The Badges Program: A Self-Directed Learning Guide for Residents for Conducting Research and a Successful Peer-Reviewed Publication.

INTRODUCTION: The Badges Program is a self-directed supplement to a program's research curriculum. This step-by-step resource helps medical residents to understand the resources needed to conduct their own research project and fulfill the Accreditation Council for Graduate Medical Education requirements for scholarly activity. METHODS: The curriculum is completed over varying amounts of time depending on the intricacy of scholastic activities. Simple case reports may take as little as 1-2 weeks whereas months to years may be required if residents are completing more intricate and elaborate projects. Associated materials include a guide organized by topic followed by sequentially completed task assignments demonstrating the user has gained a basic understanding of the corresponding objective. Upon completing a task, the user obtains its educational badge, a virtual certificate of completion the program can then track with a simple checklist for progress. Several supplementary online articles review core concepts or provide examples and web-based tutorials for becoming proficient with using reference software. No faculty training is necessary. Residents go through the steps necessary to perform research so as to gain familiarity with the process. RESULTS: Qualitative feedback obtained by informally surveying residents who have completed the Badges Program has been very positive, with residents reporting that the guide was easy to follow and the knowledge gained will help tremendously with future projects. DISCUSSION: We hope that with feedback, this resource will be expanded and refined so every resident will be able to use the Badges Program regardless of previous skills, experience, and publications.

Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques.

OBJECTIVES: The goal of this study was to identify histomorphologic characteristics of atherosclerotic plaques and to determine the amenability of some of these components to be used as markers for invasive and noninvasive imaging. BACKGROUND: Rupture of the atherosclerotic plaques is responsible for the majority of acute coronary events, and the culprit lesions demonstrate distinct histopathologic features. It has been tacitly believed that plaque rupture (PR) is associated with angiographically minimally occlusive lesions. METHODS: We obtained 295 coronary atherosclerotic plaques, including stable (fibroatheroma [FA]; n = 105), vulnerable (thin-cap fibroatheroma [TCFA]; n = 88), and disrupted plaques (plaque rupture [PR]; n = 102) from the hearts of 181 men and 32 women who had died suddenly. The hierarchical importance of fibrous cap thickness, percent luminal stenosis, macrophage area, necrotic core area, and calcified plaque area was evaluated by using recursive partitioning analysis. Because clinical assessment of fibrous cap thickness is not possible by noninvasive imaging, it was excluded from the second set of partitioning analysis. RESULTS: Thickness of the fibrous cap emerged as the best discriminator of plaque type; the cap thickness measured <55 µm in ruptured plaques, and all FA were associated with >84-µm cap thickness. Although the majority of TCFA were found in the 54- to 84-µm thickness group, those with <54-µm thickness were more likely to show <74% luminal stenosis (area under the curve: FA, 1.0; TCFA, 0.89; PR, 0.90). After exclusion of cap thickness, analysis of the plaque characteristics revealed macrophage infiltration and necrotic core to be the 2 best discriminators of plaque types (area under the curve: FA, 0.82; TCFA, 0.58; PR, 0.72). More than 75% cross-section area stenosis was seen in 70% of PR and 40% of TCFA; only 5% PR and 10% TCFA were <50% narrowed. CONCLUSIONS: This postmortem study defines histomorphologic characteristics of vulnerable plaques, which may help develop imaging strategies for identification of such plaques in patients at a high risk of sustaining acute coronary events.

Functional profiling to select chemotherapy in untreated, advanced or metastatic non-small cell lung cancer.

BACKGROUND/AIM: To assess the impact of drug selection upon the treatment of advanced and metastatic non-small cell lung cancer (NSCLC), we applied a functional platform that measures drug-induced cell death in human tumor primary-culture micro-spheroids isolated from surgical specimens. PATIENTS AND METHODS: At diagnosis, microspheroids isolated by mechanical and enzymatic disaggregation were examined for drug-induced cell-death by morphology and staining characteristics. Drugs were administered using standard protocols. Thirty-one patients, who received at least one cycle of therapy, were evaluable. All patients signed informed consent. RESULTS: Twenty out of 31 patients responded (64.5%), 1 completely and 19 partially, providing a two-fold improvement over historical control of 30% (p=0.00015), a median time-to-progression of 8.5 months and a median overall survival of 21.3 months. CONCLUSION: This functional platform is feasible and provides a favorable objective response rate, time-to-progression and survival in advanced, metastatic, untreated NSCLC, and warrants further evaluation.

Descriptive epidemiology of intraocular pressure and corneal hysteresis among U.S. veterans.

PURPOSE: Several reports have revealed a difference in various populations regarding the variability of intraocular pressure (IOP) and corneal hysteresis (CH). This retrospective study was created to determine a profile for U.S. Veterans in a large outpatient clinical setting. OVERVIEW AND METHODOLOGY: The objective was to evaluate a random cohort of patient records in this clinical setting to determine the mean and standard deviation (SD) of the following parameters: Goldmann-correlated IOP (IOPg), CH, waveform score, and central corneal thickness from the Reichert Ocular Response Analyzer. RESULTS: All patient records were reviewed by Veteran Health Affairs Eye clinical staff which resulted in data collected on 538 eyes. The mean IOP of this cohort for IOPg was 17.39 (SD 10.08). The mean for CH was calculated at 9.61 (SD 3.04) with a waveform score mean of 5.66 (SD 2.18) and central corneal thickness for 207 eyes was a mean of 545.09 (SD 51.09) nm. CONCLUSION: From the results, IOPg appears to be significantly higher and CH significantly lower than other populations reported in the literature. This information provides an accurate baseline for the evaluation of the U.S. veteran population for future.

Carotid intima-media thickness is increased in patients with mucopolysaccharidoses.

BACKGROUND: The feasibility of carotid artery intima-media thickness (C-IMT), an established cardiovascular disease marker, as a cardiac risk marker in mucopolysaccharidosis (MPS) patients was explored. OBJECTIVES: To determine if C-IMT is abnormal in MPS versus unaffected controls, and if C-IMT correlates with coronary artery diameter in MPS. MATERIAL AND METHODS: Measurements of C-IMT via neck ultrasound and echocardiographic parameters, including coronary artery diameters, were obtained from MPS and control patients, and compared. RESULTS: Sixteen MPS subjects (6 MPS I, 6 MPS II, 2 MPS III, 1 MPS VI, 1 MPS VII) and sixteen age, ethnicity, and gender-matched controls were enrolled. Median MPS and control subject ages were 8.3±4.5 and 8.6±4.3 years, respectively (p=0.73). Mean MPS and control C-IMTs were 0.54±0.070 and 0.48±0.034 mm (p=0.0029). No differences in left main, left anterior descending, or right coronary artery diameters were seen between MPS and controls. A significant proportion of MPS subjects had mitral insufficiency (14/16; p=0.0002), aortic insufficiency (10/16; p=0.0021), and left ventricular dilatation (7/16, p=0.037) versus controls. C-IMT did not correlate significantly with age, height, weight, coronary measurements, or duration of treatment. CONCLUSION: C-IMT in MPS patients is increased compared to matched controls, likely reflective of arterial intima-medial glycosaminoglycan accumulation. MPS subjects demonstrated a high percentage of left-sided valvular insufficiency and ventricular dilatation. Additional studies should be performed in MPS patients to determine if C-IMT correlates with arterial elasticity, biomarkers of vascular dysfunction, and higher risk of cardiovascular events.

A comparison of the marginal adaptation of cathode-arc vapor-deposited titanium and cast base metal copings.

STATEMENT OF PROBLEM: A new fabrication process where a titanium coping, with a gold colored titanium nitride outer layer, can be reliably fused to porcelain; however, the marginal adaptation characteristics are undetermined. PURPOSE: The purpose of the study was to compare the clinically acceptable marginal adaptation (CAMA - defined as a marginal gap mean of ≤ 60 µm) rates of cathode-arc vapor-deposited titanium and cast base metal copings to determine whether the titanium copings would produce a higher CAMA rate than the cast base metal copings. MATERIAL AND METHODS: Thirty-seven cathode-arc vapor-deposited titanium copings and 40 cast base metal copings were evaluated using an optical microscope. Fifty vertical marginal gap measurements were made of each coping, and the mean of these measurements was used to form the gap score. A 1-tailed t test was used to compare the CAMA rates, and the Satterthwaite t-score was used to analyze the consistency of the coping adaptation (α =.05). RESULTS: CAMA was achieved by 24 of the 37 (64.86%) titanium copings compared to 19 of the 40 (47.50%) base metal copings. A 1-tailed t test produced a Z-score of 1.533 (1-tailed P=.063), which allowed acceptance of the study hypothesis with only a modest risk of a Type I error. CONCLUSIONS: Cathode-arc vapor-deposited titanium copings exhibited a higher rate of CAMA compared to base metal copings.

Application of pulsed radiofrequency currents to rat dorsal root ganglia modulates nerve injury-induced tactile allodynia.

BACKGROUND: Application of pulsed radiofrequency (PRF) currents to the dorsal root ganglia (DRG) has been reported to produce relief from certain pain states without causing thermal ablation. In this study, we examined the direct correlation between PRF application to DRG associated with spinal nerve injury and reversal of injury-induced behavioral hypersensitivity in a rat neuropathic pain model. METHODS: Neuropathic lesioning was performed via left L5 spinal nerve ligation on male adult Sprague-Dawley rats. Once the injured rats had developed tactile allodynia, one group was then assigned to PRF treatment of the L5 DRG and another group was assigned to the sham treatment to the DRG. Behavioral testing was performed on both the control and treated paws using the von Frey filament test before the surgery and at indicated days. The resulting data were analyzed using a linear mixed model to assess the overall difference between the treatment groups and the overall difference among the study days. Cohen's d statistic was computed from paired difference-from-baseline scores for each of the 14 study days after treatment and these measures of effect size were then used to descriptively compare the recovery patterns over time for each study group. RESULTS: Spinal nerve injury resulted in the development of behavioral hypersensitivity to von Frey filament stimulation (allodynia) in the hindpaw of the left (injury) side. Mixed linear modeling showed a significant difference between the treatment groups (P = 0.0079) and a significant change of paw withdrawal threshold means over time (P = 0.0006) for all 12 animals. Evaluation of Cohen's d (effect size) revealed that the PRF-treated animals exhibited better recovery and recorded larger effect sizes than the sham-treated animals on 10 of the 14 post-PRF treatment days and exhibited moderate-to-strong effects posttreatment at days 8 to 10 and at and beyond day 32. CONCLUSIONS: Findings from this study support that PRF of the DRG causes reversal of nerve injury (spinal nerve ligation)-induced tactile allodynia in rats. This allodynia reversal indicates that nonablative PRF acting via modulation of the DRG can speed recovery in nerve injury-induced pain.

The relationship of the bronchodilator response phenotype to poor asthma control in children with normal spirometry.

OBJECTIVE: To determine the relationship of poor asthma control to bronchodilator response (BDR) phenotypes in children with normal spirometry. STUDY DESIGN: Children with asthma were assessed for clinical indexes of poorly controlled asthma. Pre- and post-bronchodilator spirometry were performed, and the percent BDR was determined. Multivariate logistic regression assessed the relationship of the clinical indices to BDR at ≥ 8%, ≥ 10%, and ≥ 12% BDR thresholds. RESULTS: There were 510 controller naïve children and 169 on controller medication. In the controller naïve population the mean age (± 1 SD) was 9.5 (3.4); 57.1% were male, 85.7% Hispanic. Demographics were similar in both populations. In the adjusted profile, significant clinical relationships were found particularly to positive BDR phenotypes ≥ 10% and ≥ 12% versus negative responses including younger age, (OR 2.0, 2.5; P < .05), atopy (OR 1.9, 2.6; P < .01), nocturnal symptoms in females (OR 3.4, 3.8; P < .01); ß2 agonist use (OR 1.7, 2.8; P < .01); and exercise limitation (OR 2.2, 2.5; P < .01) only in the controller naïve population. CONCLUSIONS: The BDR phenotype ≥ 10% is significantly related to poor asthma control, providing a potentially useful objective tool in controller naïve children even when the pre-bronchodilator spirometry result is normal.

A randomized, controlled, double-blind study of light emitting diode photomodulation for the prevention of radiation dermatitis in patients with breast cancer.

BACKGROUND AND OBJECTIVES: Radiation dermatitis occurs in a majority of patients with breast cancer who receive radiation therapy (RT), causes significant pain, and may necessitate treatment delay. Light emitting diode (LED) photomodulation has been reported to minimize radiation dermatitis. This study sought to further evaluate the efficacy of LED photomodulation in lessening radiation dermatitis. MATERIALS & METHODS: After surgery, patients with breast cancer received LED photomodulation or sham treatments in conjunction with three-dimensional conformal RT. Reactions were evaluated using standardized photographs graded according to National Cancer Institute criteria. RESULTS: In the LED treatment group (n=18), no patients had grade 0 reactions, six (33.3%) had grade 1 reactions, 12 (66.7%) had grade 2 reactions, and none had a grade 3 reaction. In the sham treatment group (n=15), one (6.6%) patient had a grade 0 reaction, four (26.7%) had grade 1 reactions, 9 (60.0%) had grade 2 reactions, and one (6.7%) had a grade 3 reaction. Two (11.1%) patients in the LED treatment group and one (6.7%) in the control group had to interrupt treatment. Differences between groups were not statistically significant. CONCLUSION: LED photomodulation did not reduce the incidence of radiation-induced skin reactions or interruptions in therapy. .

Differences in editorial board reviewer behavior based on gender.

BACKGROUND: Reports indicate that there are gender-based differences in aspects of the peer-review process. METHODS: This is an analysis of editorial board members' reviews of original research submissions based on gender using the web-based management program, Editorial Manager, from January 1, 2002, through December 31, 2008. We evaluated recommendations of editorial board members for acceptance/rejection using a four-tier system, agreement with editor's final decision, turnaround time from review request to submission, and editors' grades of reviews on a 5-point scale. We evaluated the performance of editorial board members with advancing tenure, seeking trends in recommendations over time. RESULTS: We included 6062 manuscript reviews representing 5958 manuscripts; 67% were assigned to male editorial board members and 33% to females. There were 38 editorial board members (25 men, 13 women) with tenure duration from 2 to 4.9 years, and 3 editors (2 men, 1 woman) serving 7, 7, and 6 years, respectively. Women were less likely to accept or accept with minor revisions than men (p < 0.003). Median turnaround times were 14 (0-55) days for women and 10 (0-33) days for men (p < 0.001). The editors' grades assigned to women were more often than men's grades in the very good to exceptional category (p < 0.0001). There was no difference based on gender, with approximately 73% decision congruence overall with the editors' final decisions. Men rejected more manuscripts than did women with advancing tenure on the editorial board (p < 0.0001). CONCLUSIONS: There are differences based on gender of editorial board members' recommendations about manuscript triage, turnaround time, and editors' grades assigned. Overall, however, these differences do not affect editors' ultimate decisions about manuscript publication.

Multisensor smart system on a chip.

Sensors are becoming of considerable importance in several areas, particularly in health care. Therefore, the development of inexpensive and miniaturized sensors that are highly selective and sensitive, and for which control and analysis is present all on one chip is very desirable. These types of sensors can be implemented with microelectromechanical systems (MEMS), and because they are fabricated on a semiconductor substrate, additional signal processing circuitry can easily be integrated into the chip, thereby readily providing additional functions, such as multiplexing and analog-to-digital conversion. Here, we present a general framework for the design of a multisensor system on a chip, which includes intelligent signal processing, as well as a built-in self-test and parameter adjustment units. Specifically, we outline the system architecture and develop a transistorized bridge biosensor for monitoring changes in the dielectric constant of a fluid, which could be used for in-home monitoring of kidney function of patients with renal failure.

Measuring accurate IOPs: Does correction factor help or hurt?

PURPOSE: To evaluate if using the Ehlers correction factor on the intraocular pressure (IOP) measured using the Goldmann applanation tonometer (GAT) improves its agreement with the PASCAL dynamic contour tonometer (DCT). PATIENTS AND METHODS: A total of 120 eyes of 120 individuals were examined. Participants underwent IOP measurement with both the DCT and the GAT and central corneal thickness measurement. The Ehlers correction factor was applied on the GAT IOP measurements to calculate Ehlers-corrected GAT IOP. The agreement between the DCT and GAT, and DCT and Ehlers-corrected GAT IOP was analyzed. The analyses were repeated by stratifying the data by race. RESULTS: The mean IOP of the GAT, DCT, and the Ehlers-corrected GAT was 15.30, 16.78, and 14.68 mmHg, respectively. The agreement as assessed by Bland-Altman plot for the GAT with the DCT and DCT and Ehlers-corrected GAT IOP was +4.1 to -6.9 and +4.15 to -8.25 mmHg, respectively. The results were similar even when stratifying the data by race. CONCLUSION: Using Ehlers correction factor to account for the effect of corneal parameters on the IOP measured by the GAT worsens the agreement with the DCT. This effect remains even when stratifying the data by race.

Portugal na visão unamuniana da Ibéria como unidade dialética / Portugal in Unamuno's view of Iberia as a dialectic unity

Embora as relações do intelectual espanhol Miguel de Unamuno com Portugal tenham recebido bastante atenção crítica, o enfoque dessa tem sido a afirmação do interesse, mantido por décadas, de Unamuno pela terra e pela literatura portuguesa, e a confirmação de relações de influência entre Unamuno e escritores portugueses destacados. Longe disso, neste trabalho consideraremos como Unamuno incorpora Portugal numa concepção geral da Ibéria como unidade dialética, e demonstraremos como seu uso de um vocabulário corporal, de carne y hueso, contribui para dar sentido pleno à sua visão de tal Ibéria dialética, na qual Portugal desempenha um papel integral.

While the topic of the Spanish intellectual Miguel de Unamuno's rela­tionship with Portugal has received a good deal of scholarly attention, this has focused on affirming Unamuno's longstanding interest in Portuguese literature and history, and on confirming the existence of relationships of influence between Unamuno and prominent Portuguese writers. This paper, instead, will consider how Unamuno fits Portugal into his broader vision of Iberia as a dialectical unity, and will demonstrate how Unamuno's use of a corporeal vocabulary, of carne y hueso, contributes to the fleshing out of his vision of a dialectical Iberia, in which Portugal plays an integral role.

Improved predictive models for plasma glucose estimation from multi-linear regression analysis of exhaled volatile organic compounds.

Exhaled volatile organic compounds (VOCs) represent ideal biomarkers of endogenous metabolism and could be used to noninvasively measure circulating variables, including plasma glucose. We previously demonstrated that hyperglycemia in different metabolic settings (glucose ingestion in pediatric Type 1 diabetes) is paralleled by changes in exhaled ethanol, acetone, and methyl nitrate. In this study we integrated these gas changes along with three additional VOCs (2 forms of xylene and ethylbenzene) into multi-linear regression models to predict plasma glucose profiles in 10 healthy young adults, during the 2 h following an intravenous glucose bolus (matched samples of blood, exhaled and room air were collected at 12 separate time points). The four-gas model with highest predictive accuracy estimated plasma glucose in each subject with a mean R value of 0.91 (range 0.70-0.98); increasing the number of VOCs in the model only marginally improved predictions (average R with best 5-gas model = 0.93; with 6-gas model = 0.95). While practical development of this methodology into clinically usable devices will require optimization of predictive algorithms on large-scale populations, our data prove the feasibility and potential accuracy of breath-based glucose testing.

Side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain: A survey of practitioners.

OBJECTIVE: To study the side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain. DESIGN: Practitioner postal survey. SETTING: Postal survey of practitioners of prolotherapy for back and neck pain in the United States and Canada. PARTICIPANTS: A sample of prolotherapy practitioners from 2 professional organizations were surveyed about their training and experience, use of specific treatment procedures, estimated prevalence of side effects, and adverse events related to prolotherapy for back and neck pain. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence of side effects and adverse events. RESULTS: Surveys were completed by 171 practitioners (response rate, 50%). Ninety-eight percent held medical degrees, and 83% were board certified in various disciplines. Respondents had a median of 10 years of experience, during which they had treated a median of 500 patients and given a median of 2000 treatments. Side effects with the highest median estimated prevalence were pain (70%), stiffness (25%), and bruising (5%). There were 472 reports of adverse events, including 69 that required hospitalization and 5 that resulted in permanent injury secondary to nerve injury. The vast majority (80%) were related to needle injuries such as spinal headache (n = 164), pneumothorax (n=123), temporary systemic reactions (n = 73), nerve damage (n = 54), hemorrhage (n = 27), nonsevere spinal cord insult (ie, meningitis, paralysis, spinal cord injury) (n = 9), and disk injury (n = 2). CONCLUSIONS: Side effects related to prolotherapy for back and neck pain, such as temporary postinjection pain, stiffness, and bruising, are common and benign. Adverse events related to prolotherapy for back and neck pain are similar in nature to other widely used spinal injection procedures. Further study is needed to fully describe the adverse event profile of prolotherapy for back and neck pain.

Exercise-induced bronchoconstriction alters airway nitric oxide exchange in a pattern distinct from spirometry.

Exhaled nitric oxide (NO) is altered in asthmatic subjects with exercise-induced bronchoconstriction (EIB). However, the physiological interpretation of exhaled NO is limited because of its dependence on exhalation flow and the inability to distinguish completely proximal (large airway) from peripheral (small airway and alveolar) contributions. We estimated flow-independent NO exchange parameters that partition exhaled NO into proximal and peripheral contributions at baseline, postexercise challenge, and postbronchodilator administration in steroid-naive mild-intermittent asthmatic subjects with EIB (24-43 yr old, n = 9) and healthy controls (20-31 yr old, n = 9). The mean +/- SD maximum airway wall flux and airway diffusing capacity were elevated and forced expiratory flow, midexpiratory phase (FEF(25-75)), forced expiratory volume in 1 s (FEV(1)), and FEV(1)/forced vital capacity (FVC) were reduced at baseline in subjects with EIB compared with healthy controls, whereas the steady-state alveolar concentration of NO and FVC were not different. Compared with the response of healthy controls, exercise challenge significantly reduced FEV(1) (-23 +/- 15%), FEF(25-75) (-37 +/- 18%), FVC (-12 +/- 12%), FEV(1)/FVC (-13 +/- 8%), and maximum airway wall flux (-35 +/- 11%) relative to baseline in subjects with EIB, whereas bronchodilator administration only increased FEV(1) (+20 +/- 21%), FEF(25-75) (+56 +/- 41%), and FEV(1)/FVC (+13 +/- 9%). We conclude that mild-intermittent steroid-naive asthmatic subjects with EIB have altered airway NO exchange dynamics at baseline and after exercise challenge but that these changes occur by distinct mechanisms and are not correlated with alterations in spirometry.

Incidence of acute endophthalmitis following penetrating keratoplasty: a systematic review.

OBJECTIVE: To determine the incidence of acute endophthalmitis following penetrating keratoplasty (PK) over time. METHODS: A systematic review of English-language articles was conducted by performing a broad search of the PubMed database from 1963 through March 2003 using such keywords as penetrating keratoplasty, endophthalmitis, and postoperative complication. Additional studies were identified from bibliographies of relevant articles and published proceedings. The proportion of eyes with acute endophthalmitis as a postoperative complication was recorded, and pooled incidence rates were assessed over time. RESULTS: From 1870 unique, potentially relevant citations, 66 original studies that addressed endophthalmitis and met the selection criteria were analyzed. A total of 90 549 PKs were pooled, resulting in an overall estimate of 0.382% post-PK endophthalmitis, but a change over time was noted. The rate of endophthalmitis was 0.200% in the 2000-2003 period, 0.453% in the 1990s, 0.376% in the 1980s, and 0.142% during the 1970s. Furthermore, a downward trend in the incidence of endophthalmitis after 1992 was observed compared with 1991 and earlier. CONCLUSIONS: This systematic review indicates that the incidence of endophthalmitis associated with PK has declined during the last decade.

Acute endophthalmitis following cataract surgery: a systematic review of the literature.

OBJECTIVES: To determine the reported incidence of acute endophthalmitis following cataract extraction over time and to explore possible contributing factors, such as type of cataract incision. METHODS: A systematic review of English-language articles was conducted by performing a broad search of PubMed from 1963 through March 2003 using such terms as cataract extraction, endophthalmitis, and postoperative complication. Additional studies were identified from bibliographies of relevant articles and published proceedings. Surgical approach was recorded, when available. Pooled incidence rates and relative risks of developing endophthalmitis using different incision techniques were assessed. RESULTS: From 4916 unique, potentially relevant citations, 215 studies that addressed endophthalmitis and met the selection criteria were analyzed. A total of 3 140 650 cataract extractions were pooled resulting in an overall rate of 0.128% of postcataract endophthalmitis. However, the incidence of acute endophthalmitis changed over time, with a significant increase since 2000 compared with previous decades (relative risk, 2.44 [95% confidence interval, 2.27-2.61]). The rate of endophthalmitis was 0.265% in the 2000-2003 period, 0.087% in the 1990s, 0.158% in the 1980s, and 0.327% during the 1970s. Furthermore, an upward trend in rates after 1992 was noted, compared with 1991 and prior. Incision type appeared to significantly influence risk, as endophthalmitis following clear corneal cataract extraction during the 1992-2003 period was 0.189% compared with 0.074% (relative risk, 2.55 [95% confidence interval, 1.75-3.71]) for scleral incision and 0.062% (relative risk, 3.06 [95% confidence interval, 2.48-3.76]) for limbal incision. CONCLUSIONS: This systematic review indicates that the incidence of endophthalmitis associated with cataract extraction has increased over the last decade. This upward trend in endophthalmitis frequency coincides temporally with the development of sutureless clear corneal incisions.