Prevalence and commonality of non-technical skills and human factors in airway management guidelines: a narrative review of the last 5 years

The primary aim of this review was to identify, analyse and codify the prominence and nature of human factors and ergonomics within difficult airway management algorithms. A directed search across OVID Medline and PubMed databases was performed. All articles were screened for relevance to the research aims and according to predetermined exclusion criteria. We identified 26 published airway management algorithms. A coding framework was iteratively developed identifying human factors and ergonomic specific words and phrases based on the Systems Engineering Initiative for Patient Safety model. This framework was applied to the papers to delineate qualitative and quantitative results. Our results show that human factors are well represented within recent airway management guidelines. Human factors associated with work systems and processes featured more prominently than user and patient outcome measurement and adaption. Human factors are an evolving area in airway management and our results highlight that further considerations are necessary in further guideline development.

AllergoOncology: ultra-low IgE, a potential novel biomarker in cancer-a Position Paper of the European Academy of Allergy and Clinical Immunology (EAACI)

Elevated serum IgE levels are associated with allergic disorders, parasitosis and specific immunologic abnormalities. In addition, epidemiological and mechanistic evidence indicates an association between IgE-mediated immune surveillance and protection from tumour growth. Intriguingly, recent studies reveal a correlation between IgE deficiency and increased malignancy risk. This is the first review discussing IgE levels and links to pathological conditions, with special focus on the potential clinical significance of ultra-low serum IgE levels and risk of malignancy. In this Position Paper we discuss: (a) the utility of measuring total IgE levels in the management of allergies, parasitosis, and immunodeficiencies, (b) factors that may influence serum IgE levels, (c) IgE as a marker of different disorders, and d) the relationship between ultra-low IgE levels and malignancy susceptibility. While elevated serum IgE is generally associated with allergic/atopic conditions, very low or absent IgE may hamper anti-tumour surveillance, indicating the importance of a balanced IgE-mediated immune function. Ultra-low IgE may prove to be an unexpected biomarker for cancer risk. Nevertheless, given the early stage of investigations conducted mostly in patients with diseases that influence IgE levels, in-depth mechanistic studies and stratification of malignancy risk based on associated demographic, immunological and clinical co-factors are warranted.

Association between neoadjuvant chemoradiation and survival for patients with locally advanced rectal cancer

AIM

To examine the overall survival differences for the following neoadjuvant therapy modalities - no therapy, chemotherapy alone, radiation alone and chemoradiation - in a large cohort of patients with locally advanced rectal cancer.

METHOD

Adults with clinical Stage II and III rectal adenocarcinoma were selected from the National Cancer Database and grouped by type of neoadjuvant therapy received: no therapy, chemotherapy only, radiotherapy only or chemoradiation. Multivariable regression methods were used to compare adjusted differences in perioperative outcomes and overall survival.

RESULTS

Among 32 978 patients included, 9714 (29.5%) received no neoadjuvant therapy, 890 (2.7%) chemotherapy only, 1170 (3.5%) radiotherapy only and 21 204 (64.3%) chemoradiation. Compared with no therapy, chemotherapy or radiotherapy alone were not associated with any adjusted differences in surgical margin positivity, permanent colostomy rate or overall survival (all P > 0.05). With adjustment, neoadjuvant chemoradiation vs no therapy was associated with a lower likelihood of surgical margin positivity (OR 0.74, P < 0.001), decreased rate of permanent colostomy (OR 0.77, P < 0.001) and overall survival [hazard ratio (HR) 0.79, P < 0.001]. When compared with chemotherapy or radiotherapy alone, chemoradiation remained associated with improved overall survival (vs chemotherapy alone HR 0.83, P = 0.04; vs radiotherapy alone HR 0.83, P < 0.019).

CONCLUSION

Neoadjuvant chemoradiation, not chemotherapy or radiotherapy alone, is important for sphincter preservation, R0 resection and survival for patients with locally advanced rectal cancer. Despite this finding, one-third of patients in the United States with locally advanced rectal cancer fail to receive stage-appropriate chemoradiation.

AllergoOncology - the impact of allergy in oncology: EAACI position paper

Th2 immunity and allergic immune surveillance play critical roles in host responses to pathogens, parasites and allergens. Numerous studies have reported significant links between Th2 responses and cancer, including insights into the functions of IgE antibodies and associated effector cells in both antitumour immune surveillance and therapy. The interdisciplinary field of AllergoOncology was given Task Force status by the European Academy of Allergy and Clinical Immunology in 2014. Affiliated expert groups focus on the interface between allergic responses and cancer, applied to immune surveillance, immunomodulation and the functions of IgE-mediated immune responses against cancer, to derive novel insights into more effective treatments. Coincident with rapid expansion in clinical application of cancer immunotherapies, here we review the current state-of-the-art and future translational opportunities, as well as challenges in this relatively new field. Recent developments include improved understanding of Th2 antibodies, intratumoral innate allergy effector cells and mediators, IgE-mediated tumour antigen cross-presentation by dendritic cells, as well as immunotherapeutic strategies such as vaccines and recombinant antibodies, and finally, the management of allergy in daily clinical oncology. Shedding light on the crosstalk between allergic response and cancer is paving the way for new avenues of treatment.

Injury surveillance in Trinidad: an accident and emergency based injury surveillance system at the San Fernando General Hospital

OBJECTIVE

Injuries are a significant cause of morbidity and mortality worldwide. Injuries disproportionately affect people living in low and middle income countries, including the Caribbean; however little is known about the epidemiology of injuries in these areas. An accident and emergency (A&E) department injury surveillance system was established at the San Fernando General Hospital, Trinidad and Tobago, to address this important data gap.

METHODS

A detailed overview of the objectives, data collection methods, and inherent strengths and limitations of this surveillance system are presented, along with results of an analysis of data collected during the first three years of operations (from 2002 to 2004).

RESULTS

Trained hospital staff collect a variety of injury/poisoning, demographic and clinical data on nearly 20,000 patients presenting each year with injury to the A&E Department. The total number of injuries in men was almost twice that in women. The majority of injuries were seen in those 25-44-years of age. Falls, other blunt force, stab/cut, traffic injury and poisoning represented the leading causes of injury. Nearly half of all the injuries occurred in the home, with the street/highway and work environments also accounting for an appreciable number of injuries. The majority of injuries were reported as unintentional.

CONCLUSION

Injuries represent an important population health and health services issue in South Trinidad. Data from the A&E Department injury surveillance system represent an important resource to inform evidence-based health policy decisions on injury prevention and public health resource allocation.

AllergoOncology: the role of IgE-mediated allergy in cancer

Epidemiological studies have suggested inverse associations between allergic diseases and malignancies. As a proof of concept for the capability of immunoglobulin E (IgE) to destruct tumor cells, several experimental strategies have evolved to specifically target this antibody class towards relevant tumor antigens. It could be demonstrated that IgE antibodies specific to overexpressed tumor antigens have been superior to any other immunoglobulin class with respect to antibody-dependent cellular cytotoxicity (ADCC) and phagocytosis (ADCP) reactions. In an alternative approach, IgE nonspecifically attached to tumor cells proved to be a powerful adjuvant establishing tumor-specific immune memory. Active Th2 immunity could also be achieved by applying an oral immunization regimen using mimotopes, i.e. epitope mimics of tumor antigens. The induced IgE antibodies could be cross-linked by live tumor cells leading to tumoricidic mediator release. Thus, IgE antibodies may not only act in natural tumor surveillance, but could possibly also be exploited for tumor control in active and passive immunotherapy settings. Thereby, eosinophils, mast cells and macrophages can be armed with the cytophilic IgE and become potent anti-tumor effectors, able to trace viable tumor cells in the tissues. It is strongly suggested that the evolving new field AllergoOncology will give new insights into the role of IgE-mediated allergy in malignancies, possibly opening new avenues for tumor therapy.

A characteristic eruption associated with ifosfamide, carboplatin, and etoposide chemotherapy after pretreatment with recombinant interleukin-1 alpha

BACKGROUND

Patients who received recombinant interleukin-1 alpha (IL-1 alpha) before chemotherapy followed by autologous bone marrow transplantation had a characteristic intertriginous cutaneous eruption that has not previously been described.

OBJECTIVE

Our aim was to document these skin changes and to determine whether IL-1 alpha as a sole agent caused recognizable changes in the skin.

METHODS

A prospective study of the skin changes in eight patients was performed. We characterized the clinical, histologic, and immunohistochemical features of the patient's skin after IL-1 alpha infusions and after chemotherapy.

RESULTS

No specific clinical or histologic changes were seen immediately after IL-1 alpha infusions. Immunohistochemical studies showed significant upregulation of endothelial leukocyte adhesion molecule-1 (ELAM-1) expression. Within 1 day of the initiation of chemotherapy (ifosfamide, carboplatin, and etoposide), a cutaneous eruption consisting of mucositis and varying degrees of erythema progressing to painful erosions in body folds and under adhesive tape developed in all patients. Histologic features were consistent with a chemotherapeutic effect on the epidermis as well as eccrine and apocrine glands. Expression of keratinocyte intercellular adhesion molecule-1 and HLA-DR as well as of ELAM-1 on dermal endothelial cells was increased. The perivascular lymphocytic infiltrate consisted mainly of CD4+ T cells.

CONCLUSION

High-dose chemotherapy with ifosfamide, carboplatin, and etoposide resulted in a characteristic cutaneous eruption that is consistent with a toxic reaction to chemotherapeutic agents. Its accentuation in skin folds and under taped areas suggests that eccrine excretion of the drugs or a toxic metabolite is an important contributing factor. IL-1 alpha may induce the expression of ELAM-1 but does not cause a cutaneous eruption.

Kidney in Galloway-Mowat syndrome: clinical spectrum with description of pathology

The Galloway-Mowat syndrome, a rare inherited disorder, is characterized by congenital microcephaly with hypotonia and developmental delay, often hiatus hernia, and nephrotic syndrome manifested in infancy or in early childhood. The glomerular lesion has been poorly characterized in the few previous reports of this syndrome. We studied three siblings with microcephaly and nephrotic syndrome occurring during the first two weeks of life. Hematuria, glycosuria and renal failure were also present. Renal biopsy and postmortem specimens of two patients were studied. Glomerular structure was disorganized; capillary lumina were of varying calibers, capillary walls were adherent to one another, and mesangial zones were poorly demarcated. Glomerular basement membrane ultrastructure was markedly altered. The normal trilaminar structure was obscured or replaced by flocculent material; furthermore, 6 to 8 nm fibrils of unknown nature permeated the space between endothelial and epithelial cells. Non-glomerular basement membranes were unaltered in appearance. This syndrome apparently represents, in part, a new disorder of glomerular basement membrane formation and function.

The perioperative management of pheochromocytoma in children

The perioperative experiences of 15 children and adolescents who underwent a total of 18 surgical procedures for resection of a pheochromocytoma were analyzed to determine clinical or hemodynamic events associated with intraoperative or postoperative complications. Of the pre- and intraoperative factors assessed, only preoperative resolution of symptoms and normalization of blood pressure were predictive of uncomplicated outcome. No intraoperative factors were statistically associated with outcome, but the four patients with complicated outcomes had had aggressively administered intraoperative fluids. Noninvasive measures of cardiac function did not help predict outcome; however, echocardiography results were available only for six patients. Two of the patients with complicated outcomes had cardiac dysfunction, suggesting undiagnosed catecholamine-induced cardiomyopathy in the other two with complicated outcomes. Intraoperative fluids should be given based on intraoperative blood pressures, the presence or absence of prior adrenergic blockade, and assessment of preoperative myocardial function. If preoperative myocardial dysfunction is revealed, intraoperative measurement of right atrial and pulmonary capillary wedge pressures may be indicated.

Acute renal failure in the neonate. Two fatal cases due to group B streptococci with rhabdomyolysis

Two cases of fatal group B streptococcal disease complicated by rhabdomyolysis in the neonate are described. They were identified by blood and cerebrospinal fluid cultures positive for group B streptococcus and by a combination of hyperkalemia, urine dipstick positive for blood without microscopic hematuria, and elevated serum muscle enzymes.

Multicentric osteolysis: report of the second successful renal transplant

A patient with end stage renal disease due to sporadic idiopathic multicentric osteolysis (type 3 multicentric osteolysis) is described. His pre-transplant course was similar to those of previously described patients, while his post-transplant course has been uncomplicated. The pathology and pathogenesis of the nephropathy of sporadic idiopathic multicentric osteolysis is not well characterized. The short term outcome of renal transplantation is excellent in our patient and in the other similar case known to have been transplanted.

Childhood familial pheochromocytoma. Conflicting results of localization techniques

Childhood familial pheochromocytoma was investigated in four patients by abdominal computed tomographic scan, [131I]metaiodobenzylguanidine scan, and vena caval catecholamine sampling. Results conflicted with surgical findings. Computed tomographic scan identified all four adrenal tumors but missed two midline tumors in one patient. [131I]metaiodobenzylguanidine scan identified two of three adrenal tumors but also suggested extra-adrenal tumors not confirmed at operation in two of three patients. Vena caval sampling for catecholamines confirmed all adrenal tumors but suggested additional tumors not verified at operation in two of three patients. All patients are asymptomatic and have normal urinary catecholamines 15 to 51 months after operation. Because of the frequency of multiple tumors in familial pheochromocytoma, different diagnostic techniques were employed. False-positive results were more frequent with [131I]metaiodobenzylguanidine and vena caval sampling. Reinterpretation of the [131I]metaiodobenzylguanidine scans at a later date led to less false-positive interpretation, although the false-negative rate remained unchanged. More pediatric experience with [131I]metaiodobenzylguanidine scans and vena caval sampling in familial pheochromocytoma is needed. Confirmation of tumor and its localization rest with meticulous surgical exploration.

Unusual ultrastructural features in a case of acute diffuse proliferative glomerulonephritis

A case consistent with recurrent acute poststreptococcal glomerulonephritis but with atypical features is described. Light microscopy revealed a diffuse proliferative glomerulonephritis. A spectrum of ultrastructural features, from the typical "humpy bumpy" subepithelial deposits to the apparent disappearance of the deposits within the epithelial cells, is presented. An unusual piling up of basement membrane material around the deposits is described, together with some areas showing an appearance reminiscent of membranous glomerulopathy. Resorption of the dense deposits within epithelial cells is suggested and a hypothesis advanced that the basement membrane reaction may indicate an incipient chronic immune complex lesion.

Renal failure as a presenting sign of diffuse sarcoidosis in an adolescent girl

We report a renal failure due to sarcoid granulomatous infiltration of the kidney that was documented by renal biopsy in an adolescent black albino girl. Treatment with prednisone was associated with improvement in the clinical disease and the histologic picture on repeat biopsy. With cessation of prednisone there was clinical and histological relapse while reinstitution of prednisone therapy was again associated with improvement. Experience with this child, as well as that reported previously in seven similar adult patients, would indicate that prednisone is an effective drug to control this unusual problem.