Dynamic angle closure following pars plana vitrectomy with perfluoropropane gas.

Purpose: To report the clinical course of an aphakic patient who developed positional secondary angle closure glaucoma following pars plana vitrectomy (PPV) with perfluoropropane (C3F8) gas tamponade. Observations: A 23-year-old male presented due to a two-year history of vision loss in the left eye. Best-corrected visual acuity (BCVA) was 20/200 and intraocular pressure (IOP) was 12 mm Hg OS. Exam revealed iridodonesis and aphakia of both eyes, and a total RRD in the left eye. The patient underwent scleral buckle plus PPV with 15 % C3F8 gas and was instructed to maintain face-down positioning for 5 days. On post-operative day 1, IOP was 32 mm Hg and exam revealed significant diffuse corneal edema, a large epithelial defect, and 85 % C3F8 fill of the vitreous cavity. Patient was started on IOP-lowering drops but continued to have elevated IOP and corneal epithelial sloughing over the next 3 weeks. He was taken for a superficial keratectomy, but when placed supine under the microscope, a large new gas bubble was visualized overlying the pupil in a now shallow anterior chamber (AC) and IOP was 52 mm Hg. The patient was positioned back upright and the gas bubble migrated posteriorly out of the AC with return of IOP to 25 mm Hg. The dynamic nature of his IOP raised concerns for intermittent angle closure by C3F8 induced by supine positioning. Thus, a pars plana aspiration of the C3F8 gas was performed and resulted in normalization of the IOP. Conclusions and importance: Dynamic, positional secondary angle closure glaucoma can occur after vitrectomy with C3F8 in the setting of aphakia. This is the first report to capture C3F8 gas migration causing intermittent acute angle closure in real-time. Due to its intermittent nature however, the diagnosis may not be initially apparent at the slit lamp. Thus, we suggest this potential complication should be carefully monitored for and discussed when advising post-vitrectomy positioning in aphakic patients.

Incidence and Risk Factors for Neutropenia After Intra-Arterial Chemotherapy for Retinoblastoma.

Importance: Intra-arterial chemotherapy (IAC) has quickly gained popularity as a mainstay of treatment for retinoblastoma. Intra-arterial chemotherapy has been described as having several advantages over systemic chemotherapy, including reducing systemic toxicity and neutropenia; however, studies on the risk of neutropenia after IAC remain limited. Objective: To estimate the incidence of neutropenia after IAC, as well as identify risk factors associated with the development of neutropenia. Design, Setting, and Participants: This case series included pediatric patients with unilateral or bilateral retinoblastoma who were treated with IAC at a single quaternary care center from July 13, 2013, to January 6, 2023. Exposure: All patients were treated with IAC and underwent multiple IAC cycles depending on treatment response. The primary chemotherapy agent used was melphalan, but topotecan or carboplatin could be used along with melphalan. Melphalan doses were kept to 0.4 mg/kg or less per cycle. After each IAC cycle, complete blood cell counts were obtained within 10 to 12 days and repeated until the absolute neutrophil count (ANC) was greater than or equal to 1000/µL. Main Outcomes and Measures: The primary outcome was the minimum ANC after each IAC cycle. The secondary outcome was the development of severe (grade 3 or 4) neutropenia (ANC <1000/µL). Regression analyses were used to identify associations between variables and outcomes. Receiver operating characteristic curves were used to calculate threshold dose for each chemotherapy agent potentially associated with the development of severe neutropenia. Results: A total of 64 eyes of 49 patients (mean [SD] age, 1.7 [1.2] years; 25 females [51.0%]) with retinoblastoma were treated with 171 cycles of IAC. The mean (SD) nadir ANC was 1325.3 (890.7)/µL and occurred a median (IQR) of 10 (10-14) days (range, 6-28 days) after IAC administration. The frequency distribution of post-IAC neutropenia grades 0, 1, 2, 3, 4, and missing was 31 (18.1% of cycles), 25 (14.6%), 40 (23.4%), 37 (21.6%), 26 (15.2%), and 12 (7.0%), respectively. Factors weakly correlated with a lower ANC were higher melphalan dose (ß = -2356 [95% CI, -4120.6 to -611.2]; adjusted R2 = 0.251; P = .01) and higher topotecan dose (ß = -4056 [95% CI, -7003.6 to -1344.5]; adjusted R2 = 0.251; P = .006). Conclusions and Relevance: In this case series of patients with retinoblastoma, the incidence of severe neutropenia after IAC was nearly 40%, which is higher than previously reported. Extended laboratory monitoring may aid in capturing previously overlooked cases of neutropenia. Topotecan may be associated with the development of neutropenia; limiting topotecan doses, especially in the setting of a high melphalan dose, may be beneficial in reducing the risk of neutropenia.

Combined Effects of Botulinum Toxin Injection and Oral Appliance Therapy on Lower Facial Contouring: A Randomized Controlled Trial.

(1) Background: Botulinum toxin (BoNT) injection is an esthetically effective and safe treatment for contouring the lower face. This study aimed to evaluate the combined effects of BoNT and supplementary oral appliance (OA) therapy on lower facial contouring. (2) Methods: We conducted a prospective randomized controlled trial from January 2015 to June 2016 at the Yonsei University Dental Hospital. Volunteers aged 20−45 years with masseter hypertrophy were randomly assigned to one of two groups: the non-OA group and the OA group. The non-OA group received BoNT injections alone, whereas the OA group received an OA in addition to BoNT injections. Changes in the bulkiest height of the lower face were evaluated by three-dimensional laser scanning before and 4, 8, 12, and 24 weeks after injections in both groups. (3) Results: In both groups, the bulkiest height reductions decreased, with a significant interaction between group (p = 0.046) and time (p < 0.001), although the overall reduction was at a similar level at 24 weeks. (4) Conclusions: The pattern of the bulkiest height reduction of the lower face after BoNT injection differed between standalone treatment and OA therapy, implying a normalizing effect of OA on masseter muscle activity.

Visual acuity outcomes after cataract surgery in type 2 diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study.

AIMS: To evaluate visual acuity (VA) outcomes of cataract surgery, and factors associated with good visual outcomes, among a population with diabetes. METHODS: Participants with type 2 diabetes enrolled in The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and ACCORD-eye substudy. 1136 eyes of 784 ACCORD participants receiving cataract surgery during follow-up (2001-2014) were included. Of these, 362 eyes had fundus photographs gradable for diabetic retinopathy. The main outcome measure was the achievement of postoperative VA of 20/40 or better. RESULTS: In the sample of 1136 eyes, 762 eyes (67.1%) achieved good visual outcome of 20/40 or better. Factors predictive of good visual outcome were higher level of educational attainment (college vs some high school, OR 2.35 (95% CI 1.44 to 3.82)), bilateral cataract surgery (OR 1.55 (1.14 to 2.10)) and preoperative VA (20/20 or better vs worse than 20/200, OR 10.59 (4.07 to 27.54)). Factors not significantly associated (p>0.05) included age, sex, race, smoking, diabetes duration, blood pressure, lipid levels and haemoglobin A1C (HbA1C). In the subsample of 362 eyes, absence of diabetic retinopathy was associated with good visual outcome (OR 1.73 (1.02 to 2.94)). CONCLUSION: Among individuals with diabetes, two-thirds of eyes achieved good visual outcome after cataract surgery. Notable factors associated with visual outcome included preoperative VA and diabetic retinopathy, but not HbA1C, underscoring that while certain ocular measures may help evaluate visual potential, systemic parameters may not be as valuable. Sociodemographic factors might also be important considerations. Although the current visual prognosis after cataract surgery is usually favourable, certain factors still limit the visual potential in those with diabetes.

Punctal stenosis associated with dupilumab therapy for atopic dermatitis.

In this case series, the authors report three patients with severe atopic dermatitis who presented with epiphora and conjunctivitis while undergoing dupilumab therapy. On clinical examination, all patients were found to have punctal stenosis, with one case having progressed to punctal obstruction. An assortment of strategies was elected, including discontinuation of dupilumab, treatment of conjunctivitis, and surgical intervention with probing, punctoplasty, and silicone intubation. This report spotlights punctal stenosis as an important new side effect of dupilumab and suggests that additional cases of dupilumab-associated lacrimal drainage impairment will continue to emerge.

Deep Learning Automated Detection of Reticular Pseudodrusen from Fundus Autofluorescence Images or Color Fundus Photographs in AREDS2.

PURPOSE: To develop deep learning models for detecting reticular pseudodrusen (RPD) using fundus autofluorescence (FAF) images or, alternatively, color fundus photographs (CFP) in the context of age-related macular degeneration (AMD). DESIGN: Application of deep learning models to the Age-Related Eye Disease Study 2 (AREDS2) dataset. PARTICIPANTS: FAF and CFP images (n = 11 535) from 2450 AREDS2 participants. Gold standard labels from reading center grading of the FAF images were transferred to the corresponding CFP images. METHODS: A deep learning model was trained to detect RPD in eyes with intermediate to late AMD using FAF images (FAF model). Using label transfer from FAF to CFP images, a deep learning model was trained to detect RPD from CFP (CFP model). Performance was compared with 4 ophthalmologists using a random subset from the full test set. MAIN OUTCOME MEASURES: Area under the receiver operating characteristic curve (AUC), κ value, accuracy, and F1 score. RESULTS: The FAF model had an AUC of 0.939 (95% confidence interval [CI], 0.927-0.950), a κ value of 0.718 (95% CI, 0.685-0.751), and accuracy of 0.899 (95% CI, 0.887-0.911). The CFP model showed equivalent values of 0.832 (95% CI, 0.812-0.851), 0.470 (95% CI, 0.426-0.511), and 0.809 (95% CI, 0.793-0.825), respectively. The FAF model demonstrated superior performance to 4 ophthalmologists, showing a higher κ value of 0.789 (95% CI, 0.675-0.875) versus a range of 0.367 to 0.756 and higher accuracy of 0.937 (95% CI, 0.907-0.963) versus a range of 0.696 to 0.933. The CFP model demonstrated substantially superior performance to 4 ophthalmologists, showing a higher κ value of 0.471 (95% CI, 0.330-0.606) versus a range of 0.105 to 0.180 and higher accuracy of 0.844 (95% CI, 0.798-0.886) versus a range of 0.717 to 0.814. CONCLUSIONS: Deep learning-enabled automated detection of RPD presence from FAF images achieved a high level of accuracy, equal or superior to that of ophthalmologists. Automated RPD detection using CFP achieved a lower accuracy that still surpassed that of ophthalmologists. Deep learning models can assist, and even augment, the detection of this clinically important AMD-associated lesion.

Two cases of severe Purtscher-like retinopathy demonstrating recurrence and progression to neovascularization and vitreous hemorrhage.

PURPOSE: To report the clinical course of two cases with Purtscher-like retinopathy (PLR), associated with peritoneal dialysis (PD), demonstrating disease recurrence and progression to neovascularization and vitreous hemorrhage. OBSERVATIONS: Case 1 (45-year old woman) experienced acute bilateral vision loss. Medical history included hypertension, end-stage renal failure (ESRF), PD, and obstructive sleep apnea. Visual acuity (VA) was 20/100 OD, 20/80 OS. Fundus findings were pathognomonic for PLR and included white streaks within arterioles. Nine months later, repeat imaging demonstrated disease recurrence and progression, including increased ischemia and new retinal neovascularization. The patient was managed with pan-retinal photocoagulation, sleep apnea treatment, and oral corticosteroids. Four months later, VA remained stable without additional progression.Case 2 (74-year old woman) experienced acute bilateral vision loss. Medical history included hypertension, ESRF, and PD, complicated by peritonitis. VA was 20/25 OD, 20/32 OS. Fundus findings were pathognomonic for PLR and included white streaks within arterioles. Three months later, further acute vision loss occurred, coinciding with recurrent peritonitis. Repeat imaging revealed disease recurrence and progression, including severely increased retinal ischemia. The PD catether was removed and the patient converted to hemodialysis. Bilateral vitreous hemorrhage later complicated the course. CONCLUSIONS AND IMPORTANCE: PLR can occur in association with PD, particularly in acute peritonitis. Contrary to classical descriptions, PLR may take a chronic and progressive course, with increasing ischemia and progression to neovascularization or vitreous hemorrhage. Increased surveillance for complications is recommended and treatment of neovascularization may be required.

Stigma and negative self-perceptions of young people living with human immunodeficiency virus in Bandung, Indonesia: a case series.

Background: Young people living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (PLWA) are at risk for HIV stigma. Methods: The HIV/AIDS Stigma Instrument for PLWA was administered to 36 young PLWA across six clinics in Bandung, Indonesia, to assess the fear of contagion (FC), verbal abuse (VA), social isolation (SI), workplace stigma (WS), health care neglect (HCN) and negative self-perception (NSP). Results: The median scores for FC, VA, SI, WS and HCN were all 0 while the median score for NSP was 4. In the last 3 months approximately 45% of surveyed PLWA felt they did not deserve to live and 64% felt completely worthless. Conclusions: While these results are preliminary, access to mental health services should be a priority in the clinics that provide antiretroviral therapies.

Implementation of a human papillomavirus screen-and-treat model in Mwanza, Tanzania: training local healthcare workers for sustainable impact.

Background: The purpose of this study is to evaluate the development of a 1-wk screening campaign and efforts towards the implementation of a sustainable system that addresses cervical cancer in Mwanza, Tanzania with a screen-and-treat model utilizing visual inspection of the cervix with acetic acid (VIA) and cryotherapy. Methods: In partnership with CureCervicalCancer (CCC), a non-profit organization based in Los Angeles, CA, USA, 11 medical students at the University of California, Irvine School of Medicine established a model for sustainable human papillomavirus screening practices in Mwanza, Tanzania. This study both quantitatively and qualitatively assesses the successes and limitations of the program model. Results: During the 5-day training, a total of 614 women attended the screenings and 556 women were screened with VIA, of whom 10.6% (n=59) were VIA positive and 89.4% (n=499) were VIA negative. Of those who were VIA positive, 83.1% (n=49) received cryotherapy while 16.9% (n=10) did not due to suspicion of advanced cancer (n=7), refusal to receive cryotherapy (n=2) or pregnancy (n=1). Conclusions: The screen-and-treat model for the identification and treatment of precancerous cervical lesions is an effective public health intervention with the potential to impact women by providing the tools and education needed by local healthcare professionals. However, limitations common to resource-poor settings, such as continuity of funding, loss to follow-up and transportation costs, remain barriers to sustainability.

Ultrasound curriculum taught by first-year medical students: A four-year experience in Tanzania.

BACKGROUND: Diagnostic imaging is an integral aspect of care that is often insufficient, if not altogether absent, in rural and remote regions of low to middle income countries (LMICs) such as Tanzania. The introduction of ultrasound can significantly impact treatment in these countries due to its portability, low cost, safety, and usefulness in various medical assessments. This study reviews the implementation of a four-week ultrasound course administered annually from 2013-2016 in a healthcare professional school in Mwanza, Tanzania by first-year allopathic US medical students. METHODS: Participants (n=582, over 4 years) were recruited from the Tandabui Institute of Health Sciences and Technology to take the ultrasound course. Subjects were predominantly clinical officer students, but other participants included other healthcare professional students, practicing healthcare professionals, and school employees. Data collected includes pre-course examination scores, post-course examination scores, course quiz scores, demographic surveys, and post-course feedback surveys. Data was analyzed using two-tailed t-tests and the single factor analysis of variance (ANOVA). RESULTS: For all participants who completed both the pre- and post-course examinations (n=229, 39.1% of the total recruited), there was a significant mean improvement in their ultrasound knowledge of 42.5%, P<0.01. CONCLUSION: Our data suggests that trained first-year medical students can effectively teach a point of care ultrasound course to healthcare professional students within four weeks in Tanzania. Future investigation into the level of long-term knowledge retention, impact of ultrasound training on knowledge of human anatomy and diagnostic capabilities, and how expansion of an ultrasound curriculum has impacted access to care in rural Tanzania is warranted.

The changing landscape of diabetes prevalence among first-generation Asian immigrants in California from 2003 to 2013.

OBJECTIVE: The prevalence of diabetes mellitus (DM) is increasing rapidly, particularly in Asia. Asian immigrants in Western countries are a fast-growing population who carry both intrinsic risks due to their genetic background and extrinsic risks associated with Western lifestyles. However, recent trends in diabetes prevalence and associated risk factors among Asian immigrants in the USA are not well understood. RESEARCH DESIGN AND METHODS: We examined adults aged 18 and older from the recent California Health Interview Survey data sets from 2003 to 2013 to determine prevalence of known DM among first-generation Asian immigrants and whites. The impact of various DM risk factors in Asian immigrants relative to whites was analyzed and multivariable regression models were constructed to obtain adjusted DM risk in Asian immigrants versus in whites. RESULTS: Across the study span, we identified 2007 first-generation Asian immigrants and 14 668 whites as having known DM or prediabetes mellitus (pre-DM). From 2003 to 2013, the prevalence of DM and pre-DM combined rose from 6.8% to 12.4% in Asian immigrants and 5.5% to 6.9% in whites. Much of the increase could be attributed to pre-DM, which rose from 0.7% to 3.2% in Asian immigrants during the study period. The impacts of age and body mass index on DM risk were consistently greater in Asian immigrants than in whites. Non-DM Asian immigrants were found less likely to engage in physical activity than were non-DM whites. After adjustment of various associated factors, Asian immigrants were more likely than whites to have DM and this relative risk for DM gradually increased across the study period. CONCLUSIONS: A rising prevalence of known DM and particularly pre-DM among Asian immigrants in California was observed during the previous decade. To reduce the burden of diabetes and its complications, future strategies should consider specific risk factors for this ethnic group, including encouraging physical activity.

Another Generation of Stigma? Assessing Healthcare Student Perceptions of HIV-Positive Patients in Mwanza, Tanzania.

HIV-related stigma remains a persistent global health concern among people living with HIV/AIDS (PLWA) in developing nations. The literature is lacking in studies about healthcare students' perceptions of PLWA. This study is the first effort to understand stigmatizing attitudes toward HIV-positive patients by healthcare students in Mwanza, Tanzania, not just those who will be directly treating patients but also those who will be indirectly involved through nonclinical roles, such as handling patient specimens and private health information. A total of 208 students were drawn from Clinical Medicine, Laboratory Sciences, Health Records and Information Management, and Community Health classes at the Tandabui Institute of Health Sciences and Technology for a voluntary survey that assessed stigmatizing beliefs toward PLWA. Students generally obtained high scores on the overall survey instrument, pointing to low stigmatizing beliefs toward PLWA and an overall willingness to treat PLWA with the same standard of care as other patients. However, there are gaps in knowledge that exist among students, such as a comprehensive understanding of all routes of HIV infection. The study also suggests that students who interact with patients as part of their training are less likely to exhibit stigmatizing beliefs toward PLWA. A comprehensive course in HIV infection, one that includes classroom sessions focused on the epidemiology and routes of transmission as well as clinical opportunities to directly interact with PLWA-perhaps through teaching sessions led by PLWA-may allow for significant reductions in stigma toward such patients and improve clinical outcomes for PLWA around the world.

Clinical Signs and Subjective Symptoms of Temporomandibular Disorders in Instrumentalists.

PURPOSE: Most of the reports on instrumentalists' experiences of temporomandibular disorders (TMD) have been reported not by clinical examinations but by subjective questionnaires. The aim of this study was to investigate the clinical signs and subjective symptoms of TMD in a large number of instrumentalists objectively. MATERIALS AND METHODS: A total of 739 musicians from a diverse range of instrument groups completed a TMD questionnaire. Among those who reported at least one symptom of TMD, 71 volunteers underwent clinical examinations and radiography for diag-nosis. RESULTS: Overall, 453 participants (61.3%) reported having one or more symptoms of TMD. The most frequently reported symptom was a clicking or popping sound, followed by temporomandibular joint (TMJ) pain, muscle pain, crepitus, and mouth opening limitations. Compared with lower-string instrumentalists, a clicking or popping sound was about 1.8 and 2 times more frequent in woodwind and brass instrumentalists, respectively. TMJ pain was about 3.2, 2.8, and 3.2 times more frequent in upper-string, woodwind, and brass instrumentalists, respectively. Muscle pain was about 1.5 times more frequent in instrumentalists with an elevated arm position than in those with a neutral arm position. The most frequent diagnosis was myalgia or myofascial pain (MFP), followed by disc displacement with reduction. Myalgia or MFP was 4.6 times more frequent in those practicing for no less than 3.5 hours daily than in those practicing for less than 3.5 hours. CONCLUSION: The results indicate that playing instruments can play a contributory role in the development of TMD.

Splenectomy is associated with a higher risk for venous thromboembolism: A prospective cohort study.

BACKGROUND: Thrombocytosis following splenectomy is a common occurrence. Whether this thrombocytosis leads to a higher risk for venous thromboembolism (VTE) remains unclear. This investigation aimed to determine if splenectomy increases the risk for VTE. METHODS: This was a prospective study conducted in the SICU between 1/2011 and 11/2013 investigating the VTE risk in patients undergoing a splenectomy compared with those undergoing any other abdominal procedure. RESULTS: In total 2503 patients were admitted to the SICU: 37 (2%) after a splenectomy and 638 (26%) after any other abdominal surgery. Splenectomy patients had a higher incidence of VTE compared to patients undergoing any other abdominal procedure (29.7% vs. 12.1%, p < 0.01). After adjustment, splenectomy was associated with a higher adjusted risk for VTE compared to the no-splenectomy group (AOR [95% CI]: 2.6 [1.2, 5.9], p = 0.02). Reactive thrombocytosis did not predict the development of VTE. CONCLUSION: Splenectomy increases the risk for VTE, however reactive thrombocytosis is not associated with this higher incidence. Further investigations are required to characterize the pathophysiologic mechanisms of VTE development following splenectomy.

Postoperative infection risk after splenectomy: A prospective cohort study.

INTRODUCTION: Splenectomy is associated with a life-long risk for overwhelming infections. The risk for early post-operative infectious complications following traumatic and elective splenectomy is, however, understudied. This investigation aimed to determine if splenectomy increases the risk for post-operative infections. METHODS: This was a retrospective review of prospectively collected data on patients admitted to the surgical intensive care unit (SICU) between 1/2011 and 7/2013 investigating the risk for infectious complications in patients undergoing a splenectomy compared with those undergoing any other abdominal surgery. RESULTS: During the 30-month study period, a total of 1884 patients were admitted to the SICU. Of those, 33 (2%) had a splenectomy and 493 (26%) had an abdominal surgery. The two groups were well balanced for age, APACHE IV score >20, and past medical history, including diabetes mellitus, cardiac history, renal failure or immunosuppression. Patients undergoing splenectomy were more likely to have sustained a traumatic injury (30% vs. 7%, p < 0.01). After adjustment, splenectomy was associated with increased risk for infectious complications (49% vs. 29%, Adjusted Odds Ratio (AOR) [95% CI]: 2.7 [1.3, 5.6], p = 0.01), including intra-abdominal abscess (9% vs. 3%, AOR [95% CI]: 4.3 [1.1, 16.2], p = 0.03). On a subgroup analysis, there were no differences between traumatic and elective splenectomy with regards to overall infectious complications (50% vs. 46%, p = 0.84), although, abdominal abscess developed only in those who had an elective splenectomy (0% vs. 12%, p = 0.55). CONCLUSION: Splenectomy increases the risk for post-operative infectious complications. Further studies identifying strategies to decrease the associated morbidity are necessary.

The Trauma Research Associates Program (T-RAP) for undergraduate students: shaping future academic surgeons.

OBJECTIVE: Offering undergraduate students research opportunities may enhance their interest in pursuing a surgical career and lead to increased academic productivity. We characterize the benefits of participating in the Trauma Research Associates Program. DESIGN: A 19-point Web-based survey. SETTING: Academic Level I Trauma Center. PARTICIPANTS: A total of 29 active and former members of the Trauma Research Associates Program. MAIN OUTCOME MEASURE(S): Academic activities and predictors associated with interest in a surgical career and research productivity. RESULTS: Surveys were completed on 26 of 29 (90%) participants. Clinical experience was the most highly ranked motivation to join the program (65%), followed by pursuing a research experience (46%). During their involvement, 73% of participants observed surgical intensive care unit rounds, 65% observed acute care surgery rounds, and 35% observed a surgical procedure in the operating room. In addition, 46% submitted at least one abstract to a surgical meeting coauthored with the Division's faculty. Furthermore, 58% reported that they enrolled in a medical school, whereas 17% pursued a full-time research job. The program influenced the interest in a surgical career in 39% of all members, and 73% reported that they would incorporate research in their medical career. Observing a surgical procedure was independently associated with development of a high interest in a surgical career (adjusted odds ratio: 6.50; 95% CI: 1.09, 38.63; p = 0.04), whereas volunteering for more than 15 hours per week predicted submission of at least 1 abstract to a surgical conference by the participant (adjusted odds ratio: 13.00; 95% CI: 1.27, 133.29; p = 0.03). CONCLUSIONS AND RELEVANCE: Development of a structured research program for undergraduate students is beneficial to both the participants and sponsoring institution. Undergraduate exposure to academic surgery enhances interest in pursuing a surgical specialty and leads to academic productivity.

Clostridium difficile increases the risk for venous thromboembolism.

BACKGROUND: Inflammatory bowel disease is associated with a higher risk for venous thromboembolism (VTE). Whether Clostridium difficile infection similarly increases this risk is unknown. METHODS: This was a retrospective analysis of patients admitted to the surgical intensive care unit (ICU) at the Cedars-Sinai Medical Center from February 2011 to July 2013. The 2 groups were compared using standard statistical methodology. RESULTS: During the 30-month study period, a total of 1,728 patients were admitted to the surgical ICU. A total of 64 patients (3.7%) tested positive for C. difficile. The use of chemical prophylaxis for VTE was significantly higher in the C. difficile group (64.1% vs 46.2%, P = .005). Nonetheless, C. difficile patients had a higher risk for development of a VTE (23.4% vs 11.0%, adjusted odds ratio [95% confidence interval]: 1.87 [1.01 to 3.48], P = .048). In a forward logistic regression model, C. difficile was found to be independently associated with the development of VTE (adjusted odds ratio [95% confidence interval]: 1.87 [1.00 to 3.47], P = .049). CONCLUSIONS: C. difficile infection increases the risk for VTE in surgical patients admitted to the ICU.

Impact of positive fluid balance on critically ill surgical patients: a prospective observational study.

PURPOSE: The purpose of this study is to determine the effect of postoperative fluid balance (FB) on subsequent outcomes in acute care surgery (ACS) patients admitted to the surgical intensive care unit (ICU). MATERIAL AND METHODS: Acute care surgery patients admitted to the surgical ICU from 06/2012 to 01/2013 were followed up prospectively. Patients were stratified by FB into FB-positive (+) and FB-negative (-) groups by surgical ICU day 5 or day of discharge from the surgical ICU. RESULTS: A total of 144 ACS patients met inclusion criteria. Although there was no statistically significant difference in crude mortality (11% for FB [-] vs 15.5% for FB [+]; P=.422], after adjusting for confounding factors, achieving an FB (-) status by day 5 during the surgical ICU stay was associated with an almost 70% survival benefit (adjusted odds ratio [95% confidence interval], 0.31 [0.13, 0.76]; P=.010). In addition, achieving a fluid negative status by day 1 provided a protective effect for both overall and infectious complications (adjusted odds ratio [95% confidence interval], 0.63 [0.45, 0.88]; P=.006 and 0.64 [0.46, 0.90]; P=.010, respectively). CONCLUSIONS: In a cohort of critically ill ACS patients, achieving FB (-) status early during surgical ICU admission was associated with a nearly 70% reduction in the risk for mortality.

To swab or not to swab? A prospective analysis of 341 SICU VRE screens.

BACKGROUND: Vancomycin-resistant Enterococcus (VRE) screening is routine practice in many intensive care units despite the question of its clinical significance. The value of VRE screening at predicting subsequent VRE or other hospital-acquired infection (HAI) is unknown. The purpose of this investigation was to examine the rate of subsequent VRE HAI in patients undergoing VRE screening. METHODS: This study was conducted in a 24-bed surgical intensive care unit (SICU) at a Level I trauma center. Patients admitted to the SICU between February and August 2011 who had rectal swab for VRE screening within 72 hours were followed prospectively for the development of VRE and other HAIs. Demographics, clinical characteristics, and infection rates were compared between VRE-positive and VRE-negative patients. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VRE screening for predicting subsequent VRE HAI were calculated. RESULTS: A total of 341 patients had VRE screening within 72 hours of SICU admission, with 32 VRE-positive (9%) and 309 VRE-negative (91%) patients. VRE-positive patients had a higher incidence of any HAI (78% vs. 35%, p < 0.001). Eight VRE-positive patients (25%) developed VRE HAI compared with only 3 VRE-negative patients (1%) (p < 0.001). VRE screening had a 73% sensitivity, 93% specificity, 25% PPV, and 99% NPV for determining subsequent VRE HAI. CONCLUSION: VRE colonization was present in 9% of SICU patients at admission. Negative VRE screen result had a high specificity and NPV for the development of subsequent VRE HAI. Empiric treatment of VRE infection may be unnecessary in VRE-negative patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III. Therapeutic study, level IV.