The perceived impact of curricular and non-curricular factors on specialty interests and choice during medical school at a single center in the United States.

BACKGROUND: Limited information exists regarding how medical students' specialty interests evolve throughout medical school, particularly interest in surgical versus non-surgical specialties. Our objective was to identify medical students' specialty interests before and after medical school and the most important curricular and non-curricular factors that shaped their specialty choice. METHODS: An online 22-question voluntary, anonymized survey was designed to assess specialty interests and factors impacting specialty choice at a single medical school in the United States. The study was pilot-tested with focus groups. The final questionnaire was distributed to final-year medical students from the Classes of 2020 and 2021. Responses were measured on a 5-point Likert scale (1 = strong negative impact to 5 = strong positive impact). RESULTS: 102 of 184 students (55%) from Class of 2020 and 85 of 174 students (49%) from Class of 2021 participated. Of 187 respondents, the majority (60%) decided on their specialty during third year. 74 of 147 students (50%) pursued a specialty among their initial specialty interests. Students with initial surgical interests were significantly (p < 0.001) less likely to choose surgical specialties (42%) compared to students with initial non-surgical interests choosing non-surgical specialties (79%). Pre-clinical years (3.67 ± 0.96) were perceived to have a significantly (p < 0.001) less positive impact on specialty interests and choice compared to clinical years. Among pre-clinical factors, physician shadowing (3.80 ± 0.83) was perceived to have the significantly (p < 0.001) greatest positive impact. During clinicals, 34% of respondents indicated that order of clerkships impacted specialty choice. 112 of 171 respondents (65%) indicated that mentorship impacted specialty choice. Physicians in the chosen specialty were perceived to have the strongest impact (4.67 ± 0.49). 65 of 171 respondents (38%) indicated that peers impacted specialty choice with classmates (3.98 ± 0.87) and near-peers (3.83 ± 0.74) perceived to have a positive impact. CONCLUSIONS: Specialty interests changed during medical school for a significant portion of students (50%). Those with initial surgical interests were more likely to change their specialty interests. Pre-clinicals were reported to have less impact on specialty choice compared to clinicals. Implementing factors such as shadowing and physician/peer mentorship, which may positively impact specialty choice, into pre-clinical curricula warrants further investigation.

Comparison of postoperative analgesia with two different doses of dexmedetomidine as an adjuvant to ropivacaine in adductor canal block for unilateral total knee replacement surgery: A randomized double-blinded study.

Background and Aims: Multimodal analgesia is used to treat severe postoperative pain (POP) in total knee replacement (TKR) surgery. Adjuvants are used with local anesthetics to improve the quality and duration of pain relief. Studies comparing different doses of dexmedetomidine in adductor canal block (ACB) are sparse to date. This study compares postoperative analgesia with two different doses of dexmedetomidine as an adjuvant to 0.2% ropivacaine in ACB for unilateral TKR. Material and Methods: In this prospective, randomized, double-blinded comparative study, sixty patients were divided into two groups: A and B. Postoperatively perineural catheter was inserted and all patients received 0.2% ropivacaine 20 mL bolus followed by an infusion of 0.2% ropivacaine with dexmedetomidine (0.5 µg/Kg in Group A and 1 µg/Kg in Group B) at 8 mL/h. Postoperative pain, motor blockade, rescue analgesia, hemodynamic parameters, sedation, and adverse effects were recorded. Student t, Chi-square, and Mann-Whitney tests were used. Results: Most patients were elderly females (M:15, F:45). Postoperatively, from 2nd to 24th hour, pain score was less in Group B (P < 0.05). The requirement of rescue analgesic was also less in Group B (A:B 330 µg:60 µg; 23%:6%). Motor blockade assessed using modified Bromage scale and sedation using Richmond agitation sedation scale did not show any statistical difference. Conclusion: Dexmedetomidine infusion at 1 µg/Kg is a better adjuvant to 0.2% ropivacaine than 0.5 µg/Kg in ACB. It provides better analgesia without producing sedation, motor blockade, hemodynamic changes, or any adverse effects.

Biplanar-pivoted V-Y Flap for Reconstruction of Medial Canthal Defects.

PURPOSE: To determine the safety and effectiveness of a biplanar-pivoted V-Y flap design in reconstructing medial canthal defects of all sizes. METHODS: Retrospective review of patients who underwent repair of medial canthal region defects with the biplanar-pivoted V-Y flap from January 2016 to May 2021. Variables collected included age, gender, surgical indication, defect sizes and location, flap(s) and/or graft(s) used, and follow-up time. Outcome measures included complications, patient satisfaction with cosmesis, ability to close the defect with minimal wound tension, and additional surgeries. RESULTS: Eighteen cases of medial canthal, nasal sidewall, and nasojugal fold area reconstruction were performed using a biplanar-pivoted V-Y flap in 18 patients. The cohort included 7 males and 11 females with a mean age of 72.4 years (range, 52-92 years) and mean follow-up time of 4.4 months (range, 1-14 months). Mean defect size was 2.0 × 1.4 cm (range, 0.5-5.5 cm). Eight patients received concomitant full-thickness skin grafts, five patients underwent simultaneous rotational flap repair, one patient underwent simultaneous nasoglabellar myocutaneous flap repair, and one patient received a simultaneous traditional, nonbiplanar V-Y plasty of the upper eyelid. All defects were closed with no wound tension. No cases of infection, hemorrhage, or wound dehiscence occurred during follow-up. Complications included mild ectropion (2 patients) and mild tip necrosis (1 patient). No patients elected for reoperation. No trapdoor deformity was observed. No patients underwent reoperation for local tumor recurrence. CONCLUSIONS: The extended mobility of the biplanar-pivoted V-Y flap provides excellent closure of defects involving the medial canthal region with minimal surgical complications.

A CASE REPORT OF CHRONIC ENDOPHTHALMITIS SECONDARY TO AQUAMICROBIUMterrae.

PURPOSE: Chronic postoperative endophthalmitis is a known complication of cataract surgery. Here, we report a case of chronic endophthalmitis following uncomplicated cataract surgery secondary to the atypical bacterium Aquamicrobium terrae . METHODS: Retrospective case report of a single patient with endophthalmitis secondary to A. terrae. RESULTS: A 61-year-old healthy patient presented with recurrent iridocyclitis following uncomplicated cataract surgery. Repeated attempts to taper off topical steroid eyedrops were unsuccessful. Anterior chamber paracentesis cultures and vitrectomy cultures grew the same gram-negative bacillus, A. terrae , on six different occasions. The patient was treated initially with a series of intravitreal ceftazidime injections and adjuvant oral minocycline with recurrence of inflammation necessitating pars plana vitrectomy with intraocular lens removal and total capsulectomy. Inflammatory episodes recurred until residual capsule fragments were ablated using endoscopic vitrectomy. Since ablation over 18 months ago, no further recurrences have occurred and the patient has excellent visual outcome. CONCLUSION: A. terrae is a gram-negative bacillus recovered from polluted soil. This is the first case of postoperative endophthalmitis secondary to A. terrae and the first description of human infection caused by this newly identified microbe.

A READABILITY COMPARISON OF ONLINE SPANISH AND ENGLISH PATIENT EDUCATION MATERIALS ABOUT VISION HEALTH.

PURPOSE: Current United States national guidelines recommend patient education materials (PEMs) be written at a 5th-6th grade level. The objective of this study was to compare the readability of Spanish vision and eye health PEMs to nationally recommended reading levels and to English versions of the same PEMs. METHODS: PEMs were collected from seven online websites of vision-related organizations that provided PEMs with Spanish and English versions. PEMs were downloaded for text to be extracted and analyzed. Readability scoring was performed with Índice Flesch-Szigriszt, Spanish and English Lexile Text Analyzers, and Flesch-Kincaid Grade Level. RESULTS: A total of 484 PEMs with Spanish and English versions were analyzed. Readability for Spanish PEMs was reported at or above the 6th grade level for 57% of articles based on Spanish Lexile scoring and 63% based on Índice Flesch-Szigriszt scoring. Readability for English PEMs was reported at or above the 6th grade level for 66% of articles based on English Lexile scoring and 75% based on Flesch-Kincaid Grade Level scoring. Wilcoxon signed-rank test comparing grade levels translated from Lexile scores for Spanish and English versions of PEMs revealed that Spanish versions of PEMs required higher grade reading levels compared to English versions of PEMs (p < .001). CONCLUSION: Spanish and English PEMs were written above nationally recommended reading levels. Online sources providing multilingual vision and eye health education should consider routinely monitoring PEMs to ensure reading levels meet the literacy needs of their audiences.

Immunotherapy-Resistant Vitreoretinal Metastatic Melanoma.

PURPOSE: To describe 2 cases of vitreoretinal metastases in patients treated with immunotherapy for metastatic melanoma. METHODS: Retrospective case series. RESULTS: We pre-sent 2 patients with metastatic melanoma treated with systemic immunotherapy with subsequent development of ocular vitreoretinal metastasis. The first patient was a male with metastatic melanoma from a site of unknown origin that was in complete remission following a course of ipilimumab and nivolumab therapy. He presented to an outside provider for evaluation of vitritis and a pigmented lesion in the right eye that was presumed secondary to toxoplasmosis. After failing initial management with oral antibiotics, he underwent diagnostic pars plana vitrectomy, and vitreous biopsy was consistent with metastatic melanoma to the vitreous. He was additionally found to have an elevated pigmented retinal mass consistent with a retinal metastasis from melanoma that initially failed treatment with plaque brachytherapy and ultimately required enucleation. The second case was a monocular male with metastatic melanoma from cutaneous melanoma with decreased vision 3 months after the initiation of nivolumab therapy. He presented with dense vitreous debris in his seeing eye and was thought to have nivolumab-associated inflammation. He was initially treated with difluprednate with improved vision and decrease in vitreous debris, but developed dense pigment deposition in the affected eye later in the treatment course. Diagnostic pars plana vitrectomy was performed, and vitreous biopsy was positive for malignant melanoma cells. His systemic disease was in remission at the time of diagnosis of ocular metastasis. External beam radiation was recommended given his monocular status. CONCLUSION: Vitreoretinal metastasis can develop despite favorable systemic response to immunotherapy in patients with metastatic cutaneous melanoma. Lack of ocular penetration and extension of life span with immunotherapeutic agents may be the underlying mechanism for vitreoretinal metastasis.

Interest in Telehealth Among Patients With Chronic Retinal Conditions.

Purpose: This work investigated interest in telehealth services for patients with chronic retinal conditions. Methods: A single-center, multi-office study was conducted of patients with chronic retinal conditions who were seen by 1 of 4 physicians during June 2020. Patients whose next appointment was 6 months or later were telephoned. Patients completed a phone interest survey about their interest in a hybrid telehealth evaluation instead of a complete office evaluation with their provider. Results: Of 2136 patients reviewed, 453 met eligibility to participate in the survey. A total of 159 patients (35.1%) participated, of whom 91 (57.2%) indicated an interest in telehealth at their next follow-up visit. Of the 68 (42.8%) patients without a current interest in telehealth, 13 (19.1%) expressed interest in pursuing telehealth in the future. Age (P = .19), sex (P = .22), race (P = .79), office location (P = .19), number of prior visits (P = .58), and median household income by patient's zip code (P = .14) were not predictors of telehealth interest. Among diagnoses, dry age-related macular degeneration was associated (P = .04) with increased interest in telehealth. An increased number of ocular diagnoses were also found to predict a decreased (P = .04) interest in telehealth. multivariable analysis revealed healthcare provider as the only significant predictor for interest in telehealth (P = .03). Conclusions: Most patients with chronic retinal conditions may be interested in incorporating telehealth into routine care. Considerations should be made to evaluate interest in telehealth to guide patients to clinical experiences that best suit their needs.

Local therapy for cancer therapy-associated uveitis: a case series and review of the literature.

BACKGROUND/AIMS: Immunotherapy and targeted therapy for metastatic cancer may cause immune-related adverse events (irAEs) such as uveitis. If irAEs are severe or require systemic steroids, cancer therapy is often held or discontinued. Local steroid therapy for cancer therapy-associated uveitis allows the continuation of cancer therapy. This series demonstrates successful management of cancer therapy-associated uveitis with local therapy based on uveitis subtype. METHODS: This is an Institutional Review Board-approved retrospective case series of patients with uveitis secondary to immunotherapy or targeted therapy managed with local treatment, and focused literature review. RESULTS: Five patients (median age: 54, range 31 to 75) were included. Time to uveitis onset following cancer therapy initiation was 3 to 12 months. All patients received checkpoint inhibitor therapy; one patient additionally received targeted therapy. Two patients presented with anterior uveitis, two with panuveitis and one with posterior uveitis. Four of five patients demonstrated evidence of posterior segment inflammation on multimodal imaging. Anterior uveitis was successfully treated with topical prednisolone acetate 1% (PA 1%) alone, and posterior segment involvement recalcitrant to topical PA 1% was treated successfully with topical difluprednate, intravitreal triamcinolone acetonide or a combination. Patients with isolated anterior uveitis did not require maintenance topical therapy; those with posterior and panuveitis required chronic low-dose topical therapy. CONCLUSION: Based on our series as well as the existing literature demonstrating the use of local therapy for irAEs, we propose an approach to local therapy for cancer therapy-associated uveitis starting with topical steroids and initiating injectable steroids in cases of recalcitrant panuveitis or posterior uveitis. Subclinical inflammation on posterior segment imaging responds robustly to difluprednate or intravitreal steroid therapy, and patients with posterior segment involvement may require more aggressive management and long-term maintenance.

Most patients are eligible for an alternative to conventional whole breast irradiation for early-stage breast cancer: A National Cancer Database Analysis.

We evaluated the proportion of patients eligible for alternatives to standard whole breast irradiation (WBI) following breast-conserving surgery using the National Cancer Database (NCDB). Using the 2016 dataset, Stage I-III patients were identified. Eligibility for hypofractionated WBI (HFRT), accelerated partial breast irradiation (APBI) and endocrine therapy (ET-alone) was defined using eligibility from large clinical trials as well as consensus guidelines. For patients with pN0 breast cancer, 20.6% and 37.0% were eligible for ET-alone based on the CALGB 9343/PRIME-II trials, respectively. In terms of HFRT, 72.5% and 50.4% were eligible based on IMPORT LOW/ASTRO HFRT guidelines, respectively. Based on IMPORT LOW/GEC-ESTRO trial/ASTRO guidelines/ABS guidelines/GEC-ESTRO guidelines, 72.5%, 86.1%, 39.0%, 72.5%, 45.7%, respectively, were eligible for APBI. Of those who qualify for HFRT per ASTRO guidelines, approximately 90% were eligible for APBI and 50% for ET-alone. This analysis shows that a large proportion of patients with node-negative breast cancer are eligible for HFRT, APBI and/or ET-alone after breast-conserving surgery.

Factors Associated With Acute and Chronic Wound Complications in Patients With Soft Tissue Sarcoma With Long-term Follow-up.

OBJECTIVES: To identify the rates of acute and chronic wound complications and factors associated in a cohort of patients treated for soft tissue sarcoma (STS) with modern radiotherapy (RT) and surgical techniques. MATERIALS AND METHODS: An Institutional Review Board-approved database was used to identify all adult nonmetastatic patients treated for STS at a single institution between 2006 and 2015 with a minimum follow-up of 1 year. Factors associated with acute and chronic wound complications were analyzed using binomial logistic regression including interaction terms. RESULTS: In all, 271 patients were identified with a median follow-up of 3.2 years. The rate of acute wound complications was 22.1%. On univariate analysis, trunk versus extremity location (P<0.001), radiation therapy (P=0.04), and preoperative therapy (P=0.03) were associated with acute wound complications and a trend was noted for reconstruction (P=0.07). On multivariate analysis, extremity tumors were associated with a higher rate of acute wound complications compared with trunk tumors without RT (P=0.02). Utilization of RT was associated with increased risk for extremity tumors (P=0.07). The rate of chronic wound complications was 3.3%. Radiation was associated with increased chronic wound complications (P=0.03) and trends were noted for trunk versus extremity location (P=0.08) and a history of acute wound complications (P=0.12). CONCLUSIONS: Several factors associated with acute and chronic wound complications were identified in STS patients including timing of RT, tumor site, and reconstruction use. The development of acute wound complications may also be associated with an increased risk of chronic wound complications.