The Impact of Homemade Laparoscopic Box Trainers on Medical Student Surgical Skills: A Randomized Control Pilot Study.

Objective: While instructional videos are commonly used in surgical education, there is a paucity of data on home laparoscopic box trainers. This pilot study evaluated impacts of augmenting instructional videos with these devices. Design: This was a randomized controlled pilot study evaluating laparoscopic surgical performance on the LapSim virtual surgical simulator before and after a 2 week curriculum of instructional videos alone (n = 8, 47.1%) vs videos plus a home laparoscopic box trainer (n = 9, 52.9%). The LapSim recorded mistake number, time, and instrument path length to complete each task. Participants completed surveys about their perceptions of surgery before and after the course. Participants: Preclinical medical students were recruited. Those with extensive surgical experience or did not complete the course were excluded. Results: For the box trainer group vs the videos alone group: mean change in mistakes was -10.0 (standard deviation [SD]:17.1) vs +.5 (SD:21.59) (P = .28); mean change in time was -433.24 (SD:304.67) seconds vs -366.16 (SD:240.10) seconds (P = .62); mean change in instrument path length was -4.27 (SD:4.38) meters vs -3.19 (SD:4.86) meters (P = .64). The box trainer group ranked "I feel as though surgery comes naturally" 1.58 points higher (95% confidence interval [CI]: .85, 2.32; P < .01) and "I am worried about being skilled at surgery" 1.26 points lower (95% CI: 2.29, -.24; P = .02) upon completing the study. The videos alone group reported no significant changes in survey responses. Conclusion: Home laparoscopic box trainers can generate confidence and reduce anxiety regarding surgical fields. This study provides a framework for future larger scale works.

South Texas orbital fracture protocol for emergency department evaluation of orbital fractures.

PURPOSE: Facial trauma and orbital fractures are common reasons for ophthalmology consultation in the emergency department (ED). The purpose of this study is to assess intervention rates and evaluate the acuity of ophthalmology consultation for orbital fractures in the ED. BASIC PROCEDURES: A retrospective chart review of orbital fractures was conducted over a 23-month period. 379 cases of orbital fractures were identified in a single-center study. All patients that received an ophthalmology consultation in the ED were included. Demographics, mechanism and location of orbital fracture, ophthalmic complications, and surgical and non-surgical ophthalmic interventions were recorded. The primary study outcome was the rate of ophthalmic consultation and intervention with and without retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP). RESULTS: Immediate ophthalmic intervention was performed in 18.7% of patients. Statistically significant subjective, radiographic, and physical exam features correlating with ophthalmic intervention were identified and included globe rupture, concern for entrapment, orbital roof fractures, and retrobulbar hematoma. Retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP) would have resulted in 186 of 379 patients requiring ophthalmology consultation, thus reducing consultation rate by 51% with an improved rate of intervention from 18.7% to 37.6%. CONCLUSIONS: Orbital fractures can be associated with severe ocular complications. Most cases, however, do not require emergent evaluation by an ophthalmologist. We propose the South Texas Orbital Fracture Protocol (STOP) for proper assessment and triaging of orbital fractures in the ED. While this clinical decision-making tool requires validation, it may offer improved healthcare efficiency, reduced costs, fewer unnecessary inter-facility transfers, and less burnout for ophthalmology residents.

Orbital roof fractures as an indicator for concomitant ocular injury.

BACKGROUND: Orbital roof fractures are a significant cause of morbidity in trauma and are associated with a spectrum of orbital and ocular injuries. This study aims to characterize orbital roof fracture patterns and quantify the rate of acute intervention as compared with non-roof involving orbital wall fractures. METHODS: This study is a retrospective analysis of 340 orbital wall fractures diagnosed by CT imaging from August 2015 to October 2016. Orbital wall fractures were categorized as roof involving (N = 50) and non-roof involving (N = 290). Comparisons were made between these two groups to indicate a statistically significant difference in mechanism of injury, subjective symptoms, CT and exam findings, and final plan of care to include acute ophthalmologic intervention at the time of consultation. RESULTS: Assault (40.7%) was the most common cause of non-roof-involving fractures while falls from height (20.0%) were associated with a higher rate of roof fractures. Roof-involving orbital wall fractures were associated with a higher prevalence of corneal abrasions (16.3%), lid lacerations (23.4%), and traumatic optic neuropathy (10.4%). A reliable subjective exam on initial ophthalmic consultation was not achieved in a larger proportion of roof fracture patients (30%). Despite this, the rate of acute intervention in this group (34%) was almost double, including lateral canthotomy and cantholysis. CONCLUSIONS: Concomitant ocular injury is common in roof-involving orbital wall fractures, and may require more urgent ophthalmologic evaluation and acute intervention. As subjective patient data is often less readily available, a high index of suspicion and thorough investigation is warranted in caring for patients with roof-involving orbital wall fractures.

Open globe trauma in a military hospital: a review of the Ocular Trauma Score to help predict enucleation or evisceration.

PURPOSE: The aim of this study was to use the Ocular Trauma Score (OTS) to review and analyze all the open globe injuries (OGIs) that presented to Brooke Army Medical Center (BAMC) from July 2011 to March 2017, and whether or not the OTS can be used to predict enucleation or evisceration. METHODS: Retrospective chart review was performed through the medical record systems at BAMC for all OGIs from July 2011 to March 2017. This study was not performed on wartime patients. The primary outcome measures were the variables in the OTS and need for enucleation or evisceration. RESULTS: A total of 126 OGIs in 125 patients were identified from July 2011 to March of 2017. A lower calculated OTS was negatively associated with the outcome variables. A total of 25 cases resulted in enucleation or evisceration (19.8%). Of these, 17 underwent enucleation and 8 underwent evisceration. The average OTS for all eyes was 37.15, and the average OTS for eyes resulting in enucleation or evisceration was 22. Retinal detachment (RD), afferent pupillary defect (APD), globe rupture, globe perforation, and presenting visual acuity (VA) were all found to be statistically significant risk factors in patients who underwent enucleation or evisceration. CONCLUSIONS: The present study shows that the OTS and the OTS pre-operative variables can help predict the likelihood that an OGI will ultimately result in enucleation or evisceration. Our study shows that the OTS is a valuable tool to use when evaluating OGI and can help in evidence-based counseling.

Fibrous Histiocytoma of the Lacrimal Sac in an 11-Year-Old Male.

Fibrous histiocytoma is a soft tissue tumor with cells resembling both fibroblasts and histiocytes. Occasionally in the orbit, they rarely arise in the lacrimal sac. Similar to prior cases described, the patient presented with symptoms of epiphora and a slowly enlarging mass inferior to the right medial canthus. Imaging demonstrated a circumscribed 1.2 cm × 1.1 cm × 1.1 cm mass within the lacrimal sac without surrounding bony destruction. Grossly, the tumor appeared homogenous and rubbery. Pathologic study results from the case demonstrated zones of hypercellularity and hypocellularity with a fibrous appearance, admixed with spindle cells and collections of foamy histiocytes. A diagnosis of benign fibrous histiocytoma was rendered, with the patient experiencing a complete resolution of symptoms at subsequent follow up. To the authors' knowledge, this is the first reported solitary case report of a fibrous histiocytoma of the lacrimal sac in a pediatric patient.

Elicitation of Diosgenin Production in Trigonella foenum-graecum (Fenugreek) Seedlings by Methyl Jasmonate.

The effects of methyl jasmonate (MeJA), an elicitor of plant defense mechanisms, on the biosynthesis of diosgenin, a steroidal saponin, were investigated in six fenugreek (Trigonella foenum-graecum) varieties (Gujarat Methi-2, Kasuri-1, Kasuri-2, Pusa Early Branching, Rajasthan Methi and Maharashtra Methi-5). Treatment with 0.01% MeJA increased diosgenin levels, in 12 days old seedlings, from 0.5%-0.9% to 1.1%-1.8%. In addition, MeJA upregulated the expression of two pivotal genes of the mevalonate pathway, the metabolic route leading to diosgenin: 3-hydroxy-3-methylglutaryl-CoA reductase (HMG) and sterol-3-ß-glucosyl transferase (STRL). In particular, MeJA increased the expression of HMG and STRL genes by 3.2- and 22.2-fold, respectively, in the Gujarat Methi-2 variety, and by 25.4- and 28.4-fold, respectively, in the Kasuri-2 variety. Therefore, MeJA may be considered a promising elicitor for diosgenin production by fenugreek plants.

Large Patent Ductus Arteriosus Masked by High Altitude Hypoxia Until Descent to Sea Level.

We present a 41-year-old female with progressive shortness of breath immediately after moving to sea level from high altitude. The patient was found to have a large PDA with systemic RV and PA pressures and pulmonary hypertension, which resolved following PDA closure.

A gentler approach to monitor for heart transplant rejection.

Despite developments in circulating biomarker and imaging technology in the assessment of cardiovascular disease, the surveillance and diagnosis of heart transplant rejection has continued to rely on histopathologic interpretation of the endomyocardial biopsy. Increasing evidence shows the utility of molecular evaluations, such as donor-specific antibodies and donor-derived cell-free DNA, as well as advanced imaging techniques, such as cardiac magnetic resonance imaging, in the assessment of rejection, resulting in the elimination of many surveillance endomyocardial biopsies. As non-invasive technologies in heart transplant rejection continue to evolve and are incorporated into practice, they may supplant endomyocardial biopsy even when rejection is suspected, allowing for more precise and expeditious rejection therapy. This review describes the current and near-future states for the evaluation of heart transplant rejection, both in the settings of rejection surveillance and rejection diagnosis. As biomarkers of rejection continue to evolve, rejection risk prediction may allow for a more personalized approach to immunosuppression.

Contemporary approach to cardiogenic shock care: a state-of-the-art review.

Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.

Clinical Characteristics of the 2019 Eastern Equine Encephalitis Outbreak in Michigan.

Background: Eastern equine encephalitis virus is a mosquito-borne alphavirus responsible for unpredictable outbreaks of severe neurologic disease in animals and humans. While most human infections are asymptomatic or clinically nonspecific, a minority of patients develops encephalitic disease, a devastating illness with a mortality rate of ≥30%. No treatments are known to be effective. Eastern equine encephalitis virus infection is rare in the United States, with an annual average nationwide incidence of 7 cases between 2009 and 2018. However, in 2019, 38 cases were confirmed nationwide, including 10 in Michigan. Methods: Data from 8 cases identified by a regional network of physicians in southwest Michigan were abstracted from clinical records. Clinical imaging and histopathology were aggregated and reviewed. Results: Patients were predominantly older adults (median age, 64 years), and all were male. Results of initial arboviral cerebrospinal fluid serology were frequently negative, and diagnosis was not made until a median of 24.5 days (range, 13-38 days) after presentation, despite prompt lumbar punctures in all patients. Imaging findings were dynamic and heterogeneous, with abnormalities of the thalamus and/or basal ganglia, and prominent pons and midbrain abnormalities were displayed in 1 patient. Six patients died, 1 survived the acute illness with severe neurologic sequelae, and 1 recovered with mild sequelae. A limited postmortem examination revealed diffuse meningoencephalitis, neuronophagia, and focal vascular necrosis. Conclusions: Eastern equine encephalitis is a frequently fatal condition whose diagnosis is often delayed, and for which no effective treatments are known. Improved diagnostics are needed to facilitate patient care and encourage the development of treatments.

Atrial Myxoma Presenting as an Atypical Stroke in a Young Patient With a Recent COVID-19 Infection.

Atrial myxomas are the most common primary tumor of the heart and can occasionally present as an ischemic stroke with neurologic symptoms secondary to embolic phenomena. We present a case of a 42-year-old male with multiple cardiovascular risk factors and coronavirus disease 2019 (COVID-19) infection two months prior who presented to the emergency department with unilateral left-sided weakness and paresthesia. After being diagnosed with multifocal ischemic strokes, further evaluation utilizing a transesophageal echocardiogram (TEE) revealed a 5 × 2 cm left atrial myxoma prolapsing the mitral valve, which was the presumed cause of the patient's strokes. The myxoma was successfully removed via robotic thoracoscopy. Our case demonstrates the importance of considering atrial myxoma in the evaluation of stroke in young and middle-aged patients even in the presence of multiple cardiovascular and thrombotic risk factors.

An Unusual Case of Buerger's Disease in a Pregnant Female.

Thromboangitis obliterans or Buerger's disease is a segmental inflammatory condition of small and medium-sized arteries and veins. It is commonly seen in males with age under 45 years and with a current or recent history of tobacco use, and in smokers. It is sporadic in young women. This report describes a primigravida with dry gangrene in both upper and lower limbs because of Buerger's disease. The primary diagnosis of the disease occurred first time in pregnancy at the 17th week of gestation with the patient reporting dry gangrene and pain in the digits and confirmed with a non-invasive Doppler study. The patient was screened for autoimmune diseases, diabetes mellitus, and the presence of hypercoagulable disorders. Echocardiography and arteriography were performed to rule out any source of emboli. The case report aims to discuss a rare diagnostic and therapeutic dilemma in the case of a pregnant woman presenting with gangrene without any history of tobacco addiction.

Multimodal etiology of drug induced angle closure with topical glaucoma therapy.

PURPOSE: We present a case of acute onset of bilateral choroidal effusions leading to angle closure glaucoma attributed to multiple mechanism of actions causing ciliary body and aqueous flow disruption in the setting of topical glaucoma therapy with latanoprost, brimonidine 0.2%, and Brinzolamide 0.1%. OBSERVATION: The patient presented with ocular hypertension in the setting of bilateral choroidal effusions, leading to angle closure without pupillary block. After cessation of the glaucoma drops and starting steroids and cycloplegics, the patient's symptoms resolved. CONCLUSIONS AND IMPORTANCE: This case report highlights the various physiological mechanisms of action that can induce angle closure glaucoma from commonly used topical medications for glaucoma treatment. Thus, a keen awareness is warranted of this idiosyncratic reaction in order to avoid morbidity and long term vision loss.

Delayed Presentation During COVID-19 Pandemic Leading to Post-Myocardial Infarction Ventricular Septal Defect.

Post-myocardial infarction ventricular septal defect (post-MI VSD) is a rare complication of ST-elevation myocardial infarction (STEMI) with an incidence of <1% in early revascularization era. Here we present the case of a 66-year-old woman with post-MI VSD owing to delay in her presentation in the current pandemic. Patient presented with worsening back pain and chest pain with confusion, and an EKG positive for inferior wall STEMI. She underwent emergent percutaneous intervention with placement of drug-eluting stent in her right coronary artery. She developed worsening heart failure and new-onset heart murmur and was found to have a VSD on a transthoracic echo. Because of her poor prognosis, family decided to pursue comfort care and patient unfortunately passed. Delay in seeking health care during the pandemic, as seen in our patient, is multifactorial including fear of contracting infection, decreased emergency medical services members, and concerns for overburdening healthcare systems. Lack of standardized in-hospital approach to emergencies while ensuring adequate protection from infection to healthcare workers, especially during the initial phase of the pandemic, led to increased door-to-balloon times in addition to the increased time to first medical contact. The importance of media outreach ensuring availability of health care in emergencies, changing emergency response algorithms to ensure safety of patients and healthcare providers, and including thrombolytic therapy where there is a delay due to stringent screening or delayed COVID-19 testing can be used to prevent worsening complications following STEMI.

5-Fluorouracil Induced Takotsubo Cardiomyopathy Complicated by Left Ventricular Thrombosis.

A 42-year-old woman with a remote history of smoking and recently diagnosed anorectal cancer presented with typical anginal chest pain, dyspnea, palpitations, and hallucinations. She was started on continuous 5-flurouracil (5-FU) infusion five days before presentation. Her physical examination was significant for bilateral bibasilar crackles and tachycardia. Her bloodwork was significant for an increased troponin and brain natriuretic peptide (BNP). Electrocardiogram (EKG) showed sinus tachycardia with ST elevation in multiple contiguous leads, whereas transthoracic echocardiogram (TTE) showed estimated ejection fraction of 17% with severe global hypokinesis with apical akinesis and matted thrombus at the apex. Coronary angiogram showed 20% occlusion of the left anterior descending artery. She was diagnosed with 5-FU induced Takotsubo cardiomyopathy complicated by left ventricular (LV) thrombosis. 5-FU was discontinued, uridine triacetate was given as reversal agent. Aspirin and apixaban were started for three months for LV thrombosis. Her six-week TTE showed return of normal heart function with resolution of LV thrombosis.

Diffuse alveolar haemorrhage in the setting of eosinophilic pneumonia.

A 65-year-old woman who presented with a constellation of symptoms, including cough with haemoptysis, fever, chills and hypoxia along with weight loss, was found to have diffuse alveolar haemorrhage. After a myriad of investigations returned normal, an open lung biopsy was performed, which revealed the diagnosis to be subacute eosinophilic pneumonia. This is one of its kind of rare presentations where eosinophilic pneumonia presents as diffuse alveolar haemorrhage and has been reported only five times prior to this.

Complete Genome Sequence of Neisseria musculi Using Illumina and PacBio Sequencing.

Neisseria musculi is an oral commensal of wild-caught mice. Here, we report the complete genome sequence of N. musculi strain NW831, generated using a combination of the Illumina and PacBio platforms.

Bartonella endocarditis in patients with right ventricle-to-pulmonary artery conduit: 2 case reports and literature review.

Bartonella species are Gram-negative bacilli and fastidious bacteria that can cause a number of clinical syndromes, including blood culture-negative infective endocarditis (IE). The two most commonly isolated species in humans are Bartonella quintana, the agent of trench fever, and Bartonella henselae, mostly known for causing cat scratch disease (Edouard et al., 2015 [1]; Edouard and Raoult, 2010 [2]). Both species also cause bacillary angiomatosis, primarily in immunocompromised patients (Edouard et al., 2015 [1]; Fournier et al., 2001 [3]). The risk of B. henselae IE is increased in patients with cardiac valvular disease and congenital heart disease (CHD) (Edouard and Raoult, 2010 [2]; Das et al., 2009 [4]; Abandeh et al., 2012 [5]; Ouellette et al., 2016 [6]; Hoffman et al., 2007 [7]; Georgievskaya et al., 2014 [8]). In this article, we detail two cases of Bartonella IE in patients with right ventricle-to-pulmonary artery (RV-PA) conduits who presented to our institution. We also perform a literature review on Bartonella IE in patients with a history of RV-PA conduit or pulmonary valve replacement.

Diplopia and Strabismus After Corneal Refractive Surgery.

INTRODUCTION: Diplopia and strabismus are known complications after corneal refractive surgery (CRS). Within the U.S. Armed Forces, refractive surgery is used to improve the operational readiness of the service member, and these complications could cause significant degradation to their capability. This study was performed in order to identify the incidence of strabismus and diplopia following CRS within the U.S. Military Health System. METHODS: A retrospective review of all patients who underwent photorefractive keratectomy (PRK) or laser-assisted in situ keratomileusis (LASIK) in the Department of Defense from January 2006 through September 2013 was designed and approved by the Naval Medical Center Portsmouth Institutional Review Board. The military health system data mart was queried for all patients who underwent one of these procedures and subsequently had an International Classification of Disease-9 code for any strabismus or diplopia through 2014 allowing at least 1 year of follow-up. We then calculated the incidence of both diplopia and strabismus for these procedures as the primary measure and the overall prevalence as a secondary measure. RESULTS: A total of 108,157 patients underwent PRK or LASIK during our study period with 41 of these patients subsequently having a diagnosis of diplopia or strabismus. After chart review, 16 of these patients were excluded resulting in 25 patients for inclusion in either the strabismus (23 patients, 0.02%) or diplopia (3 patients, 0.003%) cohorts with one patient having both. Of the 23 patients with postoperative strabismus, 4 were new cases giving an incidence of 0.004% and 2 new cases of diplopia for an incidence of 0.002%. CONCLUSION: Diplopia and strabismus are rare complications after CRS in the U.S. military population. These procedures continue to increase the operational readiness of our service members with minimal risk of these potentially debilitating complications. Overall, this study provides support for the continued use of PRK and LASIK despite study limitations related to the use of large databases for retrospective review. Future prospective studies using delineated preoperative and postoperative examinations with sensorimotor testing included may be able to resolve the limitations of this study.