Life-Threatening Stridor due to Laryngeal Tuberculosis in the COVID-19 Era: Report of a Case

Laryngeal tuberculosis is the most frequent granulomatous disease of the larynx and it is prone to be diagnosed as cancer. COVID-19 pandemic caused considerable disruption in tuberculosis service provisions both in the primary care and hospital settings. This report describes a rare case of life-threatening stridor in a patient who presented with an ulceroproliferative laryngeal mass later confirmed as laryngeal tuberculosis. Urgent tracheostomy was performed. The patient’s sputum and the computed tomography of the chest revealed a pulmonary, as well as laryngeal tuberculosis. The patient was commenced on a 24 week course of anti-tuberculous treatment which was interrupted because of a mild course of hospital-acquired coronavirus infection. 3 months after initial treatment for tuberculosis, his sputum cultures became negative. Flexible laryngoscopy was performed at our department 4 months after commencement of treatment, demonstrating complete regression of the lesion and symmetrical laryngeal mobility, hence the patient was successfully decannulated and discharged to be followed up to his community hospital. In the time of COVID-19 pandemic, we should never underestimate other severe infectious diseases.

Video Assisted Thoracoscopic Surgery in Exudative Pleural Effusion and its Complication Management: An Experience in a Community Hospital

Background: Exudative pleural effusions are common presentation of pleural disease. Long standing pleural effusion might complicate with loculations and cortex formation. Video assisted thoracoscopic surgery can be a useful tool for the diagnosis and the management of the complications. The aim of the study is to determine the cause and treat the complications related to the exudative pleural effusions. Materials and Methods: It is a retrospective analysis of prospectively collected data of all patients with exudative pleural effusions subjected to surgical management. Data were collected over a period of four years in a community hospital in Kathmandu. Results: Of 38 patients who underwent Video assisted thoracoscopic surgery only 33 were eligible for analysis. Male to female ratio was 2.3:1 with male (23) dominance. Twenty six (78.8%) had lymphocyte predominance and 23 (69.7%) had Adenosine deaminase level of more than 40 International unit in pleural fluid analysis. In histopathological examination most common finding was granulomatous inflammation 13 (39.4%), 9 (27.3%) were malignancy and 9 (27.3%) were nonspecific chronic inflammation. Of malignancies adenocarcinoma 3 (9.09%) was the most common finding, mesothelioma 2(6.06%) and 4 (12.12%) other. Conclusion: Video assisted thoracoscopic surgery has a role to play in diagnosis of exudative pleural effusions, particularly when there is dilemma in diagnosis. Video assisted thoracoscopic surgery definitely has a role in diagnosis and treatment of the complications related to pleural effusions.

A National Survey of Hand Surgeons: Understanding the Rural Landscape

Background: Twenty percent of the US population is described as being rural and may have limited access to hand surgeons, especially on an emergency basis. Little is known about case type, call hours, employment status, and other relevant details of rural hand surgery. Methods: We surveyed members of the American Society of Surgery for the Hand to begin to describe the problem. Results: There were 471 responses from 2256 members surveyed with 387 completing 100% of questions asked. Ninety (19%) identified themselves as primarily located in a rural population and 381 (81%) in a metropolitan region. In our study, rural hand surgeons were more likely to be employed by a community hospital, followed by independent private practice, multispecialty group, academics, and then locum tenens. Rural surgeons’ practices were 80% solely hand surgery, while metropolitan surgeons’ practices were 89% ( P < .01). Metropolitan surgeons felt that of the transfers from rural facilities, 46% did not need emergency hand care and that 60% of the time, there was not actually a need for specialty hand surgery care. Conclusions: Our survey begins to shed light on the details of rural hand surgery practice. We found that rural surgeons are more likely to be employed in community hospitals and take more call. When available, hand surgery specialists could prevent unnecessary transfer of patients to metropolitan areas. More work needs to be done to describe the differences between rural and metropolitan hand surgery practices as well as create rural hand surgeons.

A Clinical Monitoring Approach for Early Onset Sepsis: A Community Hospital Experience

BACKGROUND: A serial clinical examination approach to screen late preterm and term neonates at risk for early onset sepsis has been shown to be effective in large academic centers, resulting in reductions in laboratory testing and antibiotic use. The implementation of this approach in a community hospital setting has not been reported. Our objective was to adapt a clinical examination approach to our community hospital, aiming to reduce antibiotic exposure and laboratory testing. METHODS: At a community hospital with a level III NICU and &gt;4500 deliveries annually, the pathway to evaluate neonates ≥35 weeks at risk for early onset sepsis was revised to focus on clinical examination. Well-appearing neonates regardless of perinatal risk factor were admitted to the mother baby unit with serial vital signs and clinical examinations performed by a nurse. Neonates symptomatic at birth or who became symptomatic received laboratory evaluation and/or antibiotic treatment. Antibiotic use, laboratory testing, and culture results were evaluated for the 14 months before and 19 months after implementation. RESULTS: After implementation of the revised pathway, antibiotic use decreased from 6.7% (n = 314/4694) to 2.6% (n = 153/5937; P &lt; .001). Measurement of C-reactive protein decreased from 13.3% (n = 626/4694) to 5.3% (n = 312/5937; P &lt; .001). No cases of culture-positive sepsis occurred, and no neonate was readmitted within 30 days from birth with a positive blood culture. CONCLUSIONS: A screening approach for early onset sepsis focused on clinical examination was successfully implemented at a community hospital setting resulting in reduction of antibiotic use and laboratory testing without adverse outcomes.

A 21-Year Survey of Escherichia coli from Bloodstream Infections (BSI) in a Tertiary Hospital Reveals How Community-Hospital Dynamics of B2 Phylogroup Clones Influence Local BSI Rates

Sepsis is the third leading cause of mortality in Western countries and one of the Global Health Threats recognized by the WHO since 2017. Despite Escherichia coli constituting the most common cause of bloodstream infections (BSI), its epidemiology is not fully understood, in part due to the scarcity of local and longitudinal studies.

Sustained reductions in unnecessary antimicrobial administration and hospital Clostridioides difficile rates via stewardship in a nonacademic setting

A large community hospital sought to reduce its burden of hospital-acquired Clostridioides difficile infection (CDI). We implemented an antimicrobial stewardship program (ASP), resulting in marked reductions in unnecessary antimicrobial use, CDI rates, antimicrobial acquisition costs, with preservation of gram-negative susceptibilities. ASP programs are effective in a community setting.

Application of Artificial Intelligence-based Dual-modality Analysis Combining Fundus Photography and Optical Coherence Tomography in Diabetic Retinopathy Screening in a Community Hospital

Background To assess the feasibility and application value of artificial intelligence (AI)-based screening for diabetic retinopathy (DR) by combining fundus photos and optical coherence tomography (OCT) images in a community hospital.Methods Fundus photos and OCT images were taken for 600 diabetic patients in a community hospital. Ophthalmologists and AI identified these fundus photos according to international DR standards. OCT images were used to detect concomitant macular oedema (ME). The criteria for referral were DR grades 2-4 and/or the presence of ME. The sensitivity and specificity of AI grading were evaluated. The number of referable DR cases confirmed by ophthalmologists and AI was calculated.Results DR was detected in 81 (13.5%) participants by ophthalmologists and in 94 (15.6%) by AI, and 45 (7.5%) and 53 (8.8%) participants were diagnosed with referable DR by ophthalmologists and by AI, respectively. The sensitivity, specificity and area under the curve (AUC) of AI for detecting DR were 91.67%, 96.92% and 0.944, respectively. For detecting referable DR, the sensitivity, specificity and AUC of AI were 97.78%, 98.38% and 0.981, respectively. ME was detected from OCT images in 49 (8.2%) participants by ophthalmologists and in 57 (9.5%) by AI, and the sensitivity, specificity and AUC of AI were 91.30%, 97.46% and 0.944, respectively. When combining fundus photos and OCT images, the number of referrals identified by ophthalmologists increased from 45 to 75 and from 53 to 85 by AI.Conclusion AI-based DR screening has high sensitivity and specificity and may feasibly improve the referral rate of community DR.