Revised recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic - what a difference a year makes.

BACKGROUND: During the early part of the COVID-19 pandemic, the Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force published recommendations on performance of tracheotomy. Since then, our understanding of the virus has evolved with ongoing intensive research efforts. New literature has helped us better understand various aspects including patient outcomes and health care worker (HCW) risks associated with tracheotomy during the COVID-19 pandemic. Accordingly, the task force has re-evaluated and revised some of the previous recommendations. MAIN BODY: Based on recent evidence, a negative reverse transcription polymerase chain reaction (RT-PCR) COVID-19 swab status is no longer the main deciding factor in the timing of tracheotomy. Instead, tracheotomy may be considered as soon as COVID-19 swab positive patients are greater than 20 days beyond initial symptoms and 2 weeks of mechanical ventilation. Furthermore, both open and percutaneous surgical techniques may be considered with both techniques showing similar safety and outcome profiles. Additional recommendations with discussion of current evidence are presented. CONCLUSION: These revised recommendations apply new evidence in optimizing patient and health care system outcomes as well as minimizing risks of COVID-19 transmission during aerosol-generating tracheotomy procedures. As previously noted, additional evidence may lead to further evolution of these and other similar recommendations.

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.

Crude protein and rumen undergradable protein effects on reproduction and lactation performance of Holstein cows.

We conducted a study to determine the effects of excess dietary crude protein (CP) and rumen undegradable protein (RUP) on reproduction and lactation performance of Holstein cows. During each of three yearly replicates, cows were blocked by previous mature equivalent milk production and randomly assigned at calving (n = 47; partum group) or at 42 +/- 21 d postpartum (n = 134; postpartum group) to the following dietary treatments: 1) ryegrass pasture supplemented with a corn and soybean meal grain mix (high CP, moderate RUP); 2) ryegrass pasture mornings and corn silage evenings, supplemented with grain as in diet 1 (moderate CP, moderate RUP control diet), and 3) ryegrass pasture mornings and corn silage evenings, supplemented with a grain mix containing corn, soybean meal, corn gluten meal, and blood meal (moderate CP, high RUP). Dietary CP and RUP concentrations were approximately 23.1, 5.8; 17.7, 5.0; and 17.2, 6.8% of dry matter for diets 1 to 3, respectively. Plasma urea N concentrations were highest in cows fed diet 1 (25.0 mg/dl), intermediate in cows on diet 2 (20.1 mg/dl), and lowest in cows on diet 3 (18.5 mg/dl). Cows fed excess dietary protein (diet 1) exhibited lower first breeding pregnancy rates (24.1 vs. 41.0%) and lower overall pregnancy rates (53.4 vs. 75.4%) than did cows fed diet 2, increasing time nonpregnant by an average of 15.1 d per cow. Reproductive performance was similar between cows fed diets 2 and 3. Mean fat-corrected milk (FCM) yield was not affected by protein concentration (diet 1 vs. 2); however, partum group cows that received supplemental RUP (diet 3) produced more 3.5% FCM than controls in early lactation. Feeding grain diets that contained excess dietary protein impaired the reproductive performance of dairy cows grazing ryegrass.

Effects of fish meal and sodium bentonite on daily gain, wool growth, carcass characteristics, and ruminal and blood characteristics of lambs fed concentrate diets.

We evaluated the effects of replacing some soybean meal (SBM) protein with fish meal (FM) protein in diets adequate and slightly deficient in CP, with or without .75% sodium bentonite (NaB) on performance and ruminal and blood metabolites of individually fed Suffolk lambs. Diets were based on corn, SBM, and cottonseed hulls. In Exp. 1, five lambs were assigned to each of the three dietary treatments (11% CP with 3% FM, 13% CP with 0 or 3% FM). Lambs fed diets that contained 11% CP with 3% FM or 13% CP with 0% FM had similar DMI and ADG. Gain and feed efficiency were slightly improved (P = .18) by the 13% CP diet with 3% FM. In Exp. 2, 32 lambs were assigned to four dietary treatments (13.5% CP of DM) in a 2 x 2 factorial arrangement (0 or 3% FM, and 0 or .75% NaB on an as-fed basis). The DMI and ADG were increased (P < .05) by FM and NaB supplementation. Interactions (P < .05) revealed that NaB increased DMI, ADG, gain per feed (g/kg of DMI), and plasma urea N concentration in the absence of FM but not in the presence of FM in the diet. Neither FM nor NaB influenced (P = .25) wool growth. Total ruminal VFA were increased (P < .06) by FM and NaB. Differences in mineral content of phalanx bone, liver, and kidney were small and may be related to the mineral content of diets and the effect of NaB on mineral solubilities. Similar DMI and ADG of lambs fed FM and NaB separately and in combination suggest that their beneficial effect is not additive.

Radiation safety considerations for PET centers.

This article explains why technologists handling positron-emitting radionuclides may have higher measured radiation exposures than technologists working with single-photon emitting radionuclides. We will summarize measurements we have made, as well as those reported by other authors. In addition, we will describe the procedures implemented to minimize exposure.

Assessment of chemical lumbar sympathectomy in critical limb ischaemia using thermal imaging.

Objective assessment of chemical lumbar sympathectomy (CLS) is lacking. Its success is usually judged in terms of the patient's clinical improvement. We have thermographically measured the immediate temperature changes of the lower limb following CLS using a thermal imager (SAN-EI Thermotracer 6T61). Seven patients with critical limb ischaemia and one patient with Raynaud's phenomenon underwent unilateral ablation of the lumbar sympathetic chain using 5% phenol. Four patients were diabetic, two of whom had undergone previous sympathectomy on the same side. Within fifteen minutes of injection, all patients showed a rise in skin temperature in parts of the sock distribution of between 0.8 degrees C and 8.5 degrees C. We conclude that the haemodynamic effects of CLS are immediate and can be objectively measured with thermal imaging.

Splice-site mutation of the p53 gene in a family with hereditary breast-ovarian cancer.

Germline mutations within evolutionary conserved exons of the p53 gene predispose to tumor development in several familial cancer syndromes. We now report identification of a novel p53 mutation affecting the splice acceptor site of exon 6 in the germline DNA of a family with hereditary breast-ovarian cancer. This splice-site mutation, which results in omission of exon 6 and creates a frame-shift and premature stop codon in transcripts from the mutant allele, was found in seven family members--four of whom have developed breast, ovarian or choroid plexus tumors before age 35. Our finding suggests the need to examine the entire p53 gene for splice-site, frame-shift, and nonsense (as well as missense) mutations in families with early-onset hereditary breast and breast-ovarian cancers not linked to the BRCA1 gene on chromosome 17q. We propose that the term 'p53 familial cancer syndrome' be applied to clusters of tumors in families with documented germline p53 mutations, regardless of the histopathologic findings or pattern of tumor development.

Meniscal tears diagnosed with MR imaging versus arthroscopy: how reliable a standard is arthroscopy?

Arthroscopy of the menisci is considered the standard by which all noninvasive imaging procedures of the knee are measured. To better recognize the accuracy and relevance of arthroscopic correlation, a study was done in 254 consecutive patients who underwent both magnetic resonance (MR) imaging of the knee and arthroscopy. If interpretation of arthroscopic findings disagreed with MR findings, the arthroscopic videotapes were reviewed. Seventeen errors occurred in interpretation, resulting in false-positive MR images. Nine of these errors (53%) were associated with lines of high signal intensity that reached the articular surface of the posterior horn, an area incompletely seen on the arthroscopic videotapes. Two errors (12%) occurred in postmenisectomy abnormalities that the arthroscopist believed were not clinically significant; the six other errors (35%) occurred in high-signal-intensity alterations in either the free edge or the entire meniscal substance that did not correlate with clinically significant tears. Thirty-two errors occurred in interpretation, resulting in false-negative MR images. Fifteen of these errors (47%) occurred in small tears that did not require meniscectomy.

Real time ultrasonic evaluation of the fetal heart.

A series of measurements of cardiothoracic ratios (C/T) at various gestational ages are reported. Thirty fetuses ranging from 16 to 36 weeks gestational age were studied using real time ultrasonography. The cardiothoracic ratio remained constant regardless of gestational age. A case report is presented in which a congenital heart malformation was detected in utero using real time ultrasonography, illustrating the value of these measurements in selected cases.