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.

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.

Abdominal Organ Transplant Center Tobacco Use Policies Vary by Organ Program Type.

BACKGROUND: Smoking is a modifiable risk factor for cardiovascular disease, malignancy, and surgical complications. Transplant center practices toward smokers vary widely and evoke the classic tension between the ethical principles of justice and utility. We sought to assess current smoking policy variation in U.S. kidney, liver, and pancreas transplant centers. METHODS: An online survey was sent to program directors of all United Network for Organ Sharing-approved solid abdominal organ transplant programs regarding their policies toward prior and current tobacco use. RESULTS: Responses were received from 26% of kidney, 31% of liver, and 37% of pancreas transplant centers. Across organ programs, virtually all centers (97% to 100%) reported transplantations for former smokers, whereas 59% of kidney, 62% of liver, and 33% of pancreas programs reported transplantations for current smokers. Organ programs reported similar rates of having smoking cessation programs (74% to 77%) and performing serum cotinine testing (31% to 38%). Smoking was an absolute contraindication to transplantation at 38% of kidney, 15% of liver, and 50% of pancreas programs. Programs with absolute contraindication policies were less likely to perform transplantations in current smokers and more likely to check serum cotinine levels, but no more likely to have smoking cessation programs. CONCLUSIONS: There is variation in tobacco use policies among abdominal organ transplant programs and centers. Balancing equity and justice when deciding which patients to waitlist requires an individualized approach to the tobacco-using patient, consideration of organ-specific factors, tobacco-related disease burden, and overall patient health. Such multifaceted assessments might be favorable to inflexible tobacco use policies.

Effects of isoflurane and ethanol administration on c-Fos immunoreactivity in mice.

Noninvasive functional imaging holds great promise for the future of translational research, due to the ability to directly compare between preclinical and clinical models of psychiatric disorders. Despite this potential, concerns have been raised regarding the necessity to anesthetize rodent and monkey subjects during these procedures, because anesthetics may alter neuronal activity. For example, in studies on drugs of abuse and alcohol, it is not clear to what extent anesthesia can interfere with drug-induced neural activity. Therefore, the current study investigated whole-brain c-Fos activation following isoflurane anesthesia as well as ethanol-induced activation of c-Fos in anesthetized mice. In the first experiment, we examined effects of one or three sessions of gaseous isoflurane on c-Fos activation across the brain in male C57BL/6J mice. Isoflurane administration led to c-Fos activation in several areas, including the piriform cortex and lateral septum. Lower or similar levels of activation in these areas were detected after three sessions of isoflurane, suggesting that multiple exposures may eliminate some of the enhanced neuronal activation caused by acute isoflurane. In the second experiment, we investigated the ability of ethanol injection (1.5 or 2.5g/kgi.p.) to induce c-Fos activation under anesthesia. Following three sessions of isoflurane, 1.5g/kg of ethanol induced c-Fos in the central nucleus of amygdala and the centrally-projecting Edinger-Westphal nucleus (EWcp). This induction was lower after 2.5g/kg of ethanol. These results demonstrate that ethanol-induced neural activation can be detected in the presence of isoflurane anesthesia. They also suggest, that while habituation to isoflurane helps reduce neuronal activation, interaction between effects of anesthesia and alcohol can occur. Studies using fMRI imaging could benefit from using habituated animals and dose-response analyses.

Dissection of corticotropin-releasing factor system involvement in locomotor sensitivity to methamphetamine.

Sensitivity to the euphoric and locomotor-activating effects of drugs of abuse may contribute to risk for excessive use and addiction. Repeated administration of psychostimulants such as methamphetamine (MA) can result in neuroadaptive consequences that manifest behaviorally as a progressive escalation of locomotor activation, termed psychomotor sensitization. The present studies addressed the involvement of specific components of the corticotropin-releasing factor (CRF) system in locomotor activation and psychomotor sensitization induced by MA (1, 2 mg/kg) by utilizing pharmacological approaches, as well as a series of genetic knockout (KO) mice, each deficient for a single component of the CRF system: CRF-R1, CRF-R2, CRF, or the CRF-related peptide Urocortin 1 (Ucn1). CRF-R1 KO mice did not differ from wild-type mice in sensitization to MA, and pharmacological blockade of CRF-R1 with CP-154,526 (15, 30 mg/kg) in DBA/2J mice did not selectively attenuate either the acquisition or expression of MA-induced sensitization. Deletion of either of the endogenous ligands of CRF-R1 (CRF, Ucn1) either enhanced or had no effect on MA-induced sensitization, providing further evidence against a role for CRF-R1 signaling. Interestingly, deletion of CRF-R2 attenuated MA-induced locomotor activation, elucidating a novel contribution of the CRF system to MA sensitivity, and suggesting the participation of the endogenous urocortin peptides Ucn2 and Ucn3. Immunohistochemistry for Fos was used to visualize neural activation underlying CRF-R2-dependent sensitivity to MA, identifying the basolateral and central nuclei of the amygdala as neural substrates involved in this response. Our results support further examination of CRF-R2 involvement in neural processes associated with MA addiction.

Differential sensitivity of the perioculomotor urocortin-containing neurons to ethanol, psychostimulants and stress in mice and rats.

The perioculomotor urocortin-containing population of neurons (pIIIu: otherwise known as the non-preganglionic Edinger-Westphal nucleus) is sensitive to alcohol and is involved in the regulation of alcohol intake. A recent study indicated that this brain region is also sensitive to psychostimulants. Since pIIIu has been shown to respond to stress, we investigated how psychostimulant-induced pIIIu activation compares to stress- and ethanol-induced activation, and whether it is independent from a generalized stress response. Several experiments were performed to test how the pIIIu responds to psychostimulants by quantifying the number of Fos immunoreactive nuclei after acute i.p. injections of saline, 10-30 mg/kg cocaine, 5 mg/kg methamphetamine, 5 mg/kg amphetamine, 2.5 g/kg ethanol, 2 h of restraint stress, 10 min of swim stress, or six applications of mild foot shock in male C57BL/6 J mice. We also compared Fos immunoreactivity in pIIIu after acute (20 mg/kg cocaine) and repeated cocaine exposure (7 days of 20 mg/kg cocaine) injections in male C57BL/6 J mice in order to investigate the potential habituation of this response. Finally, we quantified the number of Fos immunoreactive nuclei in pIIIu after administration of saline, 2.5 g/kg ethanol, 20 mg/kg cocaine, or 2 h of restraint stress in male Sprague-Dawley rats. We found that exposure to psychostimulants and ethanol induced significantly higher Fos levels in pIIIu compared to stress in mice. Furthermore, repeated cocaine injections did not decrease Fos immunoreactivity as would be expected if this response were due to stress. In rats, exposure to ethanol, psychostimulant and restraint stress all induced pIIIu Fos immunoreactivity compared to saline-injected controls. In both mice and rats, ethanol- and cocaine-induced Fos immunoreactivity occurred exclusively in urocortin 1-positive, but not in tyrosine hydroxylase-positive, cells. These results provide evidence that the pIIIu Fos-response to psychostimulants is independent of a generalized stress in mice, but not rats. They additionally show that the pIIIu response to stress differs significantly between species.

New landmarks improve the positioning of the left Broncho-Cath double-lumen tube-comparison with the classic technique.

PURPOSE: To compare a new technique (NT) for positioning the left modified Broncho-Cath double-lumen tube (LM- DLT) by fibreoptic bronchoscopy (FOB) to the classic technique (CT). METHODS: Sixty-one adult patients undergoing elective thoracic surgery with LM-DLT were randomly assigned to the NT or to the CT group. For the NT, the endoscopist confirms the left mainstem endobronchial intubation. The proximal edge of the blue bronchial cuff should not be visualized at the carina. Then, through the left bronchial lumen, by transparency across the wall of the tube, the position of the tube is adjusted so that the carina lies midway between the black radiopaque line and the top of the bronchial cuff. After this, the orifice of the left upper lobe (LUL) bronchus should be clearly seen. For the CT, the endoscopist uses the technique described by Benumof and Slinger. After lateral positioning of the patient, the LM-DLT was repositioned if the top of the endobronchial cuff was above the carina or when the LUL bronchus was obstructed. RESULTS: The incidence of proximal repositioning was significantly less in the NT compared to the CT (16% vs 43%, P=0.007). CONCLUSION: Using this new technique, the LM-DLT is inserted deeper in the left mainstem bronchus. This new landmark augments the range of movement that can be tolerated without requiring repositioning of the LM-DLT. This NT to position and to assess LM-DLT, by transparency across the wall of the tube with FOB, is better adapted to the LM-DLT and its recent modifications.

Postoperative pain management and recovery after remifentanil-based anaesthesia with isoflurane or propofol for major abdominal surgery. Remifentanil Study Group.

We have assessed if recovery times after morphine or fentanyl, given before terminating remifentanil anaesthesia with isoflurane or propofol, are compromised. We studied patients undergoing elective, major abdominal surgery, allocated randomly to receive remifentanil and isoflurane (n = 277) or remifentanil and propofol (n = 274) anaesthesia. Twenty-five minutes before the end of surgery, patients received fentanyl 0.15 mg or morphine 15 mg in a randomized, double-blind manner followed by a second dose (fentanyl 0.05 mg, morphine 7 mg) for moderate or severe pain in recovery. Recovery was rapid and at an Aldrete score > or = 9 (median 12-15 min), 42-51% of patients reported none or mild pain. However, 26-35% of patients reported severe pain and > 90% required a second dose of opioid within 21-27 min after anaesthesia.

Nebulized surfactant for experimentally induced otitis media with effusion.

Eustachian tube dysfunction frequently results in clinical evidence of otitis media with effusion (OME). Surface active substances, surfactants, are hypothesized to play a role in normal eustachian tube function. Recent work in a rodent model has demonstrated improved eustachian tube function with topical application of surfactants to the middle ear. A novel, noninvasive, and clinically practical method of delivering surfactant to the eustachian tube was studied in a gerbil model of OME. Otitis media with effusion was experimentally induced in 20 gerbils by transtympanic inoculation of heat-killed Streptococcus pneumoniae. This represents a well established model for creating a serous effusion in the gerbil that significantly increases eustachian tube opening pressure. Effusion developed in 27 of 40 ears (67.5%) after inoculation. An inhaled nebulized surfactant was used to treat the animals with microscopically confirmed OME in one or both ears. The treatment period was 5 days. Eustachian tube opening studies were performed on both affected and nonaffected animals. Successful eustachian tube opening pressures were obtained in 30 of 36 ears (83.3%). The mean opening pressure for ears without effusion (healthy ears) was 42.8 mmHg. The mean opening pressure for ears with effusion in animals treated with nebulized surfactant was 41.4 mmHg. The difference between these mean values was not statistically significant (t = 0.32; p > 0.50). This pilot study suggests that inhaled nebulized surfactant may be efficacious in treating eustachian tube dysfunction when manifested in disorders such as OME.

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.

Hypopharyngeal carcinoma.

Hypopharyngeal carcinomas are considered indolent, silent tumors. These tumors dictate a high index of suspension. They can present with a myriad of symptoms and clinical complaints. The silent nature of these tumors unfortunately causes a high number of patients to present with advanced disease. A multimodality approach is often used. Although our approach to this disease has advanced, the overall mortality remains high at 5 years.

Passive smoking.

One in three adults in the United States smokes. Smokers inhale one quarter of the smoke from cigarettes. But 75% of cigarette smoke is released into the environment. Nonsmokers are exposed to this environmental tobacco smoke and are at risk for disease. A growing body of literature supports the association of passive, involuntary, or secondhand smoking with human pathology. This discussion examines the makeup of environmental tobacco smoke and its role in causing human disease with a review of the literature relating environmental tobacco smoke to head and neck pathology.

Hemangiomas of the head and neck.

The physician's ability to diagnose different types of vascular anomalies, predict their clinical course, and choose the correct mode of treatment has been hampered by the inconsistent, overlapping nomenclature found in the bulk of medical literature. This article discusses how to differentiate hemangiomas from other vascular anomalies. In addition, it reviews complications associated with hemangiomas and various treatment options for hemangiomas including observation, corticosteroids, interferon, surgical resection, laser surgery, and radiotherapy.