1st Attempt Research Articles

Comparison of Classic Laryngeal Mask Airway and I Gel Regarding Ease of Insertion and Efficacy of Ventilation in Lateral Position

Background: The laryngeal mask airway (LMA) is a supraglottic airway device designed to maintain a clear airway, which sits outside of and creates a seal around the larynx. Aim of our study is to compare the ease of insertion and adverse effects using the insertion of classic LMA ad I gel in lateral position and to note if there are any adverse effects between both. Subjects and Methods: Hundred patients of either gender aged between 15 and 70 years who belonged to ASA physical status I and II, who were posted for elective surgical procedures under general anaesthesia under supraglottic airway devices were recruited for study. They were randomly divided into four groups of 25 patients each by closed envelop method. First group is Group IRL: Patients in whom I gel was used in right lateral position Second group is Group ILL : Patients in whom I gel was used in left lateral position Third group is Group CRL : Patients in whom classic laryngeal mask airway was used in right lateral position Fourth group is Group CLL : Patients in whom classic laryngeal mask airway was used in left lateral position. Results: Group IRL had success rate of 88.5% in 1st attempt 11.5% in this group had 2nd attempt of LMA insertion. Group ILL had 1st attempt success rate of 76% with.  24% patients needed 2nd attempt for LMA placement Group, CRL had success rate of 86% at 1st attempt 14% patients had LMA insertion in 2nd attempt. Group CLL had 1st attempt success rate of 67% only. 33% of patients in this group needed 2nd attempt for successful LMA insertion. Conclusion: Supraglottic airway devices can be successfully used for securing airway in lateral position. Both classic LMA and I gel can be used to secure the airway. I gel is a supraglottic airway device with its own advantages which can be successfully used in patients who need lateral position for their surgery.

Preprocedural ultrasound as an adjunct to blind conventional technique for epidural neuraxial blockade in patients undergoing hip or knee joint replacement surgery: A randomised controlled trial.

Background and Aims:The patients undergoing total knee and hip replacement surgeries are mostly obese, more than 50 years of age with osteophytic spine and spine deformities making the blind conventional technique of regional anaesthesia more difficult. The aim of the study was to compare the role of preprocedural ultrasound scan to conventional blind technique in obese patients with osteophytic spines undergoing total knee or hip replacement surgeries in terms of technical difficulty, clinical efficacy, safety and patient comfort.Methods:A prospective, randomised controlled trial was conducted in which 210 consenting American Society of Anesthesiologists (ASA) grade III patients, age >50 years, Body Mass Index (BMI) ≥30 kg/m2 with osteophytic spines including abnormalities undergoing joint replacement surgeries were randomised in two groups. Ultrasound group (“B”) received Combined Spinal Epidural Anaesthesia (CSEA) after preprocedural lumbar ultrasound scan. In control group (“A”), CSEA was given by blind conventional technique. The primary objective was to compare the rate of successful epidural block on 1st needle insertion attempts in both the groups. The secondary objectives were to compare both groups in terms of ease, success, comfort and safety of epidural block.Results:Ultrasound improved success of CSEA at 1st attempt from 74.3% in control group (“A”) to 85.7% in Ultrasound group (“B”) (P = 0.038). Fewer needle insertion attempts, passes and anaesthesiologist were required in ultrasound group. Pearson correlation coefficient was 0.976 using both views.Conclusion:Preprocedural ultrasound scan is a useful adjunct to lumbar epidural blocks in obese patients with osteophytic abnormal spines.

The Impact of Teaching Critical Thinking Skills to Develop the Habits of Mind for Students

This study intended to assess English questions for 3rdintermediate stage by analyzing Ministerial English questions for the years 2017 and 2018 and for all attempts (1st, 2nd and 3rd attempt). The questions analysis in this study collects information on the variables: Remember, knowledge, apply, analyze, create and evaluate. Conclusion Depending on the results obtained, the following points are outlined: There is a significant difference between the ministerial questions and Bloom's levels of knowledge. Bloom's level of knowledge depends on an old approach while the ministerial questions depend on a new approach. Bloom's specification tables focus on knowledge and understanding while the new approach in teaching focuses on creative and communicative skills. The ministerial questions don't focus on creative, analytical and communicative skills. From all the above we can conclude that there is a deficiency in both the ministerial questions and Bloom's specification tables.

Iatrogenic Fistula: Types, Causes and Post-repair outcome – 70 cases

Aims: In Bangladesh since iatrogenic fistula is gradually increasing so aim of this study is to find out the types, causes and post-repair outcome of iatrogenic fistula.
 Methods: 70 cases in Bangladesh were reviewed between periodof January 2012 to April 2018. Detailed history, clinical examination and investigations were done to find out the causes. Proper evaluation was done for diagnosis of type of fistula and treatment plan.
 Results: Among 70 cases, 48 were vault fistulae, 10 intracervical, 7 juxta-cervical, 2 mid-vaginal and 2 at neck region, 1 uretero-vaginal and 1 extensive from neck to cervix. Regarding causes, among 70 cases, 47 fistulae developed after hysterectomy of which 38 following TAH, 6 following caesarean hysterectomy and 3 after vaginal hysterectomy. Rest 16 cases were due to caesarean section, 1 case was following coitus and 6 were due to other than gynecological-obstetric causes. 65 patients were repaired vaginally, 1 abdominally and 4 through combined route. Among 70 cases, 68 patients were successfully repaired at 1st attempt without any significant complication. 2 cases failed at 1st attempt and were dropped out.
 Conclusions: Almost all of these causes are preventable. So emphasis should be given to identify the causes of iatrogenic fistula to prevent the event. At the same time, our aim is to make these patients free of urinary smell by applying appropriate surgical technique.

How to facilitate the placement of a transesophageal probe in a ventilated patient?

PurposeTransesophageal probe insertion in the ventilated patients often is difficult. Different complex techniques were suggested for easier placement of the transesophageal probe.In this work, we describe a simple technique of TEE probe insertion in ventilated patients. Methods and resultsIn the period 2015–2018, 66 transesophageal echocardiographic examinations in anesthetized ventilated patients were carried out in accordance with the standard algorithm developed by us. During the transesophageal examination, all the patients were in the left decubital position and with their head tilted forward. In all the patients, TEE was done smoothly, from the 1st attempt, without complications. ConclusionIn the anesthetized intubated and ventilated patients, the TEE probe can be easily inserted when the patient is in the left decubital position. We suggest this algorithm in all such patients, when appropriate.

Impact of vascular access site on procedural time of endomyocardial biopsy.

Endomyocardial biopsy (EMB) is widely used for the diagnosis of unexplained ventricular dysfunction and for assessment of cardiac allograft rejection. But, the impact of vascular access site on procedural time of EMB is not well-known. From February 2014 to May 2016, consecutive patients requiring EMB were prospectively enrolled in this study. Vascular access, by either the jugular or femoral vein, was randomly assigned. EMB was randomly performed by 3 pre-identified physicians based on practical experience in EMB. Each case was required to obtain at least 3 samples. The primary endpoint was to compare the total time spent in acquiring EMB from the right ventricular septum between the jugular and femoral vein access groups. The secondary endpoints were evaluation of each set (1st to 3rd attempt) of EMB times and safety. In addition, factors affecting the EMB procedural times were evaluated. A total of 49 consecutive patients requiring EMB (3.9 attempts/patient) were enrolled (the jugular group: 23, the femoral group: 26), and 156 myocardial samples (3.2 samples/patient) were obtained. There were no significant differences in total biopsy procedural time between the 2 groups (16.3 ± 7.4 vs. 20.8 ± 9.9min, p = 0.075). Independent predictors for longer procedural time of the 1st attempt included femoral access, non-expert operators, and larger right atrium according to multiple linear regression analysis. The complication rates were not significantly different between the 2 groups, except for catheter kinking as a technical factor. Total biopsy time was not significantly different between the jugular and femoral venous access groups. However, the 1st attempt EMB procedural time by non-expert operators was longer when using the femoral approach, especially in cases involving a larger right atrium diameter.

Laryngeal mask airway Unique\u2122 position in paediatric patients undergoing magnetic resonance imaging (MRI): prospective observational study

BackgroundLaryngeal mask UNIQUE® (LMAU) is supraglottic airway device with good clinical performance and low failure rate. Little is known about the ideal position of the LMAU on the magnetic resonance imaging (MRI) and whether radiological malposition can be associated with clinical performance (audible leak) in children. The primary aim of the study was to evaluate incidence of the radiologic malposition of the LMAU according to size. The secondary outcome was the clinical performance and associated complications (1st attempt success rate, audible leak) in LMAUs in correct position vs. radiologically misplaced LMAUs.MethodsIn prospective observational study, all paediatric patients undergoing MRI of the brain under general anaesthesia with the LMAU were included (1.9.2016–16.5.2017). The radiologically correct position: LMAU in hypopharynx, proximal cuff opposite to the C1 or C2 and distance A (proximal cuff end and aditus laryngis) ≤ distance B (distal cuff end and aditus laryngis). Malposition A: LMAU outside the hypopharynx. Malposition B: proximal cuff outside C1-C2. Malposition C: distance A ≥ distance B. We measured distances on the MRI image. Malposition incidence between LMAU sizes and first attempt success rate in trainees and consultant groups was compared using Fisher exact test, difference in incidence of malpositions using McNemar test and difference in leakage according to radiological position using two-sample binomial test.ResultsOverall 202 paediatric patients were included. The incidence of radiologically defined malposition was 26.2% (n = 53). Laryngeal mask was successfully inserted on the 1st attempt in 91.1% (n = 184) cases. Audible leak was detected in 3.5% (n = 7) patients. The radiologically defined malposition was present in 42.9% (n = 3) cases with audible leak. The rate of associated complications was 1.5% (n = 3): laryngospasm, desaturation, cough. In 4.0% (n = 8) the LMAU was soiled from blood.Higher incidence of radiological malposition was in LMAU 1.0, 1.5 and LMAU 3, 4 compared to LMAU 2 or LMAU 2.5 (p < 0.001).ConclusionMalposition was not associated with impaired clinical performance (audible leak, complications) of the LMAU or the need for alternative airway management.Trial registrationClinicaltrials.gov (NCT02940652) Registered 18 October 18 2016.

Predictors of nature of ingested foreign bodies in children & assessment of operative outcomes

ObjectiveTo examine sensitivity/specificity of history & radiology to identify ingested foreign body (FB) and develop a protocol for management of ingested FBs in paediatric patients; to assess outcomes of removal of lithium button battery foreign body (LBBFB). MethodsRetrospective review. Children presenting to ENT emergency with suspected FB ingestion underwent rigid esophagoscopy and FB removal. Average age, number of attempts, duration of ingestion, success rate, and complications were analysed. ResultsCases of coin/LBBFB ingestion: 916/70. Mean age: 5.8/2.03 years (p < 0.001). Average duration of ingestion: 37/9.5 h (p < 0.001). Patients below 3: 31.3/62.8% (p < 0.001). Suggestive history/radiological signs: 100%/100%, 75.7%/98.6% (p < 0.0001). Site of impaction cricopharynx: 60.3%/74.3% (p = 0.02). LBBFB group: Successful removal in 1st attempt: 66 (94.3%). Cases requiring multiple attempts due to impaction: 4 (5.7%). Parenteral steroids were administered before successful reattempt. No relation was found between duration of ingestion/impaction. Five (7.1%) cases developed complications. Average follow-up duration: 13.59 months. ConclusionsChildren <3 years with vague history of FB ingestion and suggestive chest x-ray should be sent urgently for FB removal. Parenteral pre-and postoperative short course steroid use may be considered to improve outcomes.

The effect of low-dose rocuronium on rapid tracheal intubation using a video laryngoscope: A randomized double blind controlled study.

Background:The aim of this study was to investigate the clinical effectiveness of rocuronium in low doses on conditions during rapid tracheal intubation using video laryngoscope.Methods:Ninety-eight patients undergoing otolaryngologic surgery were randomly divided into 2 groups: group L using 0.3 mg/kg of rocuronium intravenously (n = 49) and group C using 0.6 mg/kg of rocuronium (n = 49). Sixty seconds after rocuronium administration, tracheal intubation was performed using a video laryngoscope. The overall intubation condition was evaluated along with specific conditions, including laryngoscopy condition, vocal cord position, and intubation response. Intubation profiles, including Cormack–Lehane grade, 1st attempt success rate, and intubation time, were also evaluated.Results:Overall intubation conditions showed a significant difference between group L and group C (P = .003). Although the incidence of vigorous response after tracheal intubation was higher in group L than in group C (P = .022), laryngoscopy condition and vocal cord position were similar between the 2 groups (P = .145 and .070, respectively). Intubation profiles showed no differences between the 2 groups. The frequency and amount of additional rocuronium administration during surgery were also similar.Conclusions:Low-dose rocuronium provided significantly worse overall intubation conditions compared to the conventional dose of rocuronium for rapid tracheal intubation. However, when using a video laryngoscope, it may provide clinically acceptable laryngeal muscle relaxation.

Examining validity evidence for a simulation-based assessment tool for basic robotic surgical skills.

Increasing focus on patient safety makes it important to ensure surgical competency among surgeons before operating on patients. The objective was to gather validity evidence for a virtual-reality simulator test for robotic surgical skills and evaluate its potential as a training tool. Surgeons with varying experience in robotic surgery were recruited: novices (zero procedures), intermediates (1-50), experienced (> 50). Five experienced surgeons rated five exercises on the da Vinci Skills Simulator. Participants were tested using the five exercises. Participants were invited back 3 times and completed a total of 10 attempts per exercise. The outcome was the average simulator performance score for the 5 exercises. 32 participants from 5 surgical specialties were included. 38 participants completed all 4 sessions. A moderate correlation between the average total score and robotic experience was identified for the first attempt (Spearman r = 0.58; p = 0.0004). A difference in average total score was observed between novices and intermediates [median score 61% (IQR 52-66) vs. 83% (IQR 75-91), adjusted p < 0.0001], as well as novices and experienced [median score 61% (IQR 52-66) vs. 80 (IQR 69-85), adjusted p = 0.002]. All three groups improved their performance between the 1st and 10th attempts (p < 0.00). This study describes validity evidence for a virtual-reality simulator for basic robotic surgical skills, which can be used for assessment of basic competency and as a training tool. However, more validity evidence is needed before it can be used for certification or high-stakes assessment.

Supersaturated Sparse Graphs and Hypergraphs

AbstractA central problem in extremal graph theory is to estimate, for a given graph H, the number of H-free graphs on a given set of n vertices. In the case when H is not bipartite, Erd̋s, Frankl, and Rödl proved that there are 2(1+o(1))ex(n, H) such graphs. In the bipartite case, however, bounds of the form 2O(ex(n, H)) have been proven only for relatively few special graphs H. As a 1st attempt at addressing this problem in full generality, we show that such a bound follows merely from a rather natural assumption on the growth rate of n ↦ ex(n, H); an analogous statement remains true when H is a uniform hypergraph. Subsequently, we derive several new results, along with most previously known estimates, as simple corollaries of our theorem. At the heart of our proof lies a general supersaturation statement that extends the seminal work of Erd̋s and Simonovits. The bounds on the number of H-free hypergraphs are derived from it using the method of hypergraph containers.

A study to compare digital technique and suction catheter guided technique for insertion of proseal laryngeal mask airway in children

Objectives: The present study was conducted to compare digital technique and suction catheter guided technique for Proseal laryngeal mask airway insertion regarding ease of insertion, number of attempts for successful insertion and insertion time in children. Methods: This prospective randomised study included one hundred children of age 1-12 years divided into two groups. In group I, Proseal laryngeal mask airway insertion was inserted using digital technique and in group II, suction catheter guided technique was used for insertion. Results: In group I, Proseal laryngeal mask airway insertion was successfully inserted in 45 patients (90%), while in group II, insertion was successful in 49 patients (98%). Insertion was successful in 37 patients (74%) in first attempt and 8 patients (16%) required 2nd attempt in group I, whereas in group II, 1st attempt was successful in 47 patients (94%) and 2nd attempt was required in 2 patients (4%). Proseal laryngeal mask airway insertion failed in 5 patients (10%) in group I while it failed in only 1 patient (2%) in group II. Mean insertion time was 23.88 ± 2.58 sec in group I, whereas in group II, time was 19.34 ± 1.81 sec (p=0.001), the difference being statistically significant. Conclusion: Suction catheter guided technique is easier and more successful as compared to digital technique in children. It is less traumatic and insertion time is also less with this technique.

What causes Large Price Changes? Financial Engineering Perspective

As if characterless, the stock market prices behave atypically. They cause loss and profits and because all regulatory measures. In-spite of more than a century of mental-storming large price changes is noted having idiopathic genesis. And, large price changes normally mean profit. The cause (large price changes) have been studies and ‘gaps’ have been identified in the case of the London Stock Exchange (LSE). In large exchanges ‘market order’ and ‘limit orders’ are ever present resulting in ‘gaps’. Gaps=robust trading=more employment=better economy. This transaction provides a nascent (numerical) and 1st time original attempt as to how to engineer ‘gaps’.

Supreme\u2122 laryngeal mask airway use in general Anesthesia for category 2 and 3 Cesarean delivery: a prospective cohort study

BackgroundThe Supreme™ laryngeal mask airway (SLMA) is a single-use LMA with double lumen design that allows separation of the respiratory and the alimentary tract, hence potentially reducing the gastric volume and risk of aspiration. The purpose of this prospective cohort study is to evaluate the the role of the SLMA as an airway technique for women undergoing category 2 and 3 Cesarean delivery under general anesthesia.MethodsWe recruited 584 parturients who underwent category 2 or 3 Cesarean delivery under general anesthesia, in which 193 parturients underwent category 2 and 391 parturients underwent category 3 Cesarean delivery. The primary outcome was insertion success rate at 1st attempt in SLMA insertion. The secondary outcomes included anaesthetic, obstetric outcomes and maternal side effects associated with airway device.ResultsThe 1st attempt insertion success rate was 98.3%, while the overall insertion success rate was 100%. The mean (Standard deviation) time to effective ventilation was 15.6 (4.4) seconds. Orogastric tube insertion was successful at the 1st attempt in all parturients. There was no clinical evidence of aspiration or regurgitation. No episodes of hypoxemia, laryngospasm or bronchospasm were observed intra-operatively. The incidence of complications was low and with good maternal satisfaction reported.ConclusionsThe SLMA could be an alternative effective airway in category 2 and 3 parturients emergency Cesarean Delivery under general anesthesia in a carefully-selected obstetric population.Trial registrationClinical Trials Registration: Clinicaltrials.gov Registration NCT02026882. Registered on December 31, 2013.

When Your Central Line Decides to Go for a Stroll

SESSION TITLE: Procedures SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Central venous catheters (CVCs) are fastened at the skin, but their free, intra-vascular end has a tendency to become malposition. CASE PRESENTATION: A 76-year-old woman was intubated for worsening hypoxemia, and a pigtail catheter was placed into the left lower pleural space to drain an effusion. 700 cc of serous exudative fluid was drained. A 16 cm, 7 F left subclavian triple-lumen CVC was placed on the 1st attempt for vasopressor administration, with blood being easily aspirated from all ports. A follow-up CXR demonstrated a left apical pneumothorax for which another pigtail catheter was placed in the left anterior 2nd intercostal space, resulting in lung re-expansion. Over the next 2 days there was a dramatic increase in pigtail drainage and vasopressor requirements. Repeat pleural fluid analysis revealed a glucose level of 734 mg/dL. A norepinephrine drip with a dextrose carrier was being infused though the CVC. Later that day, the fluid turned milky after propofol was started through the CVC. Chest CT done concurrently for worsening hypoxemia revealed the CVC traversing the left lung apex before entering the left brachiocephalic vein. These findings were consistent with an extravascular catheter, with the proximal ports in the pleural space. Now we could aspirate blood only from the distal port. The CVC was replaced resulting in resolution of the pleural drainage and decrease in norepinephrine requirements. DISCUSSION: Late migration of CVCs often occurs inadvertently due to arm/neck movements, increase in intra-thoracic pressure due to PEEP, PPV or the patient coughing, and due to a ‘jet effect’ of drug infusions (1). These factors can cause CVC migration up to 2-4 cm. Another factor that may have caused this migration in our patient is trans-fixation of the lung apex during CVC insertion and its subsequent outward drag by the re-expanding lung. An intrapleural CVC can cause an effusion with a pleural fluid to serum glucose ratio > 1. The fluid is usually transudative with protein < 1 g/dL, but varies depending on the infusate, degree of pleural inflammation or hemorrhage, and fluid osmolality (2). CONCLUSIONS: Malpositioned CVCs should be replaced. Intra-pleural position causes an increase in pleural effusion with fluid analysis revealing similarities to infusing drugs. Reference #1: Ahuja V, Bhaga H. Late migration of subclavian venous catheter after initial correct placement. J Anesth. 2009;23(2):310-1 Reference #2: Sahn SA. Pleural effusions of extravascular origin. Clin Chest Med. 2006;27(2):285-308 DISCLOSURE: The following authors have nothing to disclose: Udit Chaddha, Jamie Kaghihara, Kavitha Bagavathy, Ashley Prosper, Ami Oren No Product/Research Disclosure Information

Evaluation of a low-cost, 3D-printed model for bronchoscopy training.

Flexible bronchoscopy is a fundamental procedure in anaesthesia and critical care medicine. Although learning this procedure is a complex task, the use of simulation-based training provides significant advantages, such as enhanced patient safety. Access to bronchoscopy simulators may be limited in low-resource settings. We have developed a low-cost 3D-printed bronchoscopy training model. A parametric airway model was obtained from an online medical model repository and fabricated using a low-cost 3D printer. The participating physicians had no prior bronchoscopy experience. Participants received a 30-minute lecture on flexible bronchoscopy and were administered a 15-item pre-test questionnaire on bronchoscopy. Afterwards, participants were instructed to perform a series of predetermined bronchoscopy tasks on the 3D printed simulator on 4 consecutive occasions. The time needed to perform the tasks and the quality of task performance (identification of bronchial anatomy, technique, dexterity, lack of trauma) were recorded. Upon completion of the simulator tests, participants were administered the 15-item questionnaire (post-test) once again. Participant satisfaction data on the perceived usefulness and accuracy of the 3D model were collected. A statistical analysis was performed using the t-test. Data are reported as mean values (± standard deviation). The time needed to complete all tasks was 152.9 ± 71.5 sec on the 1st attempt vs. 98.7 ± 40.3 sec on the 4th attempt (P = 0.03). Likewise, the quality of performance score improved from 8.3 ± 6.7 to 18.2 ± 2.5 (P < 0.0001). The average number of correct answers in the questionnaire was 6.8 ± 1.9 pre-test and 13.3 ± 3.1 post-test (P < 0.0001). Participants reported a high level of satisfaction with the perceived usefulness and accuracy of the model. We developed a 3D-printed model for bronchoscopy training. This model improved trainee performance and may represent a valid, low-cost bronchoscopy training tool.

Comparison Between Pendant Position and Traditional Sitting Position for Successful Spinal Puncture in Spinal Anesthesia for Cesarean Section.

BackgroundSuccess of spinal anesthesia in pregnant females is strongly influenced by the position of the patient at the time of spinal insertion. Pendant position is a new position introduced to increase the intervertebral spaces. The current study aimed at comparing successful spinal puncture among the patients with pendant position in comparison with the ones with traditional sitting position for the elective caesarean section.MethodsThe current study was a non-blinded, randomized controlled trial (RCT) (registration code: NCT02753660 (ClinicalTrial.gov) on pregnant females undergoing spinal anesthesia. The participants were divided into 2 groups by the random consecutive sampling method; group A (pendant position) and group B (traditional sitting position). The successful placement of spinal needle was determined by the number of attempts, the amount of bone contact, and the time of spinal puncture. The inclusion criteria were pregnant females aged 18 to 45 years, body mass index (BMI) of 18 to 35 kg/m2, and the physical status I to III, based on American society of anesthesiologists classification (ASA).ResultsFollowing the approval of the ethical committee, 308 subjects were enrolled in the study. The rate of successful puncture on the 1st attempt of group A was significantly high (92% vs. 78%, P value = 0.001). Additionally, group A had significantly less total amount of bone contact (185 vs. 421, P value < 0.001) and shorter time for spinal puncture (9 seconds vs. 12 seconds, P value < 0.001).ConclusionsPendant position was significantly better than traditional sitting position to provide successful 1st attempt spinal puncture in pregnant females undergoing cesarean section.

Detection and isolation of Shiga-Toxin producing Escherichia coli in flour in Germany between 2014 and 2017

Official control samples of wheat and rye flour were analyzed for the presence of Shiga-toxin producing Escherichia coli (STEC) in 25 g. The detection procedure was based on enrichment in buffered peptone water and Tryptone Bile X-Glucuronide agar, followed by multiplex real-time PCR with an internal positive control. Positive samples were sub-cultured for strain isolation by a two-step procedure. In the first step, ten colonies were picked from each plate, pooled, and analyzed by real-time PCR. In addition, a bacterial material from the part with heavy growth was analyzed. If the 1st isolation attempt failed, in a second step all colonies from molecular positive plates were picked, sub-cultured, pooled and analyzed. 39% of test samples were positive by real-time PCR. STEC was isolated from 17 test samples corresponding to 19%. Molecular detection is linked to the presence of quantifiable numbers of E. coli, whereas the grain species did not have an influence. There is a non-significant correlation with some mills indicating some technological or hygienic problems in those facilities. Increasing the number of subsamples did improve the detection rate. Our findings show the frequent presence of STEC in flour in Germany.

A Randomized Prospective Study Comparing C-Mac D-Blade, Airtraq, and Fiberoptic Bronchoscope for Intubating Patients with Anticipated Difficult Airway

Background: Several complications may be correlated with difficult airway up to death. Fiberoptic bronchoscope is the gold stander to deal with difficult intubation. Airtraq laryngoscope and C-MAC® video laryngoscope are new devices that are used successfully for tracheal intubation. We compared using C-MAC D-blade video laryngoscope, Airtraq laryngoscope, and Fiberoptic bronchoscope for intubation of patient likely to have difficult intubation. Patients and methods: Ethical committee permission was obtained before 120 adult patients (ASA I-III) with expected difficult intubation were incorporated in this prospective study. Participants were randomly distributed to 3 equal groups to be intubated using either C-MAC D-blade (group 1), Airtraq (group 2), or Fiberoptic technique (group 3) after anesthesia was induced. Our primary outcome was time to tracheal intubation. Intubation data, hemodynamics, and SpO2 were evaluated. Results: Time to visualize the vocal cords (T1) and time to tracheal intubation (T2) were significantly shorter in CMAC D-blade group (group 1) and Airtraq group (group 2) than Fiberoptic group (group 3) and there was insignificant variance between group 1 and group 2. All participants were intubated in the 1st attempt except one in C-MAC Dblade group who needed 2 intubation attempts. There were insignificant variances between the 3 groups regarding number of successful trial (success rate), and manipulation used to improve vocal cord visualization or intubation. Sore throat grades were significantly lower in group 2 and 3 than group 1. Lowest SpO2 was significantly lower in group 3 than the other 2 groups. Mean arterial blood pressure and heart rate measured at 1 min and 3 min after intubation were significantly higher in group 1 than group 2 and 3. Conclusion: When compared to Fiberoptic bronchoscope both C-mac D-blade and Airtraq comparably showed shorter time to visualize vocal cords and intubate patients with anticipated difficult intubation.

Establishment of EEDI Baseline for Inland Ship of Bangladesh

Energy Efficiency Design Index (EEDI) [1] was introduced by the International Maritime organization (IMO) to stimulate innovation and technical development of all elements that increase the level of energy efficiency of a ship at design stage. Sea going ships over 400 gross tonnage are considered in the current regulation of EEDI. Inland ships are not covered by current EEDI regulations by IMO. As inland vessels share 0.6% of the global CO2 emission [2], the reduction attempt will not have bigger impact. But from the commercial point of view of a country the significance is very high, specially for under developed countries like Bangladesh. Inland self propelled ships face additional restrictions (shallow water/channel, low density water, restriction of ship's dimension, etc.) which increase the power requirement at the same speed, burning more fuel and emit more CO2. This paper is a continuation of the Ph.D research of the author where previous published paper's [3] results were updated and verified. The result of this paper would be one of the 1st attempts in the world was made to establish EEDI baseline for different types of self-propelled inland ships.