Timing the First Pediatric Tracheostomy Tube Change: A Randomized Controlled Trial.

OBJECTIVE: The first pediatric tracheostomy tube change often occurs within 7 days after placement; however, the optimal timing is not known. The primary objective was to determine the rate of adverse events of an early tube change. Secondary objectives compared rates of significant peristomal wounds, sedation requirements, and expedited intensive care discharges. STUDY DESIGN: Prospective randomized controlled trial. SETTING: Tertiary children's hospital between October 2018 and April 2020. METHODS: A randomized controlled trial enrolled children under 24 months to early (day 4) or late (day 7) first tracheostomy tube changes. RESULTS: Sixteen children were enrolled with 10 randomized to an early change. Median age was 5.9 months (interquartile range, 5.4-8.3), and 86.7% required tracheostomy for respiratory failure. All tracheostomy tube changes were performed without adverse events. There were no accidental decannulations. Significant wounds developed in 10% of children with early tracheostomy tube changes and 83.3% of children with late tracheostomy tube changes (odds ratio [OR], 45.0; 95% CI, 2.3-885.6; P = .01). This significant reduction in wound complications justified concluding trial enrollment. Hours of dexmedetomidine sedation (P = .11) and boluses of midazolam during the first 7 days (P = .08) were no different between groups. After the first change, 90% of the early group were discharged from intensive care within 5 weeks compared to 33.3% of patients in the late group (OR, 18.0; 95% CI, 1.2-260.9; P = .03). CONCLUSION: The first tracheostomy tube change in children can occur without adverse events on day 4, resulting in fewer significant peristomal wounds and earlier intensive care discharge.

Interdisciplinary Crisis Resource Management Training: How Do Otolaryngology Residents Compare? A Survey Study.

OBJECTIVE: Emergent medical crises, such as acute airway obstruction, are often managed by interdisciplinary teams. However, resident training in crisis resource management traditionally occurs in silos. Our objective was to compare the current state of interdisciplinary crisis resource management (IDCRM) training of otolaryngology residents with other disciplines. METHODS: A survey study examining (1) the frequency with which residents are involved in interdisciplinary crises, (2) the current state of interdisciplinary training, and (3) the desired training was conducted targeting Canadian residents in the following disciplines: otolaryngology, anesthesiology, emergency medicine, general surgery, obstetrics and gynecology, internal medicine, pediatric emergency medicine, and pediatric/neonatal intensive care. RESULTS: A total of 474 surveys were completed (response rate, 12%). On average, residents were involved in 13 interdisciplinary crises per year. Only 8% of otolaryngology residents had access to IDCRM training, as opposed to 66% of anesthesiology residents. Otolaryngology residents reported receiving an average of 0.3 hours per year of interdisciplinary training, as compared with 5.4 hours per year for pediatric emergency medicine residents. Ninety-six percent of residents desired more IDCRM training, with 95% reporting a preference for simulation-based training. DISCUSSION: Residents reported participating in crises managed by interdisciplinary teams. There is strong interest in IDCRM and crisis resource management training; however, it is not uniformly available across Canadian residency programs. Despite their pivotal role in managing critical emergencies such as acute airway obstruction, otolaryngology residents received the least training. IMPLICATION: IDCRM should be explicitly taught since it reflects reality and may positively affect patient outcomes.

Safety of transtympanic application of probiotics in a chinchilla animal model.

BACKGROUND: Chronic suppurative otitis media can be recalcitrant and difficult to treat, particularly with the increasing occurrence of antibiotic resistance. Lactobacillus plantarum is a probiotic that has been shown to decrease S. aureus and P. aeruginosa growth in wounds, making it a good candidate for the treatment of chronic suppurative otitis media. However, before it can be applied in the ear, its ototoxicity potential must be evaluated. METHODS: A prospective controlled trial was conducted in a chinchilla animal model at the Animal care research facilities of the Montreal Children's Hospital Research Institute to determine whether Lactobacillus plantarum is ototoxic when applied transtympanically. Ten chinchillas each had one ear randomly assigned to receive 109 CFU/mL of Lactobacillus plantarum solution, while the contralateral ear received saline. Auditory brainstem responses were measured bilaterally at 8, 20, 25 kHz before, at 7-10 days after application, and at 28 days after application of probiotic or saline. Facial nerve and vestibular function were assessed clinically. RESULTS: There were no statistically significant differences in hearing thresholds between control and experimental ears at 28 days after application. A difference of 11 dB was noted in the 25 kHz range at day 7-10, but resolved by day 28. No animals receiving probiotics developed vestibular nerve dysfunction. There was no histologic evidence of auditory hair cell damaged evidenced by scanning electron microscopy. CONCLUSION: Our study suggests that a single application of Lactobacillus plantarum at 109 CFU/mL does not cause ototoxicity in a chinchilla animal model. These preliminary safety evaluations and the pathogen inhibitory effects of L. plantarum demonstrated by previous studies present this probiotic as a candidate of interest for further investigation.

Error Detection-Based Model to Assess Educational Outcomes in Crisis Resource Management Training: A Pilot Study.

Otolaryngology-head and neck surgery (OTL-HNS) residents face a variety of difficult, high-stress situations, which may occur early in their training. Since these events occur infrequently, simulation-based learning has become an important part of residents' training and is already well established in fields such as anesthesia and emergency medicine. In the domain of OTL-HNS, it is gradually gaining in popularity. Crisis Resource Management (CRM), a program adapted from the aviation industry, aims to improve outcomes of crisis situations by attempting to mitigate human errors. Some examples of CRM principles include cultivating situational awareness; promoting proper use of available resources; and improving rapid decision making, particularly in high-acuity, low-frequency clinical situations. Our pilot project sought to integrate CRM principles into an airway simulation course for OTL-HNS residents, but most important, it evaluated whether learning objectives were met, through use of a novel error identification model.

Can floseal™ be applied safely during otologic surgery? Assessment of ototoxicity in a chinchilla animal model.

BACKGROUND: In otologic surgery good visualization is paramount, and patients with bleeding diatheses or who need to be anti-coagulated can present a significant challenge. Here, we determine whether Floseal™, a hemostatic matrix, is ototoxic in a validated animal model. METHODS: Nine chinchillas housed in the animal care facilities of the Montreal Children's Hospital Research Institute were used for the study. After a myringotomy incision was made in each tympanic membrane, baseline auditory brainstem response measurements were performed at 8, 20, and 25 kHz. In each animal one ear was randomized to receive Floseal™ to the middle ear cavity, whereas the other ear served as the control and received 0.9% sodium chloride. Outcome measures included early (day 7) and late (day 30) auditory brainstem response, clinical evidence of facial nerve or vestibular disturbance and histological evidence of ototoxity. RESULTS: There was no significant hearing threshold shift on auditory brainstem response across all tested frequencies for both experimental and control ear. No animals receiving Floseal™ developed facial or vestibular nerve dysfunction and there was no histological evidence of ototoxicity. CONCLUSION: Based on the preliminary ototoxicity assessment on nine chinchillas, transtympanic Floseal™ does not appear to be ototoxic. More studies are warranted to assess the safety and applicability of the product in humans.

Seasonal Difference in Postthyroidectomy Hypocalcemia: A Montreal-Based Study.

OBJECTIVE: Hypocalcemia following thyroidectomy often prolongs hospital stay and is potentially life-threatening. The objective of this study is to determine whether the season when thyroidectomy is performed is associated with postoperative hypocalcemia. STUDY DESIGN: Retrospective case series of patients undergoing thyroid surgery from 2009 to 2015. SETTING: Tertiary care academic institution in Montreal, Canada. SUBJECTS AND METHODS: A consecutive sample of 823 patients undergoing thyroidectomy by a single high-volume otolaryngologist for a suspected or confirmed thyroid malignancy. Patient demographics, procedure type, calcium and vitamin D supplementation, and seasonal rate of hypocalcemia postthyroidectomy were calculated and compared. RESULTS: Average seasonal rates of postthyroidectomy hypocalcemia in the winter, spring, summer, and autumn were, respectively, 8.3% (8 of 216), 7.3% (12 of 165), 1.5% (3 of 201), and 3.5% (8 of 228; P < .005). Patients operated in the winter were 5.6 times more likely to develop hypocalcemia as compared with those in the summer (P < .01; 95% confidence interval: 1.7-18.7). In a multiple regression analysis factoring in season when surgery was performed, procedure type, and preoperative vitamin D/calcium supplementation, surgery occurring in the winter predicted a hypocalcemia event (correlation coefficient [SE]: 0.72 [0.024], P = .026; 0.006 [0.025], P = .81; 0.004 [0.019], P = .82, respectively). CONCLUSION: In this study, patients undergoing thyroidectomy in the winter months were more likely to develop postoperative hypocalcemia when compared with those operated in the summer. Further studies are needed to understand the role of vitamin D in the observed seasonal difference in hypocalcemia rates.

Vitamin D deficiency and the risk of hypocalcemia following total thyroidectomy.

OBJECTIVE: To determine whether patients with vitamin D deficiency (VDD) are at increased risk for hypocalcemia following total thyroidectomy. METHODS: A retrospective study of 246 consecutive patients undergoing thyroidectomy at a McGill University teaching hospital was conducted. Patients who had subtotal thyroidectomy or concomitant parathyroidectomy or whose laboratory tests were incomplete for analysis were excluded, as were pediatric patients. The remaining 139 patients had preoperative 25-hydroxyvitamin D [25(OH)D], corrected calcium, and parathyroid hormone (PTH) measured. Postoperatively, PTH and serum calcium were measured to assess for hypocalcemia. Low vitamin D (LVD) was defined as 25(OH)D ≤ 70 nmol/L (≤ 28 ng/mL), which includes vitamin D insufficiency, 25(OH)D > 35 nmol/L (> 14 ng/mL) but ≤ 70 nmol/L (≤ 28 ng/mL), and VDD, 25(OH)D ≤ 35 nmol/L (≤ 14 ng/mL). Adequate vitamin D (AVD) corresponded to levels > 35 nmol/L (> 14 ng/mL), whereas optimal vitamin D (OVD) levels corresponded to levels > 70 nmol/L (> 28 ng/mL). RESULTS: The rate of postthyroidectomy hypocalcemia in OVD patients was 10.4% (8 of 77) compared to 3.2% (2 of 62) in LVD patients (odds ratio  =  0.29, p  =  .10). There was no hypocalcemia in the 9 VDD patients, meaning that all hypocalcemic episodes occurred in patients with AVD (7.7%; 10 of 130). The mean preoperative PTH levels for LVD patients was 4.65 pmol/L (43 ng/L) compared to 4.18 pmol/L (38.9 ng/L) for OVD patients (p  =  .073). CONCLUSIONS: In this series, preoperative LVD did not predict early postthyroidectomy hypocalcemia. On the contrary, it showed a trend toward protective effect. Adaptive changes in the parathyroid glands, such as hypertrophy, hyperplasia, or the ability to secrete more hormone secondary to prolonged VDD, may contribute to this phenomenon. A large prospective study is needed to better understand the relationship between preoperative vitamin D levels and postoperative hypocalcemia.

DRB1*0401-restricted human T cell clone specific for the major proinsulin73-90 epitope expresses a down-regulatory T helper 2 phenotype.

Recently, we have identified proinsulin (P-Ins)(73-90) as an immunodominant T cell epitope of HLA-DRB1*0401 (DR4) subjects with beta-islet cell autoimmunity and of HLA-DR4/CD4 double-transgenic mice immunized with human P-Ins. We have compared the fine specificities of one human CD4 T cell clone and two mouse T cell hybridoma clones recognizing this epitope, and, although these three clones all recognized the same core region (LALEGSLQK), there were major differences in how they interacted with the peptide (p)/HLA complex, reflecting the fact that human P-Ins is a foreign antigen in the mouse and an autoantigen in the type 1 diabetes patient. The human T cell clone was forkhead transcription factor 3 (Foxp3)-positive, a marker for regulatory T cell lineages, and secreted predominantly IL-5, IL-10, and low levels of IFNgamma in response to P-Ins(73-90). This finding is compatible with the previously detected regulatory cytokine pattern in subjects with beta-cell autoimmunity. However, added N- or C-terminal amino acids drastically changed HLA and tetramer binding capacity as well as T cell reactivity and the cytokine phenotype of the P-Ins(73-90)-specific human CD4 T cell clone, suggesting a potential for this P-Ins epitope as a target for therapeutic intervention in HLA-DR4-positive humans with beta-islet cell autoimmunity or recent-onset type 1 diabetes.