Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic

INTRODUCTION

The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic.

MAIN BODY

The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure.

CONCLUSION

The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.

Depression and survival of glioma patients: A systematic review and meta-analysis

INTRODUCTION

There is currently a lack of a well-formed consensus regarding the effects of depression on the survival of glioma patients. A more thorough understanding of such effects may better highlight the importance of recognizing depressive symptoms in this patient population and guide treatment plans in the future.

OBJECTIVE

The aim of this meta-analysis was to study the effect of depression on glioma patients' survival.

METHODS

A meta-analysis was conducted according to the PRISMA guidelines. PubMed, Embase, and Cochrane databases were searched for studies that reported depression and survival among glioma patients through 11/06/2016. Both random-effects (RE) and fixed-effect (FE) models were used to compare survival outcomes in glioma patients with and without depression.

RESULTS

Out of 619 identified articles, six were selected for the meta-analysis. Using RE model, the various measures for survival outcomes displayed worsened outcomes for both high and low-grade glioma patients with depression compared to those without depression. For binary survival outcomes, the overall pooled risk ratio for survival was 0.70 (95% CI: 0.47, 1.04; 6 studies; I² = 54.9%, P-heterogeneity = 0.05) for high grade gliomas (HGG) and 0.28 (95% CI: 0.04, 1.78; I² = 0%, P-heterogeneity = 1.00; one study) for low grade gliomas (LGG) was. A sub-group analysis in the HGG group by depression timing (pre- versus post-operative) revealed no differences between depression and survival outcomes (P-interaction = 0.47). For continuous survival outcomes, no statistically significant difference was found among the high and low-grade glioma groups (P-interaction = 0.31). The standardized mean difference (SMD) in survival outcomes was -0.56 months (95%CI: -1.13, 0.02; 4 studies, I² = 89.4%, P-heterogeneity < 0.01) for HGG and -1.69 months (95%CI: -3.26, -0.13; one study; I² = 0%, P-heterogeneity = 1.00) for LGG. In patients with HGG, the pooled HR of death also showed a borderline significant increased risk of death among depressive patients (HR 1.42, 95% CI: 1.00, 2.01). Results using the FE model were not materially different.

CONCLUSIONS

Depression was associated with significantly worsened survival regardless of time of diagnosis, especially among patients with high-grade glioma.

Towards generalised reference condition models for environmental assessment: a case study on rivers in Atlantic Canada

Evaluation of the ecological status of river sites in Canada is supported by building models using the reference condition approach. However, geography, data scarcity and inter-operability constraints have frustrated attempts to monitor national-scale status and trends. This issue is particularly true in Atlantic Canada, where no ecological assessment system is currently available. Here, we present a reference condition model based on the River Invertebrate Prediction and Classification System approach with regional-scale applicability. To achieve this, we used biological monitoring data collected from wadeable streams across Atlantic Canada together with freely available, nationally consistent geographic information system (GIS) environmental data layers. For the first time, we demonstrated that it is possible to use data generated from different studies, even when collected using different sampling methods, to generate a robust predictive model. This model was successfully generated and tested using GIS-based rather than local habitat variables and showed improved performance when compared to a null model. In addition, ecological quality ratio data derived from the model responded to observed stressors in a test dataset. Implications for future large-scale implementation of river biomonitoring using a standardised approach with global application are presented.

Size-selective predation by river otter (Lontra canadensis) improves refuge properties of shallow coastal marine nursery habitats

Young fish often avoid deep water to reduce predation risk from larger fish. Less clear are explanations for the avoidance of shallows by large piscivorous fish; however, one hypothesis suggests that this distribution reduces contact with depth-limited semi-aquatic mammal and bird piscivores. We determined prey size selection of the river otter ( Lontra canadensis (Schreber, 1777)) to test the hypothesis that larger fish are at elevated risk in shallow coastal waters in Newman Sound, Newfoundland, during June–November 2001 and May 2002. We compared otter diet (scat analysis) and prey availability (seine sampling) to test this hypothesis. Five fish taxa (Atlantic cod ( Gadus morhua L., 1758), Greenland cod ( Gadus ogac Richardson, 1836), shorthorn sculpin ( Myoxocephalus scorpius (L., 1758)), cunner ( Tautogolabrus adspersus (Walbaum, 1792)), and winter flounder ( Pseudopleuronectes americanus (Walbaum, 1792))) dominated the shallow-water fish community and were sufficiently abundant in otter scats to examine feeding preferences. Larger, piscivorous fish were selected by otters, suggesting that they were at greater risk of predation than smaller fish, consistent with our hypothesis that depth-limited, diurnally active predators restrict large fish from hunting in shallow water during daytime. We suggest that depth-limited air-breathing predators may reduce the presence of such predatory fish in shallow-water juvenile fish nursery habitats.

Search for the rare decay B0-->tau+tau- at BABAR

We present the results of a search for the decay B0-->tau+tau- in a data sample of (232+/-3)x10(6) Upsilon(4S)-->BB decays using the BABAR detector. Certain extensions of the standard model predict measurable levels of this otherwise rare decay. We reconstruct fully one neutral B meson and seek evidence for the signal decay in the rest of the event. We find no evidence for signal events and obtain Beta(B0->tau+tau-)<4.1x10(-3) at the 90% confidence level.

Pulmonary gene expression profiling of inhaled ricin

Aerosol exposure to ricin causes irreversible pathological changes of the respiratory tract resulting in epithelial necrosis, pulmonary edema and ultimately death. The pulmonary genomic profile of BALB/c mice inhalationally exposed to a lethal dose of ricin was examined using cDNA arrays. The expression profile of 1178 mRNA species was determined for ricin-exposed lung tissue, in which 34 genes had statistically significant changes in gene expression. Transcripts identified by the assay included those that facilitate tissue healing (early growth response gene (egr)-1), regulate inflammation (interleukin (IL)-6, tristetraproline (ttp)), cell growth (c-myc, cytokine-inducible SH2-containing protein (cish)- 3), apoptosis (T-cell death associated protein (tdag)51, pim-1) and DNA repair (ephrin type A receptor 2 (ephA2)). Manipulation of these gene products may provide a means of limiting the severe lung damage occurring at the cellular level. Transcriptional activation of egr-1, cish-3, c-myc and thrombospondin (tsp)-1 was already apparent when pathological and physiological changes were observed in the lungs at 12 h postexposure. These genes may well serve as markers for ricin-induced pulmonary toxicity. Ongoing studies are evaluating this aspect of the array data and the potential of several genes for clinical intervention.

Structure of the primordial diaphragm and defects associated with nitrofen-induced CDH

The goals of this study were to further our understanding of diaphragm embryogenesis and the pathogenesis of congenital diaphragmatic hernia (CDH). Past work suggests that the pleuroperitoneal fold (PPF) is the primary source of diaphragmatic musculature. Furthermore, defects associated with an animal model of CDH can be traced back to the formation of the PPF. This study was designed to elucidate the anatomic structure of the PPF and to determine which regions of the PPF malform in the well-established nitrofen model of CDH. This was achieved by producing three-dimensional renderings constructed from serial transverse sections of control and nitrofen-exposed rats at embryonic day 13.5. Renderings of left- and right-sided defects demonstrated that the malformations were always limited to the dorsolateral portions of the caudal regions of the PPF. These data provide an explanation of why the holes in diaphragmatic musculature associated with CDH are characteristically located in dorsolateral regions. Moreover, these data provide further evidence against the widely stated hypothesis that a failure of pleuroperitoneal canal closure underlies the pathogenesis of nitrofen-induced CDH.

An Internet compendium of analytical methods and spectroscopic information for monomers and additives used in food packaging plastics

An internet website (http:¿cpf.jrc.it/smt/) has been produced as a means of dissemination of methods of analysis and supporting spectroscopic information on monomers and additives used for food contact materials (principally packaging). The site which is aimed primarily at assisting food control laboratories in the European Union contains analytical information on monomers, starting substances and additives used in the manufacture of plastics materials. A searchable index is provided giving PM and CAS numbers for each of 255 substances. For each substance a data sheet gives regulatory information, chemical structures, physico-chemical information and background information on the use of the substance in particular plastics, and the food packaging applications. For monomers and starting substances (155 compounds) the infra-red and mass spectra are provided, and for additives (100 compounds); additionally proton NMR are available for about 50% of the entries. Where analytical methods have been developed for determining these substances as residual amounts in plastics or as trace amounts in food simulants these methods are also on the website. All information is provided in portable document file (PDF) format which means that high quality copies can be readily printed, using freely available Adobe Acrobat Reader software. The website will in future be maintained and up-dated by the European Commission's Joint Research Centre (JRC) as new substances are authorized for use by the European Commission (DG-ENTR formerly DGIII). Where analytical laboratories (food control or other) require reference substances these can be obtained free-of-charge from a reference collection housed at the JRC and maintained in conjunction with this website compendium.

Reconstruction of a total anterior urethral defect using buccal mucosa

Extensive urethral defects in the presence of insufficient local skin can challenge the reconstructive urologist. We report a case of complete anterior urethral loss due to Fournier's gangrene that was successfully reconstructed using autologous buccal mucosa. A 17.5 x 2.5 cm tube graft was harvested, extending from the left to right buccal regions along the lower labial fold. At long-term follow-up, the patient had an acceptable cosmetic result with maintenance of potency and the ability to urinate. Buccal mucosal grafts are a viable alternative for cases of near-total urethral reconstruction.

Local control after surgical treatment of spinal metastatic disease

Surgery was carried out on 118 patients with spinal metastatic diseases; 80 operations were palliative and 38 were curative. All patients who survived 1 year or more and all those who had local recurrence before dying (total n = 58) were included in this study. The aim of the study was to identify the factors that determine the success of local control in order to develop a new technique that could prevent local recurrence. From among the different factors that may influence the oncological result, a retrospective study concentrated particularly on the following items: sex of the patient, location and extension of the tumor on the spine, tumor involvement on the vertebra itself, and quality of tumor excision. These factors seem to have no or little influence on local control. However, sensitivity of the primary cancer to adjuvant treatments (e.g., chemotherapy, radiation therapy, hormonotherapy) and correct timing of the radiation therapy, which must be performed after, rather than before, surgery, seem to improve local control significantly. The authors therefore suggest two options for treatment. When the primary cancer is sensitive to adjuvant treatments, 'palliative' surgery with posterior fixation and nerve decompression seems sufficient to attain good function and adequate oncological results. On the other hand, when the primary cancer is resistant to adjuvant treatment or when the lesion recurs after radiation therapy, more aggressive surgery must be carried out. Complete excision of the tumor after embolization, with may be even associated local chemotherapy, is required. However, even when this is carried out, local control is difficult to achieve.

Dual angiotensin converting enzyme/thromboxane synthase inhibitors

A variety of compounds were prepared to determine whether dual angiotensin converting enzyme (ACE)/thromboxane synthase (TxS) inhibition could be obtained in the same molecule. These compounds would be used to explore the concept that a dual inhibitor would have superior antihypertensive activity in the spontaneous hypertensive rat compared to an ACE inhibitor. Potent in vitro dual ACE and TxS inhibition was obtained in the same molecule with five series of compounds. Potent blood pressure lowering in the SHR was observed after oral administration of 8b and 11. However, a correlation between blood pressure lowering and the A1 pressor response inhibition was not observed. The blood pressure-lowering actions of enalapril were significantly potentiated by concurrent administration of 3, a thromboxane synthase inhibitor. Analysis of the area under the curve for 24 h showed nearly a doubling of the blood pressure-lowering effect.

Heterocyclic lactam derivatives as dual angiotensin converting enzyme and neutral endopeptidase 24.11 inhibitors

A series of 13- and 14-membered ring lactam derivatives 9a,b, 10, 11, and 12a-c was prepared from L-cysteine. Compounds 9a,b and 12a,b were tested in vitro for inhibition of neutral endopeptidase 24.11 (NEP) and angiotensin converting enzyme (ACE) inhibition. The structure-activity profile of the series is discussed. Compound 9b, a 13-membered ring macrocyclic lactam, had an NEP IC50 of 18 nM and an ACEIC50 of 12 nM in vitro and showed dual plasma inhibition after intravenous or oral administration.

Computer-assisted compounding of neonatal/pediatric parenteral nutrition solutions

A computer software package was developed to perform the calculations involved in compounding neonatal/pediatric parenteral nutrition (PN) solutions. A 16-bit micro-computer was used to develop and evaluate the software. The program requires a minimum of user input and is menu-driven. It performs the calculations, prints appropriate labels, a preparation card and a summary of the nutritional content of the solution. Error check routines and a check for calcium-phosphate compatibility are imbedded in the program. The effect of the package on PN compounding was evaluated using a computer model. The evaluation indicated the computer-assisted system was more efficient than a manual system and the possibility of computational error was reduced. The increase in efficiency with the computer-assisted system was between 12-15% compared to a manual system. Computer modeling appeared to be a useful tool in both evaluating the software package and determining the effect it would have on work flow.

A review of the Manitoba home i.v. antibiotic program

The Manitoba Home IV Antibiotic Program was reviewed after 12 years of operation. Patient selection and the steps involved in sending a patient home on the program are outlined. The types of infections treated and the incidence of complications and therapeutic failures are presented. The drugs and supplies used are described and total costs are discussed. The data presented is based on 748 patient admissions to the program and 15,366 patient days of experience. The review concludes that the program is safe and effective and provides a viable alternative to hospitalization for patients with chronic infections.

Progesterone derivatives that bind to the digitalis receptor: synthesis of 14 beta-hydroxyprogesterone. A novel steroid with positive inotropic activity

The synthesis of 14-hydroxy-14 beta-pregn-4-ene-3,20-dione (14 beta-hydroxyprogesterone) is described. This novel steroid is about 10 times more potent than progesterone and one-tenth as potent as ouabagenin in an [3H]ouabain radioligand binding assay and is the first in a series of progesterone congeners that interact at the cardiac glycoside receptor both to possess the C/D cis ring junction and to enhance contractility of isolated cardiac tissue.

The effect of vaginal prostaglandin E2 pessaries on induction of labor

In a prospective randomized study, patients with a valid obstetric indication for induction of labor received either 3 mg prostaglandin E2 vaginal pessaries immediately prior to oxytocin (prostaglandin group, n = 99), or oxytocin alone (oxytocin group, n = 103). At the conclusion of the second day of induction, a significant reduction was noted in the incidence of failed induction in the prostaglandin group (4%) as compared to the oxytocin group (13%) (p less than 0.05). Twenty percent of patients in the prostaglandin group experienced successful induction with prostaglandin pessaries only. When oxytocin was required in the prostaglandin group, the maximal concentration of oxytocin infused and the duration at this concentration were significantly less than in the oxytocin group. No perinatal complications were attributed to the use of prostaglandin. Three minor maternal complications that were attributed to vaginal prostaglandin E2 did not require treatment. Our conclusion is that patients who require an induction of labor, when artificial rupture of the membranes is not feasible, benefit from the use of prostaglandin pessaries before the administration of oxytocin.

Ontogenesis of hypertension and responsiveness to antihypertensive agents in spontaneously hypertensive rats

Heart rate, systolic blood pressure and responses of spontaneously hypertensive rats (SHR) to guanethidine, timolol, minoxidil and phentolamine were monitored at 2, 6 and 12 months of age. All antihypertensive agents produced significant and comparable reductions in systolic blood pressure at 6 and 9 months of age, at which time systolic blood pressures were maximally elevated, but had very little effect at 2 months when pressures were only marginally higher. However, at 12 months of age, SHR maintained their response to guanethidine and timolol but responded less well to minoxidil and, especially, to phentolamine. Aortic strips of SHR contracted less than those of normotensive rats to both KCl and norepinephrine at all ages and also relaxed less to nitroglycerin. SHR aortic strips appeared to specifically lose the ability to contract to norepinephine at 12 months of age. It is suggested that a progression of change in responsiveness to antihypertensive agents exists for SHR. Furthermore, this progression will differ for agents with differing mechanisms of action and is probably a result of physical and/or biochemical factors which combine to alter the responsivity of SHR vascular smooth muscle.