Subarachnoid-Pleural Fistula: Applied Anatomy of the Thoracic Spinal Nerve Root

Subarachnoid-pleural fistula (SPF) is a rare complication of chest or spine operations for neoplastic disease. Concomitant dural and parietal pleural defects permit flow of cerebrospinal fluid into the pleural cavity or intrapleural air into the subarachnoid space. Dural injury recognized intraoperatively permits immediate repair, but unnoticed damage may cause postoperative pleural effusion, intracranial hypotension, meningitis, or pneumocephalus. We review two cases of SPF following surgical intervention for chest wall metastatic disease to motivate a detailed review of the anatomy of neural, osseous, and ligamentous structures at the intervertebral foramen. We further provide recommendations for avoidance and detection of such complication

IgG4 inhibits peanut-induced basophil and mast cell activation in peanut-tolerant children sensitized to peanut major allergens

BackgroundMost children with detectable peanut-specific IgE (P-sIgE) are not allergic to peanut. We addressed 2 non–mutually exclusive hypotheses for the discrepancy between allergy and sensitization: (1) differences in P-sIgE levels between children with peanut allergy (PA) and peanut-sensitized but tolerant (PS) children and (2) the presence of an IgE inhibitor, such as peanut-specific IgG4 (P-sIgG4), in PS patients.MethodsTwo hundred twenty-eight children (108 patients with PA, 77 PS patients, and 43 nonsensitized nonallergic subjects) were studied. Levels of specific IgE and IgG4 to peanut and its components were determined. IgE-stripped basophils or a mast cell line were used in passive sensitization activation and inhibition assays. Plasma of PS subjects and patients submitted to peanut oral immunotherapy (POIT) were depleted of IgG4 and retested in inhibition assays.ResultsBasophils and mast cells sensitized with plasma from patients with PA but not PS patients showed dose-dependent activation in response to peanut. Levels of sIgE to peanut and its components could only partially explain differences in clinical reactivity between patients with PA and PS patients. P-sIgG4 levels (P = .023) and P-sIgG4/P-sIgE (P < .001), Ara h 1–sIgG4/Ara h 1–sIgE (P = .050), Ara h 2–sIgG4/Ara h 2–sIgE (P = .004), and Ara h 3–sIgG4/Ara h 3–sIgE (P = .016) ratios were greater in PS children compared with those in children with PA. Peanut-induced activation was inhibited in the presence of plasma from PS children with detectable P-sIgG4 levels and POIT but not from nonsensitized nonallergic children. Depletion of IgG4 from plasma of children with PS (and POIT) sensitized to Ara h 1 to Ara h 3 partially restored peanut-induced mast cell activation (P = .007).ConclusionsDifferences in sIgE levels and allergen specificity could not justify the clinical phenotype in all children with PA and PS children. Blocking IgG4 antibodies provide an additional explanation for the absence of clinical reactivity in PS patients sensitized to major peanut allergens

International Consensus Statement on Rhinology and Allergy: Rhinosinusitis

Background: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR‐RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR‐RS‐2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence‐based findings of the document. Methods: ICAR‐RS presents over 180 topics in the forms of evidence‐based reviews with recommendations (EBRRs), evidence‐based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results: ICAR‐RS‐2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence‐based management algorithm is provided. Conclusion: This ICAR‐RS‐2021 executive summary provides a compilation of the evidence‐based recommendations for medical and surgical treatment of the most common forms of RS

Effect of US State Certificate of Need regulation of operating rooms on surgical resident training

Purpose: Government regulation of health care services helps prevent costs associated with expansion and duplication of services in the United States. Certificate of Need (CON) helps restrict construction of ambulatory surgery facilities and hence controls delivery of surgical intervention, but concern exists about whether this affects resident exposure to an appropriate caseload. This study investigated how CON laws impact on surgical caseload as an index of resident surgical training. Methods: This retrospective study used State Inpatient Data compiled by the Health Care Utilization Project. Mean per capita rates of 26 diverse surgical procedures were evaluated in 21 states with CON laws and 5 states without between 2004 and 2006. The proportion of procedures performed in teaching facilities was also assessed. Student’s t-tests were used to evaluate differences in these parameters between regulated and non-regulated states (a = 0.05). Multivariate analysis of variance permitted evaluation of the types of procedures that underwent shift in location performed. Results: States with CON laws did not differ significantly in procedural rates for any of the investigated surgical procedures; however, such regulation was associated with different trends in teaching center caseload, depending on the type of procedure. Complex procedures, such as Whipple operations (p = 0.14) or resection of acoustic neuroma (p = 0.37), underwent no redistribution. Conversely, common procedures that might have previously been performed in private settings, such as total hip replacement (p = 0.003) or mastectomy (p = 0.01), did occur more commonly in teaching facilities under CON regulation. CON law did not result in relocation of surgical procedures away from teaching institutions. Conclusions: These results suggest that government regulations do not discriminate against teaching facilities. Surgical residents in states with such regulation gain similar or superior exposure to procedures as residents in states without such laws

Impact of US state government regulation on patient access to elective surgical care

Purpose. Rising health care costs in the United States have led to government regulation of services via a Certificate of Need (CON) law in many states. Such regulation may decrease access to elective surgical procedures. This study describes the impact of CON laws on elective surgical care. Methods. This retrospective cohort trial used data from the Health Care Utilization Project, a publicly available, inpatient database. Rates of six elective procedures were compared between 21 CON states and 5 non-CON states (2004-2005). Further, facility type (non-profit versus for-profit), facility teaching status, and median charges were also compared as a function of CON status. Statistical analysis was performed by Student’s t-tests (?=0.05). Results. CON laws did not affect procedure rates (P = 0.11-0.97), but lower charges were found for lumbar discectomy ($16,819 versus$13,493 p=0.04), acoustic neuroma resection ($60,993 versus$46,353, P < 0.001), and microvascular decompression (MVD) for trigeminal neuralgia ($37,741 versus$27,729, P < 0.001) in CON states. Various procedures exhibited a shift from for-profit to non-profit facilities including lumbar disectomy (20% versus 9%, P=0.01), acoustic neuroma resection (5.5% versus 0.2%, P=0.03), MVD (20% versus 3%, P=0.02), and rotator cuff repair (23% versus 10%, P=0.01). CON status had no effect on proportion of cases occurring at teaching facilities. Conclusions. CON laws appear to maintain patient access to elective surgical care while successfully reducing hospital charges. The location of surgery may shift to non-profit centers suggesting preferential certificate distribution, though this only partly explains the decreased charges in states with CON regulation

Cosmetic and Cognitive Outcomes of Positional Plagiocephaly Treatment

Purpose: Positional plagiocephaly is an acquired deformation of an intrinsically normal infant skull by sustained or excessive extrinsic forces. Non-surgical techniques include counter-positioning, supervised prone time and orthotic molding for more refractory cases. Long-term effects of positional plagiocephaly on development remain undefined, and this study evaluated cosmetic and cognitive outcomes of plagiocephaly management. Method: Surveys were administered to parents of patients treated for positional plagiocephaly through the Children’s Hospital of Eastern Ontario. Categorical responses interrogated cosmetic outcome, school performance, language skills, cognitive development and societal function. Pearson coefficient analysis tested outcomes dependency on gender, age, and plagiocephaly side at the 0.05 level of significance. Results: Eighty respondents (51 male, 29 female) were divided as 58 right- and 22 left-sided pathology. Positional therapy was uniformly applied, and a helmet orthosis was utilized in 36% of cases. Median follow-up age was nine years with normal head appearance in 75% of cases. Only 4% of parents and 9% of patients observed significant residual asymmetry. These results did not vary by gender, age or deformity side. Left-sided disease predicted poorer language development and academic performance. Expressive speech abnormality occurred in twice as many patients with left-sided disease (36% versus 16%, p=0.04) along with three-fold greater special education requirements (27% versus 10%, p=0.04). Conclusions: Non-surgical plagiocephaly management achieved good cosmetic outcome among patients in this study. Children with left-sided disease frequently encountered difficulties with cognitive and scholastic endeavors, although the roles of the underlying disease and the treatment measures in this delay cannot be differentiated

Clinical predictors of facial nerve outcome after translabyrinthine resection of acoustic neuromas

Purpose: The translabyrinthine approach to acoustic neuroma resection offers excellent exposure for facial nerve dissection with 95% preservation of anatomic continuity. Acceptable outcome in facial asymptomatic patients is reported at 64-90%, but transient postoperative deterioration often occurs. The objective of this study was to identify preoperative clinical presentation and intraoperative surgical findings that predispose patients to facial nerve dysfunction after acoustic neuroma surgery. Methods: The charts of 128 consecutive translabyrinthine patients were examined retrospectively to identify new clinical and intraoperative predictors of facial nerve outcome. Postoperative evaluation of patients to normal function or mild asymmetry upon close inspection (House-Brackmann grades of I or II) was defined as an acceptable outcome, with obvious asymmetry to no movement (grades III to VI) defined as unacceptable. Intraoperative nerve stimulation was performed in all cases, and clinical grading was performed by a single neurosurgeon in all cases. Results: Among patients with no preoperative facial nerve deficit, 87% had an acceptable result. Small size (P < 0.01) and low intraoperative nerve stimulation of < 0.10 mA (P< 0.01) were reaffirmed as predictive of functional nerve preservation. Additionally, preoperative tinnitus (P = 0.03), short duration of hearing loss (P< 0. 01), and lack of subjective tumour adherence to the facial nerve (P = 0.02) were independently correlated with positive outcome. Conclusions: Our experience with the translabyrinthine approach reveals the previously unestablished associations of facial nerve outcome to include presence of tinnitus and duration of hypoacusis. Independent predictors of tumour size and nerve stimulation thresholds were reaffirmed, and the subjective description of tumour adherence to the facial nerve making dissection more difficult appears to be important