Cairns Hospital

BACKGROUND: Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success. METHODS: We generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030. FINDINGS: We estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone. INTERPRETATION: Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030. FUNDING: Bill & Melinda Gates Foundation, US Agency for International Development.

Great uncertainty exists in the global exchange of carbon between the atmosphere and the terrestrial biosphere. An important source of this uncertainty lies in the dependency of photosynthesis on the maximum rate of carboxylation (V cmax) and the maximum rate of electron transport (J max). Understanding and making accurate prediction of C fluxes thus requires accurate characterization of these rates and their relationship with plant nutrient status over large geographic scales. Plant nutrient status is indicated by the traits: leaf nitrogen (N), leaf phosphorus (P), and specific leaf area (SLA). Correlations between V cmax and J max and leaf nitrogen (N) are typically derived from local to global scales, while correlations with leaf phosphorus (P) and specific leaf area (SLA) have typically been derived at a local scale. Thus, there is no global-scale relationship between V cmax and J max and P or SLA limiting the ability of global-scale carbon flux models do not account for P or SLA. We gathered published data from 24 studies to reveal global relationships of V cmax and J max with leaf N, P, and SLA. V cmax was strongly related to leaf N, and increasing leaf P substantially increased the sensitivity of V cmax to leaf N. J max was strongly related to V cmax, and neither leaf N, P, or SLA had a substantial impact on the relationship. Although more data are needed to expand the applicability of the relationship, we show leaf P is a globally important determinant of photosynthetic rates. In a model of photosynthesis, we showed that at high leaf N (3 gm(-2)), increasing leaf P from 0.05 to 0.22 gm(-2) nearly doubled assimilation rates. Finally, we show that plants may employ a conservative strategy of J max to V cmax coordination that restricts photoinhibition when carboxylation is limiting at the expense of maximizing photosynthetic rates when light is limiting.

Research software is a fundamental and vital part of research, yet significant challenges to discoverability, productivity, quality, reproducibility, and sustainability exist. Improving the practice of scholarship is a common goal of the open science, open source, and FAIR (Findable, Accessible, Interoperable and Reusable) communities and research software is now being understood as a type of digital object to which FAIR should be applied. This emergence reflects a maturation of the research community to better understand the crucial role of FAIR research software in maximising research value. The FAIR for Research Software (FAIR4RS) Working Group has adapted the FAIR Guiding Principles to create the FAIR Principles for Research Software (FAIR4RS Principles). The contents and context of the FAIR4RS Principles are summarised here to provide the basis for discussion of their adoption. Examples of implementation by organisations are provided to share information on how to maximise the value of research outputs, and to encourage others to amplify the importance and impact of this work.

A survey of laryngeal mask airway (LMA) usage was conducted to provide general information about safety and efficacy with special emphasis on controversial issues such as positive pressure ventilation (PPV), prolonged anesthesia, and laparoscopic and nonlaparoscopic intraabdominal surgery. During the 2-yr study period, of the 39,824 patients who underwent general anesthesia, 11,910 (29.9%) patient airways were managed with the LMA. Forty-four percent underwent PPV. Placement was successful in 99.81%, and in 23 patients the LMA was abandoned in favor of the tracheal tube (TT). Use of the LMA for any intraabdominal procedure was considered nonconventional and occurred in 2222 (18.7%) patients. On 579 occasions procedures lasted > 2 h. A total of 44 critical incidents were documented. Eighteen (0.15%) were related to the airway and none required intensive care management. There were 26 critical incidents not related to the airway which resulted in two admissions to the intensive care unit and one death. There were three cases of failed tracheal intubation managed with the LMA. This survey demonstrates that the LMA technique is safe and effective for both spontaneous and controlled ventilation. Use of the LMA for gynecologic laparoscopy, gynecologic laparotomy, and procedures > 2 h also appears safe.

Abstract The UN's globally adopted Convention on Biological Diversity coverage target for marine protected areas (MPAs) is ≥10% by 2020. In 2014, the World Parks Congress recommended increasing this to ≥30%. We reviewed 144 studies to assess whether the UN target is adequate to achieve, maximize, or optimize six environmental and/or socioeconomic objectives. Results consistently indicate that protecting several tens‐of‐percent of the sea is required to meet goals (average 37%, median 35%, modal group 21–30%), greatly exceeding the 2.18% currently protected and the 10% target. The objectives we examined were met in 3% of studies with ≤10% MPA coverage, 44% with ≤30% coverage, and 81% with more than half the sea protected. The UN's 10% target appears insufficient to protect biodiversity, preserve ecosystem services, and achieve socioeconomic priorities. As MPA coverages generated from theoretical studies inherently depend on scenario(s) considered, our findings do not represent explicit recommendations but rather provide perspective on policy goals.

BACKGROUND: The ProSeal laryngeal mask airway (PLMA) is a new laryngeal mask device with a modified cuff to improve seal and a drainage tube to provide a channel for regurgitated fluid and gastric tube placement. In the present randomized, crossover study, the authors tested the hypothesis that ease of insertion, airway sealing pressure, and fiberoptic position differ between the PLMA and the standard laryngeal mask airway (LMA). For the PLMA, we also assess ease of gastric tube placement and the efficacy of an introducer tool. METHODS: Sixty paralyzed, anesthetized adult patients were studied. Both devices (only size 4) were inserted into each patient in random order. Airway sealing pressure and fiberoptic position were determined during cuff inflation from 0 to 40 ml in 10-ml increments. Gastric tube insertion was attempted with the PLMA if there was no gas leak from the drainage tube. In 60 additional patients, ease of insertion for the PLMA was compared with and without an introducer. RESULTS: First-time success rates were higher (60 of 60 vs. 52 of 60; P = 0.003) and the effective airway time shorter (9 +/- 3 s vs20 +/- 18 s; P < 0.0001) for the LMA. There were no failed uses of either device within three attempts. Airway sealing pressure was 8-11 cm H2O higher for the PLMA at all cuff volumes (P < 0.00001) and was higher in females for both devices. Fiberoptic position was better with the LMA at all cuff volumes (P < 0.00001), but vocal cord visibility was similar (LMA, 59 of 60; PLMA, 56 of 60). For the PLMA, gastric tube placement was successful in 58 of 58 patients and took 9 +/- 5 s. First-time success rates were higher (59 of 60 vs53/60; P = 0.03) and the effective airway time shorter (15 +/- 13 s vs 23 +/- 18 s; P = 0.008) with the introducer. CONCLUSION: The PLMA is capable of achieving a more effective seal than the LMA and facilitates gastric tube placement, but it is more difficult to insert unless an introducer tool is used. When correctly positioned, the PLMA isolates the glottis from the upper esophagus with possible implications for airway protection.

BACKGROUND: There remains a concern that Indigenous Australians have been over-researched without corresponding improvements in their health; this trend is applicable to most Indigenous populations globally. This debate article has a dual purpose: 1) to open a frank conversation about the value of research to Indigenous Australian populations; and 2) to stimulate ways of thinking about potential resolutions to the lack of progress made in the Indigenous research benefit debate. DISCUSSION: Capturing the meaning of research benefit takes the form of ethical value-oriented methodological considerations in the decision-making processes of Indigenous research endeavours. Because research practices come from Western knowledge bases, attaining such positions in research means reconciling both Indigenous and Western knowledge systems to produce new methodologies that guide planning, evaluating and monitoring of research practices as necessary. Increasingly, more sophisticated performance measures have been implemented to ensure academic impact and benefits are captured. Assessing societal and other non-academic impacts and benefits however, has not been accorded corresponding attention. Research reform has only focussed on research translation in more recent years. The research impact debate must take account of the various standards of accountability (to whom), impact priorities (for whom), positive and negative impacts, and biases that operate in describing impact and measuring benefit. SUMMARY: A perennial question in Indigenous research discourse is whether the abundance of research conducted; purportedly to improve health, is justified and benefits Indigenous people in ways that are meaningful and valued by them. Different research stakeholders have different conceptions of the value and nature of research, its conduct, what it should achieve and the kinds of benefits expected. We need to work collaboratively and listen more closely to the voice of Indigenous Australians to better understand, demonstrate and measure health research benefits. The authors conclude that as an imperative, a systematic benefit assessment strategy that includes identification of research priorities and planning, monitoring and evaluation components needs to be developed and implemented across research projects. In Indigenous health research, this will often mean adopting a benefit-led approach by changing the way research is done and preferencing alternative research methodologies. As a point of departure to improving impact and reaching mutually beneficial outcomes for researchers and partners in Indigenous health research, we need to routinise the assessment of benefit from outset of research as one of the standards toward which we work.

Importance: Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with mortality of more than 20%. Combining standard therapy with a β-lactam antibiotic has been associated with reduced mortality, although adequately powered randomized clinical trials of this intervention have not been conducted. Objective: To determine whether combining an antistaphylococcal β-lactam with standard therapy is more effective than standard therapy alone in patients with MRSA bacteremia. Design, Setting, and Participants: Open-label, randomized clinical trial conducted at 27 hospital sites in 4 countries from August 2015 to July 2018 among 352 hospitalized adults with MRSA bacteremia. Follow-up was complete on October 23, 2018. Interventions: Participants were randomized to standard therapy (intravenous vancomycin or daptomycin) plus an antistaphylococcal β-lactam (intravenous flucloxacillin, cloxacillin, or cefazolin) (n = 174) or standard therapy alone (n = 178). Total duration of therapy was determined by treating clinicians and the β-lactam was administered for 7 days. Main Outcomes and Measures: The primary end point was a 90-day composite of mortality, persistent bacteremia at day 5, microbiological relapse, and microbiological treatment failure. Secondary outcomes included mortality at days 14, 42, and 90; persistent bacteremia at days 2 and 5; acute kidney injury (AKI); microbiological relapse; microbiological treatment failure; and duration of intravenous antibiotics. Results: The data and safety monitoring board recommended early termination of the study prior to enrollment of 440 patients because of safety. Among 352 patients randomized (mean age, 62.2 [SD, 17.7] years; 121 women [34.4%]), 345 (98%) completed the trial. The primary end point was met by 59 (35%) with combination therapy and 68 (39%) with standard therapy (absolute difference, -4.2%; 95% CI, -14.3% to 6.0%). Seven of 9 prespecified secondary end points showed no significant difference. For the combination therapy vs standard therapy groups, all-cause 90-day mortality occurred in 35 (21%) vs 28 (16%) (difference, 4.5%; 95% CI, -3.7% to 12.7%); persistent bacteremia at day 5 was observed in 19 of 166 (11%) vs 35 of 172 (20%) (difference, -8.9%; 95% CI, -16.6% to -1.2%); and, excluding patients receiving dialysis at baseline, AKI occurred in 34 of 145 (23%) vs 9 of 145 (6%) (difference, 17.2%; 95% CI, 9.3%-25.2%). Conclusions and Relevance: Among patients with MRSA bacteremia, addition of an antistaphylococcal β-lactam to standard antibiotic therapy with vancomycin or daptomycin did not result in significant improvement in the primary composite end point of mortality, persistent bacteremia, relapse, or treatment failure. Early trial termination for safety concerns and the possibility that the study was underpowered to detect clinically important differences in favor of the intervention should be considered when interpreting the findings. Trial Registration: ClinicalTrials.gov Identifier: NCT02365493.

BACKGROUND: Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS: In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS: A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS: Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).

PURPOSE: This article describes the characteristics and reviews the methodological quality of interventions designed to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, Canada and the USA. DATA SOURCES: A total of 17 electronic databases and 13 websites for the period of 2002-13. STUDY SELECTION: Studies were included if they evaluated an intervention strategy designed to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, the USA or Canada. DATA EXTRACTION: Information on the characteristics and methodological quality of included studies was extracted using standardized assessment tools. RESULTS OF DATA SYNTHESIS: Sixteen published evaluations of interventions to improve cultural competency in health care for Indigenous peoples were identified: 11 for Indigenous peoples of the USA and 5 for Indigenous Australians. The main types of intervention strategies were education and training of the health workforce, culturally specific health programs and recruitment of an Indigenous health workforce. Main positive outcomes reported were improvements in health professionals' confidence, and patients' satisfaction with and access to health care. The methodological quality of evaluations and the reporting of key methodological criteria were variable. Particular problems included weak study designs, low or no reporting of consent rates, confounding and non-validated measurement instruments. CONCLUSION: There is a lack of evidence from rigorous evaluations on the effectiveness of interventions for improving cultural competency in health care for Indigenous peoples. Future evaluations should employ more rigorous study designs and extend their measurement of outcomes beyond those relating to health professionals, to those relating to the health of Indigenous peoples.

BACKGROUND: The laryngeal mask airway ProSeal (PLMA), a new laryngeal mask device, was compared with the laryngeal mask airway Classic (LMA) with respect to: (1) insertion success rates and times; (2) efficacy of seal; (3) fiberoptically determined anatomic position; (4) orogastric tube insertion success rates and times; (5) total intraoperative complications; and (6) postoperative sore throat in nonparalyzed adult patients undergoing general anesthesia, hypothesizing that these would be different. METHODS: Three hundred eighty-four nonparalyzed anesthetized adult patients (American Society of Anesthesiologists physical status I-II) were randomly allocated to the PLMA or LMA for airway management. In addition, 50% of patients were randomized for orogastric tube placement. Unblinded observers collected intraoperative data, and blinded observers collected postoperative data. RESULTS: First-attempt insertion success rates (91 vs. 82%, P = 0.015) were higher for the LMA, but after three attempts success rates were similar (LMA, 100%; PLMA, 98%). Less time was required to achieve an effective airway with the LMA (31 +/- 30 vs. 41 +/- 49 s; P = 0.02). The PLMA formed a more effective seal (27 +/- 7 vs. 22 +/- 6 cm H2O; P < 0.0001). Fiberoptically determined anatomic position was better with the LMA (P < 0.0001). Orogastric tube insertion was more successful after two attempts (88 vs. 55%; P < 0.0001) and quicker (22 +/- 18 vs. 38 +/- 56 s) with the PLMA. During maintenance, the PLMA failed twice (leak, stridor) and the LMA failed once (laryngospasm). Total intraoperative complications were similar for both groups. The incidence of postoperative sore throat was similar. CONCLUSION: In anesthetized, nonparalyzed patients, the LMA is easier and quicker to insert, but the PLMA forms a better seal and facilitates easier and quicker orogastric tube placement. The incidence of total intraoperative complications and postoperative sore throat are similar.

Vegetation gap patterns in arid grasslands, such as the "fairy circles" of Namibia, are one of nature's greatest mysteries and subject to a lively debate on their origin. They are characterized by small-scale hexagonal ordering of circular bare-soil gaps that persists uniformly in the landscape scale to form a homogeneous distribution. Pattern-formation theory predicts that such highly ordered gap patterns should be found also in other water-limited systems across the globe, even if the mechanisms of their formation are different. Here we report that so far unknown fairy circles with the same spatial structure exist 10,000 km away from Namibia in the remote outback of Australia. Combining fieldwork, remote sensing, spatial pattern analysis, and process-based mathematical modeling, we demonstrate that these patterns emerge by self-organization, with no correlation with termite activity; the driving mechanism is a positive biomass-water feedback associated with water runoff and biomass-dependent infiltration rates. The remarkable match between the patterns of Australian and Namibian fairy circles and model results indicate that both patterns emerge from a nonuniform stationary instability, supporting a central universality principle of pattern-formation theory. Applied to the context of dryland vegetation, this principle predicts that different systems that go through the same instability type will show similar vegetation patterns even if the feedback mechanisms and resulting soil-water distributions are different, as we indeed found by comparing the Australian and the Namibian fairy-circle ecosystems. These results suggest that biomass-water feedbacks and resultant vegetation gap patterns are likely more common in remote drylands than is currently known.

A survey of laryngeal mask airway usage in 1400 infants and children by ten trainee anaesthetists was undertaken to provide information about insertion and complication rates using the standard insertion technique and a limited range of standardised anaesthetic techniques. Placement was successful in 90% (1258/1400) at the first attempt, 8% (112/1400) at the second attempt and 2% (29/1400) required an alternative technique of insertion. One patient vomited during insertion and the procedure was abandoned, but aspiration did not occur. The overall problem rate was 11.5% and there were significantly more problems during induction of anaesthesia (p < 0.02). Oxygen saturation decreased below 90% briefly on 23 occasions (1.7%). The incidence of problems was unrelated to the mode of ventilation, or whether isoflurane or total intravenous anaesthesia with propofol was used for maintenance. Most problems came with use of the size 1 laryngeal mask (p < 0.001). The subspecialty with the highest problem rate was ear, nose and throat surgery (p < 0.001). There was a significant decrease in problems with increasing experience (p < 0.001). There was no major morbidity associated with use of the device. We conclude that the laryngeal mask provides a safe and effective form of airway management for infants and children in the hands of supervised anaesthesia trainees both for spontaneous and controlled ventilation using either isoflurane or total intravenous anaesthesia.

PURPOSE: The Acute Disease Quality Initiative (ADQI) Workgroup recently released a consensus definition of sepsis-associated acute kidney injury (SA-AKI), combining Sepsis-3 and Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria. This study aims to describe the epidemiology of SA-AKI. METHODS: This is a retrospective cohort study carried out in 12 intensive care units (ICUs) from 2015 to 2021. We studied the incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes of SA-AKI based on the ADQI definition. RESULTS: Out of 84,528 admissions, 13,451 met the SA-AKI criteria with its incidence peaking at 18% in 2021. SA-AKI patients were typically admitted from home via the emergency department (ED) with a median time to SA-AKI diagnosis of 1 day (interquartile range (IQR) 1-1) from ICU admission. At diagnosis, most SA-AKI patients (54%) had a stage 1 AKI, mostly due to the low urinary output (UO) criterion only (65%). Compared to diagnosis by creatinine alone, or by both UO and creatinine criteria, patients diagnosed by UO alone had lower renal replacement therapy (RRT) requirements (2.8% vs 18% vs 50%; p < 0.001), which was consistent across all stages of AKI. SA-AKI hospital mortality was 18% and SA-AKI was independently associated with increased mortality. In SA-AKI, diagnosis by low UO only, compared to creatinine alone or to both UO and creatinine criteria, carried an odds ratio of 0.34 (95% confidence interval (CI) 0.32-0.36) for mortality. CONCLUSION: SA-AKI occurs in 1 in 6 ICU patients, is diagnosed on day 1 and carries significant morbidity and mortality risk with patients mostly admitted from home via the ED. However, most SA-AKI is stage 1 and mostly due to low UO, which carries much lower risk than diagnosis by other criteria.

In this randomized, cross-over cadaver study, we determined whether a new airway device, the ProSeal laryngeal mask airway (PLMA; Laryngeal Mask Company, Henley-on-Thames, UK), prevents aspiration of regurgitated fluid. We studied five male and five female cadavers (6-24 h postmortem). The infusion set of a pressure-controlled, continuous flow pump was inserted into the upper esophagus and ligated into place. Esophageal pressure (EP) was increased in 2-cm H(2)O increments. This was performed without an airway device (control) and over a range of cuff volumes (0-40 mL) for the classic laryngeal mask airway (LMA), the PLMA with the drainage tube clamped (PLMA clamped) and unclamped (PLMA unclamped). The EP at which fluid was first seen with a fiberoptic scope in the hypopharynx (control), above or below the cuff, or in the drainage tube, was noted. Mean EP at which fluid was seen without any airway device was 9 (range 8-10) cm H(2)O. EP at which fluid was seen was always higher for the PLMA clamped and LMA compared with the control (all, P<0.0001). The mean EP at which fluid was seen for the PLMA unclamped was similar to the control at 10 (range 8-13) cm H(2)O. For the PLMA unclamped, fluid appeared from the drainage tube in all cadavers at 10-40 mL cuff volume and in 8 of 10 cadavers at zero cuff volume. Mean EP at which fluid was seen above the cuff was similar for the PLMA clamped and LMA at 0-30 mL cuff volume, but was higher for PLMA clamped at 40-mL cuff volume (81 vs 48 cm H(2)O, P = 0.006). Mean EP at which fluid was seen below the cuff was similar at 0-10 mL cuff volume, but was higher for the PLMA clamped at 20, 30, and 40 mL cuff volume (62, 68, 73 vs. 46, 46, 46 cm H(2)O, respectively, P<0.04). For the PLMA clamped and the LMA, fluid appeared simultaneously above and below the cuff at all cuff volumes. We concluded that in the cadaver model, the correctly placed PLMA allows fluid in the esophagus to bypass the pharynx and mouth when the drainage tube is open. Both the LMA, and PLMA with a closed drainage tube, attenuate liquid flow between the esophagus and pharynx. This may have implications for airway protection in unconscious patients.

Cryopreservation of sperm, embryos and, more recently, oocytes plays an important and increasing role in assisted reproduction, due to improvements of old, and introduction of new technologies. In parallel, concerns are increasing about the technical and biological safety of these procedures. However, published data regarding the confirmed or theoretical hazards of these procedures are sparse and sometimes contradictory. The purpose of this review will summarize data and opinions about one of the most disputed risks, the potential hazard of contamination and disease transmission through cryopreservation. Special attention is concentrated on the weak points of the technology including open vitrification systems, sterilization of liquid nitrogen and safety of commonly used storage tanks including straws and cryovials. Suggestions are also made for practical measures to avoid these dangers while preserving the benefits and perspectives of new cryopreservation technologies.

An analysis of 1500 laryngeal mask airway uses by one anaesthetist using the standard insertion technique was conducted to determine successful insertion rates, position by fibreoptic larynoscopy, complication rates and whether there is a long-term learning curve. The correlation between laryngeal mask airway placement and modified Mallampati grade was also determined. The first time insertion rate was 95.5% with an overall failure rate after three attempts of 0.4%. One hundred and fifteen patients were Mallampati III or IV. All failed placements were Mallampati I or II. Problems occurred in 94 patients (6.27%), but oxygen saturation decreased below 90% on only ten occasions and below 80% on one occasion. There were no episodes of regurgitation. The vocal cords were visible from the mask aperture bars in 97.1%. Comparison of insertion rates, fibreoptic position and complications for the first and second 750 insertions provides evidence for a 'long' term learning curve. These data could be used as a guide for 'optimal' or expected successful laryngeal mask airway insertion rates in adults undergoing routine anaesthesia.

UNLABELLED: We conducted a randomized, controlled, crossover study to determine cervical spine motion for six airway management techniques in human cadavers with a posteriorly destabilized third cervical (C-3) vertebra. A destabilized C-3 segment was created in 10 cadavers (6-24 h postmortem). Cervical motion was recorded by continuous lateral fluoroscopy. The following airway management techniques were performed in random order on each cadaver with manual in-line stabilization applied: face mask ventilation (FM), laryngoscope-guided orotracheal intubation (OETT), fiberscope-guided nasal intubation (FOS-NETT), esophageal tracheal Combitube((R)) (Kendall-Sheridan, Neustadt, Germany) insertion (ETC), intubating laryngeal mask insertion with fiberscope-guided tracheal intubation (ILM-OETT), and laryngeal mask airway insertion (LMA). Afterward, maximum head-neck flexion (FLEX-MAX) and maximum head-neck extension (EXT-MAX) without manual in-line stabilization was performed to determine maximum motion. The maximum posterior displacement of C-3 and the maximum segmental sagittal motion of C2-3 were determined. There was a significant increase in posterior displacement for the FM (1.9 +/- 1.2 mm, P: < 0.01), OETT (2.6 +/- 1.6 mm, P: < 0.0001), ETC (3.2 +/- 1.6 mm, P: < 0.0001), ILM-OETT (1.7 +/- 1.3 mm, P: < 0. 01), LMA (1.7 +/- 1.3 mm, P: < 0.01), FLEX-MAX (3.7 +/- 1.9 mm, P: < 0.0001), EXT-MAX (1.8 +/- 1.7, P: < 0.01), however, not for FOS-NETT (0.1 +/- 0.7 mm). Posterior displacement was less for the ILM-OETT and LMA than for the ETC (both P: < 0.04). There were no significant increases in segmental sagittal motion with any airway manipulation other than with FLEX-MAX (-4.5 +/- 4.0 degrees, P: < 0.01). Posterior displacement was similar to FLEX-MAX for the OETT and ETC; however, it was less for the FM, FOS-NETT, ILM-OETT, and LMA (all P: < 0.01). Posterior displacement was similar to EXT-MAX for all airway manipulations other than for FOS-NETT (P: < 0.001). For cervical motion and the techniques tested, the safest method of airway management in a patient with a posteriorly destabilized C-3 segment is FOS-NETT. LMA devices may be preferable to the ETC. IMPLICATIONS: In the cadaver model of a destabilized third cervical vertebrae, significant displacement of the injured segment occurs during airway management with the face mask, laryngoscope-guided oral intubation, the esophageal tracheal Combitube (Kendall-Sheridan, Neustadt, Germany), the intubating and standard laryngeal mask airway; but not with fiberscope-guided nasal intubation. For cervical motion and the techniques tested, the safest airway technique with this injury is fiberscope-guided nasotracheal intubation. Laryngeal mask devices are preferable to the esophageal tracheal Combitube.

BACKGROUND: There is controversy over (1) the relative incidence of sore throat between the face mask (FM) and laryngeal mask airway (LMA), (2) the efficacy of LMA intracuff pressure reduction as a mechanism for minimizing sore throat, and (3) the relative incidence of sore throat with the LMA between males and females. In a randomized double-blind study, the authors compared laryngopharyngeal, neck, and jaw discomfort with the FM and LMA at high and low cuff volumes in males and females. METHODS: Three hundred adult patients were randomly assigned to three equal-sized groups for airway management: (1) the FM, (2) the LMA with a fully inflated cuff (LMA-High), or (3) the LMA with a semi-inflated cuff (LMA-Low). Anesthesia was administered with propofol, nitrous oxide, oxygen, and isoflurane. In the FM group, a Guedel-type oropharyngeal airway and jaw thrust were used only if necessary. In the LMA groups, cuff inflation was achieved with either 15 or 30 ml for the size 4 (females) and 20 or 40 ml for the size 5 (males). The LMA was removed when the patient was awake. Patients were questioned 18-24 h postoperatively about surgical pain, sore throat, sore neck, sore jaw, dysphonia, and dysphagia, and about whether they were satisfied with their anesthetic. RESULTS: The incidence of sore throat was lower in the FM (8%) than the LMA-High (42%) and LMA-Low (20%) groups (both: P < or = 0.02). The incidence of sore neck was higher for the FM (14%) than the LMA-High group (6%; P = 0.05) but similar to the LMA-Low group (8%). The incidence of sore jaw was higher in the FM (11%) than the LMA-High (3%) and LMA-Low (3%) groups (both: P = 0. 02). There were no differences among groups for surgical pain or dysphonia. The incidence of dysphagia was lower in the FM (1%) than the LMA-High group (11%; P = 0.003), but similar to the LMA-Low group (1%). The incidence of sore throat and dysphagia was lower in the LMA-Low group than the LMA-High group for both males and females (all: P < or = 0.04). There were no differences in discomfort levels between males and females in any group. Two patients from the FM group and one from the LMA-High group were not satisfied with their anesthetic. These complaints were unrelated to postoperative morbidity. CONCLUSION: The LMA causes more sore throat and dysphagia but less jaw pain than the FM. Sore throat and dysphagia are more common with the LMA if the initial cuff volume is high. There are no differences in discomfort levels between males and females. However, these discomforts do not influence patient satisfaction after LMA or FM anesthesia.

AIM: This paper is a report of a study to examine the relationship between intention to change profession and intention to change employer among newly graduated nurses. BACKGROUND: Few studies of the worldwide nursing workforce shortage consider the contribution of changing professions to the shortage. Organizational behaviour research has identified that professional commitment and organizational commitment have an important role in organizational turnover and that professional commitment and intention to change professions may have a greater role in organizational turnover than is presently understood. METHOD: A model of the relationships between affective professional commitment job satisfaction, organizational commitment, intention to change professions and organizational turnover intention was developed through review of the organizational behaviour literature and tested using path analysis. The sample was drawn from all nurses in Queensland, Australia, entering the workforce for the first time in 2005. RESULTS: The model was tested with a final sample size of 131 nurses in the initial period of exposure to the workplace. Affective professional commitment and organizational commitment were statistically significantly related to intention to change professions. Job satisfaction, organizational commitment and intention to change professions were statistically significantly related to intention to change employer. CONCLUSION: Turnover research in nursing should include intention to change professions as well as intention to change employer. Policies and practices that enhance the development of affective professional commitment prior to exposure to the workplace and support affective professional commitment, job satisfaction and organizational commitment in the workplace are needed to help reduce nurse turnover.