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Background: Studies comparing percutaneous tracheostomy (PT) and surgical tracheostomy (ST) complications in the critically ill patient population with high acuity, complexity, and severity of illness are sparse. This study evaluated the outcomes of elective PT versus ST in such patients managed at a quaternary referral center., Aims: The primary aim was to detect a difference in hospital mortality between the two techniques. The secondary aims were to compare Intensive Care Unit (ICU) mortality, complications (including stoma site, tracheostomy-related, and decannulation complications), ICU and hospital length of stay, and time to decannulation., Methods: This was a single-center retrospective observational study of ICU admission from August 2018 to August 2021. Patients were included if an elective tracheostomy was performed during their ICU admission. Patients with a pre-existing tracheostomy and those who underwent an obligatory tracheostomy requirement (e.g. total laryngectomy) were excluded. Cohorts were matched using Hainmueller's entropy balancing. Binary data were evaluated using logistic regression and continuous data with ordinary least squares regression., Results: 349 patients with a tracheostomy were managed in the ICU during the observation period. They were predominantly males (75% in PT; 67% in ST), with a mean age in the PT and ST group of (47; SD = 18) and (55; SD = 16), respectively. After exclusion, 135 patients remained, with 63 in the PT group and 72 in the ST group. Patients receiving ST were significantly older with a higher Body Mass Index (BMI) than the PT group. There were no significant differences in gender, Acute Physiological And Chronic Health Evaluation (APACHE) III, and the Australian and New Zealand Risk Of Death (ANZROD) between the two groups. There was no difference in hospital mortality between groups (OR 0.91, CI 0.26-3.18, p  = 0.88). There were also no differences in ICU mortality, ICU and hospital length of stay, and time to decannulation. PT was associated with a greater likelihood of complications (OR 4.19; 95% CI 1.73-10.13; p  < 0.01). PT was associated with a greater risk of complications in those who had this performed early (<10 days of intubation) as well as late (>10 days of intubation)., Conclusions: Percutaneous tracheostomy was associated with higher complications compared to surgical tracheostomy. They were related to tracheostomy cuff deflation, stomal site bleeding and infection, sputum plugging, and accidental and failed decannulation. These findings have identified opportunities to improve patient outcomes., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Intensive Care Society 2024.)

Construct: We compared the quality of clinician-authored and student-authored multiple choice questions (MCQs) using a formative, mock examination of clinical knowledge for medical students., Background: Multiple choice questions are a popular format used in medical programs of assessment. A challenge for educators is creating high-quality items efficiently. For expediency's sake, a standard practice is for faculties to repeat items in examinations from year to year. This study aims to compare the quality of student-authored with clinician-authored items as a potential source of new items to include in faculty item banks., Approach: We invited Year IV and V medical students at the University of Adelaide to participate in a mock examination. The participants first completed an online instructional module on strategies for answering and writing MCQs, then submitted one original MCQ each for potential inclusion in the mock examination. Two 180-item mock examinations, one for each year level, were constructed. Each consisted of 90 student-authored items and 90 clinician-authored items. Participants were blinded to the author of each item. Each item was analyzed for item difficulty and discrimination, number of item-writing flaws (IWFs) and non-functioning distractors (NFDs), and cognitive skill level (using a modified version of Bloom's taxonomy)., Findings: Eighty-nine and 91 students completed the Year IV and V examinations, respectively. Student-authored items, compared with clinician-authored items, tended to be written at both a lower cognitive skill and difficulty level. They contained a significantly higher rate of IWFs (2-3.5 times) and NFDs (1.18 times). However, they were equally or better discriminating items than clinician-authored items., Conclusions: Students can author MCQ items with comparable discrimination to clinician-authored items, despite being inferior in other parameters. Student-authored items may be considered a potential source of material for faculty item banks; however, several barriers exist to their use in a summative setting. The overall quality of items remains suboptimal, regardless of author. This highlights the need for ongoing faculty training in item writing.

Background: Complicated appendicitis encompasses a spectrum of severity with heterogeneity in definition and substantial variation in care. Enhanced recovery after surgery or 'fast-track' protocols aim to reduce practice variation by standardizing care. These initiatives may improve quality and efficiency of care, preserve resources and expedite discharge. This study aims to evaluate the impact of a standardized Enhanced Recovery Pathway (ERP) on the post-operative recovery of children with a subset of complicated appendicitis termed 'advanced' appendicitis., Methods: We defined advanced appendicitis as gangrenous or suppurative appendicitis without perforation, contained iatrogenic perforation, or localized purulent fluid. Children with operative findings reflecting these criteria were enrolled in the ERP protocol. Key protocol components include early upgrade of diet, avoidance of intravenous analgesia, abridged intravenous antibiotics, early ambulation and standardized discharge criteria. The study period was May 2018 to June 2019. A historical cohort was used as the comparator group., Results: Outcomes for 44 children treated under the ERP were compared to 44 historical controls. There was a 20% reduction in median post-operative length of stay (1.80 vs. 2.24 days, p = 0.02). Intravenous analgesia was received by fewer patients (6.8% vs. 36.4%, p = 0.01) with significant reduction in antiemetic requirement (p = 0.03). No significant difference in 30-day complication rates was observed., Conclusion: Reduced post-operative length of stay and reduction in practice variation were achieved after implementation of a 'fast-track' protocol for children with advanced appendicitis. Additional benefits of this protocol include reduced provision of intravenous morphine analgesia, decreased resource use and cost savings., (© 2021 Royal Australasian College of Surgeons.)

Background: 'Fast-track' surgery protocols aim to standardize and rationalize post-operative care, with evidence of safety and efficacy in both uncomplicated and complicated childhood appendicitis. Generalization for broader adoption has been limited by variation in protocol design, including specific antibiotic choice, discharge criteria, post-operative monitoring and patient selection., Methods: A systematic review of the literature was performed to evaluate the current evidence underpinning fast-track protocols for childhood appendicitis and identify areas of consensus and controversy., Results: About 33 studies met the inclusion criteria, including four prospective observational studies, 20 case-control studies, seven cohort studies and two randomized controlled trials studying uncomplicated (n = 9), complicated (n = 18) and mixed cohorts (n = 6). Reduction in length of hospital stay was almost universally reported, with equivalent or improved complication rates. Key themes of protocols included antibiotic choice and duration, discharge criteria and post-operative laboratory and radiographic testing. Rationalized analgesia is an underexplored aspect of protocol design, and a standardized definition of complicated appendicitis remains elusive., Conclusion: Standardized care of childhood appendicitis has been shown to be safe and effective in several local and international centres. Next steps include investigation of a complicated appendicitis protocol that integrates rationalized analgesia in appendicectomy recovery, and development of a consistent classification scheme for complicated disease to aid in identification of amenable cohorts., (© 2019 Royal Australasian College of Surgeons.)

This study was designed to determine whether long-term (2 years) brain exposure to mobile telephone radiofrequency (RF) fields produces any astrocytic activation as these glia react to a wide range of neural perturbations by astrogliosis. Using a purpose-designed exposure system at 900 MHz, mice were given a single, far-field whole body exposure at a specific absorption rate of 4 W/kg on five successive days per week for 104 weeks. Control mice were sham-exposed or freely mobile in a cage to control any stress caused by immobilization in the exposure module. Brains were perfusion-fixed with 4% paraformaldehyde and three coronal levels immunostained for glial fibrillary acidic protein (GFAP). These brain slices were then examined by light microscopy and the amount of this immunomarker quantified using a color deconvolution method. There was no change in astrocytic GFAP immunostaining in brains after long-term exposure to mobile telephony microwaves compared to control (sham-exposed or freely moving caged mice). It was concluded that long-term (2 years) exposure of murine brains to mobile telephone RF fields did not produce any astrocytic reaction (astrogliosis) detectable by GFAP immunostaining., (© 2015 Wiley Periodicals, Inc.)