TRUNCATED AT 250 WORDS)