Youth cannabis use in Canada post-legalization: service providers' perceptions, practices, and recommendations.

BACKGROUND: In 2018, Canada legalized recreational cannabis use with the purpose of protecting youth and restricting access. However, concerns have been raised that this objective has not been met as rates of cannabis use among youth aged 16-24 have not declined. Youth cannabis use is associated with various adverse effects including psychosis, anxiety, depression, suicidality, respiratory distress, cannabinoid hyperemesis syndrome, and intoxications. Service providers play a crucial role in addressing youth cannabis use. This study aimed to understand Ontario service providers' perceptions, practices, and recommendations on youth cannabis use. METHODS: This mixed method study included a survey and two focus groups. The survey was distributed to mental health service providers serving youth aged 16-24 across Ontario who were given the option to participate in a focus group. The survey included closed and open-ended questions regarding perceptions, practices, and recommendations, while the focus groups explored these categories in greater depth. Descriptive statistics were used to analyze close-ended questions and interpretative content analysis was applied for open-ended questions. Focus group data were analyzed using thematic analysis. RESULTS: The survey was completed by 160 service providers and 12 participated in two focus groups. Regarding perceptions, 60% of survey participants agreed with legalization, 26% had a strong understanding of medical versus recreational cannabis, 84% believed that cannabis has physical and mental health risks, and 49% perceived stigmatization. Less than half of the survey participants reported screening or assessing cannabis use, 16% stated they are highly familiar with treating cannabis use, and 67% reported that they rarely work with families. Subthemes identified in the focus groups under perceptions included normalization and stigmatization, harms for youth, and stigma, racism, and discrimination. Subthemes under practice included cannabis not being the primary focus, challenges with screening, assessment, and intervention, and referral to specialized services. Both the survey and focus group participants recommended increasing public education, enhancing service provider training, improving regulation and policies, reducing stigma and minimization, improving service access, and providing more culturally responsive services. CONCLUSION: Youth cannabis use in Canada remains a significant public health concern, necessitating a more comprehensive plan to protect Ontario youth and reduce associated harms.

Penn State equation versus indirect calorimetry for nutritional assessment in patients with traumatic brain injury.

BACKGROUND: Nutritional assessment can be challenging in patients with traumatic brain injury (TBI), and indirect calorimetry may be a more suitable method than predictive equations. We compared the Penn State equation versus the gold standard of indirect calorimetry for the nutritional assessment of patients with TBI, and quantified the difference between nutritional requirements and actual patient intake. METHODS: This single-centre, prospective cohort study included patients with moderate (Glasgow Coma Scale score 9-12) and severe (Glasgow Coma Scale score 3-8) TBI admitted to the Montreal General Hospital intensive care unit (ICU) between June 2018 and March 2019. Penn State equation estimates and indirect calorimetry measurements were collected, and actual intake was drawn from medical records. We compared the 2 assessment methods using a Spearman correlation coefficient. RESULTS: Twenty-three patients with TBI (moderate in 7 and severe in 16) were included in the study. Overall, there was a moderate positive correlation between the Penn State equation estimate and indirect calorimetry readings (correlation coefficient 0.457, p = 0.03); however, the correlation was weaker in severe TBI (correlation coefficient 0.174, p = 0.5) than in moderate TBI (correlation coefficient 0.929, p = 0.003). When compared to indirect calorimetry assessment, patients received 5.4% (p = 0.5) of required intake on the first day and 43.9% (p = 0.8) of required daily intake throughout their ICU stay. CONCLUSION: Patients with moderate or severe TBI in the ICU received less than 50% of their nutritional requirements. The difference between the Penn State equation and indirect calorimetry assessments was most noticeable for patients with severe TBI, which indicates that indirect calorimetry may be a more suitable tool for assessment of nutritional needs in this population.

Adenosine deaminase cutoff value when diagnosing tuberculous pleurisy in patients aged 40 years and older.

INTRODUCTION: Tuberculous pleurisy (TBP) is one of the most common manifestations of extra-pulmonary tuberculosis. In patients aged ≥40 years, a closed needle pleural biopsy is recommended with an adenosine deaminase (ADA) level of 40-70 U/L. We aim to investigate whether the cutoff value of ADA and the cancer ratio in patients with TBP aged ≥40 years is different and determine the effects of both compounded biomarkers on diagnosing TBP. MATERIALS AND METHODS: Between 2009 and 2016, the ADA levels were measured in pleural effusions from patients who were admitted to the Chest disease clinic. RESULTS: Of the 196 patients included in the study, 104 were aged ≥40 years. A significant relationship was found between the serum LDH/pleural ADA (sLDH/pADA) ratio and ADA levels in patients aged >40 years (OR: 0.935 and OR: 1.085, respectively). The model using an ADA value ≥30 and an sLDH/pADA ratio <16 yielded a sensitivity of 94.25% (95% CI, 87.1-98.10) in all patients and 69.23% (95% CI, 54.9-81.28) in patients aged >40 years. CONCLUSION: ADA and the sLDH/pADA ratio are simple, cost-efficient, and obtain fast results and, therefore, are the preferred methods in TBP diagnosis. The diagnosis rate in the present study was 91% using ADA levels in combination with the sLDH/pADA ratio, both of which can be obtained only through thoracentesis.

Promotion of Regular Oesophageal Motility to Prevent Regurgitation and Enhance Nutrition Intake in Long-Stay ICU Patients. A Multicenter, Phase II, Sham-Controlled, Randomized Trial: The PROPEL Study.

OBJECTIVES: To evaluate the effect of esophageal stimulation on nutritional adequacy in critically ill patients at risk for enteral feeding intolerance. DESIGN: A multicenter randomized sham-controlled clinical trial. SETTING: Twelve ICUs in Canada. PATIENTS: We included mechanically ventilated ICU patients who were given moderate-to-high doses of opioids and expected to remain alive and ventilated for an additional 48 hours and who were receiving enteral nutrition or expected to start imminently. INTERVENTIONS: Patients were randomly assigned 1:1 to esophageal stimulation via an esophageal stimulating catheter (E-Motion Tube; E-Motion Medical, Tel Aviv, Israel) or sham treatment. All patients were fed via these catheters using a standardized feeding protocol. MEASUREMENTS AND MAIN RESULTS: The co-primary outcomes were proportion of caloric and protein prescription received enterally over the initial 7 days following randomization. Among 159 patients randomized, the modified intention-to-treat analysis included 155 patients: 73 patients in the active treatment group and 82 in the sham treatment group. Over the 7-day study period, the percent of prescribed caloric intake (± SE) received by the enteral route was 64% ± 2 in the active group and 65% ± 2 in sham patients for calories (difference, -1; 95% CI, -8 to 6; p = 0.74). For protein, it was 57% ± 3 in the active group and 60% ± 3 in the sham group (difference, -3; 95% CI, -10 to 3; p = 0.30). Compared to the sham group, there were more serious adverse events reported in the active treatment group (13 vs 6; p = 0.053). Clinically important arrhythmias were detected by Holter monitoring in 36 out of 70 (51%) in the active group versus 22 out of 76 (29%) in the sham group (p = 0.006). CONCLUSIONS: Esophageal stimulation via a special feeding catheter did not improve nutritional adequacy and was associated with increase risk of harm in critically ill patients.

Carotid intima-media thickness in chronic obstructive pulmonary disease and survival: A multicenter prospective study.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is associated with increased cardiovascular morbidity and mortality. Carotid intima-media thickness (CIMT) is a noninvasive method assessing atherosclerosis. OBJECTIVE: It was aimed to determine relationship and survival between COPD and CIMT. METHODS: CIMT was measured using Doppler ultrasound (USG) in 668 stable COPD patients at 24 centers. Patients were followed-up for 2 years. RESULTS: There were 610 patients who completed the study. There were 200 patients CIMT with <0.78 mm (group 1), and 410 with CIMT ≥ 0.78 mm (group 2). There was a significant difference at the parameters of age, gender, smoking load, biomass exposure, GOLD groups and degree of airway obstruction (FEV1) between groups 1 and 2. Our results revealed positive correlations between mean CIMT and age, smoking load (pack-years), biomass exposure (years), exacerbation rate (last year), duration of hypertension (years) and cholesterol level; negative correlations between CIMT and FEV1 (P < 0.05). According to logistic regression model, compared with group A, risk of CIMT increase was 2.2-fold in group B, 9.7-fold in group C and 4.4-fold in group D (P < 0.05). Risk of CIMT increase was also related with cholesterol level (P < 0.05). Compared with infrequent exacerbation, it was 2.8-fold in the patients with frequent exacerbation (P < 0.05). The mean survival time was slightly higher in group 1, but not significant (23.9 vs 21.8 months) (P > 0.05). CONCLUSION: This study is the first regarding CIMT with combined GOLD assessment groups. It has revealed important findings supporting the increase in atherosclerosis risk in COPD patients. We recommend Doppler USG of the carotid artery in COPD patients at severe stages.

Management of penetrating intraperitoneal colon injuries: A meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: The management of penetrating colon injuries in civilians has evolved over the last four decades. The objectives of this meta-analysis are to evaluate the current treatment regimens available for penetrating colon injuries and assess the role of anastomosis in damage control surgery to develop a practice management guideline for surgeons. METHODS: Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines section of EAST conducted a systematic review using MEDLINE and EMBASE articles from 1980 through 2017. We developed three relevant problem, intervention, comparison, and outcome (PICO) questions regarding penetrating colon injuries. Outcomes of interest included mortality and infectious abdominal complications. RESULTS: Thirty-seven studies were identified for analysis, of which 16 met criteria for quantitative meta-analysis and included 705 patients considered low-risk in six prospective randomized studies. Seven hundred thirty-eight patients in 10 studies undergoing damage control laparotomy and repair or resection and anastomosis (R&A) were included in a separate meta-analysis. Meta-analysis of high-risk patients undergoing repair or R&A was not feasible due to inadequate data. CONCLUSIONS: In adult civilian patients sustaining penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention we recommend that colon repair or R&A be performed rather than routine colostomy. In adult high-risk civilian trauma patients sustaining penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than routine colostomy. In adult civilian trauma patients sustaining penetrating colon injury who had damage control laparotomy, we conditionally recommend that routine colostomy not be performed; instead, definitive repair or delayed R&A or anastomosis at initial operation should be performed rather than routine colostomy. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.

Characteristics of Active Tuberculosis Patients Requiring Intensive Care Monitoring and Factors Affecting Mortality.

BACKGROUND: One to three percent of cases of acute tuberculosis (TB) require monitoring in the intensive care unit (ICU). The purpose of this study is to establish and determine the mortality rate and discuss the causes of high mortality in these cases, and to evaluate the clinical and laboratory findings of TB patients admitted to the pulmonary ICU. METHODS: The data of patients admitted to the ICU of Yedikule Chest Diseases and Chest Surgery Education and Research Hospital due to active TB were retrospectively evaluated. Demographic characteristics, medical history, and clinical and laboratory findings were evaluated. RESULTS: Thirty-five TB patients (27 males) with a median age of 47 years were included, of whom 20 died within 30 days (57%). The Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores were significantly higher, and albumin and PaO2/FIO2 levels were significantly lower, and shock, multiple organ failure, the need for invasive mechanical ventilation and drug resistance were more common in the patients who died. The mortality risk was 7.58 times higher in the patients requiring invasive mechanical ventilation. The SOFA score alone was a significant risk factor affecting survival. CONCLUSION: The survival rate is low in cases of tuberculosis treated in an ICU. The predictors of mortality include the requirement of invasive mechanical ventilation and multiple organ failure. Another factor specific to TB patients is the presence of drug resistance, which should be taken seriously in countries where there is a high incidence of the disease. Finding new variables that can be established with new prospective studies may help to decrease the high mortality rate.

Characteristics of Active Tuberculosis Patients Requiring Intensive Care Monitoring and Factors Affecting Mortality / 결핵및호흡기질환

BACKGROUND: One to three percent of cases of acute tuberculosis (TB) require monitoring in the intensive care unit (ICU). The purpose of this study is to establish and determine the mortality rate and discuss the causes of high mortality in these cases, and to evaluate the clinical and laboratory findings of TB patients admitted to the pulmonary ICU. METHODS: The data of patients admitted to the ICU of Yedikule Chest Diseases and Chest Surgery Education and Research Hospital due to active TB were retrospectively evaluated. Demographic characteristics, medical history, and clinical and laboratory findings were evaluated. RESULTS: Thirty-five TB patients (27 males) with a median age of 47 years were included, of whom 20 died within 30 days (57%). The Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores were significantly higher, and albumin and PaO2/FIO2 levels were significantly lower, and shock, multiple organ failure, the need for invasive mechanical ventilation and drug resistance were more common in the patients who died. The mortality risk was 7.58 times higher in the patients requiring invasive mechanical ventilation. The SOFA score alone was a significant risk factor affecting survival. CONCLUSION: The survival rate is low in cases of tuberculosis treated in an ICU. The predictors of mortality include the requirement of invasive mechanical ventilation and multiple organ failure. Another factor specific to TB patients is the presence of drug resistance, which should be taken seriously in countries where there is a high incidence of the disease. Finding new variables that can be established with new prospective studies may help to decrease the high mortality rate.

Promoting quality of care in disaster response: A survey of core surgical competencies.

BACKGROUND: Recent humanitarian crises have led to a call for professionalization of the humanitarian field, but core competencies for the delivery of surgical care have yet to be established. The objective of this study was to survey surgeons with experience in disaster response to identify surgical competencies required to be effective in these settings. METHODS: An online survey elucidating demographic information, scope of practice, and previous experience in global health and disaster response was transmitted to surgeons from a variety of surgical societies and nongovernmental organizations. Participants were provided with a list of 111 operative procedures and were asked to identify those deemed essential to the toolset of a frontline surgeon in disaster response via a Likert scale. Responses from personnel with experience in disaster response were contrasted with those from nonexperienced participants. RESULTS: A total of 147 surgeons completed the survey. Participants held citizenship in 22 countries, were licensed in 30 countries, and practiced in >20 countries. Most respondents (56%) had previous experience in humanitarian response. The majority agreed or strongly agreed that formal training (54%), past humanitarian response (94%), and past global health experiences (80%) provided adequate preparation. The most commonly deemed important procedures included control of intraabdominal hemorrhage (99%), abdominal packing for trauma (99%), and wound debridement (99%). Procedures deemed important by experienced personnel spanned multiple specialties. CONCLUSION: This study addressed specifically surgical competencies in disaster response. We provide a list of operative procedures that should set the stage for further structured education programs.

Preparing for Euro 2012: developing a hazard risk assessment.

INTRODUCTION: Risk assessment is a vital step in the disaster-preparedness continuum as it is the foundation of subsequent phases, including mitigation, response, and recovery. HYPOTHESIS/PROBLEM: To develop a risk assessment tool geared specifically towards the Union of European Football Associations (UEFA) Euro 2012. METHODS: In partnership with the Donetsk National Medical University, Donetsk Research and Development Institute of Traumatology and Orthopedics, Donetsk Regional Public Health Administration, and the Ministry of Emergency of Ukraine, a table-based tool was created, which, based on historical evidence, identifies relevant potential threats, evaluates their impacts and likelihoods on graded scales based on previous available data, identifies potential mitigating shortcomings, and recommends further mitigation measures. RESULTS: This risk assessment tool has been applied in the vulnerability-assessment-phase of the UEFA Euro 2012. Twenty-three sub-types of potential hazards were identified and analyzed. Ten specific hazards were recognized as likely to very likely to occur, including natural disasters, bombing and blast events, road traffic collisions, and disorderly conduct. Preventative measures, such as increased stadium security and zero tolerance for impaired driving, were recommended. Mitigating factors were suggested, including clear, incident-specific preparedness plans and enhanced inter-agency communication. CONCLUSION: This hazard risk assessment tool is a simple aid in vulnerability assessment, essential for disaster preparedness and response, and may be applied broadly to future international events.

Predictors of mortality and morbidity for acute care surgery patients.

BACKGROUND: As the implementation of exclusive acute care surgery (ACS) services thrives, prognostication for mortality and morbidity will be important to complement clinical management of these diverse and complex patients. Our objective is to investigate prognostic risk factors from patient level characteristics and clinical presentation to predict outcomes including mortality, postoperative complications, intensive care unit (ICU) admission and prolonged duration of hospital stay. METHODS: Retrospective review of all emergency general surgery admissions over a 1-year period at a large teaching hospital was conducted. Factors collected included history of present illness, physical exam and laboratory parameters at presentation. Univariate analysis was performed to examine the relationship between each variable and our outcomes with chi-square for categorical variables and the Wilcoxon rank-sum statistic for continuous variables. Multivariate analysis was performed using backward stepwise logistic regression to evaluate for independent predictors. RESULTS: A total of 527 ACS admissions were identified with 8.1% requiring ICU stay and an overall crude mortality rate of 3.04%. Operative management was required in 258 patients with 22% having postoperative complications. Use of anti-coagulants, systolic blood pressure <90, hypothermia and leukopenia were independent predictors of in-hospital mortality. Leukopenia, smoking and tachycardia at presentation were also prognostic for the development of postoperative complications. For ICU admission, use of anti-coagulants, leukopenia, leukocytosis and tachypnea at presentation were all independent predictive factors. A prolonged length of stay was associated with increasing age, higher American Society of Anesthesiologists class, tachycardia and presence of complications on multivariate analysis. CONCLUSIONS: Factors present at initial presentation can be used to predict morbidity and mortality in ACS patients.

A systematic review of synthetic and biologic materials for abdominal wall reinforcement in contaminated fields.

BACKGROUND: Guidelines recommend the use of bioprosthetics for abdominal wall reinforcement in contaminated fields, but the evidence supporting the use of biologic over synthetic non-absorbable prosthetics for this indication is poor. Therefore, the objective was to perform a systematic review of outcomes after synthetic non-absorbable and biologic prosthetics for ventral hernia repair or prophylaxis in contaminated fields. METHODS: The systematic literature search identified all articles published up to 2013 that reported outcomes after abdominal wall reinforcement using synthetic non-absorbable or biologic prosthetics in contaminated fields. Studies were included if they included at least 10 cases (excluding inguinal and parastomal hernias). Quality assessment was performed using the MINORS instrument. The main outcomes measures were the incidence of wound infection and hernia at follow-up. Weighted pooled proportions were calculated using a random effects model. RESULTS: A total of 32 studies met the inclusion criteria and were included for synthesis. Mean sample size was 41.4 (range 10-190), and duration of follow-up was >1 year in 72 % of studies. Overall quality was low (mean 6.2, range 1-12). Pooled wound infection rates were 31.6 % (95 % CI 14.5-48.7) with biologic and 6.4 % (95 % CI 3.4-9.4) with synthetic non-absorbable prosthetics in clean-contaminated cases, with similar hernia rates. In contaminated and/or dirty fields, wound infection rates were similar, but pooled hernia rates were 27.2 % (95 % CI 9.5-44.9) with biologic and 3.2 % (95 % CI 0.0-11.0) with synthetic non-absorbable. Other outcomes were comparable. CONCLUSIONS: The available evidence is limited, but does not support the superiority of biologic over synthetic non-absorbable prosthetics in contaminated fields.

Neutrophil-lymphocyte ratio may be superior to C-reactive protein for predicting the occurrence of postmenopausal osteoporosis.

OBJECTIVE: Recent studies revealed that inflammation plays a critical role in bone remodeling and the pathogenesis of postmenopausal osteoporosis, a major health concern. Neutrophil-lymphocyte ratio (NLR) is a cost-effective marker of inflammation that has been linked with several diseases. This study aimed to compare NLR and C-reactive protein (CRP) levels in osteopenic, osteoporotic, and control subjects and to assess the correlation between NLR levels, CRP, and bone mineral density (BMD) in postmenopausal women. METHODS: In this cross-sectional study, the relationship between NLR, CRP, and BMD in 438 women was investigated using uni- and multivariate analyses. BMD (g/cm²) was measured by dual-energy X-ray absorptiometry (DEXA) at the lumbar spine and femur. Complete blood count (CBC), CRP, glucose/lipid metabolism, and established risk factors were determined. RESULTS: In the osteoporotic group, NLR and CRP levels were found to be elevated as compared to the osteopenic and control groups (NLR: 4.68 ± 0.72, 3.17 ± 0.43, 2.01 ± 0.54; CRP: 12.3 ± 4.1, 4.1 ± 2.7, 3.2 ± 2.1, respectively). A negative correlation was present between NLR and the lumbar spine (L2-L4) and femoral neck BMD after adjusting other risk factors. There was no correlation between CRP levels and BMD after adjusting other risk factors. NLR was significantly associated with L2-L4 BMD (ß = -0.653, p<0.001) and femoral neck BMD (ß = -0.178, p<0.001), but CRP level had no association with BMD in a multivariate model. CONCLUSIONS: Our data indicate that NLR may be a better predictor than CRP for occurrence of osteoporosis in postmenopausal women.

Mean platelet volume in patients with fibromyalgia.

Fibromyalgia is a syndrome characterised by chronic widespread pain at multiple tender points, as well as joint stiffness and systemic symptoms. The aetiology and pathogenesis of fibromyalgia still remain unclear, although many contributory factors have been suggested. The presence of some common features between fibromyalgia and cardiovascular risk factors (e.g. depression and sleep disturbance) led to question of whether there is there a relationship between fibromyalgia and cardiovascular disease and/or atherosclerosis. Mean platelet volume, which is a determinant of platelet activation, is a newly emerging independent risk factor for cardiovascular disease.The present study was designed to evaluate levels of mean platelet volume in patients with fibromyalgia; the study population consisted of 283 individuals with this syndrome, who were compared with 72 healthy controls. Erythrocyte sedimentation rate, C-reactive protein, white blood cell count, platelet count and mean platelet volume levels were retrospectively recorded via the computerised patient database. The levels of mean platelet volume were significantly higher in the fibromyalgia group than in the control group (8.09 ± 0.84 fl and 7.73 ± 0.65 fl, respectively, p < 0.001). There were no statistical differences between groups with regard to platelet count and other parameters. These results suggest that an early atherosclerosis marker, mean platelet volume, is elevated in patients with fibromyalgia. This indicates increased platelet activation and therefore a higher risk of future cardiovascular disease.

Anticancer use of nanoparticles as nucleic acid carriers.

Advances in nanotechnology opened up new horizons in the field of cancer research. Nanoparticles made of various organic and inorganic materials and with different optical, magnetic and physical characteristics have the potential to revolutionize the way we diagnose, treat and follow-up cancers. Importantly, designs that might allow tumor-specific targeting and lesser side effects may be produced. Nanoparticles may be tailored to carry conventional chemotherapeutics or new generation organic drugs. Currently, most of the drugs that are commonly used, are small chemical molecules targeting disease-related enzymes. Recent progress in RNA interference technologies showed that, even proteins that are considered to be "undruggable" by small chemical molecules, might be targeted by small RNAs for the purpose of curing diseases, including cancer. In fact, small RNAs such as siRNAs, shRNAs and miRNAs can drastically change cellular levels of almost any given disease-associated protein or protein group, resulting in a therapeutic effect. Gene therapy attempts were failing mainly due to delivery viral vector-related side effects. Biocompatible, non-toxic and efficient nanoparticle carriers raise new hopes for the gene therapy of cancer. In this review article, we discuss new advances in nucleic acid and especially RNA carrier nanoparticles, and summarize recent progress about their use in cancer therapy.

Early tracheal stenosis causing extubation failure and prolonged ventilator dependency.

Postintubation stenosis is the most frequent cause of benign tracheal stenosis and may cause reintubation and delay in weaning of intensive care unit patients. This case study describes typical patients with tracheal stenosis and the management of these patients. Five patients requiring reintubation and mechanical ventilation due to early intubation-related stenosis are discussed. Stridor developed in three cases after extubation. In these cases, bronchoscopy revealed tracheal stenosis. Dilatation and silicone stent placement were performed using rigid bronchoscopy. The other two patients were on ventilators when they were admitted to the intensive care unit and their stenoses were also treated by rigid bronchoscopy. Hypercapnia and hypoxia resolved after intervention in three cases. Of the remaining two patients, one had the tracheostomy closed and in the other patient ventilation was stopped but the tracheostomy was maintained. Tracheal stenosis developing in the subglottic region after extubation, especially after exposure to cuff pressure, may lead to reintubation. A tracheostomy may hinder the diagnosis of progressive stenosis and may lead to unnecessary maintenance of ventilator treatment. Early intubation-related tracheal stenosis should therefore be considered in cases of weaning or extubation failure and prompt appropriate investigation and treatment.

The role of feed regulating peptides on weight loss in patients with pulmonary tuberculosis.

PURPOSE: Malnutrition is a prominent feature of tuberculosis (TB). The aim of our study was to explore the function of plasma regulatory proteins in pulmonary TB and to investigate the relationship between these parameters and loss of body weight. METHODS: Plasma levels of fasting insulin, leptin, ghrelin, adiponectin and orexin-A were measured in 23 pulmonary TB patients, 39 patients with pulmonary sarcoidosis, 22 patients with different diffuse interstitial lung diseases and 21 healthy patients serving as controls. RESULT: Plasma leptin (p<0.001) and orexin-A (p<0.01) levels were significantly decreased in TB patients compared with those of the other study subjects. TB patients also had higher levels of plasma ghrelin compared with those of the other study subjects, while sarcoidosis patients had higher plasma adiponectin levels than the other study subjects. Glucose levels were similar in all groups, yet, insulin and Homeostasis Model of Assessment-Insulin Resistance (HOMA-IR) levels were significantly higher in the TB group compared to the other study groups. There was no correlation between leptin, ghrelin, adiponectin and orexin-A and other parameters. CONCLUSIONS: These data suggest that leptin and orexin-A levels have effects on weight loss in patients with pulmonary tuberculosis. Particularly, leptin may play a role in the early immune response to pulmonary TB and prolonged inflammation may further suppress leptin production. Measurement of HOMA-IR can indeed be used as a marker for the risk of activated TB. Further clinical studies are needed to better understand the role of feed regulating proteins in pulmonary tuberculosis.

Training future surgeons for management roles: the resident-surgeon-manager conference.

OBJECTIVE To demonstrate that senior surgical residents would benefit from focused training by professionals with management expertise. Although managerial skills are recognized as necessary for the successful establishment of a surgical practice, they are not often emphasized in traditional surgical residency curricula. DESIGN Senior residents from all surgical subspecialties at McGill University were invited to participate in a 1-day management seminar. Precourse questionnaires aimed at evaluating the residents' perceptions of their own managerial knowledge and preparedness were circulated. The seminar was then given in the form of interactive lectures and case-based discussions. The questionnaires were readministered at the end of the course, along with an evaluation form. Precourse and postcourse data were compared using the Freeman-Halton extension of the Fisher exact test to determine statistical significance (P < .05). SETTING McGill University Health Centre in Montreal, Quebec, Canada. PARTICIPANTS A total of 43 senior residents. RESULTS Before the course, the majority of residents (27 of 43 [63%]) thought that management instruction only happened "from time to time" in their respective programs. After the course, 15 residents (35%) felt that management topics were "well addressed," and 19 (44%) felt that management topics have been "very well addressed" (P < .01). Residents noted a significant improvement in their ability to perform the following skills after the course: giving feedback, delegating duties, coping with stress, effective learning, and effective teaching. On the ensemble of all managerial skills combined, 26 residents (60%) rated their performance as "good" or "excellent" after the course vs only 21 (49%) before the course (P = .02). Residents also noted a statistically significant improvement in their ability to perform the managerial duties necessary for the establishment of a surgical practice. CONCLUSIONS Surgical residency programs have the responsibility of preparing their residents for leadership and managerial roles in their future careers. An annual seminar serves as a starting point that could be built on for incorporating formal management training in surgical residency curricula.