Prediction of difficult tracheal intubations in thyroid surgery. Predictive value of neck circumference to thyromental distance ratio

INTRODUCTION:Difficult tracheal intubation (DTI) contributes to perioperative morbidity and mortality. There are conflicting study results about the most predictive DTI risk criteria in patients undergoing thyroid surgery. MATERIALS AND METHODS:We conducted a prospective observational study on 500 consecutive patients aged 6518 years to identify predictors for DTI. Body weight, body mass index (BMI), inability to prognath, head movement, mouth opening, Mallampati score, neck circumference (NC), thyromental distance (TMD), neck circumference to thyromental distance ratio (NC/TMD), tracheal deviation apparent on chest x-ray, mediastinal goiter, histology and history of DTI were measured as possible predictors of DTI. Spearman's rank correlation test and multiple logistic regression analysis were performed. RESULTS:DTI was observed in 9.6% of all patients. Compared with the group of patients without DTI, the group of patients with DTI had significantly greater median values for body weight, BMI, NC, NC/TMD, Mallampati score, el-Ganzouri score, incidence of mediastinal goiter, and had reduced TMD and mouth opening. Significant correlations between BMI 6530 kg/m2 and the Mallampati score 653 (R = 0.124, p = 0.00541), Cormack-Lehane 653 (R = 0.128, p = 0.00409), NC 6540 cm (R = 0.376, p<0.001), and NC/TMD 655 (R = 0.103, p = 0.0207) were found. The logistic regression analysis revealed that an NC 6540 cm at the goiter level, but not an NC/TMD ratio 655, was the strongest predictor of DTI (p<0.001). The area under the receiver operating characteristic curve for NC/TMD was better than the curve for NC. The sensitivity and specificity of NC/TMD were also greater, compared with NC. An NC of 40.00 cm and an NC/TMD of 5.85 were the estimated cut-off points. DISCUSSION:This study found that NC was a strong predictor of DTI. The results also suggested that NC/TMD could be used as a measure to stratify the risk of DTI in patients undergoing thyroid surgery

Work-related problems in multiple sclerosis: a literature review on its associates and determinants

Purpose: To explore which variables are associated to or determinants of work-related difficulties or unemployment in persons with multiple sclerosis (MS). Method: Papers published between 1993 and February 2015 were included. Quality was judged as poor, acceptable, good or excellent. Determinants were extracted from prospective and retrospective data, associated variables from cross-sectional data; variables were grouped by similarity. Evidence was judged as strong if there were at least two good studies reporting the same results; limited if there was only one good and some acceptable studies. Results: Forty-two papers were selected, for a total of 31192 patients (75% females). Work-related difficulties were referred as unemployment, lower amount of worked hours or job cessation. Strong evidence of impact over work-related difficulties was found for a core set of variables, i.e. expanded disability status scale, MS duration, patients’ age, fatigue and walking problems. Little evidence exists on the impact of contextual factors. Discussion: Most of the variables identified as associated to or determinants of work-related difficulties can be treated through rehabilitative interventions. It is important that future research addresses not only unemployment issues in MS, but also the amount and severity of problems affecting work-related tasks relying on specific assessment instruments

Work-related difficulties in patients with traumatic brain injury: a systematic review on predictors and associated factors

<p><b>Purpose</b>: To address the content of work-related difficulties and explore which variables are associated to or determinants of these difficulties in persons that suffered from Traumatic Brain Injury (TBI). <b>Method</b>: Papers published between 1993 and February 2015 were included. Quality was judged as poor, acceptable, good or excellent. Determinants were extracted from longitudinal data, associated variables from cross-sectional data; variables were grouped by similarity. Evidence was judged as strong if the same results were reported by two or more good studies; limited if reported by one good and some acceptable studies. <b>Results</b>: Forty-two papers were selected (25,756 patients). Work-related difficulties were referred as unemployment, job instability or job cessation. Strong evidence of impact was found for: low educational level, pre-injury unemployment, Glasgow Coma Scale score and TBI severity, length of stay in acute and rehabilitation settings, lower Functional Independence Measure scores and presence of cognitive disturbances. <b>Discussion</b>: Evidence on the effect of rehabilitation interventions on TBI patients’ work-related difficulties exists, but is poorly measured. Future studies should address the sustainability of holistic and tailored interventions targeting employees, employers and workplaces and aimed to reduce the gap between work duties and worker’s abilities, using appropriate assessment instruments measuring difficulties in work activities.Implications for rehabilitation</p><p>Traumatic Brain Injury (TBI) primarily affects young persons of working age causing a broad range of motor, sensory and cognitive impairments. A combination of variables related both to pre-morbid and to injury-related factors predict and are associated to work-related difficulties.</p><p>While demographic and injury characteristics cannot be modified, some TBI outcomes (e.g. cognitive impairments or functional status) may be addressed by specific rehabilitative interventions: the knowledge of the specific work-related difficulties of TBI patients is of importance to tailor rehabilitation programs that maximize vocational outcomes.</p><p>Rehabilitation researchers should give attention to vocational issues and use assessment instruments addressing the difficulties in work-related activities, in order to demonstrate the benefits of rehabilitative interventions on TBI patients’ ability to work.</p><p></p> <p>Traumatic Brain Injury (TBI) primarily affects young persons of working age causing a broad range of motor, sensory and cognitive impairments. A combination of variables related both to pre-morbid and to injury-related factors predict and are associated to work-related difficulties.</p> <p>While demographic and injury characteristics cannot be modified, some TBI outcomes (e.g. cognitive impairments or functional status) may be addressed by specific rehabilitative interventions: the knowledge of the specific work-related difficulties of TBI patients is of importance to tailor rehabilitation programs that maximize vocational outcomes.</p> <p>Rehabilitation researchers should give attention to vocational issues and use assessment instruments addressing the difficulties in work-related activities, in order to demonstrate the benefits of rehabilitative interventions on TBI patients’ ability to work.</p

Electrical impedance tomography: A compass for the safe route to optimal PEEP

Setting the proper level of positive end-expiratory pressure (PEEP) is a cornerstone of lung protective ventilation. PEEP keeps the alveoli open at the end of expiration, thus reducing atelectrauma and shunt. However, excessive PEEP may contribute to alveolar overdistension. Electrical impedance tomography (EIT) is a non-invasive bedside tool that monitors in real-time ventilation distribution. Aim of this narrative review is summarizing the techniques for EIT-guided PEEP titration, while providing useful insights to enhance comprehension on advantages and limits of EIT for current and future users. EIT detects thoracic impedance to alternating electrical currents between pairs of electrodes and, through the analysis of its temporal and spatial variation, reconstructs a two-dimensional slice image of the lung depicting regional variation of ventilation and perfusion. Several EITbased methods have been proposed for PEEP titration. The first described technique estimates the variations of regional lung compliance during a decremental PEEP trial, after lung recruitment. The optimal PEEP value is represented by the best compromise between lung collapse and overdistension. Later on, a second technique assessing alveolar recruitment by variation of the end-expiratory lung impedance was validated. Finally, the global inhomogeneity index and the regional ventilation delay, two EIT-derived parameters, showed promising results selecting the optimal PEEP value as the one that presents the lowest global inhomogeneity index or the lowest regional ventilation delay. In conclusion EIT represents a promising technique to individualize PEEP in mechanically ventilated patients. Whether EIT is the best technique for this purpose and the overall influence of personalizing PEEP on clinical outcome remains to be determined

Multi-drug resistant and extended spectrum beta-lactamase Gram-negative bacteria in bilateral lung transplant recipients. Incidence, risk factors and in-hospital mortality

In the last few decades, the incidence of multidrug-resistant and extended spectrum beta-lactamase (MDR/ESBL) Gram-negative (GN) bacteria has progressively increased among lung transplant (LT) recipients. A prompt diagnosis, prevention and management of these pathogens remain the cornerstone for successful organ transplant

Are Thalamic Intrinsic Lesions Operable? No-Man’s Land Revisited by the Analysis of a Large Retrospective, Mono-Institutional, Cohort

Thalamic gliomas represent a heterogeneous subset of deep-seated lesions for which surgical removal is advocated, although clear prognostic factors linked to advantages in performance status or overall survival are still lacking. We reviewed our Institutional Cancer Registry, identifying patients who underwent surgery for thalamic gliomas between 2006 and 2020. Associations between possible prognostic factors such as tumor volume, grade, the extent of resection and performance status (PS), and overall survival (OS) were evaluated using univariate and multivariate survival analyses. We found 56 patients: 31 underwent surgery, and 25 underwent biopsy. Compared to biopsy, surgery resulted positively associated with an increase in the OS (hazard ratio, HR, at multivariate analysis 0.30, 95% confidence interval, CI, 0.12–0.75). Considering the extent of resection (EOR), obtaining GTR/STR appeared to offer an OS advantage in high-grade gliomas (HGG) patients submitted to surgical resection if compared to biopsy, although we did not find statistical significance at multivariate analysis (HR 0.53, 95% CI 0.17–1.59). Patients with a stable 3-month KPS after surgery demonstrated to have a better prognosis in terms of OS if compared to biopsy (multivariate HR 0.17, 95% CI, 0.05–0.59). Age and histological grades were found to be prognostic factors for this condition (p = 0.04 and p = 0.004, respectively, chi-square test). Considering the entire cohort, p53 positivity (univariate HR 2.21, 95% CI 1.01–4.82) and ATRX positivity (univariate HR 2.69, 95% CI 0.92–7.83) resulted associated with a worse prognosis in terms of OS. In this work, we demonstrated that surgery aimed at tumor resection might offer a stronger survival advantage when a stable 3-month KPS after surgery is achieved