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.

A guide to interpreting contraceptive efficacy studies.

Results of trials of various birth control methods and contraceptive products may provide misleading data and engender unrealistic expectations regarding efficacy. An analysis of published efficacy-trials reveals numerous fallacies in their design, performance, and reporting. Consequently, family planning clinicians find it virtually impossible to make valid comparisons among the methods or products. This article reviews the definitions and measures that have been used to assess contraceptive efficacy, describes and illustrates some of the flaws that confound interpretation and comparison of studies, and presents a set of recommendations for future studies. A summary table providing comparative failure rates for all methods of contraception is included.

Coronary heart disease prevention in childhood: one-year results of a randomized intervention study.

A six-year intervention study of the feasibility and effectiveness of a program aimed at the primary prevention of coronary heart disease (CHD) has been initiated among children in six school districts in Westchester County, New York. Schools randomly were assigned either to the intervention program or to a control group. The intervention program consists of a curriculum focusing on nutrition, physical fitness, and cigarette smoking prevention. The study population at baseline comprised 1,822 fourth-graders. This paper presents the findings at baseline and at one-year follow-up for the following target risk factors: systolic and diastolic blood pressure, plasma total and high-density lipoprotein (HDL) cholesterol, serum thiocyanate, ponderosity index, triceps skinfold thickness, and postexercise pulse recovery rate. After one year of intervention, the program was found to be acceptable to school administrators, teachers, parents, and children. Small net changes in the favorable direction were observed for diastolic blood pressure and thiocyanate. Intervention programs in schools may, after sufficient duration, prove to be effective in lowering CHD risk.

Facial sweat gland carcinoma metastasizing to neck nodes: a diagnostic and therapeutic challenge.

We report an unusual case involving a patient with sweat gland carcinoma of the cheek who presented with ipsilateral neck lymph node metastasis 10 years after his initial presentation. Pathological analysis of the surgical specimen revealed a strong reactivity of tumor cells to gross cystic disease fluid protein 15, estrogen receptor protein, and progesterone receptor protein. On the basis of these results, tamoxifen citrate therapy was initiated empirically. Our patient has been disease free for more than 3 years. Based on this and another case reported in the literature, we believe that antiestrogen therapy could prove beneficial in a subset of patients with sweat gland carcinoma. We recommend future multicenter clinical trials to assess the effectiveness of postoperative tamoxifen therapy for patients with estrogen and progesterone receptor protein-positive metastatic sweat gland carcinoma.

Longitudinal observations (1987-1997) on the prevalence of middle ear disease and associated risk factors among Inuit children of Inukjuak, Nunavik, Quebec, Canada.

The prevalence of middle ear disease in 2-6 year old children in 1997 was compared with that observed in 1987 in the same Inuit community in northern Quebec. Risk and protective factors associated with middle ear disease were also assessed. A total of 122 children participated. The assessments included: otological examination, cerumen sampling for analysis of organochlorine compounds, medical file review, and parent questionnaire regarding environmental and lifestyle factors. Comparison of ear examination results in 1997 and 1987 showed that there had been no change in the prevalence of chronic otitis media [9.4% to 10.8%] and proportion of ear drums with minimal scarring [45.6% to 45.4%], an increase in the proportion of normal ear drums [23.9% to 39.0%], a decrease the proportion with maximal scarring [17.8% to 2.0%] and little difference in the rate of serous otitis media [3.3% to 2.8%]. Factors found to be significantly associated with middle ear disease included: number of persons/bedroom, number of siblings with a history of ear disease, age at first, second and third visit to the nursing station for ear problems, and type of milk (formula vs. non-formula) in bottle fed children.

Medial fracture dislocation of hallucal interphalangeal joint. A case report.

A case of medical fracture dislocation of the hallucal interphalangeal joint is presented. The patient did not recall the specific mechanism that caused this injury. However, this type of injury would have to entail a substantial lateral-to-medial force at the distal phalanx. The authors' review of the literature did not reveal a similar case involving a medial dislocation of the distal phalanx. This transverse plane pathology was treated with closed reduction because of a lack of sesamoid or volar plant involvement in the joint.

The dynamics of contraceptive use in Peru.

In 1986, the Demographic and Health Surveys project administered the first six-year calendar history of events that included women's contraceptive use and their reasons for discontinuation in experimental surveys in Peru and the Dominican Republic. In this report the experimental survey from Peru is examined to demonstrate how the calendar data can be used to calculate multiple increment-decrement life table rates of contraceptive discontinuation--including contraceptive failure, method switching, and abandonment of use--and of resumption of method use following discontinuation. These analyses reveal that nearly half of all Peruvian women who begin to use a method will stop using it within one year; 29 percent of women discontinue method use for nonpregnancy-related reasons within one year of initiating use. Women who switch methods do so frequently, and many will return to a method used previously, or move on to a third method. Women who become pregnant after abandoning contraceptive use have similar contraceptive-use patterns to women who experience a contraceptive failure.

PIP: An analysis of calendar data from January 1981 to interview date in 1986 (Demographic and Health Survey) on 1065 ever married Peruvian women who had ever used a contraceptive was used to show how researcher can use these data to calculate multiple increment-decrement life table rates of contraceptive discontinuation and renewed method use after discontinuation. 46.4% of women discontinued a method within 1 year. 29% discontinued a method for nonpregnancy related reasons within 1 year of use. Women who stopped using a method were more likely to switch directly to another method than not use any method. The risk of unplanned pregnancy was therefore low for these women. Women who discontinued use of a method but not switch directly to another method likely ceased having sexual intercourse, while others either ran out of supplies, were dissatisfied with the method, or could not find acceptable alternative methods. Regardless of the reason for not switching to another method after discontinuation, these women were at an increased risk of unplanned pregnancy. Women who discontinued a method and did not directly switch to another method were just as likely to return to the abandoned method as they were to switch to another method, but were likely to become pregnant before they returned to the abandoned method or switched to another method. Contraceptive use patterns of such pregnant women matched those of women whose contraceptives failed. Both groups of women tended to return to the method that failed. The considerable amount of method switching in a population may demonstrate either that women profit from a wide range of contraceptive choices or they cannot easily obtain and are not satisfied with currently available contraceptives. Since Peru had one of the weakest family planning programs in Latin America during the 1980s, the latter 2 reasons were most likely the case.

Plasmacytomas of the larynx.

Laryngeal plasmacytomas are rare neoplasms that present difficulties in diagnosis, both clinically and pathologically. Lymph node metastases are found in up to 25% of patients but do not alter the prognosis. Systemic dissemination occurs in 17-35% of cases and significantly shortens survival. Radiotherapy plays a major role in the primary treatment of these lesions, but the optimum dose is not yet known. Chemotherapy is reserved for locally advanced or disseminated disease. Survival at five years is approximately 50%, but the known risk of late recurrences or disseminated disease makes life-long follow-up mandatory.

Percutaneous tracheostomy: comparison of Ciaglia and Griggs techniques.

Endoscopic percutaneous dilatational tracheostomy is at least as safe as standard open tracheostomy in the operating room (OR). Recently, a single dilator was introduced to accomplish dilatation of the tracheal aperture in one step, thus obviating the need for multiple graduated dilators. Experience with endoscopic percutaneous tracheostomy (PCT) using the single dilator in 40 patients to date supports the premise that the procedure is safe, rapid, and technically simple. In the study by Añon et al, two very different techniques, are compared: the Ciaglia percutaneous dilatational tracheostomy technique using multiple dilators and the Griggs percutaneous technique using guidewire-dilating forceps. Although relative complication rates for the two techniques are not significantly different, both procedures are performed in a 'blind' fashion, without the benefit of a bronchoscope. The reported incidence of serious complications in this study is high, and almost certainly avoidable with the addition of direct bronchoscopic visualization. Operative time is reported to be shorter with the Griggs technique, but this finding is unlikely to hold true for the single dilator technique, which reduces procedure time to less than 15 min. This author's experience with bedside endoscopic PCT using the single dilator indicates that it is a safe, rapid and cost-effective procedure with a low complication rate.

Contraceptive failure in the United States: a critical review of the literature.

The overall goal of this paper is to provide for the first time a comprehensive critical review of the literature on contraceptive failure in developed countries, primarily the United States. The first two sections of our paper lay the groundwork for a critical assessment of the extensive body of studies on this subject, by systematically exploring the concepts and measurement of contraceptive efficacy and the methodological pitfalls that snare many investigators and compromise their results. The next two sections focus on results in the literature. First we provide a method-by-method critique of the available studies and then we summarize our conclusions in a single table that provides efficacy information necessary for women and couples to make an informed choice of a method of contraception. We close with a set of substantive observations and also a set of methodological recommendations intended to improve the quality and comparability of findings from future research.

Reproductive and socioeconomic determinants of child survival: confounded, interactive, and age-dependent effects.

Studies of infant and child mortality have evolved to distinguish between two sets of explanatory variables-factors related to reproductive or maternal characteristics and socioeconomic factors, generally described as characteristics of the family or household. Almost all multivariate analyses include variables from each of these two sets, but there has been little consideration of the relationship between them. We examine how these two sets of variables jointly affect mortality. We test first for confounded effects by examining socioeconomic effects while excluding and then including reproductive variables in nested multivariate models. Next, we look for age-dependent effects among the explanatory variables and find that reproductive and socioeconomic factors affect mortality at differing ages of children. Finally, we examine interactive effects of the two sets of variables. We conclude that the higher mortality observed among the low status groups is not a result of greater concentration of poor reproductive patterns in those groups. Instead, higher status groups probably have more resources available for combating the negative effects of the same high-risk reproductive patterns.

PIP: Data on 9185 births that occurred between 1958-73 in 26 villages in Ludhiana District in Punjab state, India were analyzed to determine how reproductive and socioeconomic factors influence child mortality. Specifically confounded, interactive, and age-dependent effects were examined. Overall, only reproductive factors were associated with neonatal mortality. These factors included maternal age (p.05 for 20 year old mothers and p.1 for 35 year old mothers) and =or 15 month birth interval (p.05). =or 15 month birth interval also affected 2-6 month old mortality (p.05) as well as mother's education ([.05). The socioeconomic factors of being a girl (p.05), lower caste Sikh (p.05), and having a low income (p.05) were all positively associated with child mortality beginning at 7 months. The nutrition, medical, and family planning interventions of the Narangwal project (1968-74) improved child survival for only =or 7 month old children born during or after 1963 (p.05). 0-36 month old children born to mothers with no education were less likely to surmount the negative effects related to a young mother, high birth order, short previous birth intervals, and a previous sibling death (p.05). The low status groups were just as likely to exhibit poor reproductive patterns as were the high status groups, but the low status groups tended to experience higher mortality because they did not have access to the resources needed to over come the negative effects of the same high risk reproductive patterns as did the high status groups.

Button battery ingestion: a case report and review of the literature.

Disc batteries represent a distinct type of pediatric foreign body because of their potential for severe morbidity and mortality. We present the case of an 18-month-old boy who ingested a lithium battery and, despite a delay in diagnosis, had a favorable outcome. Button batteries are being used with increasing frequency in a variety of devices including hearing aids, watches and calculators. Most contain a heavy metal such as mercury, and an alkaline electrolyte. Esophageal impaction results in a corrosive esophagitis leading to perforation with the attendant sequelae. Injury may occur by four mechanisms: (1) electrolyte leakage from batteries; (2) alkali produced from external currents; (3) mercury toxicity, and (4) pressure necrosis. Early diagnosis and urgent removal are required for esophageal impaction. More distal sites can be managed conservatively with spontaneous passage occurring in the majority of cases. Prevention should be directed at placing the cells out of reach and child-proofing battery-powered appliances.

American women's sexual behavior and exposure to risk of sexually transmitted diseases.

According to nationally representative data from the 1988 National Survey of Family Growth and the 1988 and 1989 General Social Surveys, 67% of all women aged 15-44 who have ever had intercourse have had more than one partner, 41% have had four or more, 23% six or more and 8% more than 10; 71% have had one or more nonmarital partners. Fewer than 1% of currently married women report having had more than one partner in the previous three months, compared with 13% of formerly married women and 9% of single women who are sexually active. For the most part, women with multiple partners do not have characteristics that set them apart from other women; women in all age-groups and racial or ethnic groups appear equally likely to have multiple partners while unmarried. Fifty-seven percent of women who report multiple partners have never been married, and another one-quarter are currently divorced. Twenty-one percent are teenagers, 46% are aged 20-29 and 24% are in their 30s. Between 27% and 39% of all sexually active women aged 18-44 are estimated to have had direct or indirect contact with more than one sexual partner during the preceding 12 months (including women with only one partner whose partner had multiple partners). About 20% of currently sexually active women reported using the condom, but one in five condom users had not used one at last intercourse. Once social and demographic factors are controlled, condom users with multiple partners are less likely than other condom users to have used a condom at last intercourse.

Parental involvement in minors' abortion decisions.

In a 1991 study based on a nationally representative sample of more than 1,500 unmarried minors having an abortion, 61% of the respondents said that one or both of their parents (usually the mother) knew about the abortion. Only 26% of the respondents said their father knew about the abortion; furthermore, 57% of the mothers who knew about their daughter's pregnancy did not tell her father. In this study, which was conducted in states without parental involvement laws in effect, about 75% of the parents who knew about the pregnancy had been told by the daughter herself, and the great majority supported their daughter's decision to have an abortion. Among the minors whose parents found out without being told by the minor, 18% said their parents were forcing them to have an abortion and 6% reported physical violence, being forced to leave home or damage to their parents' health. Minors who did not tell their parents were disproportionately older (aged 16 or 17), white and employed. The minors' most common reasons for not telling their parents were wanting to preserve their relationship with their parents and wanting to protect the parents from stress and conflict. Of those who did not tell their parents, 30% had experienced violence in their family, feared that violence would occur or were afraid of being forced to leave home. Among minors whose parents were unaware of the pregnancy, all consulted someone other than clinic staff about the abortion; most frequently, they consulted their boyfriend (89%), an adult (52%) or a professional (22%).

PIP: This study examines factors involved in the decision making process of pregnant adolescents to either carry the fetus to term or seek abortion. It specifically investigates minors' initial feelings about their pregnancy and the nature and degree of parental involvement. Results are based on a study of a nationally representative sample of 1519 unmarried minors having an abortion in states without parental involvement laws. 61% of respondents stated that 1 or both parents were aware of the abortion, while only 26% of fathers were informed. 57% of informed mothers did not tell their spouse. 75% of parents who knew about the pregnancy had been told by the daughter and the majority supported the youth's decision. Where parents found out without being told by the daughter, 18% of these girls said that parents were forcing an abortion. Further, 6% reported physical violence, being forced to leave home, or damage to parents' health. Those minor opting to not inform parents were disproportionately older (ages 16-17), white, and employed. These youths generally chose not to inform parents because of the desire to preserve parent-daughter relationships and to protect parents from undue stress and conflict. 30% of those who chose not to tell parents had experienced violence in the family, feared violence would erupt, or were worried about being forced to leave home. Among those minors whose parents were unaware of the pregnancy, all had consulted someone other than clinic staff about the abortion; 89% discussed the matter with their boyfriend, 52% with an adult, and 22% with a professional.

Tracheostomy: a retrospective review of 281 cases.

Although tracheostomy is an ancient technique, disagreement continues concerning the complication rate associated with the procedure. A retrospective review of 281 consecutive tracheostomies was undertaken to evaluate the current risks of tracheostomy in tertiary care teaching hospitals. In addition, we sought to identify factors associated with increased morbidity. The intraoperative and postoperative complications were analyzed regarding indication and comorbidity factors. The majority of cases (56%) were performed on ICU patients. The total complication rate was 24%. A statistically significant increased risk of complications was found both in emergency situations and in ICU patients. Delaying tracheostomy was associated with prolongation of ICU stay. Despite the relatively large number of patients studied, there were no deaths.

Abortion patients in 1994-1995: characteristics and contraceptive use.

Results of a 1994-1995 national survey of 9,985 abortion patients reveal that women who live with a partner outside marriage or have no religious identification are 3.5-4.0 times as likely as women in the general population to have an abortion. Nonwhites, women aged 18-24, Hispanics, separated and never-married women, and those who have an annual income of less than +15,000 or who are enrolled in Medicaid are 1.6-2.2 times as likely to do so; residents of metropolitan counties have a slightly elevated likelihood of abortion. When age is controlled, women who have had a live birth are more likely to have an abortion than are those who have never had children. Catholics are as likely as women in the general population to have an abortion, while Protestants are only 69% as likely and Evangelical or born-again Christians are only 39% as likely. Since 1987, the proportion of abortions obtained by Hispanic women and the abortion rate among Hispanics relative to that for other ethnic groups have increased. The proportion of abortion patients who had been using a contraceptive during the month they became pregnant rose from 51% in 1987 to 58%. Nonuse is most common among women with low education and income, blacks, Hispanics, unemployed women and those who want more children. The proportion of abortion patients whose pregnancy is attributable to condom failure has increased from 15% to 32%, while the proportions reporting the failure of other barrier methods and spermicides have decreased.

PIP: This article reports data collected in a 1994-95 Alan Guttmacher Institute survey of 9985 abortion patients on a broad range of characteristics, including socioeconomic status, religious affiliation, residence, childbearing intention, and contraceptive use prior to pregnancy. The survey found that women who live with a partner outside marriage or have no religious identification are 3.5-4.0 times as likely as women in the general population to have an abortion. Non-Whites, women aged 18-24 years, Hispanics, separated and never-married women, and those who have an annual income of less than $15,000 or who are enrolled in Medicaid are 1.6-2.2 times as likely to have an abortion; residents of metropolitan countries have a slightly elevated likelihood of abortion. When age is controlled, women who have had a live birth are more likely to have an abortion than are those who have never had children. Catholics are as likely as women in the general population to have an abortion, while Protestants are only 69% as likely and Evangelical or born-again Christians are only 39% as likely. The survey further found that since 1987, the proportion of abortions obtained by Hispanic women and the abortion rate among Hispanics relative to that for other ethnic groups have increased. The proportion of abortion patients who had been using a contraceptive during the month they became pregnant increased from 51% in 1987 to 58%. Nonuse of contraception is most common among women with low education and income, Blacks, Hispanics, unemployed women, and those who want more children. The proportion of abortion patients whose pregnancy is attributable to condom failure increased from 15% to 32%, while the proportions reporting the failure of other barrier methods and spermicides have decreased.