Submental intubation in complex maxillofacial trauma: Pilot balloon protection

AIMS

This study aims to describe our refined technique of submental intubation to avoid the recorded intraoperative complications related to tube passage and pilot balloon rupture.

CASE SERIES

This is a retrospective case series of 21 patients with complex maxillofacial trauma who underwent submental intubation from January 2019 to January 2023. All the patients underwent to the same procedure with a new technique of pilot balloon protection: the pilot balloon was not deflated because, once the connector was removed, only the tube was curved and passed through the incision extraorally while the cuff remained inflated. The wire of the pilot balloon was passed behind the last tooth so as not to interfere with the maxillary-mandibular fixation, remaining extraorally under the anesthetist's view.

DISCUSSION

Only 2 patients (9.5%) reported complications related to submental intubation: in particular a patient (4.8%) reported oral floor infection, and in another patient (4.8%) an unesthetic skin scar was observed. No patients reported intraoperative complications related to the procedure.

CONCLUSION

The technique of pilot balloon protection that we have proposed seems to be effective in reducing the intraoperative complications related to the passage of the pilot balloon, such as rupture, damage or early extubation.

Controlled Trial of Automated External Defibrillators in the London Ambulance Service

This controlled trial was performed in London and compared outcomes of patients treated by ambulance staff using either basic life support alone or an automated external defibrillator (AED) as an adjunct to basic life support. Five of the 212 (2%) patients were successfully resuscitated by crews using basic life support alone, compared with seven of 186 (4%) patients treated by crews equipped with the AED. Neurological outcomes in the AED group were better. However, meaningful statistical comparisons are not possible with so few survivors. The AED used (Lifepak 200, PhysioControl Corp) was found to be sensitive and specific, and ambulance staff operated the defibrillator correctly. The use of AEDs in an option to maximize the provision of defibrillators in the community and could readily be incorporated into basic ambulance training.

Continuing professional development of occupational medicine practitioners: a needs assessment

OBJECTIVE

The aim of this study was to identify elements of occupational medicine practice used on a frequent basis which are considered to be of high priority for continuing professional development (CPD).

METHODS

A postal questionnaire covering 28 areas of knowledge or practice was sent to all members of the Society of Occupational Medicine in September 2000. Respondents were asked to allocate scores to the 28 items for both CPD priority and frequency of use.

RESULTS

The return rate for questionnaires was 29.5%. There was reasonable agreement between frequency of use and CPD priority ratings for the elements covered in the questionnaire.

CONCLUSIONS

Despite the low return rate for questionnaires, this survey has helped identify themes which are important to physicians practising occupational medicine and has also highlighted those which are less important for inclusion in a CPD programme. Some differences in responses were identified between accredited specialists, specialist registrars and non-specialist practitioners of occupational medicine. The findings from this survey should be useful to providers of continuing medical education in planning courses, study days and electronic or distance learning educational packages.

T lymphocyte phenotypic profile in lung segments affected by cavitary and non-cavitary tuberculosis

Clinical manifestations of pulmonary tuberculosis (TB) may depend on a complex interaction between the host and the pathogen. Clinical outcomes of pulmonary tuberculosis are variable, ranging from asymptomatic lifelong infection to parenchymal lung destruction, resulting in cavitary lesions. To investigate the hypothesis that local cellular immune response may affect presentation and outcome in tuberculosis, we performed bronchoalveolar lavage (BAL) in lung segments affected by cavitary and non-cavitary tuberculosis. We then correlated the type of cellular response at the level of the involved lung segments with clinical evolution in terms of cavity formation. We found alveolar lymphocytosis in patients with both cavitary and non-cavitary pulmonary tuberculosis, with increased CD4+ lymphocytes in patients with non-cavitary pulmonary tuberculosis. A predominant Th1 immune response has been observed in non-cavitary patients, while cavitary involved segments exhibit the presence of Th2 lymphocyte subsets. These data, while confirming the importance of Th1-type CD4+ cells and IFN-gamma in effective cellular immunity in active pulmonary tuberculosis, also suggest that the presence of Th2 lymphocytes may contribute to tissue necrosis phenomena associated with cavitary evolution of pulmonary tuberculosis. Our observations indicate the importance of the type of local immune response at the site of disease in the development of different clinical characteristics and outcome in pulmonary tuberculosis.

Phenotypic features of alveolar monocytes/macrophages and IL-8 gene activation by IL-1 and TNF-alpha in asthmatic patients

The alveolar macrophage (AM), a major defense cell in the lung, participates in immune and inflammatory reactions through the release of several regulatory and chemotactic cytokines. In particular, macrophages are considered to play a pivotal proinflammatory role in the production and maintenance of airway inflammation and bronchial hyperreactivity. To assess the phenotypic pattern of AM from asthmatic subjects, we performed the following experiments: 1) cytofluorometric analysis of specific phenotypic features (CD11b, CD14, CD16, CD45, HLA-DR, CD71, CD95, and CD44) 2) assessment of the production of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1, and the chemotactic regulatory cytokine IL-8 by unstimulated and lipopolysaccharide-stimulated AM. In these patients, we phenotypically characterized the AM, showing their strong proinflammatory activity also in patients with mild asthma. Their activity has been clarified by our biomolecular data that showed a constitutive basal IL-8 production by AM, and also indicated that IL-1 and TNF-alpha were able to upregulate the ability of activated human AM to produce IL-8 at the protein and messenger ribonucleic acid (mRNA) levels.

Respiratory infections and asthma

Clinical and experimental evidence suggests an important role for respiratory infections in the development of asthma attacks. Viral upper respiratory infections have been associated with 80% of asthma exacerbations in children and 50% of all asthma episodes in adults. Human rhinovirus has been implicated as the principal virus associated with asthma episodes. Separate studies indicate that atypical bacteria such as Chlamydia pneumoniae and Mycoplasma pneumoniae may precipitate asthma symptoms. Although not completely clarified, the intricate pathogenetic mechanisms by which viral infections promote asthma attacks have been extensively investigated in recent years. By contrast, it has not yet been established whether atypical bacterial infections are an epiphenomenon or a pathogenic event in asthma.

Subpleural lung involvement in Behçet's disease: first localization of a systemic entity

Behçet's disease (BD) is a chronic multisystem vasculitis, affecting many organs and the vascular system, of unknown aetiology. Eyes, skin, joints, the oral cavity, the central nervous system, and, less frequently, heart, lung, kidney, the genital system and the gastrointestinal tract can be involved. Intrathoracic manifestations of BD consist mainly of thromboembolism of the superior vena cava and/or other mediastinal veins; aneurysms of the aorta and pulmonary arteries; pulmonary infarct and haemorrhage; pleural effusion; and, rarely, myocardial and/or hilar lymphoid involvement. In the present case, the patient presented with BD with an asymptomatic subpleural lung mass and bilateral pulmonary artery enlargement. The patient was treated with a combination of surgical and medical therapy with complete resolution of the lung involvement and without any parenchymal relapses after an 8-month follow-up.

Epithelioid haemangioendothelioma of the lung: a high malignancy case

Pulmonary epithelioid haemangioendothelioma (PEH) is a rare lung tumour of vascular origin and low-grade malignancy that affects various organs: liver, central nervous system, lung, etc. A rare malignant case of PEH is described. The cryptic clinical appearance and the nonspecific results of radiography and haematological tests caused great difficulty in arriving at a definite diagnosis. Histological analysis and immunohistochemical detection of CD31+ (a membrane receptor and a sensitive and specific marker for vascular lesions), on open lung biopsy, enabled the correct diagnosis to be made.

[Blood tumor markers in patients with lung cancer]

Over the past years, a number of serum components have been confirmed as useful biological markers of lung cancer. Although none have been sensitive or specific enough to enable early diagnosis, they do seem to facilitate the monitoring and prediction of disease prognosis. We studied tumor markers in 66 patients with lung cancer: serum levels of ferritin, carcinoembryonic antigen (CEA), alpha-fetoprotein (alpha-FP); tissue polypeptide antigen (TPA), cytocheratin fragment 19, 21-1 (CYFRA 21-1) and carbohydrate antigen 125 (CA 125) levels were measured and correlated to tumor stage and histological type. Postulating a specificity of 95% versus benign diseases of the lung, we confirmed the following diagnostic sensitivity for the markers: ferritin = 39.3%; CEA = 42.4%; alpha-FP = 5.1%; TPA = 57.5%; CYFRA 21-1 = 65.1%; CA 125 = 46.9%. CYFRA 21-1 showed significantly higher sensitivity in non small cell lung cancer patients than in those with small cell lung cancer (Wilcoxon, p = 0.02). Moreover since survival time was significantly shorter in patients with high serum CYFRA 21-1, these levels seemed to be correlated with the prognosis.

Drug-induced impaired performance

The use of medication is becoming increasingly common in the workforce in an effort to minimise the time away from work. Little is written about the behavioural impact of drugs and rarely is it considered in risk assessments. Employees may equally suffer from the effects of illicit drugs, alcohol or even the residual effects of anaesthesia after day-case or minimally invasive surgery. This paper sets out to accomplish three objectives: first, to review methods of evaluating behavioural effects of drugs, their strengths and weaknesses; second, to review established performance effects of principal classes of behaviourally toxic drugs on driving as a model; and third, to propose some guidelines to assist occupational physicians and other clinicians in assessing the risks incurred from drug-induced impaired performance.