Paediatric emergency front-of-neck airway: issues of ethics, law, and philosophy

Practitioners can face significant challenges when managing the airways of infants and neonates because of their unique anatomical and physiological features. The requirement for emergency airway management in this age group is rare. Details of emergency airway techniques in paediatric practice guidelines are missing or lack consensus, and it is known that outcomes for affected children can be poor. Ideally, these children should be managed by experienced paediatric airway practitioners working in a team. However, situations can arise where practitioners, unfamiliar and inexperienced with infants, find themselves in charge. So, what happens when such a practitioner encounters this life-or-death scenario and feels ill-equipped to act? The ethical and legal issues surrounding the management of this emergency are clearly defined, but they can be unknown or misunderstood by doctors. Compounding the extreme stress of the scenario is the moral and ethical dilemma of whether to act or not. The following discussion explores these issues and examines the philosophical and psychological perspectives.

Synthesis and Thermal Oxidation Resistance of Boron-Rich Boron-Carbide Material

A boron-rich boron-carbide material (B4+δC) was synthesized by spark plasma sintering of a ball-milled mixture of high-purity boron powder and graphitic carbon at a pressure of 7 MPa and a temperature of 1930 °C. This high-pressure, high-temperature synthesized material was recovered and characterized by X-ray diffraction, X-ray photoelectron spectroscopy, Raman spectroscopy, Vickers hardness measurements, and thermal oxidation studies. The X-ray diffraction studies revealed a single-phase rhombohedral structure (space group R-3m) with lattice parameters in hexagonal representation as a = 5.609 ± 0.007 Å and c = 12.082 ± 0.02 Å. The experimental lattice parameters result in a value of δ = 0.55, or the composition of the synthesized compound as B4.55C. The high-resolution scans of boron binding energy reveal the existence of a B-C bond at 188.5 eV. Raman spectroscopy reveals the existence of a 386 cm-1 vibrational mode representative of C-B-B linear chain formation due to excess boron in the lattice. The measured Vickers microhardness at a load of 200 gf shows a high hardness value of 33.8 ± 2.3 GPa. Thermal gravimetric studies on B4.55C were conducted at a temperature of 1300 °C in a compressed dry air environment, and its behavior is compared to other high-temperature ceramic materials such as high-entropy transition metal boride. The high neutron absorption cross section, high melting point, high mechanical strength, and thermal oxidation resistance make this material ideal for applications in extreme environments.

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.

Unrecognised oesophageal intubation: time for action

Patients worldwide die every year from unrecognised oesophageal intubation, which is an avoidable complication of airway management usually resulting from human error. Unrecognised oesophageal intubation can occur in any patient of any age whenever intubation occurs regardless of the seniority or experience of the airway practitioner or others involved in the patient's airway management. The tragic fact is that it continues to happen despite improvements in monitoring, airway devices, and medical education. We review these improvements with strategies to eliminate this problem.

Updated guideline on equipment to manage difficult airways: Australian and New Zealand College of Anaesthetists

The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways.

Effects of Inertial Load on Sagittal Plane Kinematics of the Lower Extremity During Flywheel-Based Squats

ABSTRACT

Worcester, KS, Baker, PA, and Bollinger, LM. Effects of inertial load on sagittal plane kinematics of the lower extremity during flywheel-based squats. J Strength Cond Res 36(1): 63-69, 2022-Increasing load increases flexion of lower extremity joints during weighted squats; however, the effects of inertial load on lower extremity kinematics during flywheel-based resistance training (FRT) squats remain unclear. The purpose of this study was to evaluate sagittal plane kinematics of lower extremity joints during FRT squats at various inertial loads. Nine recreationally resistance-trained subjects (3M, 6F) completed a bout of FRT squats with inertial loads of 0.050, 0.075, and 0.100 kg·m2. Two-dimensional sagittal plane kinematics were monitored with retroreflective markers at a rate of 60 Hz. Joint angles and angular velocities of the knee, trunk + hip, trunk inclination, and ankle were quantified throughout concentric and eccentric actions. Effects of inertial load were determined by repeated-measures analysis of variance with α = 0.05. Average power and average vertical velocity decreased with increasing inertial load, whereas average force increased. Minimal and maximal sagittal plane joint angles of the knee, trunk + hip, trunk inclination, and ankle were not significantly different among inertial loads. However, peak joint angular velocities of the knee and trunk + hip tended to decrease with increasing inertial load. Conversely trunk inclination and ankle dorsiflexion velocities were not significantly different among inertial loads. Increasing inertial load from 0.050 to 0.100 kg·m2 significantly reduces average power during FRT squats primarily by decreasing movement velocity, which seems to be specific to the knee and hip joints. It is possible that lower concentric energy input at high inertial loads prevents increased joint flexion during FRT squats.

Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study

Background:

Tracheal intubation for patients with COVID-19 is required for invasive mechanical ventilation. The authors sought to describe practice for emergency intubation, estimate success rates and complications, and determine variation in practice and outcomes between high-income and low- and middle-income countries. The authors hypothesized that successful emergency airway management in patients with COVID-19 is associated with geographical and procedural factors.

Methods:

The authors performed a prospective observational cohort study between March 23, 2020, and October 24, 2020, which included 4,476 episodes of emergency tracheal intubation performed by 1,722 clinicians from 607 institutions across 32 countries in patients with suspected or confirmed COVID-19 requiring mechanical ventilation. The authors investigated associations between intubation and operator characteristics, and the primary outcome of first-attempt success.

Results:

Successful first-attempt tracheal intubation was achieved in 4,017/4,476 (89.7%) episodes, while 23 of 4,476 (0.5%) episodes required four or more attempts. Ten emergency surgical airways were reported—an approximate incidence of 1 in 450 (10 of 4,476). Failed intubation (defined as emergency surgical airway, four or more attempts, or a supraglottic airway as the final device) occurred in approximately 1 of 120 episodes (36 of 4,476). Successful first attempt was more likely during rapid sequence induction versus non–rapid sequence induction (adjusted odds ratio, 1.89 [95% CI, 1.49 to 2.39]; P < 0.001), when operators used powered air-purifying respirators versus nonpowered respirators (adjusted odds ratio, 1.60 [95% CI, 1.16 to 2.20]; P=0.006), and when performed by operators with more COVID-19 intubations recorded (adjusted odds ratio, 1.03 for each additional previous intubation [95% CI, 1.01 to 1.06]; P=0.015). Intubations performed in low- or middle-income countries were less likely to be successful at first attempt than in high-income countries (adjusted odds ratio, 0.57 [95% CI, 0.41 to 0.79]; P=0.001).

Conclusions:

The authors report rates of failed tracheal intubation and emergency surgical airway in patients with COVID-19 requiring emergency airway management, and identified factors associated with increased success. Risks of tracheal intubation failure and success should be considered when managing COVID-19.

The authors report a secondary analysis of associations of intubation and operator characteristics related to the primary outcome of first-attempt intubation success in 4,476 intubations among 1,722 clinicians at 607 institutions across 32 countries, also considering differential rates of success between high-income and low- and middle-income countries. Although successful first-attempt intubation was noted in 89.7% of intubations, 0.5% required four or more attempts, an emergency surgical airway was required in 0.2%, and a composite variable of failed intubation occurred in 0.8%. Multivariable analysis demonstrated that successful first attempts were more likely with rapid sequence intubations, when operators used powered air-purifying respirators, and with increasing operator experience. Intubations performed in low- and middle-income countries were nearly half as likely to be successful on first attempt than in high-income countries. These results provide potentially useful information for global and local policy-making related to this and future pandemics. However, the observational nature, along with lack of patient level characteristics, leave room for substantial residual confounding of these associations.

Supplemental Digital Content is available in the text.

Incidence of post-induction hypoxemia in children and the effect of induction gas composition

BACKGROUND

Pediatric preoxygenation and inhalation induction of anesthesia can include a mixture of gases. In children, the clinical impact on oxygenation while using other gases with oxygen during an inhalation induction is unknown.

AIM

We aimed to determine the impact of oxygen, nitrous oxide, and air concentrations added to the volatile agent by recording the incidence of hypoxemia following an inhalation gaseous induction in children.

METHOD

Records from an Automated Information Management System were used to find the incidence of hypoxemia following an inhalation induction of anesthesia. Episodes of hypoxemia (SaO₂  < 90% sustained for at least 120 s) were recorded in the 10 min after the 3-min induction period. Nitrous oxide and oxygen concentrations were recorded and nitrogen concentration was deduced. We also considered patient sex, age, and ASA status as covariates.

RESULTS

A total of 27 258 cases were included in the analysis. The overall incidence of hypoxemia following an inhalation induction of anesthesia was 5.08% (95% CI 4.83 5.35). Hypoxemia was more common in younger patients and those with higher ASA scores. Controlling for those factors and sex, the incidence of hypoxemia increased 1.2-fold when inspired oxygen concentration was less than 60% and hypoxemia was 2.37 times greater than the overall incidence when the inspired oxygen concentration was less than 40%. There was no clear effect of different concentrations of nitrous oxide or nitrogen when those were factored into the model.

CONCLUSION

The risk of hypoxemia following an inhalation induction of anesthesia in children is minimized when the inspired concentration of oxygen is greater than 60%.

A comparison of cannula insufflation device performance for emergency front of neck airway

BACKGROUND

Pediatric emergency front of neck airway guidelines recommend oxygenation via cannula cricothyroidotomy or tracheotomy.

AIM

The primary aim was to measure test lung pressures and volumes generated by cannula insufflation devices recommended for emergency front of neck airway compared with a pressure limit of 50 cm H₂ O and volume limit of 20 ml/kg. The secondary aim was to calculate pressure and volume variability. The primary end point was test lung expansion.

METHOD

Adult, child, and infant airway models, each with three degrees of upper airway obstruction, were oxygenated using six cannula insufflation devices: 3-way stopcock, Rapid-O₂ , Manujet, Enk oxygen flow modulator, Ventrain, and self-inflating bags. Test lung pressures and volumes were recorded.

RESULTS

Pressures and volumes from all devices were highly variable, despite oxygen flow calibration and strict adherence to oxygen insufflation protocols. With upper airway occlusion, pressures >50 cm H₂ 0 were produced by Rapid-O₂ and Enk oxygen flow meter in adult and infant lungs, 3-way stopcock in adult and child lungs, and Manujet in all lung sizes. Ventrain produced acceptable pressures <35 cm H₂ O in all models. Test lung volumes >20 ml/kg were recorded in airway models with fully obstructed proximal airways using Rapid-O₂ and Enk oxygen flow meter in infant lungs, and Manujet in all lung sizes. Rapid-O₂ produced lung volumes >20 ml/kg in the infant model with partially obstructed and open upper airways. Test lung volumes >20 ml/kg were produced by the 3-way stopcock in adult, child, and infant models. Insufflation was unsuccessful with the self-inflating bag. Ventrain produced acceptable volumes <7 ml/kg in all airway models.

CONCLUSION

Rapid-O₂ , Enkoxygen flow meter, Manujet, and 3-way stopcock oxygenation devices produced highly variable and excessive airway pressures and volumes in models with obstructed upper airways. Self-inflating bag insufflation was unsuccessful. Ventrain was the only device that insufflated oxygen with acceptable pressures and volumes in adult, child, and infant airway models with any degree of airway obstruction.

Difficult Airway Management in Adult COVID-19 Patients: Statement by the Society of Airway Management

The COVID-19 disease, caused by Coronavirus SARS-CoV-2, often results in severe hypoxemia requiring airway management. Because SARS CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue the Society for Airway Management (SAM) created a task force to review existing literature and current Practice Guidelines for management of the difficult airway by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. SAM task force created recommendations for management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of AGREE Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. and difficult airway management often takes longer, may involve multiple procedures with aerosolization potential, strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When patient's airway risk assessment suggests awake tracheal intubation is an appropriate choice of technique, procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with tight seal facemask may be performed to reduce risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as first-line strategy for airway management. If emergent invasive airway access is indicated, we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.

Construct Validity, Test-Retest Reliability, and Repeatability of Performance Variables Using a Flywheel Resistance Training Device

Bollinger, LM, Brantley, JT, Tarlton, JK, Baker, PA, Seay, RF, and Abel, MG. Construct validity, test-retest reliability, and repeatability of performance variables using a flywheel resistance training device. J Strength Cond Res 34(11): 3149-3156, 2020-Power production is highly associated with physical performance; however, the ability to quantitatively measure power output during resistance exercise is lacking. The purpose of this study was to determine the validity and test-retest reliability of flywheel-based performance testing. Twelve young, resistance trained subjects completed 2 bouts of resistance exercise using a flywheel resistance training device (Exxentric kbox 4 Pro). Each session consisted of 3 sets of 3 exercise (bent-over row, Romanian deadlift, and biceps curl) with varying moments of inertia (0.050, 0.075, and 0.100 kg·m, respectively) in random order. Each set consisted of 5 maximal effort repetitions with 3-minute recovery between sets. Average power, peak concentric and eccentric power, average force, average speed, and total work for each set were recorded. Regression analysis revealed a near-perfect relationship between measured and predicted power, force, and work at given workloads. Pearson's r between trials 1 and 2 revealed good (≥0.70) to excellent (≥0.90) test-retest reliability for all outcomes with the exception of peak eccentric power for biceps curls (r = 0.69), which narrowly missed the cutoff for acceptable reliability. Bland-Altman plots revealed small (approximately 5-15%), but statistically significant bias between the 2 trials for some measures. Coefficient of repeatability for all outcomes was relatively high, indicating poor repeatability. Flywheel-based performance testing provides valid data. However, reliability varies between individual lifts and specific outcomes. Given the poor repeatability between trials, it is likely that subjects who are unaccustomed to this modality may require multiple testing sessions or a thorough familiarization period to ensure accurate measures of power, force, speed, and work during flywheel-based performance testing.

Superhard Boron-Rich Boron Carbide with Controlled Degree of Crystallinity

Superhard boron-rich boron carbide coatings were deposited on silicon substrates by microwave plasma chemical vapor deposition (MPCVD) under controlled conditions, which led to either a disordered or crystalline structure, as measured by X-ray diffraction. The control of either disordered or crystalline structures was achieved solely by the choice of the sample being placed either directly on top of the sample holder or within an inset of the sample holder, respectively. The carbon content in the B-C bonded disordered and crystalline coatings was 6.1 at.% and 4.5 at.%, respectively, as measured by X-ray photoelectron spectroscopy. X-ray diffraction analysis of the crystalline coating provided a good match with a B₅₀C₂-type structure in which two carbon atoms replaced boron in the α-tetragonal B₅₂ structure, or in which the carbon atoms occupied different interstitial sites. Density functional theory predictions were used to evaluate the dynamical stability of the potential B₅₀C₂ structural forms and were consistent with the measurements. The measured nanoindentation hardness of the coatings was as high as 64 GPa, well above the 40 GPa threshold for superhardness.

Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study

Healthcare workers involved in aerosol‐generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID‐19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID‐19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self‐reporting. The primary endpoint was the incidence of laboratory‐confirmed COVID‐19 diagnosis or new symptoms requiring self‐isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure‐related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow‐up of 32 (18–48 [0–116]) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID‐19 subsequently reported a COVID‐19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID‐19 transmission.

First-Principles Predictions and Synthesis of B50C2 by Chemical Vapor Deposition

Density functional theory predictions have been combined with the microwave-plasma chemical vapor deposition technique to explore metastable synthesis of boron-rich boron-carbide materials. A thin film synthesis of high-hardness (up to 37 GPa) B₅₀C₂ via chemical vapor deposition was achieved. Characterization of the experimental crystal structure matches well with a new theoretical model structure, with carbon atoms inserted into the boron icosahedra and 2b sites in a α-tetragonal B₅₂ base structure. Previously reported metallic B₅₀C₂ structures with carbons inserted only into the 2b or 4c sites are found to be dynamically unstable. The newly predicted structure is insulating and dynamically stable, with a computed hardness value and electrical properties in excellent agreement with the experiment. The present study thus validates the density functional theory calculations of stable crystal structures in boron-rich boron-carbide system and provides a pathway for large-area synthesis of novel materials by the chemical vapor deposition method.

Non-equilibrium hybrid organic plasma processing for superhydrophobic PTFE surface towards potential bio-interface applications

Superhydrophobic surfaces have gained increased attention due to the high water-repellency and self-cleaning capabilities of these surfaces. In the present study, we explored a novel hybrid method of fabricating superhydrophobic poly(tetrafluoroethylene) (PTFE) surfaces by combining the physical etching capability of oxygen plasma with the plasma-induced polymerization of a organic monomer methyl methacrylate (MMA). This novel hybrid combination of oxygen-MMA plasma has resulted in the generation of superhydrophobic PTFE surfaces with contact angle of 154°. We hypothesized that the generation of superhydrophobicity may be attributed to the generation of fluorinated poly(methyl methacrylate) (PMMA) moieties formed by the combined effects of physical etching causing de-fluorination of PTFE and the subsequent plasma polymerization of MMA. The plasma treated PTFE surfaces were then systematically characterized via XPS, FTIR, XRD, DSC and SEM analyses. The results have clearly shown a synergistic effect of the oxygen/MMA combination in comparison with either the oxygen plasma alone or MMA vapors alone. Furthermore, the reported new hybrid combination of Oxygen-MMA plasma has been demonstrated to achieve superhydrophobicity at lower power and short time scales than previously reported methods in the literature. Hence the reported novel hybrid strategy of fabricating superhydrophobic PTFE surfaces could have futuristic potential towards biointerface applications.

Successful Application of Optiflow THRIVE to Restore Oxygenation and Facilitate Retrieval of an Aspirated Nut in a Severely Hypoxic Child: A Case Report

In this case, the novel use of high-flow nasal oxygen successfully treated severe hypoxia by delivering oxygen through a very narrow space between the bronchoscope and the tracheal wall. Removal of a foreign body from a child's lung can be associated with hypoxia and cardiorespiratory arrest. The shared airway of the bronchoscope must allow surgical instrumentation and oxygenation. This simultaneous use can compromise gas exchange, leading to hypoxia. In this case, high-flow nasal oxygen supplemented bronchoscope oxygenation to treat a severely hypoxic child and facilitate subsequent removal of a peanut without further incident.

Late Holocene volcanic and anthropogenic mercury deposition in the western Central Andes (Lake Chungará, Chile)

Volcanism is one of the major natural processes emitting mercury (Hg) to the atmosphere, representing a significant component of the global Hg budget. The importance of volcanic eruptions for local-scale Hg deposition was investigated using analyses of Hg, inorganic elemental tracers, and organic biomarkers in a sediment sequence from Lake Chungará (4520 m a.s.l.). Environmental change and Hg deposition in the immediate vicinity of the Parinacota volcano were reconstructed over the last 2700 years, encompassing the pre-anthropogenic and anthropogenic periods. Twenty eruptions delivering large amounts of Hg (1 to 457 μg Hg m^-2 yr^-1 deposited at the timescale of the event) were locally recorded. Peaks of Hg concentration recorded after most of the eruptions were attributed to a decrease in sedimentation rate together with the rapid re-oxidation of gaseous elemental Hg and deposition with fine particles and incorporation into lake primary producers. Over the study period, the contribution of volcanic emissions has been estimated as 32% of the total Hg input to the lake. Sharp depletions in primary production occurred at each eruption, likely resulting from massive volcaniclastic inputs and changes in the lake-water physico-chemistry. Excluding the volcanic deposition periods, Hg accumulation rates rose from natural background values (1.9 ± 0.5 μg m^-2 yr^-1) by a factor of 2.3 during the pre-colonial mining period (1400-900 yr cal. BP), and by a factor of 6 and 7.6, respectively, during the Hispanic colonial epoch (400-150 yr cal. BP) and the industrial era (~140 yr cal. BP to present). Altogether, the dataset indicates that lake primary production has been the main, but not limiting, carrier for Hg to the sediment. Volcanic activity and climate change are only secondary drivers of local Hg deposition relative to the magnitude of regional and global anthropogenic emissions.

Computational Predictions and Microwave Plasma Synthesis of Superhard Boron-Carbon Materials

Superhard boron-carbon materials are of prime interest due to their non-oxidizing properties at high temperatures compared to diamond-based materials and their non-reactivity with ferrous metals under extreme conditions. In this work, evolutionary algorithms combined with density functional theory have been utilized to predict stable structures and properties for the boron-carbon system, including the elusive superhard BC₅ compound. We report on the microwave plasma chemical vapor deposition on a silicon substrate of a series of composite materials containing amorphous boron-doped graphitic carbon, boron-doped diamond, and a cubic hard-phase with a boron-content as high as 7.7 at%. The nanoindentation hardness of these composite materials can be tailored from 8 GPa to as high as 62 GPa depending on the growth conditions. These materials have been characterized by electron microscopy, X-ray photoelectron spectroscopy, Raman spectroscopy, X-ray diffraction, and nanoindentation hardness, and the experimental results are compared with theoretical predictions. Our studies show that a significant amount of boron up to 7.7 at% can be accommodated in the cubic phase of diamond and its phonon modes and mechanical properties can be accurately modeled by theory. This cubic hard-phase can be incorporated into amorphous boron-carbon matrices to yield superhard materials with tunable hardness values.

Morphological Transition in Diamond Thin-Films Induced by Boron in a Microwave Plasma Deposition Process

The purpose of this study is to understand the basic mechanisms responsible for the synthesis of nanostructured diamond films in a microwave plasma chemical vapor deposition (MPCVD) process and to identify plasma chemistry suitable for controlling the morphology and electrical properties of deposited films. The nanostructured diamond films were synthesized by MPCVD on Ti-6Al-4V alloy substrates using H₂/CH₄/N₂ precursor gases and the plasma chemistry was monitored by the optical emission spectroscopy (OES). The synthesized thin-films were characterized by x-ray diffraction and scanning electron microscopy. The addition of B₂H₆ to the feedgas during MPCVD of diamond thin-films changes the crystal grain size from nanometer to micron scale. Nanostructured diamond films grown with H₂/CH₄/N₂ gases demonstrate a broad (111) Bragg x-ray diffraction peak (Full-Width at Half-Maximum (FWHM) = 0.93° 2θ), indicating a small grain size, whereas scans show a definite sharpening of the diamond (111) peak (FWHM = 0.30° 2θ) with the addition of boron. OES showed a decrease in CN (carbon–nitrogen) radical in the plasma with B₂H₆ addition to the gas mixture. Our study indicates that CN radical plays a critical role in the synthesis of nanostructured diamond films and suppression of CN radical by boron-addition in the plasma causes a morphological transition to microcrystalline diamond.

A wear simulation study of nanostructured CVD diamond-on-diamond articulation involving concave/convex mating surfaces

Using microwave-plasma Chemical Vapor Deposition (CVD), a 3-micron thick nanostructured-diamond (NSD) layer was deposited onto polished, convex and concave components that were machined from Ti-6Al-4V alloy. These components had the same radius of curvature, 25.4mm. Wear testing of the surfaces was performed by rotating articulation of the diamond-deposited surfaces (diamond-on-diamond) with a load of 225N for a total of 5 million cycles in bovine serum resulting in polishing of the diamond surface and formation of very shallow, linear wear grooves of less than 50nm depth. The two diamond surfaces remained adhered to the components and polished each other to an average surface roughness that was reduced by as much as a factor of 80 for the most polished region located at the center of the condyle. Imaging of the surfaces showed that the initial wearing-in phase of diamond was only beginning at the end of the 5 million cycles. Atomic force microscopy, scanning electron microscopy, Raman spectroscopy, and surface profilometry were used to characterize the surfaces and verify that the diamond remained intact and uniform over the surface, thereby protecting the underlying metal. These wear simulation results show that diamond deposition on Ti alloy has potential application for joint replacement devices with improved longevity over existing devices made of cobalt chrome and ultra-high molecular weight polyethylene (UHMWPE).

Global climate evolution during the last deglaciation

Deciphering the evolution of global climate from the end of the Last Glacial Maximum approximately 19 ka to the early Holocene 11 ka presents an outstanding opportunity for understanding the transient response of Earth's climate system to external and internal forcings. During this interval of global warming, the decay of ice sheets caused global mean sea level to rise by approximately 80 m; terrestrial and marine ecosystems experienced large disturbances and range shifts; perturbations to the carbon cycle resulted in a net release of the greenhouse gases CO(2) and CH(4) to the atmosphere; and changes in atmosphere and ocean circulation affected the global distribution and fluxes of water and heat. Here we summarize a major effort by the paleoclimate research community to characterize these changes through the development of well-dated, high-resolution records of the deep and intermediate ocean as well as surface climate. Our synthesis indicates that the superposition of two modes explains much of the variability in regional and global climate during the last deglaciation, with a strong association between the first mode and variations in greenhouse gases, and between the second mode and variations in the Atlantic meridional overturning circulation.

Education in airway management

In airway management, poor judgment, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate. Curriculum change is underway in many medical organisations in an effort to correct these problems, and airway management is likely to be explicitly addressed as a clinical fundamental within any new anaesthetic curriculum. Competency-based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire constantly to improve performance with a career-long commitment to education.

Failure to ventilate with supraglottic airways after drowning

We report the failure of an i-gel and an Ambu AuraOnce supraglottic airway to ventilate a drowning victim. Failure was attributed to changes in lung physiology following submersion and inhalation of water that may have required ventilation pressures up to 40 cmH2O to treat the victim's hypoxaemia. The ease of use and rapid insertion of supraglottic airways without interrupting cardiac compression has prompted recommendations for their use during resuscitation. The relatively low leak pressures attainable from many supraglottic airways, however may cause inadequate lung ventilation and entrainment of air into the stomach when these devices are used in drowning victims.

Dermatofibrosarcoma protuberans arising in a decorative tattoo

Dermatofibrosarcoma protuberans (DFSP) is an uncommon, locally aggressive cutaneous tumour of intermediate grade malignancy. A number of reports have linked local trauma of varying aetiology with the later development of DFSP. In addition, a variety of skin disorders and, in rare cases, cutaneous tumours, have been described in association with decorative tattoos. This is often associated with delayed diagnosis. We report the first case of DFSP arising in a tattoo and discuss the available evidence for a causative link between DFSP and local trauma of this nature.

An audit of laryngoscopes and application of a new ISO standard

OBJECTIVE

The International Organization for Standardization (ISO) recently published an International Standard (ISO 7376:2009) which specifies illuminance levels and tests for illumination from hook-on type laryngoscopes used for intubation. A clinical study examining luminance for laryngoscopy found that 100 cd·m(-2) was the minimum level acceptable for laryngoscopy. The purpose of this study was to measure the quality of light from laryngoscopes available for use by anesthetists in an anesthetic department and compare them to the ISO illuminance standard and published minimum acceptable luminance limits.

METHODS

A measuring device was constructed to support each laryngoscope in a standardized manner. For 190 reusable laryngoscopes, illuminance was measured with a lux meter at the base of this device. Eighteen clinically available laryngoscopes were then examined in detail, as a snapshot study, with multiple light recordings according to the ISO Standard. We also measured the luminance provided by each laryngoscope.

RESULTS

Only two of the 18 laryngoscopes met the minimum illuminance level of 500 lux after 10 min. Nine laryngoscopes provided a luminance <100 cd·m(-2), which is the reported minimum required luminance for laryngoscopy. None of the 18 laryngoscopes tested complied with the ISO standard for laryngoscope light distribution.

CONCLUSIONS

Laryngoscope light should be regularly audited. Results from these audits can be used to retire or repair substandard laryngoscopes to maintain acceptable standards of laryngoscope light. Audit results produce tangible evidence that is useful when applying for capital expenditure. Light measurements are not easy to make. There needs to be a convenient device to reliably measure laryngoscope illumination.

Equipment to manage a difficult airway during anaesthesia

Airway complications are a leading cause of morbidity and mortality in anaesthesia. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/ resources/professional-documents). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).

A prospective randomized trial comparing supraglottic airways for flexible bronchoscopy in children

OBJECTIVE

A prospective randomized, controlled trial was conducted comparing supraglottic airways (SGA) for flexible bronchoscopy in 100 children.

BACKGROUND

Pediatric flexible bronchoscopy is commonly performed using a SGA as both a ventilation device and a conduit for flexible bronchoscopy. We observed that some disposable SGAs were associated with increased resistance to bronchoscope manipulation compared to the LMA Classic (cLMA).

METHODS

We compared the cLMA to the Ambu Aura Once, Portex Soft Seal, Boss Systems disposable silicone laryngeal mask, and LMA Unique. We recorded the subjective resistance of the bronchoscope manipulation within the SGA by linear analog score and measured the time to insert the bronchoscope from the proximal end of the SGA to the right upper lobe. We also scored the view of the larynx through the bronchoscope and measured SGA cuff pressures.

RESULTS

Resistance to bronchoscope manipulation during pediatric flexible bronchoscopy was higher using polyvinyl chloride (PVC) disposable SGAs (Ambu, Unique, and Portex) than the silicone re-usable cLMA (P < 0.0001). The Unique and Ambu laryngeal masks were clinically inferior to the cLMA at all levels of the airway (P < 0.0001). The Portex Soft Seal was not different above the larynx but was significantly statistically inferior at (P < 0.04) and below the larynx (P < 0.006) and inferior overall (P < 0.007). Boss Systems single-use laryngeal mask was as effective as the cLMA.

CONCLUSION

In this trial, PVC single-use laryngeal masks were inferior to the silicone cLMA and Boss Systems laryngeal masks for flexible bronchoscopy in children.

Constraints on the formation of sedimentary dolomite

The experimental replacement of calcite and aragonite by dolomite under a variety of conditions indicates that dolomitization can take place in marine and lacustrine environments under two conditions: (i) low dissolved sulfate concentrations and (ii) insubstantial contemporaneous silica diagenesis. Common sites for dolomite formation are areas where the dissolved sulfate concentration is reduced by microbial sulfate reduction, through the mixing of seawater with large amounts of fresh water, or where low-sulfate alkaline lacustrine environments prevail. Even under these conditions, dolomite formation may be inhibited by the concurrent transformation of opal-A (amorphous silica) to opal-CT (disordered cristobalite and tridymite), whereas the subsequent transformation of opal-CT to quartz favors the formation of dolomite.

How did the Macintosh laryngoscope become so popular?

The Macintosh laryngoscope has been described as 'the most numerously and widely made durable item in the history of anesthesia' (Sir Anthony Jephcott, February 6, 1983). This laryngoscope was originally designed to facilitate intubation in unparalyzed patients and became universally adopted by the anesthetic community. In spite of enormous subsequent changes in anesthetic practice, the Macintosh laryngoscope continues to dominate 50 years after its key indication has become obsolete. This study explores the development and success of this ubiquitous instrument.

Experimental adaptation of the Enk oxygen flow modulator for potential pediatric use

AIM

A bench study of the Enk oxygen flow modulator (Enk OFM) was conducted to test its performance and potential use in pediatric patients using the Advanced Paediatric Life Support (APLS) guidelines (Advanced Paediatric Life Support, 2005: 224).

BACKGROUND

The Enk OFM is a preassembled emergency transtracheal ventilation device.

METHODS

The Enk OFM was connected to two sources of oxygen: first, to a Precision Medical flowmeter and second, to an Aestiva anesthetic machine axillary flowmeter. Testing was performed on standard cannulae of 20, 18, and 16 gauge caliber and also a 7.5 cm 15G Emergency Transtracheal Airway Catheter (Cook Medical). Serial hole occlusion of the Enk OFM was applied and the resulting flow rates were measured by a RespiCal Timeter.

RESULTS

Oxygen flow was best controlled by occluding all holes of the Enk OFM and incrementally increasing oxygen flow by the flowmeter with an initial setting of 1 l min(-1) year(-1) of age. Contrary to the original description of this device (Anesth Analg 1998; 86: 203S), sequential occlusion of the five side holes does not lead to a significant exponential increase in gas flow. Incomplete occlusion of the Enk OFM provided insufficient and unpredictable flow.

CONCLUSIONS

The Enk OFM should be fully occluded for inspiration with flow rates set at 1 l min(-1) year(-1) of age and adjusted to effect. These flow rates are consistent with the APLS recommendations. Flows above 15 l min(-1) are potentially dangerous and the Enk OFM fails to perform as an on-off device. Flowmeter settings of <1 l min(-1) risk no flow. Cannulae of at least 18G should be used for optimal flow.

Functional gracilis flap in thenar reconstruction

Restoration of lost opposition in the context of significant thenar soft tissue defects represents a tremendous reconstructive challenge. Free functioning muscle transfer has been described in this context and has the advantage of providing both a functioning muscle unit as well as soft tissue coverage in a single reconstructive procedure. It adds to the injured limb, and by sparing donor tendons avoids the need for re-education of motor function. We describe the use of a free innervated gracilis muscle flap for functional thenar reconstruction in two unique cases following extensive traumatic loss of thenar skin and musculature. Crucially, in each case, the recurrent motor branch of the median nerve had been destroyed at its point of insertion into the thenar muscle remnants.

AIM

To date, the main reported disadvantages of free functioning muscle transfer in thenar reconstruction include difficult flap dissections, donor site morbidity, inadequate strength and excursion of the transplanted muscle and excessively bulky flaps. Our aim was, as far as possible, to address these issues.

SURGICAL PROCEDURE

Each thenar defect was measured and a corresponding segment of gracilis muscle, measured in situ, was raised on the proximal neurovascular pedicle. End-side microvascular anastomosis was performed between the medial circumflex femoral artery and the radial artery. The venae comitantes of the pedicle were anastomosed end-end with those of the radial artery and also with the cephalic vein. Epineural anastomosis was performed between the motor branch of the obturator nerve and the recurrent motor branch of the median nerve. Each flap was covered with a split thickness skin graft.

RESULTS

Both flaps survived without any complication. Both patients regained excellent voluntary thumb opposition, sufficient to allow return to full-time employment, and had restoration of sufficient thenar bulk. This was achieved with minimal donor site morbidity.

CONCLUSIONS

Restoration of lost opposition, in the context of significant thenar soft tissue defects, can be achieved using a free functional gracilis flap. This produces clinically excellent functional results and can be carried out as a single stage reconstructive procedure. This is a novel application of a tremendously versatile donor muscle in functioning free muscle transfer.

Airway management during an EXIT procedure for a fetus with dysgnathia complex

Nonsyndromal dysgnathia is a rare disorder with a probable genetic basis characterized by a hypoplastic or absent mandible (agnathia), microstomia, microglossia, and ear anomalies secondary to a defect in the ventral portion of the first branchial arch caused by defective neural crest migration or proliferation. Dysgnathic newborn infants often suffer fatal respiratory failure from airway obstruction. Nineteen children with isolated dysgnathia complex are described in the literature--six were stillborn, eight died shortly after birth, and only five survived infancy. All survivors required tracheostomy to maintain an airway. It is difficult to intubate the trachea of these children and early airway management planning is important. We report a neonate who presented with a prenatal ultrasound diagnosis of severe micrognathia, polyhydramnios and a family history of severe micrognathia. Airway management was achieved with fiberoptic intubation through a laryngeal mask airway (LMA) during an ex utero intrapartum treatment procedure. Fiberoptic intubation was hampered by copious amounts of amniotic fluid. This child and her sibling are the first two siblings with isolated dysgnathia complex to have survived infancy and provide further support for a genetic basis to this condition.

Early warming of tropical South America at the last glacial-interglacial transition

Glaciation in the humid tropical Andes is a sensitive indicator of mean annual temperature. Here, we present sedimentological data from lakes beyond the glacial limit in the tropical Andes indicating that deglaciation from the Last Glacial Maximum led substantial warming at high northern latitudes. Deglaciation from glacial maximum positions at Lake Titicaca, Peru/Bolivia (16 degrees S), and Lake Junin, Peru (11 degrees S), occurred 22,000 to 19,500 calendar years before the present, several thousand years before the Bølling-Allerød warming of the Northern Hemisphere and deglaciation of the Sierra Nevada, United States (36.5 degrees to 38 degrees N). The tropical Andes deglaciated while climatic conditions remained regionally wet, which reflects the dominant control of mean annual temperature on tropical glaciation.

Low-temperature growth of nanostructured diamond films

Nanostructured diamond films are grown on a titanium alloy substrate using a two-step deposition process. The first step is performed at elevated temperature (820 degrees C) for 30 min using a H2/CH4/N2 gas mixture to grow a thin (approximately 600 nm) nanostructured diamond layer and to improve film adhesion. The remainder of the deposition involves growth at low temperature (< 600 degrees C) in a H2/CH4/O2 gas mixture. The continuation of the smooth nanostructured diamond film growth during low-temperature deposition is confirmed by in situ laser reflectance interferometry, atomic force microscopy, micro-Raman spectroscopy, and surface profilometry. Similar experiments performed without the initial nanostructured diamond layer resulted in poorly adhered films with a more crystalline appearance and a higher surface roughness. This low-temperature deposition of nanostructured diamond films on metals offers advantages in cases where high residual thermal stress leads to delamination at high temperatures.