Update on the Role of Fungus in Allergy, Asthma, and the Unified Airway.

The united airway refers to the combined upper and lower airways and their interconnected pathophysiologic relationships. Inflammatory airway diseases (chronic rhinosinusitis, asthma, and so forth) have been linked to fungal species through type 2 immune responses. These type 2 immune responses involve the cytokines interleukin (IL)-4, IL-5, IL-13, and a myriad of other inflammatory processes that lead to a spectrum of diseases from allergic bronchopulmonary mycosis to chronic rhinosinusitis. Historically, these diseases have been managed primarily with corticosteroids but recent revelations in the molecular pathophysiology provide opportunities for more diverse treatment options for patients with uncontrolled disease.

Dural sinus narrowing in patients with spontaneous anterior skull base cerebrospinal fluid leak.

Objectives: Current evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak. Methods: A retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test. Results: Analysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In patient with sCSF leaks, there was a significantly higher proportion of patients with DVS narrowing compared with published literature examining this condition in the general population (80% vs. 40%, CI 0.59-0.93, p < .001). Conclusion: The prevalence of DVS narrowing in patients with sCSF leaks is substantial and likely greater than the general population. Moreover, there appears to be narrowing in most patients with sCSF leak. Preoperative radiological evaluation of the DVS using MR venography may be useful in patients with sCSF leaks as DVS stenosis may be an underdiagnosed etiology. Further study is needed to evaluate this. Level of Evidence: IV.

New Developments in Allergic Fungal Rhinosinusitis Pathophysiology and Treatment.

BACKGROUND: Allergic fungal rhinosinusitis (AFRS) is an endotype of chronic rhinosinusitis (CRS) with nasal polyps characterized by eosinophilic mucin laden with fungal hyphae entrapped in expanded sinus cavities with an exaggerated hypersensitivity to fungal elements. The last decade has elucidated fungi-driven inflammatory pathways contributing to the pathophysiology of chronic inflammatory respiratory diseases. In addition, novel therapeutic biologic options have become available for CRS over the last several years. OBJECTIVE: To review the current literature examining AFRS, focusing on recent developments in our understanding of its pathophysiology and implications for treatment options. METHODS: Review article. RESULTS: Fungi-driven respiratory inflammation has been linked to fungal proteinases and toxin activity. In addition, AFRS patients demonstrate a local sinonasal immunodeficiency in antimicrobial peptides and hence limited antifungal activity, along with an exaggerated type 2 inflammatory response, highlighting a possible imbalanced type 1, type 2, and type 3 profile. The elucidation of these dysregulated molecular pathways has highlighted novel potential therapeutic targets. As such, the clinical management of AFRS, which once included surgery and extended courses of oral corticosteroids, is transitioning away from long courses of oral corticosteroids to incorporate novel delivery mechanisms of topical therapeutic targets and biologics for recalcitrant disease. CONCLUSION: AFRS is an endotype of CRS with nasal polyps (CRSwNP) for which the molecular pathways leading to its inflammatory dysfunction are beginning to be illuminated. In addition to affecting treatment options, these understandings may shape necessary changes to diagnostic criteria and the extrapolated effects of environmental changes on AFRS. More critically, a better appreciation of fungi-driven inflammatory pathways may have implications for the understanding of broader CRS inflammation.

Enhanced recovery after cystectomy in patients with preoperative narcotic use.

INTRODUCTION: The aim of this study was to evaluate the outcomes of radical cystectomy with an enhanced recovery after surgery (ERAS) protocol in patients with a history of chronic preoperative narcotic use compared to narcotic-naive patients. METHODS: We identified 553 patients who underwent open radical cystectomy with ERAS. Preoperative narcotic use was identified in 34 patients who were then matched to 68 narcotic-naive patients. Postoperative outcomes, opioid use, and visual analog scale (VAS) pain scores were analyzed and compared. All routes of opioid use were recorded and converted to a morphine equivalent dose (MED). RESULTS: Patients with preoperative narcotic use reported higher median VAS pain scores per day (postoperative day [POD1]: 5.2 vs. 3.9, p=0.003; POD2: 5.1 vs. 3.6, p<0.001; POD3: 4.6 vs. 3.8, p=0.004) and used significantly more opioids (median MED) per day (POD1: 13.2 vs. 10.0, p=0.02; POD2: 11.3 vs. 6.4, p=0.003; POD3: 10.2 vs. 5.0, p=0.005) following surgery. Preoperative narcotic users were noted to have a significantly higher incidence of 90-day re-admissions (41.2% vs. 20.6%, p=0.03). There was no difference in median hospital stay (4 vs. 4 days, p=0.6), 30-or 90-day complications (64.7% vs. 60.3%, p=0.8 and 82.4% vs. 75.0%, p=0.4, respectively) or gastrointestinal complications (29.4% vs. 26.5%, p=0.8), including postoperative ileus (11.8% vs. 20.6%, p=0.2). CONCLUSIONS: Patients with preoperative narcotic exposure report higher pain scores and require more opioid use following radical cystectomy with ERAS and are more likely to be re-admitted within 90 days. However, there was no observed difference in hospital stay or complications.

Effects of thyroplasty implant stiffness on glottal shape and voice acoustics.

OBJECTIVES: Vocal fold (VF) stiffness and geometry are determinant variables in voice production. Type 1 medialization thyroplasty (MT), the primary surgical treatment for glottic insufficiency, changes both of these variables. Understanding the cause and effect relationship between these variables and acoustic output might improve voice outcomes after MT. In this study, the effects of thyroplasty implants with variable stiffness on glottal shape and acoustics were investigated. METHODS: In an ex vivo human larynx phonation model, bilateral MT with implants of four stiffness levels (1386, 21.6, 9.3, and 5.5 kPa) were performed. Resulting acoustics and aerodynamics were measured across multiple airflow levels. A vertical partial hemilaryngectomy was performed and stereoscopic images of the VF medial surface taken to reconstruct its three-dimensional (3D) surface contour. The results were compared across implants. RESULTS: The effects of implant stiffness on acoustics varied by airflow. Softer implants resulted in improved acoustics, as measured by cepstral peak prominence (CPP), at lower airflow levels compared to stiffer implants but this relationship reversed at high airflow levels. Stiffer implants generally required less airflow to generate a given subglottal pressure. Stiffer implants resulted in greater medialized surface area and maximal medialization, but all implants had similar effects on overall VF medial surface contour. CONCLUSION: Softer implants result in less medialization but better acoustics at low airflow rates. Stiffer implants provide better acoustics and more stable pressure-flow relationships at higher airflow rates. This highlights a potential role for patient-specific customized thyroplasty implants of various stiffness levels. LEVEL OF EVIDENCE: NA.

Adult-Type Rhabdomyoma of the Omohyoid Muscle.

Rhabdomyomas are benign tumors composed of mesenchymal tissue and having a histologic appearance similar to skeletal muscle. Extracardiac rhabdomyomas are rare, and the majority of the adult subtype occur in the head and neck (H&N) region. Diagnosis can be challenging due to fine-needle aspiration (FNA) and core needle biopsy being suspicious for sampling error from surrounding muscle or concerning for rhabdomyosarcoma. We present a case of a slowly enlarging left neck mass in the strap musculature of a 45-year-old Hispanic male. Multiple FNA and core biopsies failed to establish a diagnosis, and excisional biopsy was pursued revealing a hypertrophied left inferior belly of the omohyoid muscle. Histological analysis was diagnostic of an adult-type extracardiac rhabdomyoma, with complete surgical excision being the gold standard treatment for these tumors. The patient had an uneventful recovery. Skeletal muscle tumors of the H&N are uncommon, and benign extracardiac rhabdomyoma must be considered in the differential diagnosis to prevent unnecessarily aggressive intervention and appropriate patient counseling before and after surgery.

Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally?

PURPOSE: The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques. METHODS: We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications. RESULTS: We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004). CONCLUSION: This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper. LEVELS OF EVIDENCE: Level III-Treatment study, Retrospective comparative study.

An examination of Eyal & Hurst's (2008) framework for promoting retention in resource-poor settings through locally-relevant training: A case study for the University of Guyana Surgical Training Program.

BACKGROUND: Eyal and Hurst proposed that locally relevant medical education can offset the prevalence of physician "brain drain" in resource-poor regions of the world, and presented a framework of the ethical and pragmatic benefits and concerns posed by these initiatives. The present study explored the framework's utility through a case study of the University of Guyana Diploma in Surgery (UGDS) program. METHODS: The framework's utility was evaluated using a case study design that included review and analysis of documents and semi-structured interviews with graduates, trainees, faculty members, and policy makers associated with the UGDS program. Data were analyzed from constructivist and interpretivist perspectives, and compared against the benefits and concerns described by Eyal and Hurst. RESULTS: The framework is a useful template for capturing the breadth of experience of locally relevant training in the Guyanese setting. However, the results suggest that delineating the framework factors as either beneficial or concerning may constrict its applicability. The case study design also provided specific insights about the UGDS program, which indicate that the Program has promoted the retention of graduates and a sustainable culture of postgraduate medical education in Guyana. CONCLUSION: It is suggested that the framework be modified so as to represent the benefits and concerns of locally relevant training along a continuum of advantage. These approaches may help us understand retention within a resource-poor country, but also within particularly remote areas and public health care systems generally.

Variability of diagnostic approach, surgical technique, and medical management for children with biliary atresia in Canada - Is it time for standardization?

BACKGROUND: The Canadian 4-year native liver survival rate for biliary atresia (BA) after Kasai Portoenterostomy (KP) is 39%. The Canadian Biliary Atresia Registry (CBAR) was used to examine variability of surgical and medical management of BA. METHODS: Gastroenterologists and surgeons in all 14 Canadian pediatric tertiary centers were invited to complete an online survey of their BA management practices. RESULTS: Of gastroenterologists, diagnostic procedures included liver biopsy (92%), HIDA scan (58%), and percutaneous cholangiogram (46%). Surgeons reported Roux-en-Y lengths of 20-50cm with 78% avoiding diathermy at the portal plate; 16% performed laparoscopic exploration, but none laparoscopic KP. Postoperative corticosteroids and antibiotics were used by 24% and 85% of gastroenterologists, respectively, with similar rates for surgeons. At discharge, gastroenterologists prescribed oral antibiotics (80%), and ursodeoxycholic acid (95%), while surgeons reported lower rates (62% and 55%). Considerable variation existed in follow-up monitoring. No center had a standard protocol for evaluating suspected cholangitis. There was a lack of consensus for defining failed KP and referral criteria for transplant evaluation. CONCLUSION: In Canada, treatment of BA is not centralized, and there is variability in diagnostic approaches and management. Collaboration through CBAR will allow for implementation and evaluation of standardized surgical and medical management with a goal to improve outcomes. LEVEL OF EVIDENCE: Survey study. Level IV evidence.

Procedural skills training for Canadian medical students participating in international electives.

BACKGROUND: International medical electives (IMEs) are unique learning opportunities; however, trainees can risk patient safety. Returning medical students often express concern about doing procedures beyond their level of training. The Canadian Federation of Medical Students has developed guidelines for pre-departure training (PDT), which do not address procedural skills. The purpose of this research is to determine which procedural skills to include in future PDT. METHODS: Twenty-six medical students who returned from IMEs completed surveys to assess PDT. Using a Likert scale, we compared procedures performed by students before departing on IME to those performed while abroad. We used a similar scale to assess which procedures students feel ought to be included in future PDT. RESULTS: There was no significant increase in number of procedures performed while on IME. Skills deemed most important to include in future PDT were intravenous line insertion, suturing of lacerations, surgical assisting and post-operative wound care. CONCLUSIONS: Pre-departure training is new and lacks instruction in procedural skills. Over half the students rated several procedural skills such as IV line insertion, suturing, assisting in surgery, post operative wound management and foley catheterization as important assets for future PDT.

The burden of waiting: DALYs accrued from delayed access to pediatric surgery in Kenya and Canada.

BACKGROUND: Disability-adjusted life years (DALYs) have become the standard metric for estimating burden of disease (BoD), but have not yet been applied to delayed access to surgical procedures. This study estimates the DALYs accrued from delayed access to surgical care in two pediatric surgical units in Kenya and Canada. METHODS: Records of operations for 13 congenital health states in a Kenyan and a Canadian hospital were prospectively collected for 2012. DALYs caused by delayed presentation were estimated using disability weights and ideal and actual age at surgery. RESULTS: 1208 first-time procedures in general surgery, neurosurgery, plastic surgery, and urology were included. Delays were longest in general surgery and longer in Kenya than in Canada in all specialties. The longest delays in Kenya were for orchidopexy (72 months) and anorectoplasty (PSARP) (74 months), and in Canada for orchidopexy (40 months). Corresponding total delayed BoD was highest in general surgery and neurosurgery and higher again in Kenya than in Canada (484 cf. 84 DALYs). CONCLUSIONS: Estimating BoD resulting from delayed surgery is feasible and reflects both late presentation and limited access to care. Further exploration of these factors can make delayed DALYs a useful measure of health care coverage and waitlist prioritization.

Surgical training in Guyana: the next generation.

The pioneering surgical training partnership between the Canadian Association of General Surgeons (CAGS) and the University of Guyana has successfully graduated 14 surgeons since 2006. The association has recruited 29 surgeons who have made 75 teaching visits to Guyana, and CAGS involvement has been critical to providing local credibility to the program, organizing the curriculum structure and developing rigorous examinations. The program is now locally sustained, with graduates leading a number of clinical hospital programs. The initial diploma qualification is being reassessed, as other specialties have introduced postgraduate Master of Medicine degree programs. Many graduates are pursuing additional training opportunities overseas, and almost all of those remaining in Guyana have returned to the tertiary centre from the regional hospitals. The program has succeeded in training surgeons and raising the standards of surgical care in Guyana, but broader health system efforts are necessary to retain surgeons in outlying regional hospitals.

Do geography and resources influence the need for colostomy in Hirschsprung's disease and anorectal malformations? A Canadian association of paediatric surgeons: association of paediatric surgeons of Nigeria survey.

BACKGROUND: This survey compared surgical management of Hirschsprung's disease (HD) and anorectal malformations (ARM) in high and low resource settings. MATERIALS AND METHODS: An online survey was sent to 208 members of the Canadian Association of Paediatric Surgeons (CAPS) and the Association of Paediatric Surgeons of Nigeria (APSON). RESULTS: The response rate was 76.8% with 127 complete surveys (APSON 34, CAPS 97). Only 29.5% of APSON surgeons had frozen section available for diagnosis of HD. They were more likely to choose full thickness rectal biopsy (APSON 70.6% vs. CAPS 9.4%, P < 0.05) and do an initial colostomy for HD (APSON 23.5% vs. CAPS 0%, P < 0.05). Experience with trans-anal pull-through for HD was similar in both groups (APSON 76.5%, CAPS 66.7%). CAPS members practising in the United States were more likely to perform a one-stage pull-through for HD during the initial hospitalization (USA 65.4% vs. Canada 28.3%, P < 0.05). The frequency of colostomy in females with vestibular fistula varied widely independent of geography. APSON surgeons were less likely to have enterostomal therapists and patient education resources. CONCLUSIONS: Local resources which vary by geographic location affect the management of HD and ARM including colostomy. Collaboration between CAPS and APSON members could address resource and educational needs to improve patient care.

Outcomes of neonatal patent ductus arteriosus ligation in Canadian neonatal units with and without pediatric cardiac surgery programs.

BACKGROUND/PURPOSE: Preterm infants needing patent ductus arteriosus (PDA) ligation are transferred to a pediatric cardiac center (CC) unless the operation can be done locally by a pediatric surgeon at a non-cardiac center (NCC). We compared infant outcomes after PDA ligation at CC and NCC. METHODS: We analyzed 990 preterm infants who had PDA ligation between 2005 and 2009 using the Canadian Neonatal Network database. In-hospital mortality and major morbidities were compared between CC (n=18) and NCC (n=9). RESULTS: SNAP-II-adjusted mortality rates were similar (CC=8.7% vs NCC=10.7%, P=.32). Significant cranial ultrasound abnormalities (CC=24.1% vs NCC=32.1%, P<.01) and culture-proven sepsis (CC=39.7% vs NCC=54.8%, P<.01) were more frequent in infants treated at NCC. Infants transferred to CC had higher rates of cranial ultrasound abnormalities (transferred 31.6% vs non-transferred 20.4%, P<.01). NSAIDs prior to PDA ligation were used more often at NCC (CC 36.6% vs NCC 75.6%, P<.001). CONCLUSIONS: Mortality rates after PDA ligation were similar at CC and NCC, but cranial ultrasound abnormalities and sepsis rates were higher at NCC. Higher morbidity may be associated with different PDA management strategies, including NSAID use or infant transfer. Further studies are needed to investigate the reasons for these differences in morbidity.

Outcomes following neonatal patent ductus arteriosus ligation done by pediatric surgeons: a retrospective cohort analysis.

PURPOSE: Patent Ductus Arteriosus (PDA) ligation in premature infants is an urgent procedure performed by some but not all pediatric surgeons. Proficiency in PDA ligation is not a requirement of Canadian pediatric surgery training. Our purpose was to determine the outcomes of neonatal PDA ligation done by pediatric surgeons. METHODS: We performed a retrospective review of premature infants who underwent PDA ligation by pediatric surgeons in 3 Canadian centers from 2005 to 2009. Outcomes were compared to published controls. RESULTS: The review identified 98 patients with a mean corrected GA and weight at repair of 29 weeks and 1122 g, respectively. There were no intraoperative deaths. The 30-day and inhospital mortality rates were 1% and 5%. Mortality and morbidity were comparable to the published outcomes. CONCLUSIONS: This study documents that a significant number of preterm infant PDA ligations are safely done by pediatric surgeons. To meet the Canadian needs for this service by pediatric surgeons, proficiency in PDA ligation should be considered important in pediatric surgery training programs.

Exploring the hidden curriculum: a qualitative analysis of clerks' reflections on professionalism in surgical clerkship.

BACKGROUND: Professionalism is an important part of the hidden curriculum that is gaining attention in surgical education. McMaster University, Hamilton, Ontario, Canada, has introduced a small group discussion model using critical incident reports (CIRs) to elicit students' reflections on ethical, communication, and professionalism challenges during surgical clerkship. We described the themes identified by surgical clerks in their CIRs. METHODS: Using thematic analysis, 4 investigators coded 64 CIRs iteratively until conceptual saturation. Rigor and validity were ensured throughout the process. Data were further explored to compare the CIRs of junior and senior clerks. RESULTS: Twenty-seven themes and 4 relationship domains emerged: the clerk's relationship to patients, the health care team, the health care system, and self. Challenges with communication, the consent process, and breaking bad news were most commonly cited. Theme frequencies differed between junior and senior clerks. CONCLUSIONS: Small group discussions of critical incident reports allow surgical clerks to reflect on their developing professional relationships. The themes that have been identified can be used to guide professionalism education and uncover the hidden curriculum.

Evaluating the long-term impact of the Trauma Team Training course in Guyana: an explanatory mixed-methods approach.

BACKGROUND: We evaluated the retention of trauma knowledge and skills after an interprofessional Trauma Team Training (TTT) course in Guyana and explored the course impact on participants. METHODS: A mixed-methods design evaluated knowledge using a multiple-choice quiz test, skills and trauma moulage simulation with checklists, and course impact with qualitative interviews. Participants were evaluated at 3 time points; before, after, and 4 months after TTT. RESULTS: Forty-seven course participants included 20 physicians, 17 nurses, and 10 paramedical providers. All participants had improved multiple-choice quiz test scores after the course and retained knowledge after 4 months, with nonphysicians showing the most improved scores. Trauma skill and moulage scores declined slightly after 4 months, with the greatest decline observed in complex skills. Qualitatively, course participants self-reported impact of the TTT course included improved empowerment, knowledge, teamwork, and patient care. CONCLUSIONS: Interprofessional team-based training led to the retention of trauma knowledge and skills as well as the empowerment of nonphysicians. The decline in performance of some trauma skills indicates the need for a regular trauma update course.

Evaluation of a new pediatric intraosseous needle insertion device for low-resource settings.

BACKGROUND AND PURPOSE: The Near Needle Holder (NNH) (Near Manufacturing, Camrose, Alberta, Canada) is a reusable tool to introduce a standard hollow needle for pediatric intraosseous (IO) infusion. We compared the NNH to the Cook Dieckmann (Cook Critical Care, Bloomington, IN) manual IO needle in a simulation setting. METHODS: Study subjects were 32 physicians, nurses, and medical students participating in a trauma course in Guyana. After watching a training video and practicing under supervision, subjects were observed inserting each device into a pediatric leg model using a randomized crossover design. Outcome measures were time to successful insertion, technical complications, ease of use, and safety of each device. RESULTS: The mean time for IO insertion (32 ± 13 seconds) was similar for both devices (P = .92). Subjects rated the NNH device equivalent in ease of use to the Cook IO needle but slightly lower in perceived safety to the user. CONCLUSIONS: After training, all subjects successfully inserted the NNH IO device in a simulation environment, and most rated it as easy to use and safe. The NNH is a significant advance because IO needles are often not available in emergency departments in developing countries. Further studies are needed to evaluate clinical effectiveness of the NNH.

International surgery: the development of postgraduate surgical training in Guyana.

BACKGROUND: Like many developing countries, Guyana has a severe shortage of surgeons. Rather than rely on overseas training, Guyana developed its own Diploma in Surgery and asked for assistance from the Canadian Association of General Surgeons (CAGS). This paper reviews the initial results of Guyana's first postgraduate training program. METHODS: We assisted with program prerequisites, including needs assessment, proposed curriculum, University of Guyana and Ministry of Health approval, external partnership and funding. We determined the outputs and outcomes of the program after 2 years, and we evaluated the impact of the program through a quantitative/qualitative questionnaire administered to all program participants. RESULTS: Five residents successfully completed the 2-year program and are working in regional hospitals. Another 9 residents are in the training program. Twenty-four modules or short courses have been facilitated, alternating Guyanese with visiting Canadian surgical faculty members coordinated through CAGS. A postgraduate structure, including an Institute for Health Sciences Education and Surgical Postgraduate Education Committee, has been developed at the Georgetown Public Hospital Corporation (GPHC). An examination structure similar to Canada's has been established. Hospital staff morale is greater, surgical care is more standardized and academic opportunities have been enhanced at GPHC. Four regional hospitals have welcomed the new graduates, and surgical services have already improved. Canadian surgeons have a greater understanding of and commitment to surgical development in low-income countries. CONCLUSION: Guyana has proven that, with visiting faculty assistance, it can mount its own postgraduate training suitable to national needs and will provide a career path to encourage its own doctors to remain and serve their country.