TRACHEOSTOMY COMPLICATIONS AND THEIR MANAGEMENT

The word tracheostomy derived from two greek words meaning ‘I cut the trachea’ has been known for about 3500 yrs. The process has evolved over the years and has undergone revolutionary changes in the methodology, instrumentation and indications. Although tracheostomy is now commonly used the complication rate remains high. In our series it was 48% which is comparable with other series. The purpose of this paper is to discuss the complications of tracheostomy with special attention to their management and prevention.KEY WORDS: Complications, Tracheostomy     

Obesity: Risk Factor for Increased Resource Utilization at Bidirectional Glenn

Background

Underweight infants with single‐ventricle cardiac physiology have been shown to have increased morbidity, mortality, and resource utilization. The purpose of this study was to determine whether patients who were overweight, as defined by weight‐for‐length z score >90th percentile, were similarly at risk for increased resource utilization, as defined by mechanical ventilation hours (VHs) and intensive care unit length of stay (ICU LOS).

Methods

We evaluated resource utilization for 109 patients from our institution who underwent bidirectional Glenn surgery from January 2010 to June 2015 and met prespecified inclusion criteria. Patients were divided into 3 groups: underweight (z score, <5th percentile), normal weight (z score, 5th–90th percentile), and overweight (z score, >90th percentile).

Results

ICU LOS was longer in the overweight group (median, 18.5 days) when compared with the under‐ and normal‐weight groups (median LOS, 11 and 9 days, respectively) but did not reach statistical significance. VHs were also increased in the overweight group (median, 72 hours) when compared with the underweight (median, 27 hours) and normal weight (median, 25 hours) groups. This increase in VHs was statistically significant (P = .03).

Conclusions

This study suggests that patients with single‐ventricle physiology who are overweight at the time of their bidirectional Glenn surgery may be at risk for increased resource utilization as compared with those who meet or fail to meet their caloric recommendations. These findings represent an underappreciated risk factor in this already‐vulnerable patient population, providing potential opportunity for intervention and improved outcomes.     

Disaggregating Canadian immigrant smoking behaviour by country of birth

As of the 2006 census, nearly one fifth of Canada's population was foreign-born. With such a sizeable and fast-growing immigrant population, research in immigrant health in Canada is increasingly important, including research on the smoking behaviours of Canada's immigrants. Research has shown that immigrants are significantly less likely to smoke than non-immigrants, yet differences by immigrant origins have yet to be fully explored. This paper explores smoking prevalence and cessation amongst immigrants in Canada disaggregated by country of birth. Additionally, it examines the impact of neighbourhood level effects on smoking cessation to determine if residential location has an impact on the likelihood of quitting. Results reveal important heterogeneities previously unseen in studies employing aggregate data. While immigrants in general were less likely to smoke than non-immigrants, and are also more likely to quit than non-immigrants, considerable variation exists between immigrant groups defined by origin region or country. Asian immigrants were the least likely to smoke but exhibited the greatest variation between countries of origin. Vietnamese men were found to be the most likely immigrant group to smoke and among the least likely to quit. While neighbourhood disadvantage was negatively associated with quitting smoking, it is not as important as individual socioeconomic characteristics in explaining variations in smoking cessation. The research illustrates the need for disaggregated data to account for the diversity of Canada's immigrant population.     

Centrilobular emphysema: CT-pathologic correlation

Over a 5-year period, 25 patients who had undergone chest computed tomography (CT) died and were autopsied. Their lungs were fixed in the inflated state and were assessed for the presence and severity of centrilobular emphysema (CLE). Three radiologists independently evaluated the CT scans for nonperipheral low-attenuation areas, peripheral low-attenuation areas, pulmonary vascular pruning, pulmonary vascular distortion, and pulmonary density gradient. The CT criterion that best correlated with the presence and severity of CLE was the nonperipheral low-attenuation area. With this CT criterion, lung destruction was correctly identified in 13 of 15 cases. The absence of this criterion resulted in correct identification of eight of ten normal lungs. These preliminary data suggest that CLE can be reliably identified and quantified with current CT scanners.     

Prostatic evaluation by transrectal sonography with histopathologic correlation: the echopenic appearance of early carcinoma

Fifty-two patients with clinical stage A and B carcinomas of the prostate were imaged by ultrasound (US) transrectally with a 5-MHz linear array transducer and transabdominally with a 3-MHz sector scanner prior to radical prostatectomy. The fresh specimens of 44 prostate glands were scanned in a water bath with a 5-MHz linear array transducer in multiple planes. In all cases, histopathologic correlation was obtained. Prostatic carcinoma presented as an echopenic lesion in 54% of the specimens, as a slightly hypoechoic area in 22%, and could not be identified in 24% because of its isoechoic characteristics. In contrast to many previous reports, no instance of echogenic cancer was observed.     

Peptic ulcer and gastric carcinoma: diagnosis with biphasic radiography compared with fiberoptic endoscopy

The diagnostic value of biphasic radiographic examination of the stomach and duodenum was compared with that of fiberoptic endoscopy in a prospective, blinded study of 385 patients with dyspepsia. This investigation was directed at gastric malignancies and peptic ulcers. Methodologically there is no absolute standard for a study of this kind because histologic examination is useful for detection of cancer but inadequate for ulcers. As an alternative, kappa indexes and the sensitivity and specificity, as derived by Hui and Walter, were calculated and compared. For the detection of gastric carcinoma, radiographic and endoscopic findings had almost perfect agreement beyond chance. For gastric ulcers, radiography and endoscopy had substantial agreement, which became perfect if small ulcers (less than 5 mm) were excluded. For duodenal ulcers, radiography had a lower sensitivity than endoscopy; this disagreement disappeared if small ulcers were excluded. Both methods have equal merit; choice of the initial diagnostic procedure will therefore depend on cost, discomfort to the patient, and risk of complications.     

Recovery of autologous erythrocytes in transfused patients

A microcapillary method utilizing phthalate esters or an ultracentrifuge method are both capable of separating autologous from homologous erythrocytes in polytransfused patients. The microcapillary technique which is readily adaptable to blood bank laboratories provides a previously unavailable method for defining blood group antigen typings in transfused patients. Such typings are of vital importance in the laboratory evaluation of transfused patients with multiple or weak blood group antibodies.     

Total radical trapping antioxidant potential (TRAP) and exercise

The relationship between physical activity, physical fitness and total radical trapping antioxidant potential (TRAP) was examined in the Northern Ireland Health and Activity Survey. This was a cross-sectional population study (n = 1600) using a two-stage probability sample of the population. TRAP was calculated using the sum of the individual serum antioxidant concentrations (urate, protein thiols, ascorbate, alpha tocopherol and bilirubin) multiplied by their respective stoichiometric values. Physical fitness was determined by estimation of VO2max by extrapolation from submaximal oxygen uptake, and physical activity was recorded by computer-assisted interview. Mean serum TRAP concentrations were significantly higher in males (653 +/- 8.2 mumol/l, mean +/- SEM) compared to females (564 +/- 8.0 mumol/l) (p < 0.0001). Both male and female smokers had significantly lower TRAP values than non-smokers (males p < 0.0001, females p = 0.02). In females, there was a positive relationship of TRAP with age (p < 0.001) and body mass index (p < 0.001) but a negative relationship with physical fitness (p < 0.05). The known beneficial effects of exercise and activity do not appear to be directly mediated through increased antioxidant status.      

Falling status epilepticus mortality rates in England and Wales: 2001–2013?

Status epilepticus (SE) is associated with significant mortality and accounts for ~10% of epilepsy‐related deaths. Epilepsy and SE mortality data from 2001 to 2013, in addition to annual age group populations for England and Wales, were obtained from the Office of National Statistics website ( www.ons.gov.uk ). Age‐adjusted mortality rates for epilepsy and SE with 95% confidence intervals (CIs) were calculated using the European Standard Population. Trends in mortality rates for both epilepsy and SE were investigated using the Spearman coefficient. The crude mean epilepsy mortality rate per 100,000 person‐years between 2001 and 2013 was 1.87 (95% CI 1.83–1.91), with a corresponding SE mortality rate of 0.14 (95% CI 0.13–0.15). The mean age‐adjusted epilepsy mortality rate per 100,000 person years was 3.24 (95% CI 3.12–3.35), with a corresponding SE mortality rate of 0.24 (95% CI 0.21–0.27). All epilepsy deaths significantly decreased from 2001 to 2013 (Spearman's ρ ?0.733, p = 0.004); this decrease was predominantly due to a decrease in SE deaths (Spearman's ρ ?0.917, p < 0.001). In summary, our finding supports the hypothesis that the policy of early and aggressive treatment of SE may be improving the prognosis of this condition in England and Wales.