The impact of COVID-19 on endoscopy and cancer screening: a focus on access and equity.

The SARS-CoV2 pandemic has had a profound and lasting impact on healthcare delivery. Gastrointestinal endoscopy services were limited during the early phases of the pandemic, which has resulted in ongoing procedural backlog. Procedural delays have had continuing effects including delayed colorectal cancer (CRC) diagnoses and exacerbation of existing disparities in the CRC-screening and treatment pathways. In this review, we outline these effects as well as the variety of strategies that have been proposed to eliminate this backlog, including increased endoscopy hours, re-triaging of referrals, and alternative CRC-screening strategies.

Acute Onset of Pneumococcal Pneumonia Following Instrumentation of the Respiratory Tract.

We describe 22 patients who developed pneumococcal pneumonia within 96 hours of respiratory tract instrumentation. In 59% of cases, the time to onset of symptoms was <24 hours. Instrumentation bypasses normal protective barriers and carries organisms directly to the lower airways, leading to the rapid development of pneumonia.

Guidelines vs Actual Management of Skin and Soft Tissue Infections in the Emergency Department.

BACKGROUND: Infections of skin and soft tissue (SSTI) commonly cause visits to hospital emergency departments (EDs). The Infectious Diseases Society of America (IDSA) has published guidelines for the management of SSTI, but it is unclear how closely these guidelines are followed in practice. METHODS: We reviewed records of patients seen in the ED at a large tertiary care hospital to determine guidelines adherence in 4 important areas: the decision to hospitalize, choice of antibiotics, incision and drainage (I&D) of abscesses, and submission of specimens for culture. RESULTS: The decision to hospitalize did not comply with guidelines in 19.6% of cases. Nonrecommended antibiotics were begun in the ED in 71% of patients with nonpurulent infections and 68.4% of patients with purulent infections. Abscesses of mild severity were almost always treated with antibiotics, and I&D was often not done (both against recommendations). Blood cultures were done (against recommendations) in 29% of patients with mild-severity cellulitis. Abscess drainage was almost always sent for culture (recommendations neither favor nor oppose). Overall, treatment fully complied with guidelines in 20.1% of cases. CONCLUSIONS: Our results show a striking lack of concordance with IDSA guidelines in the ED management of SSTI. Social factors may account for discordant decisions regarding site of care. Use of trimethoprim/sulfamethoxazole (TMP/SMX) in cellulitis was the most common source of discordance; this practice is supported by some medical literature. Excess antibiotics were often used in cellulitis and after I&D of simple abscesses, opposing antibiotic stewardship. Ongoing education of ED doctors and continued review of published guidelines are needed.

White Blood Cell Counts, Alcoholism, and Cirrhosis in Pneumococcal Pneumonia.

BACKGROUND: An elevated white blood cell (WBC) count is a characteristic finding in pneumococcal pneumonia. Very low WBC counts, occurring in some cases, are often associated with overwhelming pneumonia and have been attributed to alcohol-induced suppression of bone marrow. However, a systematic study of neutropenia, leukocytosis, alcohol ingestion, and cirrhosis in pneumococcal pneumonia has not been previously reported. METHODS: Using a database of patients with pneumococcal pneumonia at our medical center, we extracted data on WBC counts at admission, differential counts, alcohol ingestion, and cirrhosis, and we related these to 7-day and 30-day mortality. RESULTS: White blood cell counts were <6000/mm3 in 49 of 481 patients (10.2%) with pneumococcal pneumonia and >25000/mm3 in 40 (8.3%). Mortality at 7 days was 18.4% and 12.5%, respectively, 5-fold and 3-fold greater in patients with WBC <6000 or >25000 than in those with WBC counts between 6000 and 25000 (P < .001). Increased band forms were not associated with a worse outcome (P = .12). Alcohol use and cirrhosis were not associated with WBC counts <6000 (P = .63 and P = .41, respectively). CONCLUSIONS: In a large series of cases of pneumococcal pneumonia, WBC counts <6000 or >25000 correlated significantly with increased 7-day mortality. More than 10% band forms was not associated with a poor outcome. Alcohol abuse was not associated with low WBC or increased mortality. Our findings suggest that greater consideration be given to more intense care for patients with bacterial pneumonia who have very high or very low WBC counts at the time of hospital admission.