Javon Bea Hospital-Rockton

Since the very first publication on rapid sequence induction and intubation (RSII) [1], the controversy surrounding the practice has far outpaced the available evidence. This imbalance is one reason the Project for Universal Management of Airways (PUMA) group felt compelled to issue a preview of its forthcoming universal airway guidelines [2]. The Ship of Theseus analogy, cited in the insightful editorial by Lyons and Wiles [3], is an apt metaphor for the evolution of RSII. However, an alternative interpretation, offered by philosopher Thomas Hobbes, might be even more fitting. Hobbes envisioned a scenario in which a custodian reassembles a second ship using all of the original parts discarded by the Athenians, thereby creating a paradox: which of the two is the true Ship of Theseus? This thought experiment raises profound questions about identity, continuity and function. The proposed RSII algorithm from PUMA cited by Lyons and Wiles [3] reflects this paradox. It integrates both the ‘original’ and ‘reassembled’ elements of RSII as conceived by pioneers like Safar and Stept, while also incorporating essential modern updates: continuous oxygen delivery throughout the procedure; strategies to maximise first-pass tracheal intubation success; and the reframing of cricoid force as an optional, operator-dependent manoeuvre. Certain legacy elements of the original RSII have rightly been set aside. Modern anaesthesiology is increasingly data-informed, leveraging audits, observational studies, non-inferiority trials and randomised controlled trials. In the 1970s, the predominant fear during induction in patients with full stomachs was aspiration. Today, the scientific community broadly recognises the concept of the ‘physiologically difficult airway’ [4] and our primary concerns have shifted, recognising the pressing challenges of physiological derangement, including hypoxia and cardiovascular collapse, as emphasised by recent literature [4]. Modern RSII should focus on maximising tracheal intubation first-pass success, most often using videolaryngoscopy paired with the ideal adjunct (yet to be definitively identified). Simultaneously, continuous oxygenation – potentially via high-flow nasal oxygen – should be prioritised, alongside the confirmation of tracheal tube placement using best practice standards [4]. Moreover, RSII should be ‘rapid’ only in the narrow window between the loss of airway reflexes and inflation of the tracheal tube cuff. Every other phase should be deliberate and meticulous: thorough airway management planning; point-of-care gastric ultrasound; tailored drug selection for induction and haemodynamic optimisation (including, at times, the decision to use no induction drugs and proceed with an awake tracheal intubation); and, role and task assignments using a structured checklist-based approach [5]. The absence of conclusive evidence does not imply the absence of value. The RSII may never be wholly evidence-based, but sufficient data now exists to support a consensus-driven, evidence-informed framework. Should future research allow us to systematise RSII fully, clinical judgement will always be essential. A prudent and skilled clinician must still assess the specific risks and benefits for each individual patient. And, as Lyons and Wiles remind us through their editorial and daily practice, this principle applies to all elective, emergency and rapid sequence inductions. This guiding principle must also underlie any medico-legal review or coroner's report. Perhaps the components of RSII have changed and the ships are no longer the same, but the destination of patient safety is unchanged.

Background/AimNon-islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome associated with a variety of benign and malignant tumors. It is most commonly associated with tumors of epithelial or mesenchymal origin. Management of NICTH primarily involves resection of the underlying tumor, along with other therapies. We report a case of NICTH secondary to metastatic rectal adenocarcinoma. While NICTH has previously been associated with colorectal cancers, few cases (if any) have been reported in patients with primary rectal cancer.Case ReportWe present the case of a 51-year-old male with a medical history of pre-diabetes, gastroesophageal reflux disease, and tobacco use disorder. He was admitted for evaluation of rapid weight loss and was found to have rectal thickening, along with lesions in the lungs, liver, pancreas, and other sites, raising concern for metastasis. He underwent a colonoscopy with biopsy, which confirmed primary rectal adenocarcinoma. During his inpatient stay, he experienced recurrent episodes of hypoglycemia. A diagnosis of NICTH was supported by the low levels of pro-insulin, insulin, C-peptide, IGF-I and an elevated IGF-II:IGF-I ratio. The patient was treated with corticosteroids, glucagon, continuous dextrose infusions, and parenteral nutrition to manage hypoglycemia.ConclusionThis case highlights the importance of considering NICTH in the differential diagnosis for patients with unexplained or refractory hypoglycemia, especially when a notable mass or malignancy is suspected. It also highlights the need for a multimodal approach in managing the underlying hypoglycemia.

Peripherally inserted central catheters (PICCs) have become popular over tunneled catheters in neonatal intensive care units (NICUs) due to their ease of use and convenience. Although rare, a PICC fracture can be a severe and potentially fatal complication. This narrative review aims to identify factors predisposing neonates to PICC fracture and related complications, such as catheter jamming, and explore strategies for preventing and detecting this complication. A thorough search of PubMed and Google Scholar was conducted using relevant keywords to identify articles discussing PICC fracture in neonates. The review encompassed English-language literature on PICC fracture in neonates, with additional pertinent publications identified through citation searching. The incidence of PICC fracture in neonates varies from less than 1% to 10%, with a higher risk associated with prolonged catheterization, lower gestational age and lower birth weight, and the use of multi-lumen catheters. PICC fractures can occur during insertion, maintenance, or removal. Factors such as catheter duration, gestational age, birth weight, and catheter type increase the risk of PICC fracture. Excessive syringe pressure, securement failure, and excessive force during removal are contributing factors. Catheter fatigue and thin-walled catheter design are common causes of breakage. Preventive measures include proper training of healthcare providers, regular monitoring, early recognition, and prompt catheter removal upon fracture. Preventing and detecting PICC fractures is crucial for neonatal safety. Vigilance during insertion, maintenance, and removal, along with care to avoid excessive force during removal and high pressure during flushing, can help prevent catheter breakage. More research is required to improve prevention strategies for PICC fractures in neonates.

Endoscopy has been increasingly utilized to manage esophageal perforations [1] [2] [3].

The correlation between procoagulant levels-factor VIII (FVIII), von Willebrand factor (vWF), and fibrinogen-and risk of thrombosis has been well documented in adult populations. We hypothesize that interaction of passively transferred isoagglutinins in premature neonates with a compromised immune system may trigger an immune response that can target the immature gastrointestinal tract. The objective of this study is to evaluate if there are procoagulant level differences in preterm newborns stratified by ABO blood group. VWF, FVIII, and fibrinogen levels were analyzed in neonates ≤32 weeks and/or birthweight ≤1500 g over the first 6 weeks of life. Demographic, blood type, and transfusion data were collected. Elevations in vWF and FVIII were found to be statistically significant in the third week of life in non-O neonates vs. type O neonates. FVIII was also found to be significantly elevated in week 1. Transfused neonates also showed elevations between weeks 0 and 3. There appears to be a time-dependent variation in procoagulant factor levels in preterm newborns. Although the clinical significance remains unclear, prothrombotic factors vWF and FVIII are significantly higher in non-O blood-type preterm neonates in the third week of life.

The juvenile tyrannosaurid specimen BMR P2002.4.1 possesses a series of four partially healed, oblong lesions along the left maxilla and nasal bones. The morphology of the lesions and their positioning and orientation are compatible with the jaws of the specimen, suggesting that the lesions may have been the result of a bite from an attacker of similar size and species as the bite victim. Bone remodeling of the lesions indicates partial healing and demonstrates that the injury was not fatal. The injury appears to have affected the growth of the skull, causing a slight warping of the left maxilla and a slight leftward curvature of the nasal. Previous examples of intraspecific behavior in theropods have noted various injuries on skulls; the majority of documented injuries are in adults. The presence and nature of these wounds suggests that juvenile tyrannosaurid behavior included intraspecific aggression among similar-sized individuals, as has been observed in modern crocodilians. Although it is not possible to unequivocally infer behavior from a fossil specimen, as a juvenile animal it is unlikely that the behavior directly reflects sexual competition or conflict, although it may represent learning behavior for later conflict as competing adults or territoriality over food or spatial resources.