Five-year audit of adherence to an anaesthesia pre-induction checklist

Although patient safety related to airway management has improved substantially over the last few decades, life‐threatening events still occur. Technical skills, clinical expertise and human factors contribute to successful airway management. Checklists aim to improve safety by providing a structured approach to equipment, personnel and decision‐making. This audit investigates adherence to our institution's airway checklist from 1 June 2016 to 31 May 2021. Inclusion criteria were procedures requiring airway management and we excluded all procedures performed solely under regional anaesthesia, sedation without airway management or paediatric and cardiovascular surgery. The primary outcome was the proportion of wholly performed pre‐induction checklists. Secondary outcomes were the pattern of adherence over the 5 years well as details of airway management, including: airway management difficulties; time and location of induction; anaesthesia teams in operating theatres (including teams for different surgical specialities); non‐operating theatre and emergency procedures; type of anaesthesia (general or combined); and urgency of the procedure. In total, 95,946 procedures were included. In 57.3%, anaesthesia pre‐induction checklists were completed. Over the 5 years after implementation, adherence improved from 48.3% to 66.7% (p < 0.001). Anticipated and unanticipated airway management difficulties (e.g. facemask ventilation, supraglottic airway device or intubation) defined by the handling anaesthetist were encountered in 4.2% of all procedures. Completion of the checklist differed depending on the time of day (61.3% during the day vs. 35.0% during the night, p < 0.001). Completion also differed depending on location (66.8% in operating theatres vs. 41.0% for non‐operating theatre anaesthesia, p < 0.001) and urgency of procedure (65.4% in non‐emergencies vs. 35.4% in emergencies, p < 0.001). A mixed‐effect model indicated that urgency of procedure is a strong predictor for adherence, with emergency cases having lower adherence (OR 0.58, 95%CI 0.49–0.68, p < 0.001). In conclusion, over 5 years, a significant increase in adherence to an anaesthesia pre‐induction checklist was found, and areas for further improvement (e.g. emergencies, non‐operating room procedures, night‐time procedures) were identified.

Autism and toe-walking: are they related? Trends and treatment patterns between 2005 and 2016

PURPOSE

This study quantified toe-walking trends and treatment decisions in patients with autism spectrum disorder (ASD) in the United States between 2005 and 2016 using a large national private-payer database.

METHODS

A retrospective database review was performed on paediatric patients with ASD, and for International Classification of Diseases-9/10 diagnosis codes for toe-walking. Patients were filtered based on treatment type by Current Procedural Terminology (CPT) code. Continued toe-walking rates were assessed for each patient population and treatment group. A Pearson's chi-squared test was used to evaluate differences in group characteristics.

RESULTS

Of 2 221 009 paediatric patients in the database, 5739 patients had a diagnosis of ASD, and 8.4% of patients with ASD also had a diagnosis of toe-walking (n = 484). For typically developing children in the database, 0.47% of patients had a diagnosis of persistent toe-walking. In all, 59.3% of ASD patients underwent physical therapy, 7.4% serial casting and 3.3% surgical correction, compared with 38.1%, 3.6% and 1.2% of normally developing children, respectively (chi-square 6.4031; p < 0.040699). Without intervention, 63.6% of patients with ASD continued to toe-walk within ten years of their diagnosis, with 19.3% of patients without ASD (chi-square 82.9762; p < 0.0001).

CONCLUSION

This study supports the association between a greater prevalence of toe-walking in children with ASD. We showed that patients with ASD and toe-walking receive surgical correction at nearly triple the rate of children without ASD who toe-walk. The continued rate of toe-walking is comparable between treatment groups as well as between ASD and typically developing children. Typically developing children have higher rates of toe-walking resolution without intervention than children with ASD.

LEVEL OF EVIDENCE

Level II.

Human pancreatic tumor cells are sensitized to ionizing radiation by knockdown of caveolin-1

Caveolin-1 (Cav-1) is an integral transmembrane protein and a critical component in interactions of integrin receptors with cytoskeleton-associated and signaling molecules. Since integrin-mediated cell adhesion generates signals conferring radiation resistance, we examined the effects of small interfering RNA-mediated knockdown of Cav-1 alone or in combination with beta1-integrin or focal adhesion kinase (FAK) on radiation survival and proliferation of pancreatic carcinoma cell lines. Irradiation induced Cav-1 expression in PATU8902, MiaPaCa2 and Panc1 cell lines. The cell lines showed significant radiosensitization after knockdown of Cav-1, beta1-integrin or FAK and cholesterol depletion by beta-cyclodextrin relative to nonspecific controls. Under knockdown conditions, proliferation of non-irradiated and irradiated cells was significantly attenuated relative to controls. These findings correlated with changes in expression or phosphorylation of Akt, glycogen synthase kinase 3beta, Paxillin, Src, c-Jun N-terminal kinase and mitogen-activated protein kinase. Analysis of DNA microarray data revealed a Cav-1 overexpression in a subset of pancreatic ductal adenocarcinoma samples. The data presented show, for the first time, that disruption of interactions of Cav-1 with beta1-integrin or FAK affects radiation survival and proliferation of pancreatic carcinoma cells and suggest that Cav-1 is critical to these processes. These results indicate that strategies targeting Cav-1 may be useful as an approach to improve conventional therapies, including radiotherapy, for pancreatic cancer.

[Temozolomide as therapeutic option for patients with metastatic melanoma and poor prognosis]

BACKGROUND AND OBJECTIVE

Stage IV melanoma patients with a very advanced disease are usually excluded from clinical trials. We treated 25 stage IV patients with temozolomide - a cytostatic drug with 100% oral bioavailability and considerable penetration of CNS tissue.

PATIENTS/METHODS

25 patients (17 female, 8 male) between 24 and 82 years (mean: 55.5 years) were included in this retrospective study. 19 patients had received at least one and up to four previous chemotherapy regimens during the course of stage IV disease. 11 (44%) patients showed cerebral metastases prior to therapy with temozolomide. 200 mg/m2 temozolomide were given orally at home on day 1 to 5 in week 1 and in week 5, respectively.

RESULTS

Out of 23 evaluable patients 2 (8.7%) showed a partial remission, 2 (8,7%) a minor response, 6 (26.1%) had stable disease, 1 (4,3%) a mixed response, and 12 (52.1%) patients experienced disease progression. Sites of remission included brain, lung, liver, lymph nodes and muscle. Two patients interrupted therapy due to severe leuko- and thrombocytopenia (WHO grade 3 and 4). All other patients tolerated treatment with temozolomide well and no dose reduction was necessary. The median overall survival was 7 months (2-28+ months) since beginning of therapy and 15 months (4-63+ months) since onset of stage IV disease.

CONCLUSION

Temozolomide represents a safe treatment option in patients with metastatic melanoma and poor prognosis.

Necrotizing fasciitis due to Streptococcus pneumoniae after intramuscular injection of nonsteroidal anti-inflammatory drugs: report of 2 cases and review

Two cases of pneumococcal necrotizing fasciitis (NF) occurred after intramuscular injections of nonsteroidal anti-inflammatory drugs; another 5 cases reported in the literature fulfilled the criteria for NF involving Streptococcus pneumoniae. Conditions associated with alterations of immune function could be identified in 6 of the 7 cases; 2 patients died despite surgical and antimicrobial treatment.

Combinatorial biochemistry in plants: the case of O-methyltransferases

Combinatorial chemistry is common place today in chemical synthesis. Virtually thousands of derivatives of a molecule can be achieved by automated systems. The use of biological systems to exploit combinatorial chemistry (combinatorial biochemistry) now has multiple examples in the polyketide field. The modular functional domain structure of polyketide synthases have been recombined through genetic engineering into unnatural constellations in heterologous hosts in order to produce polyketide structures not yet discovered in nature. We present herein an example for a potential type of combinatorial biochemistry in alkaloidal systems using various combinations of Thalictrum tuberosum (meadow rue) O-methyltransferase subunits that result in heterodimeric enzymes with substrate specificities that differ from those of the homodimeric native enzymes.

Molecular cloning and functional expression of O-methyltransferases common to isoquinoline alkaloid and phenylpropanoid biosynthesis

In cell suspension cultures of the meadow rue Thalictrum tuberosum, biosynthesis of the anti-microbial alkaloid berberine can be induced by addition of methyl jasmonate to the culture medium. The activities of the four methyltransferases involved in the formation of berberine from L-tyrosine are increased in response to elicitor addition. Partial clones generated by RT-PCR with methyltransferase-specific primers were used as hybridization probes to isolate four cDNAs encoding O-methyltransferases from a cDNA library prepared from poly(A)+ RNA isolated from methyl jasmonate-induced cell suspension cultures of T. tuberosum. RNA gel blot hybridization indicated that the transcripts for the methyltransferases accumulated in response to addition of methyl jasmonate to the cell culture medium. The cDNAs were functionally expressed in Spodoptera frugiperda Sf9 cells and were shown to have varying and broad substrate specificities. A difference of a single amino acid residue between two of the enzymes was sufficient to alter the substrate specificity. The four cDNAs were expressed either as four homodimers or as six heterodimers by co-infection with all possible combinations of the four recombinant baculoviruses. These 10 isoforms thus produced displayed distinct substrate specificities and in some cases co-infection with two different recombinant baculoviruses led to the O-methylation of new substrates. The substrates that were O-methylated varied in structural complexity from simple catechols to phenylpropanoids, tetrahydrobenzylisoquinoline, protoberberine and tetrahydrophenethylisoquinoline alkaloids, suggesting that some biosynthetic enzymes may be common to both phenylpropanoid and alkaloid anabolism.

[Symptomatic abdominal aortic aneurysm and left-sided infrarenal vena cava]

Coincidence of an abdominal aortic aneurysm and abnormalities of the inferior vena cava is a rare condition but has significance for surgical therapy. By the preoperative use of various imaging techniques and adapted surgical procedure the risk of the operation is decreasing to a minimal level. A case of symptomatic abdominal aneurysm and left-sided infrarenal vena cava is presented and the importance of preoperative examinations and operative strategy is discussed.

Temporal stability of polydipsia-hyponatremia

We evaluated temporal stability and outcome predictors associated with polydipsia-hyponatremia (PH). Severity of PH was measured on two occasions separated by at least 1 year in 25 chronic psychiatric inpatients (24 with schizophrenia). Three-quarters of the sample had clinically evident PH on follow-up. Follow-up PH severity was significantly related to intake severity and hospitalization length. Our findings suggest that PH may be a persistent condition with specific outcome predictors.

[Spontaneous remission in chronic lymphatic leukemia]

We describe three patients with chronic lymphocytic leukemia who had a complete spontaneous remission, and review the cases reported in the literature. The mechanism leading to spontaneous remission is unknown, but it is speculated that the loss of a leukemia inducing oncogene or the reappearance of a leukemia suppressor gene could be involved. The interesting observation that, in some reported patients, the remission followed a viral infection, raises the question whether a virus-induced defense mechanism plays a causal role.

[Surgery in chronic pancreatitis. II. Late results following non-resection operations]

Between 1966 and 1985, 994 patients with chronic pancreatitis were treated at a University Surgical Department, 346 by drainage or diversion procedure, 339 by resection and 309 conservatively. The most frequent non-resecting procedures were: pancreatic pseudocyst drainage in 146, biliary-digestive tract anastomosis in 80, gastro-enterostomy in 15, biliary-tract revision in 58 and pancreatic duct drainage in 7 patients. More than half the patients had previously been operated on at least once. Overall postoperative death rate was 6.6%. Of those operated on up to 1983, whose subsequent course was analysed retrospectively, 16% had died (mean observation period 4.6 years). As many as 29% of patients had further bouts of pancreatitis. Weight remained steady or increased in 82%, the number of those with diabetes increased by 6%. All but 12% remained free of pain postoperatively or had only minor and occasional symptoms. Alcohol abuse decreased markedly. If alcohol consumption remained moderate (less than 50 g daily), late mortality rate was definitely decreased. Drainage or diversion procedures and pancreas resection are not competitive but complementary methods in chronic pancreatitis. Imaging techniques have helped the trend towards more conservative management.

[Surgery of chronic pancreatitis. I. Late results after resection management]

From 1966 to 1985, 994 patients were treated for chronic pancreatitis. In 339 (34%), a resection of the pancreas was carried out. There were 166 left resections as compared to 175 right resections (Whipple, total duodenopancreatectomy). Almost half of the patients had already been operated on beforehand. The surgical lethality after partial duodenopancreatectomy could be lowered from 15% to 1.6%. After left resection, it continued without change to be 4% to 7%. Total duodenopancreatectomy and subtotal left resection were no longer carried out. 31% of the 246 patients followed up in a retrospective study died in the later course (mean period of follow-up observation: 6.5 years). Less than 10% of the patients died of complications due to pancreatitis. Three quarters of the patients maintained constant weight or gained weight. In half of the patients, there was a manifest diabetes mellitus postoperatively. 76% were free of pain postoperatively or had only slight symptoms. The late results are essentially determined by the readiness of the patients to adopt a disciplined style of life with reduction of alcohol consumption. This must be considered in the establishment of the indication for pancreatectomy in chronic pancreatitis.

Efficacy of immunoglobulins in gram-negative infections in experimentally induced peritonitis in the rat

The effect of adjuvantly administered, newly developed immunoglobulin preparations in combination with an antibiotic is investigated by means of an animal experimental model. The animal model was peritonitis which was induced by a left-open colotomy in the rat. Administration of a combination therapy of immunoglobulins and an antibiotic succeeded in reducing lethality and shock index (according to Staub [15]) significantly by up to 50% as compared to the untreated control group. Using sub-therapeutic dosage of the antibiotic (50% of the human equivalent dose) the synergistic effect of the immunoglobulins could be confirmed clearly. A single summation of the offered immunoglobulin preparations cannot achieve an improvement in the results. In the present examinations additional IgM-enrichment does not result in a further improvement over the usually normal immunoglobulin levels in the preparations.

[Complications after resection in cases of chronic pancreatitis (author's transl)]

Mortality and post-operative complications are reported in 236 patients with chronic pancreatitis, who underwent pancreas resection in the Surgical Clinic of the University of Mainz between 1967 and 1979. Early mortality was 10.2%, late death (average observation time: 3 years 36 weeks) occurred in 19.0% of all patients. The most common intra-operative and early complication was haemorrhage, in later illness and deaths, alcohol-induced disorders of the liver and their consequences, played a large part. In 12 cases, persisting pancreatitis required further operation. Exact differentiation of the indications, with the aid of ultrasound and computed tomography, is necessary.

[Trends in surgery for chronic pancreatitis (author's transl)]

Improved preoperative assessment (ERCP, sonography, computer tomography) of pathological changes of the pancreas has impressively changed indications for surgery, timing of the operation and surgical methods used. Intraoperative diagnostics have lost ground due to newer techniques. The aim of surgical treatment is pain relief and the prevention of complications (cholestasis, duodenal stenosis, segmental portal hypertension). Introduction of endoscopic duct visualisation was followed by an increase of resecting techniques based on impressiveness of pathology of ductal changes. Non-invasive methods such as sonography and computer assisted tomography have improved definition of pathological changes and re-encouraged less radical surgery using drainage and anastomosing techniques. Therapeutic consequences of diagnostic progress are demonstrated in 503 cases treated surgically between 1964 and 1981.