Assessing a standardized decision-making algorithm for blood culture collection in the intensive care unit

PurposeBlood cultures are commonly ordered for patients with low risk of bacteremia. Indications for obtaining blood cultures are often broad and ill defined, and decision algorithms for appropriate blood cultures have not been comprehensively evaluated in critically-ill populations.MethodsWe conducted a retrospective analysis to assess the frequency of inappropriate blood cultures in the ICUs at Montefiore Medical Center based on an evidence-based guidance algorithm. Blood cultures were reviewed against this algorithm to determine their appropriateness. We calculated the prevalence of inappropriate blood culture and explored the reasons for these collected cultures.Results300 patients were randomly selected from an initial cohort of 3370 patients. 294 patients were included and of these, 167 patients had at least 1 blood culture drawn. 125 patients had one or more inappropriate blood culture. 61.4% of blood cultures drawn were assessed to be inappropriate. The most common reason for inappropriate cultures was a culture drawn as a result of isolated fever or leukocytosis.ConclusionIn a cohort of critically-ill patients, inappropriate blood cultures were common. The indications for blood cultures are often not evidence-based, and evidence-based algorithms to guide the collection of blood cultures may offer a way to decrease inappropriate culture orders.     

Vestibular neuronitis in a vestibular schwannoma patient

This is a unique presentation of an acute vestibular syndrome (AVS) caused by vestibular neuronitis (VN) of a vestibular nerve (CNVIII) already affected by vestibular schwannoma (VS).A 48-year-old patient, formerly diagnosed with an intracanalicular VS, presented with AVS.The patient underwent clinical and neurotological examination including video Head Impulse Test and a 4-hour delayed-enhanced 3D-FLAIR MRI using intravenous gadolinium.Clinical and neurotological findings were consistent with VN of the CNVIII formerly diagnosed with VS. A 4-hour delayed-enhanced 3D-FLAIR MRI showed significant enhancement of the labyrinth also indicating VN of the same nerve affected by VS.Pragmatic corticosteroid therapy and vestibular exercises were applied resulting in satisfactory recovery of the patient.As vestibular symptoms are common in VS patients, investigating another cause of dizziness and vertigo in VS patients can be marginalized. Nevertheless, VS presenting as AVS is very unusual.VN should not be overlooked as a possible cause of acute vertigo in a patient previously diagnosed with VS.     

Increased Disparities in Patients Diagnosed with Metastatic Lung Cancer Following Lung CT Screening in the United States

ObjectivesWe sought to determine if implementation of low dose computed tomography (LDCT) screening for lung cancer in the United States had led to changes in patients being diagnosed with metastatic lung cancer over time.Materials and MethodsThe Surveillance, Epidemiology, and End Result (SEER) database was utilized to determine the proportion of lung cancers diagnosed as stage I to III and stage IV from 2009-2018. Changes in lung cancer stage distribution were compared in the overall population and by race.ResultsFrom 2009 to 2018, the proportion of stage I to III lung cancers increased from 52% (51.3%-53.2%) in 2009 to 56% (54.0%-55.8%) in 2018 (P < .001). Correspondingly, the proportion of lung cancers diagnosed in stage IV decreased from 48% (46.8%-48.7%) in 2009 to 45% (44.2%-46.0%) (P < .001) in 2018. For white patients, the proportion increased from 53% (51.6%-53.7%) to 56% (55.1%-57.1%) (P < .001). However, for black patients, no trend was present, with the proportion being 51% (47.9%-53.4%) in 2009 and 52% (49.0%-54.2%) in 2018 (P = .303).ConclusionSince the implementation of LDCT screening, the proportion of early-stage lung cancers increased in the general population. These changes in stage distribution were not present in black patients.     

Surgical procedure and treatment results of pharyngoplasty CWICKs for obstructive sleep apnea

ObjectiveUvulopalatopharyngoplasty (UPPP) is performed as a surgical treatment at the oropharyngeal level for obstructive sleep apnea, but there are problems with variations in treatment effects and postoperative complications. Therefore, to improve those, we have devised and put into practice the so-called CWICKs, which is a modified version of barbed reposition pharyngoplasty as a surgical method. We outline the procedure of CWICKs and report the treatment results in comparison with the conventional UPPP.MethodsCWICKs are surgeries that use resorbable wound closure devices to pull the posterior palatal arch outward and elevate it anteriorly and superiorly to maintain an open upper airway during sleep at the soft palate level. We compared the therapeutic effects of 46 patients evaluated by polysomnography before and after surgery among CWICKs performed in our department between January 2015 and December 2019 and 91 patients who underwent UPPP in our department between January 2000 and December 2008.ResultsIn 46 patients who underwent CWICKs, significant improvement was observed before and after surgery using the apnea hypopnea index (AHI), obstructive apnea index (OAI), ration of each sleep stage, and SpO2 level > 90%. The improvement rate of AHI was 68.4%, and the surgical success rate was 58.7%. Postoperative patient satisfaction was also good, and significant improvement in subjective sleepiness (Epworth Sleepiness Scale) and subjective sleep quality (Pittsburgh Sleep Quality Index) was observed before and after surgery. No postoperative complications such as dysphagia or scar stenosis were observed in any of the patients in the CWICKs group. Compared with the 91 cases of UPPP, which is the conventional method, there was no significant difference in the improvement rate of AHI (p = 0.199), but the improvement rate of OAI had significantly improved (p = 0.013). Regarding the postoperative sleep stage, In the CWICKs group, a significant decrease in stage 1 and a significant increase in stage 2, stage 3, and stage rapid eye movement were observed, whereas in the UPPP group, no significant improvement in stage 3 was observed. Multivariate analysis of surgical success did not show an association with surgical methods (CWICKs or UPPP). On the other hand, an association was shown with age (<45), palatine tonsil size (≥3 / 5), high MPH (≥14 mm), and OAI rate (> 1/3).ConclusionThe treatment outcome of CWICKs was equal to or better than that of the conventional UPPP. Future follow-up is required for long-term prognosis, but no serious postoperative complications, such as dysphagia or scar stenosis, have been observed. CWICKs are considered to be minimally invasive, simple, and effective surgical procedures with few complications.     

A SEER analysis of survival and prognostic factors in merkel cell carcinoma of the head and neck region

While Merkel cell carcinoma (MCC) of the head and neck is highly malignant, it remains poorly characterized due to its rarity. The purpose of this study was to examine prognostic factors for overall survival (OS) and disease-specific survival (DSS) in patients with MCC of the head and neck region. The Surveillance, Epidemiology and End Results registry was reviewed for patients diagnosed between 1984 and 2016 with histologically confirmed, primary MCC of the head and neck region. A total of 2818 patients met the inclusion criteria, with a median age at diagnosis of 77 years. At five and 10 years, respectively, the OS was 42.4% and 25.1% and the DSS was 67.9% and 64.1%. Multivariate Cox analysis indicated that predictors of decreased DSS included age at diagnosis ≥75 years, white race, increasing tumor spread, lymph node involvement and either the lip or the scalp/neck as a primary site. When adjusting for the aforementioned factors, tumor depth was not found to be a prognostic factor for DSS. We anticipate these results will help clinicians to counsel patients regarding expectations and potential prognosis.