The impact of a blood-culture diagnostic stewardship intervention on utilization rates and antimicrobial stewardship.

Blood-culture overutilization is associated with increased cost and excessive antimicrobial use. We implemented an intervention in the adult intensive care unit (ICU), combining education based on the DISTRIBUTE algorithm and restriction to infectious diseases and ICU providers. Our intervention led to reduced blood-culture utilization without affecting safety metrics.

Altmetric Analysis of Dermatology Manuscript Dissemination During the COVID-19 Era: Cross-Sectional Study.

BACKGROUND: Alternative bibliometrics or altmetrics, is a measure of an academic article's impact on social media outlets, which is quantified by the Altmetric Attention score (AAS). Given a lack of data for altmetric trends during the COVID-19 pandemic, we conducted a comprehensive, multivariable analysis of top dermatology manuscripts published during this time period. OBJECTIVE: We aim to assess (1) the relationship between traditional bibiliometrics and Altmetrics and (2) factors associated with high AAS. METHODS: All abstracted articles published in the top-5 (ranked by SCImago Journal Rankings) peer-reviewed dermatology journals published in 2021 were included in our study. We collected AAS as the dependent variable and categorical predictor variables included journal title, whether a conflict of interest existed, open access status, whether the article was related to COVID-19 or skin-of-color research, and the type of research (eg, clinical, basic science, review, etc). Numerical predictor variables consisted of the impact factor of journal, total citations, and number of authors. Multivariable linear or logistic regression models were used. RESULTS: The relationship between AAS and citation number was significant by multivariable analysis during the COVID-19 pandemic (P<.001). Numerous factors, including studies related to COVID-19, whether the article was open access, title of the journal, and journal impact factor were also independently related to higher AAS (P<.002). CONCLUSIONS: Our results validate the use of altmetrics as a complement to traditional bibliometrics, especially in times of widespread scientific interest. Despite existing in a complex realm of bibliometrics, there are also discernable patterns associated with higher AAS. This is especially relevant in the era of growing technologic importance and utility to assess the impact of scientific works within the general public.

The protective role of postoperative radiation therapy in low and intermediate grade major salivary gland malignancies: A study of the Canadian Head and Neck Collaborative Research Initiative.

BACKGROUND: The objective of this study was to examine the utility of postoperative radiation for low and intermediate grade cancers of the parotid and submandibular glands. METHODS: The authors conducted a retrospective, Canadian-led, international, multi-institutional analysis of a patient cohort with low or intermediate grade salivary gland cancer of the parotid or submandibular gland who were treated from 2010 until 2020 with or without postoperative radiation therapy. A multivariable, marginal Cox proportional hazards regression analysis was performed to quantify the association between locoregional recurrence (LRR) and receipt of postoperative radiation therapy while accounting for patient-level factors and the clustering of patients by institution. RESULTS: In total, 621 patients across 14 tertiary care centers were included in the study; of these, 309 patients (49.8%) received postoperative radiation therapy. Tumor histologies included 182 (29.3%) acinic cell carcinomas, 312 (50.2%) mucoepidermoid carcinomas, and 137 (20.5%) other low or intermediate grade primary salivary gland carcinomas. Kaplan-Meier LRR-free survival at 10 years was 89.0% (95% confidence interval [CI], 84.9%-93.3%). In multivariable Cox regression analysis, postoperative radiation therapy was independently associated with a lower hazard of LRR (adjusted hazard ratio, 0.53; 95% CI, 0.29-0.97). The multivariable model estimated that the marginal probability of LRR within 10 years was 15.4% without radiation and 8.8% with radiation. The number needed to treat was 16 patients (95% CI, 14-18 patients). Radiation therapy had no benefit in patients who had early stage, low-grade salivary gland cancer without evidence of nodal disease and negative margins. CONCLUSIONS: Postoperative radiation therapy may reduce LLR in some low and intermediate grade salivary gland cancers with adverse features, but it had no benefit in patients who had early stage, low-grade salivary gland cancer with negative margins.

Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta-analysis.

OBJECTIVE: Endoscopic sinus surgery (ESS) and endoscopic skull base surgery (ESBS) approaches have revolutionized the management of sinonasal and intracranial pathology. Maintaining surgical hemostasis is essential as bleeding can obscure the visibility of the surgical field, thus increasing surgical duration, risk of complications, and procedural failure. Tranexamic acid (TXA) acts to reduce bleeding by inhibiting fibrin degradation. This review aims to assess whether TXA improves surgical field quality and reduces intraoperative blood loss compared with control. METHODS: We searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library from inception until September 1, 2022. Two reviewers independently screened citations, extracted data, and assessed methodological quality using the Cochrane risk-of-bias tool for randomized trials. Data were pooled using a random-effect model, with continuous data presented as mean differences and dichotomous data presented as odds ratios. RESULTS: Seventeen ESS randomized controlled trials (n = 1377) and one ESBS randomized controlled trial (n = 50) were reviewed. Significant improvement in surgical field quality was achieved with both systemic TXA (six studies, p < 0.00001) and topical TXA (six studies, p = 0.01) compared with the control. Systemic TXA (eight studies) and topical TXA (three studies) both achieved a significant reduction in intraoperative blood loss compared with the control (p < 0.00001). There were significant differences in operative times (p < 0.001) but no significant difference in perioperative outcomes (p = 0.30). CONCLUSION: This meta-analysis demonstrated that the administration of TXA in ESS can improve surgical field quality and reduce intraoperative blood loss. TXA use did not result in increased perioperative complications including thrombotic events.

Demographic and applicant-specific predictors of medical school research productivity in a national cohort of dermatology residents.

Research is a crucial aspect of medical advancement, and applicants applying to dermatology often have high research outputs. With United States Medical Licensing Examination (USMLE) Step 1 becoming pass/fail, research productivity may be more emphasized. We primarily sought to assess predictors of medical school research productivity. Class of 2023 dermatology residents publicly listed on Accreditation Council for Graduate Medical Education-accredited programs were included. Their medical school bibliography and demographics were assessed using PubMed and other platforms (eg, Doximity, LinkedIn). By multivariable analysis, students who attended a top 25 medical school (ranked by US News and World Report) or were PhD graduates had significantly higher H-indices, average impact factors, and total years of research activity (P < .01). Top 25 medical school graduates also had significantly higher total peer-reviewed publications, first authorships, and clinical research papers (P < .01). PhD graduates had significantly more clinical research and fewer dermatology-related papers (P < .03). Graduates of osteopathic medical schools had significantly fewer review papers (P = .02). Gender and graduation from an international medical school had no relationship with research productivity. Our study demonstrates a correlation between applicant-specific factors and research productivity. Because the emphasis on research productivity may increase, understanding the mechanisms behind these relationships may guide future dermatology applicants or their mentors.

Perceived Barriers and Use of Evidence-Based Practices for Adolescent HPV Vaccination among East Texas Providers.

Adolescents living in rural areas are less likely to be up to date on the human papillomavirus (HPV) vaccine, which can prevent cervical cancer. We administered a telephone survey to 27 clinics in rural East Texas to assess perceived barriers to HPV vaccination and current use of evidence-based interventions to promote HPV vaccination. Perceived barriers were assessed using a 5-point Likert scale and clinical implementation of evidence-based practices was determined. Findings are reported using descriptive statistics. The most commonly reported barriers were missed vaccination opportunities due to the pandemic (66.7%), followed by vaccine hesitancy due to the pandemic (44.4%) and due to the HPV vaccine specifically (33.3%). Fewer than a third of clinics reported using the evidence-based strategies of use of a "refusal to vaccinate" form (29.6%), having an identified HPV vaccine champion (29.6%), and recommending the HPV vaccine at age 9 (22.2%). While many clinics surveyed currently implement evidence-based practices to promote HPV vaccination, there is a need and desire for additional HPV vaccination interventions in East Texas clinics.

Bilateral Vocal Cord Paralysis Secondary to Leptomeningeal Metastases With Unknown Primary Malignancy: A Case Report and Review of the Literature.

Bilateral vocal cord paralysis (BVCP) most commonly occurs secondary to iatrogenic injury and/or malignancy, but can also be a consequence of central nervous system (CNS) pathology. We report a case of BVCP secondary to leptomeningeal consequence in the context of unknown primary malignancy. The aim of this report is to promote awareness for BVCP caused by rare CNS pathology and highlight the importance of complete neoplastic and paraneoplastic workups in new-onset BVCP with unclear etiology. Here, we present a case report and review of the literature. A 68-year-old female presented with new-onset BVCP in the context of progressive dysphagia in addition to rectal and urinary incontinence. She underwent an awake tracheostomy. Her infectious and paraneoplastic workups did not identify a cause for her BVCP. Her brain MRI demonstrated enhancement of multiple cranial nerves, spine MRI demonstrated leptomeningeal enhancement, and cerebrospinal fluid (CSF) cytology was positive for metastatic adenocarcinoma. Her functional status was poor and she was deemed ineligible for chemotherapy and transitioned to palliative care. She died three months following her hospital admission. Leptomeningeal metastasis is a rare cause of new-onset BVCP. Airway management remains a critical component in BVCP. The sudden onset of BVCP in the context of generalized neurologic symptoms or cranial nerve deficits should prompt complete neoplastic and paraneoplastic investigation.

Social Media Impact of Articles Published by Dermatology Residents During Medical School: Cross-sectional Study.

BACKGROUND: The Altmetric score (AS) is a novel measure of publication impact that is calculated by the number of mentions across various social media websites. This method may have advantages over traditional bibliometrics in the context of research by medical students. OBJECTIVE: This study aimed to determine whether dermatology matriculants who graduated from higher-ranked medical schools published more articles with greater impact (ie, a higher AS) than those from lower-ranked institutions. METHODS: A PubMed search for articles published by dermatology residents who started medical school in 2020 was conducted. Demographic information and Altmetric data were collected, and medical schools were sorted according to US News' top-25 and non-top-25 categories. RESULTS: Residents who completed their medical training at a top-25 institution published more papers (mean 4.93, SD 4.18 vs mean 3.11, SD 3.32; P<.001) and accrued a significantly higher total AS (mean 67.9, SD 160 vs mean 22.9, SD 75.9; P<.001) and average AS (mean 13.1, SD 23.7 vs mean 6.71, SD 32.3; P<.001) per article than those who graduated from non-top-25 schools. CONCLUSIONS: Our results indicate that students in top-25 schools may have greater access to research resources and opportunities. With a pass/fail United States Medical Licensing Examination Step 1 exam that may increasingly shift focus toward scholarly output from medical students, further discussion on how to create a more equitable dermatology match is essential.

Diagnosis and Localization of Cerebrospinal Fluid Rhinorrhea: A Systematic Review.

BACKGROUND: Cerebrospinal fluid (CSF) rhinorrhea results from abnormal communications between the subarachnoid and sinonasal spaces. Accurate preoperative diagnosis and localization are vital for positive clinical outcomes. However, the diagnosis and localization of CSF rhinorrhea remain suboptimal due to a lack of accurate understanding of test characteristics. OBJECTIVE: This systematic review aims to assess the diagnostic accuracy of various tests and imaging modalities for diagnosing and localizing CSF rhinorrhea. METHODS: A systematic review of the MEDLINE and EMBASE databases was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Our search identified 4039 articles-53 cohort studies and 24 case series describing 1622 patients were included. The studies were heterogeneous and had a wide range of sensitivities and specificities. Many specificities were incalculable due to a lack of true negative and false positive results, thus precluding a meta-analysis. Median sensitivities and specificities were calculated for cohort studies of the following investigations: high-resolution computed tomography (HRCT) 0.93/0.50 (sensitivity/specificity), magnetic resonance cisternography (MRC) 0.94/0.77, computed tomography cisternography (CTC) 0.95/1.00, radionuclide cisternography (RNC) 0.90/0.50, and contrast-enhanced magnetic resonance cisternography (CEMRC) 0.99/1.00, endoscopy 0.58/1.00, topical intranasal fluorescein (TIF) 1.00/incalculable, intrathecal fluorescein (ITF) 0.96/1.00. Case series were reviewed separately. Etiology and site-specific data were also analyzed. CONCLUSION: MR cisternography is more accurate than high-resolution CT at diagnosing and localizing CSF rhinorrhea. CT cisternography, contrast-enhanced MR cisternography, and radionuclide cisternography have good diagnostic characteristics but are invasive. Intrathecal fluorescein shows promising data but has not been widely adopted for purely diagnostic use. Office endoscopy has limited data but does not sufficiently diagnose CSF rhinorrhea independently. These findings confirm with current guidelines and evidence.

Virtual Reality for Vestibular Rehabilitation: A Systematic Review.

INTRODUCTION: Vertigo is a debilitating symptom, leading to increased healthcare utilization and lost patient productivity. Vestibular rehabilitation is used to manage the symptomatic manifestations of vestibular disease. However, vestibular rehabilitation is limited by accessibility and time commitment. Recently, virtual reality has been described as a vestibular rehabilitation tool that may circumvent these barriers to treatment. Despite this, the efficacy of virtual reality for vestibular rehabilitation remains unclear. This study aims to review and summarize the current literature on the effectiveness of virtual reality-based vestibular rehabilitation. METHODS: A systematic review of the MEDLINE, EMBASE, and Alternative and Complementary Medicine databases was conducted for prospective studies describing virtual reality-based vestibular rehabilitation. RESULTS: Our search identified 382 unique articles. Six randomized controlled trials and four other studies were ultimately included. Study sample sizes ranged from 13 to 70 participants and varied in diagnoses from any unilateral peripheral vertigo to specific pathologies. Different virtual reality interventions were used. Comparator groups ranged from supervised vestibular rehabilitation to independent Cawthorne-Cooksey exercises. Outcomes consisted of validated questionnaires, objective clinical tests, and measurements of balance or reflexes. CONCLUSION: The studies reviewed in this study are preliminary evidence to suggest the benefit of virtual reality-based vestibular rehabilitation. However, these studies are limited by their inclusion criteria, heterogeneity, comparator design, and evidence-based clinical outcomes. Further research should address these limitations.

Ambient Noise Levels and Wireless Headsets for Communication in Aerosolizing Otolaryngology Surgery During COVID-19.

The objective of this short scientific communication is to describe and test a strategy to overcome communication barriers in coronavirus disease 2019 (COVID-19) era otolaryngology operating rooms. Thirteen endoscopic sinus surgeries, 4 skull base surgeries, and 1 tracheotomy were performed with powered air-purifying respirators. During these surgeries, surgical team members donned headsets with microphones linked via conference call. Noise measurements and survey responses were obtained and compared to pre-COVID-19 data. Noise was problematic and caused miscommunication as per 93% and 76% of respondents, respectively. Noise in COVID-19 era operating rooms was significantly higher compared to pre-COVID-19 era data (73.8 vs 70.2 decibels, P = .04). Implementation of this headset strategy significantly improved communication. Respondents with headsets were less likely to encounter communication problems (31% vs 93%, P < .001). Intraoperative measures to protect surgical team members during aerosolizing surgeries may impair communication. Linking team members via a conference call is a solution to improve communication.

Noise in Endoscopic Sinus and Skull Base Surgery Operating Rooms.

BACKGROUND: Noise in the operating room (OR) contributes to miscommunication among team members and may negatively impact patient outcomes. OBJECTIVES: This study aimed to quantify noise levels during endoscopic sinus and skull base surgery. The secondary aim was to understand how OR team members perceive noise during endoscopic sinus and skull base surgery. METHODS: Noise levels were measured using the validated phone application SoundMeter X 10.0.4 (r1865) (Faber Acoustical, Utah, USA) at the ear-level of the surgeon, scrub nurse, circulating nurse, and anesthesiologist. At the end of each surgery, OR team members were asked to complete a six-question questionnaire about noise during that surgery. RESULTS: One thousand four hundred and two noise measurements were recorded across 353 trials. The loudest mean noise measurement was 84.51 dB and maximum noise measurement was 96.21 dB at the ear-level of the surgeon. Noise was significantly higher at the ear-level of the surgeon and scrub nurse in comparison to the circulating nurse (p = .000) and anesthesiologist (p = .000). Forty percent of questionnaire respondents believed noise was a problem and 38% stated that noise caused communication issues during surgery. CONCLUSION: Surgeons and scrub nurses have significantly higher noise exposure in comparison to circulating nurses and anesthesiologists during endoscopic sinus and skull base surgery. For these members of the OR team, noise is also identified as problematic and causing issues with communication. Mechanisms to reduce potential noise may be implemented to improve communication and patient outcomes in endoscopic sinus and skull base surgery.