Cost-effective airway cultures in the cystic fibrosis patient.

BACKGROUND: Cystic fibrosis (CF) patients have a high incidence of multidrug-resistant infections, rendering CF patients a treatment challenge. OBJECTIVE: To evaluate culture protocols for CF patients and develop a cost-effective culture regimen that identifies clinically relevant pathogens. STUDY DESIGN: Retrospective review. METHODS: At the time of endoscopic sinus surgery, CF patients underwent both sinus and bronchial lavage cultures. Medical records from 2002 to 2006 were reviewed. RESULTS: Twenty-four cases were identified; 12 had complete sets of cultures. Seven of 12 had sinus aerobic bacteria that were also present in bronchial culture. Anaerobic cultures from both sites were all negative (42%) or nondiagnostic (58%). Thirty-three percent of sinus fungal cultures and 91.6% of bronchial fungal cultures were positive. Sinus acid fast bacillus cultures were all negative. CONCLUSION: CF culture protocols may be streamlined by eliminating all anaerobic cultures, as well as sinus acid fast bacillus and fungal cultures for a 52% reduction in cost.

Radiologic staging system for allergic fungal rhinosinusitis (AFRS).

OBJECTIVES: 1) Develop an objective method for quantifying radiologic bone erosion in allergic fungal rhinosinusitis (AFRS); and 2) assess the utility of the new CT scan staging system in differentiating AFRS patient groups. METHODS: Patients from two tertiary care rhinology practices with AFRS and available CT scans (1999-2007) were included for review by trained graders. The following novel assessment scale was used: Each paranasal sinus wall with expansion/erosion was scored 1 point, with maximum 3 points possible for each frontal sinus, 2 points for each ethmoid complex, 3 points for each sphenoid sinus, 3 points for each maxillary sinus, and 1 point each for the frontal and sphenoid intersinus septae, yielding maximum of 24 possible points. RESULTS: A total of 111 CT scans were reviewed. Mean score was 7.8 (range, 0-24). Males scored significantly higher than females (mean, 9.3 vs 5.6, P = 0.001). African Americans scored significantly higher than Caucasians (mean, 9.6 vs 5.0, P < 0.001). CONCLUSIONS: A scoring system for bone remodeling in AFRS is presented. Males and African-Americans with AFRS demonstrate significantly more bone erosion. Additional analysis of disease course will assess the utility of this staging system in predicting outcomes.

Socioeconomic factors in the diagnosis of allergic fungal rhinosinusitis.

OBJECTIVES: 1) To investigate socioeconomic and demographic factors differentiating allergic fungal rhinosinusitis (AFRS) from other chronic rhinosinusitis (CRS) diagnostic groups. 2) To consider the potential impact of epidemiological differences on AFRS disease course. STUDY DESIGN: Retrospective review. STUDY METHODS: Retrospective review of AFRS patients, CRS patients with nasal polyps (CRSwNP) without AFRS, and CRS patients without polyps (CRSsNP). Analysis of group differences was performed for age at presentation, gender, ethnicity, insurance status, and socioeconomic measures with the use of medical records and a South Carolina demographic database. RESULTS: AFRS presentation age was lower than CRSwNP and CRSsNP (P < 0.001). The AFRS group had more African Americans (P < 0.001) and uninsured or Medicaid patients (P < 0.001) than expected. AFRS patients resided in counties with higher poverty percentage (P = 0.011), lower median income (P = 0.048), and more African American residents (P = 0.020) than CRSsNP patients. No group differences existed for gender or physicians per 1000 county residents. CONCLUSION: Demographic and socioeconomic factors may affect AFRS presentation and treatment.

Socioeconomic factors in allergic fungal rhinosinusitis with bone erosion.

BACKGROUND: Previous studies have shown an increase in the incidence of orbital and skull base erosion in African Americans and males diagnosed with allergic fungal rhinosinusitis (AFRS). However, underlying reasons for the advanced presentation of AFRS in certain ethnic and gender groups are currently unknown. We evaluated several socioeconomic and demographic factors for their possible contribution to advanced presentation of AFRS in our patient population. Such factors have not been examined previously in the literature. The aim of this study was to evaluate the contribution of race, ethnicity, and various socioeconomic factors to the advanced presentation of AFRS with orbital and skull base bone erosion. METHODS: Retrospective review of medical records and radiological studies were performed for 54 consecutive AFRS patients presenting to a tertiary care rhinology practice. Presence of radiological evidence of bone erosion was compared with demographic data and insurance status, as indicated in the medical record. Bone erosion status was evaluated also against state demographic data, divided by county. RESULTS: Males were significantly more likely to present with bone erosion than females (p = 0.009). In this analysis, age and race were not statistically associated with the presence of bone erosion. Additionally, no statistically significant correlations were identified between bone erosion and several socioeconomic factors listed from the patient's county of residence (percentage below the poverty level, median household income, population percentage of African Americans, or number of physicians per 1000 residents). CONCLUSION: No socioeconomic factors were identified that correlated with the incidence of bone erosion in patients diagnosed with AFRS. Factors other than socioeconomic status and access to health care appear to play a role in the advanced presentation of AFRS.

Laboratory versus portable sleep studies: a meta-analysis.

OBJECTIVE: The objective of this meta-analysis study was to compare the accuracy of home sleep studies with laboratory polysomnography in the diagnosis of obstructive sleep apnea (OSA). METHODS: Eligible studies included prospective cohort studies of portable and in-laboratory sleep studies performed on the same groups of patients. A comparison of respiratory disturbance index (RDI), mean low oxygen saturation levels, sleep time, rate of inadequate studies, and average cost per examination was made between portable and in-laboratory sleep studies. A total of 18 papers were identified in two independent Medline searches. RESULTS: RDI values on portable sleep studies were 10% lower on average compared with laboratory studies (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.87-0.92). There was no significant difference in the mean low oxygen saturation on portable versus laboratory studies (OR, 1.0; 95% CI, 0.94-1.10). Recorded sleep time was significantly higher by 13% for laboratory compared with portable studies (OR, 0.87; 95% CI, 0.86-0.89), and portable studies were significantly more likely to give a poor recording when compared with laboratory examinations (P = .0001). The cost of home studies ranged from 35% to 88% lower than laboratory studies across a number of countries. CONCLUSION: Home sleep studies provide similar diagnostic information to laboratory polysomnograms in the evaluation of sleep-disordered breathing but may underestimate sleep apnea severity. The lower cost of home sleep studies makes it a viable screening tool for patients with suspected OSA; however, these lower costs are partially offset by the higher rate of inadequate examinations.

Incidence of skull base and orbital erosion in allergic fungal rhinosinusitis (AFRS) and non-AFRS.

OBJECTIVE: To compare the incidence of bony erosion associated with allergic fungal rhinosinusitis (AFRS) with the incidence of bony erosion seen in other types of inflammatory sinusitis. STUDY DESIGN: Retrospective review. RESULTS: AFRS was diagnosed in 27 patients, and 15/27 (56%) had bony skull base or orbital erosion. Non-AFRS chronic sinusitis required surgery in 158 patients, but only 8 (5%) had bony skull base or orbital erosion (P < 0.01). AFRS patients were 12.6 times (P < 0.01) more likely to have bony erosion than non-AFRS patients. African American males were 15.0 times (P < 0.01) more likely to have bony erosion than whites and African American females combined. CONCLUSION: Bony erosion with intracranial and intraorbital extension is much more common in AFRS than all other types of inflammatory sinusitis combined. African American males have a higher incidence of AFRS, as well as intracranial and intraorbital extension. EBM RATING: C-4.

'Push' versus 'pull' percutaneous endoscopic gastrostomy tube placement in patients with advanced head and neck cancer.

OBJECTIVES/HYPOTHESIS: Percutaneous endoscopic gastrostomy tube (PEG) placement by means of the "pull" method has been reported to result in a significantly higher complication rate when compared with "push" PEG placement. These findings have led to a renewed interest in the push, or Russell introducer, method of PEG placement at the authors' institution when PEG is required before definitive treatment of advanced head and neck cancer. The authors sought to determine whether the push method of PEG placement is associated with a lower incidence of complications in this patient population. STUDY DESIGN: Nonrandomized, retrospective patient analysis. METHODS: The medical records of all patients presenting to the Medical College of Georgia (Augusta, GA) who received a diagnosis of squamous cell carcinoma of the head and neck between 1999 to 2001 were retrospectively reviewed. Patients who required PEG placement as part of their treatment comprised the study population. RESULTS: The push PEG technique was used in 29 patients, and the pull technique was used in 50 patients. There was a statistically significant difference in the complication rate between the two techniques. Patients who underwent placement by means of the pull technique had an overall complication rate of 30% (15 of 50) versus a 0% (0 of 29) complication rate in patients undergoing the push technique (P =.0006, Fisher's Exact test). CONCLUSION: The push PEG technique appears to have a significantly lower risk of complications compared with the pull technique in patients with advanced head and neck cancer. The authors recommend considering the use of the push method when PEG placement is required.