Fire safety and emergency evacuation guidelines for intensive care units and operating theatres: for use in the event of fire, flood, power cut, oxygen supply failure, noxious gas, structural collapse or other critical incidents: Guidelines from the Association of Anaesthetists and the Intensive Care Society

The need to evacuate an ICU or operating theatre complex during a fire or other emergency is a rare event but one potentially fraught with difficulty: Not only is there a risk that patients may come to harm but also that staff may be injured and unable to work. Designing newly-built or refurbished ICUs and operating theatre suites is an opportunity to incorporate mandatory fire safety features and improve the management and outcomes of such emergencies: These include well-marked manual fire call points and oxygen shut off valves (area valve service units); the ability to isolate individual zones; multiple clear exit routes; small bays or side rooms; preference for ground floor ICU location and interconnecting routes with operating theatres; separate clinical and non-clinical areas. ICUs and operating theatre suites should have a bespoke emergency evacuation plan and route map that is readily available. Staff should receive practical fire and evacuation training in their clinical area of work on induction and annually as part of mandatory training, including 'walk-through practice' or simulation training and location of manual fire call points and fire extinguishers, evacuation routes and location and operation of area valve service units. The staff member in charge of each shift should be able to select and operate fire extinguishers and lead an evacuation. Following an emergency evacuation, a network-wide response should be activated, including retrieval and transport of patients to other ICUs if needed. A full investigation should take place and ongoing support and follow-up of staff provided.

Comparison of cholinesterase inhibitor safety in real-world practice

Introduction

Cholinesterase inhibitors (ChEIs) are widely used to treat mild to moderate Alzheimer's disease and related dementia. Clinical trials have focused on placebo comparisons, inadequately addressing within-class comparative safety.

Methods

New users of ChEIs in British Columbia were categorized into five study cohorts: low-dose donepezil, high-dose donepezil, galantamine, rivastigmine patch, and oral rivastigmine. Comparative safety of ChEIs assessed hazard ratios using propensity score adjusted Cox regression.

Results

Compared with low-dose donepezil, galantamine use was associated with a lower risk of mortality (adjusted hazard ratio: 0.84, 95% confidence interval: 0.60–1.18), cardiovascular serious adverse events (adjusted hazard ratio: 0.78, 95% confidence interval: 0.62–0.98), and entry into a residential care facility (adjusted hazard ratio: 0.72, 95% confidence interval: 0.59–0.89).

Discussion

Given the absence of randomized trial data showing clinically meaningful benefit of ChEI therapy in Alzheimer's disease, our study suggests preferential use of galantamine may at least be associated with fewer adverse events than treatment with donepezil or rivastigmine.

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Galantamine was associated with fewer adverse events than donepezil or rivastigmine.

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Galantamine users experienced longer independent living.

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The 3-year risk of cardiovascular events and mortality was lowest with galantamine.

Does the gene matter? Genotype-phenotype and genotype-outcome associations in congenital melanocytic naevi

Background

Genotype–phenotype studies can identify subgroups of patients with specific clinical features or differing outcomes, which can help shape management.

Objectives

To characterize the frequency of different causative genotypes in congenital melanocytic naevi (CMN), and to investigate genotype–phenotype and genotype–outcome associations.

Methods

We conducted a large cohort study in which we undertook MC1R genotyping from blood, and high‐sensitivity genotyping of NRAS and BRAF hotspots in 156 naevus biopsies from 134 patients with CMN [male 40%; multiple CMN 76%; projected adult size (PAS) > 20 cm, 59%].

Results

Mosaic NRAS mutations were detected in 68%, mutually exclusive with BRAF mutations in 7%, with double wild‐type in 25%. Two separate naevi were sequenced in five of seven patients with BRAF mutations, confirming clonality. Five of seven patients with BRAF mutations had a dramatic multinodular phenotype, with characteristic histology distinct from classical proliferative nodules. NRAS mutation was the commonest in all sizes of CMN, but was particularly common in naevi with PAS > 60 cm, implying more tolerance to that mutation early in embryogenesis. Facial features were less common in double wild‐type patients. Importantly, the incidence of congenital neurological disease, and apparently of melanoma, was not altered by genotype; no cases of melanoma were seen in BRAF‐mutant multiple CMN, however, this genotype is rare.

Conclusions

CMN of all sizes are most commonly caused by mutations in NRAS. BRAF is confirmed as a much rarer cause of multiple CMN, and appears to be commonly associated with a multinodular phenotype. Genotype in this cohort was not associated with differences in incidence of neurological disease in childhood. However, genotyping should be undertaken in suspected melanoma, for guidance of treatment.

What's already known about this topic?

Multiple congenital melanocytic naevi (CMN) have been shown to be caused by NRAS mosaic mutations in 70–80% of cases, by BRAF mosaicism in one case report and by inference in some previous cases.

There has been debate about genotypic association with different sizes of CMN, and no data on genotype–outcome.

What does this study add?

NRAS mosaicism was found in 68%, BRAF in 7% and double wild‐type in 25% of cases of CMN.

NRAS was the commonest mutation in all sizes of CMN, but was nearly universal in projected adult size > 60 cm.

BRAF is often associated with a distinct multinodular clinical/histological phenotype.

Adverse outcomes did not differ between genotypes on current numbers.

https://doi.org/10.1111/bjd.18747 available online

Neuronal Gonadotrophin-Releasing Hormone (GnRH) and Astrocytic Gonadotrophin Inhibitory Hormone (GnIH) Immunoreactivity in the Adult Rat Hippocampus

Gonadotrophin-releasing hormone (GnRH) and gonadotrophin inhibitory hormone (GnIH) are neuropeptides secreted by the hypothalamus that regulate reproduction. GnRH receptors are not only present in the anterior pituitary, but also are abundantly expressed in the hippocampus of rats, suggesting that GnRH regulates hippocampal function. GnIH inhibits pituitary gonadotrophin secretion and is also expressed in the hippocampus of a songbird; its role outside of the reproductive axis is not well established. In the present study, we employed immunohistochemistry to examine three forms of GnRH [mammalian GnRH-I (mGnRH-I), chicken GnRH-II (cGnRH-II) and lamprey GnRH-III (lGnRH-III)] and GnIH in the adult rat hippocampus. No mGnRH-I and cGnRH-II+ cell bodies were present in the hippocampus. Sparse mGnRH-I and cGnRH-II+ fibres were present within the CA1 and CA3 fields of the hippocampus, along the hippocampal fissure, and within the hilus of the dentate gyrus. No lGnRH-III was present in the rodent hippocampus. GnIH-immunoreactivity was present in the hippocampus in cell bodies that resembled astrocytes. Males had more GnIH+ cells in the hilus of the dentate gyrus than females. To confirm the GnIH+ cell body phenotype, we performed double-label immunofluorescence against GnIH, glial fibrillary acidic protein (GFAP) and NeuN. Immunofluorescence revealed that all GnIH+ cell bodies in the hippocampus also contained GFAP, a marker of astrocytes. Taken together, these data suggest that GnRH does not reach GnRH receptors in the rat hippocampus primarily via synaptic release. By contrast, GnIH might be synthesised locally in the rat hippocampus by astrocytes. These data shed light on the sites of action and possible functions of GnRH and GnIH outside of the hypothalamic-pituitary-gonadal axis.

Gonadotropin releasing hormone (GnRH) and gonadotropin inhibitory hormone (GnIH) in the songbird hippocampus: regional and sex differences in adult zebra finches

Hypothalamic gonadotropin releasing hormone (GnRH) and gonadotropin inhibitory hormone (GnIH) are vital to reproduction in all vertebrates. These neuropeptides are also present outside of the hypothalamus, but the roles of extra-hypothalamic GnRH and GnIH remain enigmatic and widely underappreciated. We used immunohistochemistry and PCR to examine whether multiple forms of GnRH (chicken GnRH-I (GnRH1), chicken GnRH-II (GnRH2) and lamprey GnRH-III (GnRH4)) and GnIH are present in the hippocampus (Hp) of adult zebra finches (Taeniopygia guttata). Using immunohistochemistry, we provide evidence that GnRH1, GnRH2 and GnRH4 are present in hippocampal cell bodies and/or fibers and that GnIH is present in hippocampal fibers only. There are regional differences in hippocampal GnRH immunoreactivity, and these vary across the different forms of GnRH. There are also sex differences in hippocampal GnRH immunoreactivity, with generally more GnRH1 and GnRH2 in the female Hp. In addition, we used PCR to examine the presence of GnRH1 mRNA and GnIH mRNA in micropunches of Hp. PCR and subsequent product sequencing demonstrated the presence of GnRH1 mRNA and the absence of GnIH mRNA in the Hp, consistent with the pattern of immunohistochemical results. To our knowledge, this is the first study in any species to systematically examine multiple forms of GnRH in the Hp or to quantify sex or regional differences in hippocampal GnRH. Moreover, this is the first demonstration of GnIH in the avian Hp. These data shed light on an important issue: the sites of action and possible functions of GnRH and GnIH outside of the HPG axis.

Repositioning a displaced tracheostomy tube with an Aintree intubation catheter mounted on a fibre-optic bronchoscope

Although tracheostomy tube displacement is uncommon, the management is often difficult and the associated mortality is high. It is important to ensure that the airway is secure and then either replace or reposition the tracheostomy tube. This case report describes the use of an Aintree intubation catheter (C-CAE-19.0-56-AIC, William Cook Europe, Denmark) mounted on an intubating fibre-optic bronchoscope (11302BD1, Karl Storz Endoskope, Germany) to reposition a partially displaced tracheostomy tube.

Group B streptococcal meningitis complicating elective abortion: report of 2 cases

The incidence of invasive disease due to Streptococcus agalactiae (group B streptococcus [GBS]) in adults is on the rise; however, meningitis in adults due to GBS remains rare. We report 2 cases of GBS meningitis complicating elective abortion, 1 of which was a septic incomplete abortion. Only 1 case of bacterial meningitis complicating elective abortion has been reported previously.

Polymorphisms of the beta(2)-adrenergic receptor determine exercise capacity in patients with heart failure

The beta(2)-adrenergic receptor (beta(2)AR) exists in multiple polymorphic forms with different characteristics. Their relevance to heart failure (HF) physiology is unknown. Cardiopulmonary exercise testing was performed on 232 compensated HF patients with a defined beta(2)AR genotype. Patients with the uncommon Ile164 polymorphism had a lower peak VO(2) (15.0+/-0.9 mL. kg(-1). min(-1)) than did patients with Thr164 (17.9+/-0.9 mL. kg(-1). min(-1), P<0.0001). The percentage achieved of predicted peak VO(2) was also lower in patients with Ile164 (62. 3+/-4.5% versus 71.5+/-5.1%, P=0.045). The relative risk of a patient having a VO(2) </=14 mL. kg(-1). min(-1) who had Ile164 was 8.0 (P=0.009). Catheterization-based invasive exercise testing revealed depressed changes in the exercise-induced cardiac index, systemic vascular resistance, stroke volume, and VO(2) in patients with Ile164. The polymorphisms at position 16 also impacted exercise capacity: peak VO(2) for Arg16 versus Gly16 was 17.0+/-0.8 versus 15. 6+/-0.5 mL. kg(-1). min(-1), respectively (P=0.03). Because the polymorphisms at loci 16 and 27 can occur together, 4 homozygous combinations exist. Patients with Arg16/Glu27 had the highest percentage achieved of predicted peak VO(2) (75. 7+/-6.4%), whereas those with Gly16/Gln27 had the lowest (55.3+/-2. 8%, P=0.0032). The above findings were not confounded by baseline clinical characteristics, including beta-blocker usage. We conclude that the beta(2)AR polymorphisms Ile164, Gly16, and the combination of Gly16 and Gln27 are associated with depressed exercise performance in HF and represent a genetically determined factor in the pathophysiology of HF.

Rapid prenatal diagnosis by fluorescent in situ hybridization of chorionic villi: an adjunct to long-term culture and karyotype

OBJECTIVE

This series was designed to assess in a pilot study the feasibility of using fluorescence in situ hybridization on chorionic villi.

STUDY DESIGN

We constructed probes derived from specific subregions of human chromosomes 21, 18, 13, X, and Y that give a single copylike signal when used in conjunction with suppression hybridization.

RESULTS

In a blind series of 47 samples all, including one trisomy 21, were correctly identified. The samples were correctly classified as disomic for five chromosomes.

CONCLUSIONS

The combination of chromosome-specific probe sets composed primarily of cosmid contigs and optimized hybridization and detection allowed accurate chromosome enumeration in uncultured human chorionic villi; these results are consistent with those obtained by traditional cytogenetic analysis and suggest a use for fluorescence in situ hybridization as an adjunct to karyotyping when rapid results are needed.

Malignant hyperthermia during isoflurane anaesthesia

Two cases are presented which illustrate the essential features, diagnosis and management of malignant hyperthermia. Both cases occurred in association with isoflurane, and in patients who were exposed during previous anaesthetics to recognised trigger agents without apparent manifestation of the syndrome.

A national task analysis of infection control practitioners, 1982 Part three: The relationship between hospital size and tasks performed

One aspect of the Certification Board of Infection Control's (CBIC) task analysis survey was to determine those tasks done most frequently and considered most important by ICPs. A randomized stratified sample of ICPs was taken from U.S. hospitals of various bed-size categories. There were 473 responses (78.8%) from a targeted sample of 600 ICPs. Statistical analyses were done to find if a relationship existed between hospital size and the tasks performed. The frequency of performance and importance of the majority of infection control tasks studied were found to vary in relation to hospital size. Some tasks were found to be both important and frequently performed by the majority of ICPs in all hospital bed-size categories. These included performing and reporting epidemiologic surveillance, educating personnel, developing infection control policies and procedures, and consulting with hospital personnel. Other tasks were found to be relatively less important and infrequently performed by the majority of ICPs in all hospital bed-size categories. These included performing bedside patient care procedures, recommending specific antimicrobial therapy, and using statistical methods. The greatest differences in the performance of tasks were found in the subsample of the ICPs from hospitals with less than or equal to 100 beds.

A national task analysis of infection control practitioners, 1982

Respondents (N = 473) from a randomized stratified sample (N = 600) of U.S. hospital ICPs in a national survey sponsored by the Certification Board of Infection Control were asked to rate specific task, knowledge, and ability statements related to infection control for frequency and importance. The questions included 175 items, of which 99 were for specific tasks and 76 were for knowledge and abilities for practice. Areas covered included patient care practices, infectious diseases, epidemiology and statistics, microbiologic practices, sterilization and disinfection, education, employee health services, and management and communications. A "profile respondent" group (N = 317) was defined as persons most likely to be practicing the full scope of infection control practice and was used to identify key tasks, knowledge, and abilities for practice. Results showed that patient care practices (i.e., suctioning, dressing changes, and catheterization) were rarely performed. The development of infection control policies and procedures were key tasks. Knowledge of microbiology and infectious diseases in order to interpret laboratory reports and other patient data was rated as essential; however, few respondents actually performed laboratory procedures. Epidemiologic principles were frequently used for surveillance and problem investigation. Although presentation of epidemiologic data was rated as important, analytic statistics were rarely used. Assessment of educational needs and teaching were large components of ICPs' activities.

A national task analysis of infection control practitioners, 1992 Part One: Methodology and demography

A task analysis survey was conducted in 1982 by the Certification Board of Infection Control ( CBIC ) to determine the tasks performed by ICPs and the knowledge and abilities needed to perform these tasks. Data were obtained from 473 (78.8%) respondents to a nationwide mail survey of 600 ICPs . The respondents represent a randomized, stratified sample of ICPs in various types of U.S. acute care hospitals ranging in size from fewer than 50 beds to more than 500 beds. The results of the survey were used, in part, to develop the Infection Control Certification Examination, offered for the first time on November 19, 1983. According to the survey results, the modal or typical ICP is a white woman between the ages of 31 and 50 years using the title of infection control nurse. She has been employed full time for 2 to 10 years in infection control practice in a Joint Commission on Accreditation of Hospitals (JCAH)--accredited community acute care hospital having 301 to 500 beds. She is working at the supervisory level, is on the nursing department payroll, votes as a member of the hospital's infection control committee, and received her last degree or diploma more than 15 years ago.

Cyproterone acetate in treatment of post-orchidectomy hot flushes. Double-blind cross-over trial

12 patients with troublesome hot flushes after orchidectomy (as a primary treatment for prostatic carcinoma) were treated with cyproterone acetate or placebo in a double-blind cross-over trial. The frequency of hot flushes was significantly reduced during the three weeks that cyproterone acetate (100 mg three times a day) was given. 5 patients complained of lassitude while on cyproterone acetate, but in none was it necessary to discontinue treatment.