A Multidisciplinary Approach to Verbal Communication Interventions for Mechanically Ventilated Adults With a Tracheostomy.

There is developing evidence with regard to the feasibility, utility, and safety of verbal communication interventions with patients with tracheostomy who are invasively ventilated. In the past 2 decades, research efforts have focused on establishing evidence for communication interventions, including introducing an intentional leak into the ventilatory circuit such as with a fenestrated tube, leak speech or ventilator-adjusted leak speech, the use of a one-way valve in-line with the ventilator, and above cuff vocalization. This narrative review describes the benefits of a multi-disciplinary approach, summarizes verbal communication interventions, and provides guidance on the indications, contraindications and considerations for patient selection. Our clinical procedures based on collective clinical experience are shared. A multidisciplinary team approach enables holistic management across acuity, ventilation, airway, communication, and swallowing parameters. This collaborative approach is recommended to maximize the chance of successful opportunities for patients to communicate safely and effectively.

Thoracic and lumbar spine trauma classification systems fail to predict post-traumatic kyphotic deformity.

Background: Post-traumatic kyphosis of the thoracic and lumbar spine can lead to pain and decreased function. MRI has been advocated to assess ligament integrity and risk of kyphosis. Methods: All thoracic and lumbar spine MRI performed for evaluation of trauma over a 3-year period at a single institution were reviewed. Patients were included if there was an MRI showing a vertebral body fracture and follow-up radiographs. Two observers retrospectively reviewed all radiographs, CT and MRI scans, and classified injuries based on the Denis, TLICS, AO and load sharing classification systems. Change in kyphosis between injury and follow-up studies was measured. The initial radiology reports made at time of patient injury were compared to the retrospective interpretations. Results: There were 67 separate injuries in 62 patients. Kyphosis measuring ≥ 10° developed despite an intact PLC in 6/14 nonoperative cases, and 3/7 surgically treated cases; when PLC was partially injured, it developed in 6/10 cases (8 treated nonoperatively, 2 treated operatively. Thirty injuries had complete disruption of PLC by MRI, 24 treated with fusion. Kyphosis ≥ 10° developed in 3/6 treated nonoperatively, and 8/24 treated with fusion. Development of kyphosis was independent of degree of vertebral body comminution. It developed equally in patients with Grade 2 and Grade 3 Denis injuries. It developed in patients with intact PLC when multiple vertebrae were involved and/or there was compressive injury to anterior longitudinal ligament (ALL). There was high interobserver variability in assessment of severity of ligamentous injury on MRI. Conclusions: Classification systems of thoracic and lumbar spine injury and integrity of the PLC failed to predict the risk of development of post-traumatic kyphotic deformity.

Exploring the association between khat use and psychiatric symptoms: a systematic review.

OBJECTIVES: Consumption of the drug khat is high across East Africa and the South-Western Arabian Peninsula despite evidence for its adverse psychiatric effects. This systematic review aims to explore cross-sectional research in the field to determine the strength of the association between khat use and psychiatric symptoms METHODS: Six databases were searched in October 2021-Ovid Medline, Embase, APA PsycINFO, CINAHL, Scopus and Proquest-using the following search terms: "khat" OR "qat" OR "qaad" OR "catha" OR "miraa" OR "mairungi" AND "depression" OR "anxiety" OR "mania" OR "psych*" OR "schiz*" OR "mental" OR "hallucinations" OR "delusions" OR "bipolar". Eligible studies were cross-sectional studies of any population or setting comparing the prevalence of psychiatric symptoms in long term or dependent khat users with non-users. The quality of each study was appraised by the Newcastle-Ottawa scale. A meta-analysis was planned using a random effects model to produce an OR with 95% CIs-using the Mantel-Haenszel method-alongside an I2 statistic to represent heterogeneity. The quality of this meta-analysis was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) scoring system. RESULTS: 35 studies were eligible for inclusion (total participants=31 893), spanning 5 countries (Ethiopia, Somalia, Kenya, Saudi Arabia, UK). Meta-analysis suggests that khat use is associated with an 122% increased prevalence of psychiatric symptoms (OR 2.22, 95% CIs 1.76 to 2.79, p<0.00001, GRADE score: 'very low'). CONCLUSIONS: The high heterogeneity of the meta-analysis is likely due to the wide variation between the studies within the evidence base. To perform a more accurate systematic review, further primary studies are needed with standardised measurements of variables, particularly khat consumption. PROSPERO REGISTRATION NUMBER: CRD42020224510.

Perceptions of Individuals With Chronic Lung Disease on Home Use of Pulse Oximetry.

BACKGROUND: Pulse oximeters are often used at home by patients with chronic respiratory diseases and more recently for remote monitoring of patients with COVID-19. There are no published data outside a supervised telemedicine setting regarding patients' experiences with these devices. Our objective was to explore patients' usage patterns and perceptions of using pulse oximetry at home. METHODS: Patients with chronic respiratory disease who had a pulse oximeter at home were recruited to complete a structured survey. RESULTS: Thirty participants with a range of chronic respiratory diseases (mean age 71 y, 16 females) were recruited. Most participants (83%) used home oxygen therapy. Pulse oximeters were bought online (46.7%), at a pharmacy (40%), at a medical equipment store (6.7%), through a clinic (3.3%), or from an oxygen supplier (3.3%). Use was self-initiated in 56.7% of cases and was based on a health care-related recommendation in 26.7% of cases. Sixty percent of participants used the oximeter daily, with 90% expressing confidence in interpreting their oximeter readings primarily due to education from health care professionals and in-patient experiences. Almost all participants adjusted their activity levels or management based upon oximeter readings. Most participants reported that using a pulse oximeter at home was helpful in judging their physical limitations and provided reassurance and confidence in their disease management. CONCLUSIONS: Subjects appeared confident in their use of home pulse oximetry. Health professionals should identify patients who use pulse oximeters for monitoring and ensure that they are able to interpret readings correctly and, if appropriate, adjust management safely.

CT-guided gastrostomy tube placement-a single center case series.

PURPOSE: The role of computed tomography (CT)-guided gastrostomy tube placement is still evolving. It is a valuable alternative to guide gastrostomy tube placement in a few selected patients, who are not candidates for the established endoscopy- or fluoroscopy-guided gastrostomy tube placement. Our objective was to describe our institutional experience placing gastrostomy tubes using CT guidance and to conduct a review of literature for similar studies to provide the best current evidence on success rates and complications. METHODS: We identified gastrostomy tubes placed under CT guidance at our institution using a comprehensive case log. We also identified studies in the literature, through a systematic search of PubMed. In both the local and literature analyses, we recorded success and complication rates. RESULTS: A total of 31 patients underwent 33 attempted CT-guided gastrostomy tube placements at our institution, with 32 successful procedures yielding a success rate of 97%. The overall rate of successful gastrostomy tube placement using CT-guidance was 94.9% (634/668), as reported in the existing literature. CONCLUSION: CT-guidance is an effective method for gastrostomy tube placement and may play an important role in patients for whom endoscopic or fluoroscopic gastrostomy tube placement is not feasible.

Role of Computed Tomography-guided Biopsies in the Era of Electromagnetic Navigational Bronchoscopy: A Retrospective Study of Factors Predicting Diagnostic Yield in Electromagnetic Navigational Bronchoscopy and Computed Tomography Biopsies.

OBJECTIVES: Over 25% of the high-risk population screened for lung cancer have an abnormal computed tomography (CT) scan. Conventionally, these lesions have been biopsied with CT guidance with a high diagnostic yield. Electromagnetic navigational bronchoscopy (ENB) with transbronchial biopsy has emerged as a technology that improves the diagnostic sensitivity of conventional bronchoscopic biopsy. It has been used to biopsy lung lesions, due to the low risk of pneumothorax. It is, however, a new technology that is expensive and its role in the diagnosis of the solitary pulmonary nodule (SPN) is yet to be determined. The purpose of this study was to evaluate the diagnostic yield of CT-guided biopsy (CTB) following non-diagnostic ENB biopsy and identify characteristics of the lesion that predicts a low diagnostic yield with ENB, to ensure appropriate use of ENB in the evaluation of SPN. MATERIALS AND METHODS: One hundred and thirty-five lung lesions were biopsied with ENB from January 2017 to August 2019. Biopsies were considered diagnostic if pathology confirmed malignancy or inflammation in the appropriate clinical and imaging setting. We evaluated lesions for several characteristics including size, lobe, and central/peripheral distribution. The diagnostic yield of CTB in patients who failed ENB biopsies was also evaluated. Logistic regression was used to identify factors likely to predict a non-diagnostic ENB biopsy. RESULT: Overall, ENB biopsies were performed in 135 patients with solitary lung lesions. ENB biopsies were diagnostic in 52% (70/135) of the patients. In 23 patients with solitary lung lesions, CTBs were performed following a non-diagnostic ENB biopsy. The CTBs were diagnostic in 87% of the patients (20/23). ENB biopsies of lesions <21.5 mm were non-diagnostic in 71% of cases (42/59); 14 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% of them were diagnostic (12/14). ENB biopsies of lesions in the lower lobes were non- diagnostic in 59% of cases (35/59); 12 of these patients with non-diagnostic ENB biopsies had CTBs, and 83% were diagnostic (10/12). ENB biopsies of lesions in the outer 2/3 were non-diagnostic in 57% of cases (50/87); 21 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% were diagnostic (18/21). CONCLUSION: CTBs have a high diagnostic yield even following non-diagnostic ENB biopsies. Lesions <21.5 mm, in the outer 2/3 of the lung, and in the lower lung have the lowest likelihood of a diagnostic yield with ENB biopsies. Although CTBs have a slightly higher pneumothorax rate, these lesions would be more successfully diagnosed with CTB as opposed to ENB biopsy, in the process expediting the diagnosis and saving valuable medical resources.

Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective.

Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.

Lumbosacral plexiform neurofibroma: a rare case in an adult without neurofibromatosis type I.

Plexiform neurofibromas are an uncommon variant of neurofibromas that are described as being essentially pathognomonic of neurofibromatosis type 1 (NF1). Plexiform neurofibromas in the absence of NF1 are extremely rare. We present the case of a 38-year-old woman with a large multilobulated lumbosacral mass extending into the pelvis and proximal thigh. Histopathology of a CT-guided biopsy of the mass revealed it to be a neurofibroma. The imaging findings were consistent with a plexiform subtype. Further imaging and clinical workup showed that the patient had no other identifiable neurofibromas and did not meet criteria for the diagnosis of NF1.

Transcatheter embolization of anticoagulation related pancreatic pseudocyst hemorrhage: A case report.

Hemorrhage associated with anticoagulation therapy is a feared and relatively common complication. Few cases have been documented of spontaneous pancreatic hemorrhage related to anticoagulation, and fewer yet of ruptured pancreatic pseudocyst secondary to anticoagulation-related bleeding. We describe the case of a 74-year-old female with massive intra- and extraperitoneal hemorrhage secondary to an anticoagulation-related ruptured hemorrhagic pancreatic pseudocyst that was treated successfully with coil embolization. An inferior vena cava filter was placed at the same time as the embolization procedure, as she had a contraindication for anticoagulation in the setting of submassive pulmonary emboli and lower extremity deep venous thrombosis.