El trasplante de córnea en Villa Clara: diez años transcurridos de la primera intervención quirúrgica / Corneal transplantation in Villa Clara: after ten years the first surgical intervention

Introducción: La córnea constituye el elemento más importante del sistema óptico, al ser el primer medio transparente del ojo; tiene la finalidad de mejorar la calidad de la imagen que se forma en la retina, por lo que su transparencia es imprescindible para poder obtener una buena agudeza visual. Cuando sus capas están afectadas por diferentes enfermedades, se requiere sustituir este tejido dañado; este procedimiento, denominado trasplante de córnea o queratoplastia, tiene diferentes finalidades. Objetivo: Caracterizar los resultados de la cirugía de trasplante de córnea tras diez años del primer procedimiento quirúrgico en la provincia de Villa Clara. Métodos: Se realizó un estudio observacional descriptivo longitudinal retrospectivo, con una muestra de 204 pacientes operados de trasplante de córnea en el Hospital Universitario Clínico-Quirúrgico «Arnaldo Milián Castro» de Villa Clara, en el período comprendido entre 2008 y 2018. Las variables estudiadas fueron: sexo, finalidad del procedimiento, diagnóstico y complicaciones. Resultados: Predominó el sexo masculino (53,4 %); la finalidad más frecuente del trasplante tuvo fines ópticos (85,8 %); principal diagnóstico: la queratopatía bullosa (42,7 %); dentro de las complicaciones más frecuentes estuvieron: el rechazo al injerto, el defecto epitelial y el glaucoma secundario. Conclusiones: La cirugía de trasplante de córnea en la provincia de Villa Clara significa un gran avance en el desarrollo y perfeccionamiento para el tratamiento de múltiples afecciones corneales. Los diagnósticos más frecuentes fueron: la queratopatía bullosa y las opacidades corneales; las complicaciones más frecuentes, el rechazo al injerto, la aparición de defectos epiteliales y el glaucoma secundario.

Introduction: the cornea constitutes the most important element of the optical system, being the first transparent medium of the eye; its purpose is to improve the quality of the image that is formed on the retina, so its transparency is essential to obtain good visual acuity. When its layers are affected by different diseases, it is required to replace this damaged tissue; this procedure called cornea transplant or keratoplasty has different purposes. Objective: to characterize the results of corneal transplant surgery ten years after the first surgical procedure in Villa Clara province. Methods: a retrospective, longitudinal, descriptive and observational study was carried out with a sample of 204 patients who underwent corneal transplant surgery at "Arnaldo Milián Castro" Clinical and Surgical University Hospital in Villa Clara between 2008 and 2018. Age, purpose of the procedure, diagnosis and complications were the variables studied. Results: male gender predominated (53.4%); the most frequent purpose of the transplant was for optical purposes (85.8%); bullous keratopathy (42.7%) was the main diagnosis as well as, graft rejection, epithelial defect and secondary glaucoma were among the most frequent complications. Conclusions: corneal transplant surgery in Villa Clara province means a great advance in the development and improvement for the treatment of multiple corneal conditions. The most frequent diagnoses were bullous keratopathy and corneal opacities; graft rejection, the appearance of epithelial defects and secondary glaucoma were the most frequent complications.

Androgen Receptor Inhibitors in the Treatment of Acne Vulgaris: Efficacy and Safety Profiles of Clascoterone 1% Cream.

The purpose of this narrative review is to provide a summary of the clinical trials on the efficacy and safety of clascoterone 1% cream (Winlevi) to grant providers an understanding of which patients will benefit most from this novel topical antiandrogen medication. Clascoterone 1% cream (Winlevi) offers a new and exciting treatment approach for a difficult and common skin condition such as acne vulgaris. This topical androgen antagonist is the first of its kind but will hopefully provoke investigations into other androgen receptor antagonists with similar or better efficacy.

Teledermatology and Skin of Color Patients.

The COVID-19 pandemic popularized telemedicine for many medical systems around the world. Although it came with many advantages for some individuals, it created challenges for other populations, particularly patients with skin of color and minority populations (largely comprised of patients with skin of color). The social determinants of health (SODH) are defined as individuals' living, working, and learning circumstances that can affect their health and quality of life.

The Shortage of Trauma Surgeons in the US.

BACKGROUND: As the United States (US) population increases, the demand for more trauma surgeons (TSs) will increase. There are no recent studies comparing the TS density temporally and geographically. We aim to evaluate the density and distribution of TSs by state and region and its impact on trauma patient mortality. METHODS: A retrospective cohort analysis of the American Medical Association Physician Masterfile (PM), 2016 US Census Bureau, and Centers for Disease Control and Prevention (CDC's) Web-based Injury Statistics Query and Reporting System (WISQARS) to determine TS density. TS density was calculated by dividing the number of TSs per 1 000 000 population at the state level, and divided by 500 admissions at the regional level. Trauma-related mortality by state was obtained through the CDC's WISQARS database, which allowed us to estimate trauma mortality per 100 000 population. RESULTS: From 2007 to 2014, the net increase of TS was 3160 but only a net increase of 124 TSs from 2014 to 2020. Overall, the US has 12.58 TSs/1 000 000 population. TS density plateaued from 2014 to 2020. 33% of states have a TS density of 6-10/1 000 000 population, 43% have a density of 10-15, 12% have 15-20, and 12% have a density >20. The Northeast has the highest density of TSs per region (2.95/500 admissions), while the Midwest had the lowest (1.93/500 admissions). CONCLUSION: The density of TSs in the US varies geographically, has plateaued nationally, and has implications on trauma patient mortality. Future studies should further investigate causes of the TS shortage and implement institutional and educational interventions to properly distribute TSs across the US and reduce geographic disparities.

Gender, Race, Age, Allopathic Degree, Board Score, and Research Experience Among Applicants Matching to General and Orthopedic Surgery Residencies, 2015-2019.

BACKGROUND: Surgical fields are historically dominated by male physicians. Increasing the diversity of the physician workforce improves training and patient experiences. We aim to investigate any differences in qualifications and match rates between male and female applicants to general surgery (GS) and orthopedic surgery (OS) residencies in the United States. METHODS: A retrospective cohort analysis was performed utilizing the Association of American Medical Colleges data regarding Electronic Residency Application Service (ERAS) applicants and matched Accreditation Council for Graduate Medical Education (ACGME) residents into GS and OS residencies from 2015 to 2019. Descriptive statistics and independent sample T-tests were performed with significance defined as P < .05. RESULTS: 26 568 GS and 7076 OS ERAS applicants matched at a rate of 25.2% and 55.3%, respectively. Men and women matched into GS at rates of 23.0% and 29.2%, respectively. Men and women matched into OS at rates of 55.2% and 56.2%, respectively. Men aged ≥36 years matched into OS at a significantly higher rate than women aged years ≥36 (11.9% vs. 1.4%, P = .009). Female GS ERAS applicants and entering ACGME residents had a higher mean number of research experiences than male GS ERAS applicants (2.66 vs. 2.26, P < .001) and entering male GS ACGME residents (2.96 vs. 2.56, P = .008). CONCLUSIONS: Male and female GS and OS applicants have similar qualifications. Women match into GS and OS at higher rates than men but comprise disproportionately lower numbers of applicants. Greater mentorship opportunities and recruitment of female applicants are needed to expand, diversify, and increase representation of women in surgery.

Emergency Medical Service Transport Time and Trauma Outcomes at an Urban Level 1 Trauma Center: Evaluation of Prehospital Emergency Medical Service Response.

BACKGROUND: The use of helicopter emergency medical services (HEMS) for trauma patients has been debated since its introduction. We aim to compare outcomes for trauma patients transported by ground EMS (GEMS) vs. HEMS using raw and adjusted mortality in a level 1 trauma center. METHODS: A 6-year retrospective cohort study utilizing our level 1 trauma center registry for patients transferred by GEMS or HEMS was performed. Demographics and outcome measures were compared. Raw and adjusted mortality was evaluated. Adjusted mortality was determined incorporating confounders, including patient demographics, comorbid conditions, mechanism of injury, injury severity score (ISS), Glasgow Coma Scale score, and EMS transport time. Chi-square, multivariable logistic regression, and independent sample T-test were utilized with significance, defined as P < .05. RESULTS: Of 12 633 patients, 10 656 were transported via GEMS and 1977 with HEMS. Mean age was 55 for GEMS and 40 for HEMS (P < .001). Mean ISS was 9.29 and 11.73 for GEMS and HEMS (P < .001). Mean Revised Trauma Score was higher (less severe) for GEMS vs. HEMS (7.6 vs. 7.12, P < .001). Mean transport times for GEMS and HEMS was 39.45 vs. 47.29 minutes (P = .02). Raw mortality was 2.55% (307/10 656) for GEMS and 6.78% (134/1977) for HEMS. Adjusted mortality revealed a 16.6% increased mortality for GEMS compared to HEMS (adjusted odds ratio = 1.166, 95% CI: .815-1.668). CONCLUSIONS: Air-lifted trauma patients were younger, more severely injured, and more hemodynamically unstable and required longer transport time but experienced lower adjusted mortality. Future research is needed to investigate whether reducing transport times and augmenting the advanced care already implemented by HEMS crews can improve outcomes.

Venous Thromboembolism Chemoprophylaxis in Trauma and Emergency General Surgery Patients: A Systematic Review.

BACKGROUND: Appropriate venous thromboembolism (VTE) chemoprophylaxis in trauma and emergency general surgery (EGS) patients is crucial. OBJECTIVE: The purpose of this study is to review the recent literature and offer recommendations for VTE chemoprophylaxis in trauma and EGS patients. METHODS: We conducted a literature search from 2000 to 2021 for articles investigating VTE chemoprophylaxis in adult trauma and EGS patients. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. RESULTS: Our search resulted in 34 articles. Most studies showed low-molecular-weight heparin (LMWH) is similar to unfractionated heparin (UFH) for VTE prevention; however, LMWH was more commonly used. Adjusted chemoprophylaxis dosing did not change the VTE rate but the timing did. Direct oral anticoagulants (DOACs) have been shown to be safe and effective in trauma and traumatic brain injury (TBI)/spinal cord injury (SCI). Studies showed VTE prophylaxis in EGS can be inconsistent and improves with guidelines that lower VTE events. CONCLUSIONS: There may be no benefit to receiving LMWH over UFH in trauma patients. In addition, different drugs under the class of LMWH do not change the incidence of VTE. Adjusted dosing of enoxaparin does not seem to affect VTE incidence. The use of DOACs in the trauma TBI and SCI setting has been shown to be safe and effective in reducing VTE. One important consideration with VTE prophylaxis may be the timing of prophylaxis initiation, specifically as it relates to TBI, with a higher likelihood of developing VTE as time progresses. EGS patients are at a high risk of VTE. Improved compliance with clinical guidelines in this population is correlated with decreased thrombotic events.

Post-traumatic Splenic Injury Outcomes for Nonoperative and Operative Management: A Systematic Review.

BACKGROUND: Splenectomies are widely performed, but there exists controversy regarding care for splenic injury patients. The purpose of this study is to provide a comprehensive review of the literature over the last 20 years for operative management (OM) versus nonoperative management (NOM) versus splenic artery embolization (SAE) for traumatic splenic injuries and associated outcomes. METHODS: A review of literature was performed following the PRISMA guidelines through a search of PubMed, EMBASE, Cochrane Library, JAMA Network, and SAGE journals from 2000 to 2020 regarding splenic injury in trauma patients and their management. Articles were then selected based on inclusion/exclusion criteria with GRADE criteria used on the included articles to assess quality. RESULTS: Twenty retrospective cohorts and one prospective cohort assessed patients who received OM versus NOM or SAE. Multiple studies indicated that NOM, in properly selected patients, provided better outcomes than its operative counterpart. CONCLUSION: This review provides additional evidence to support the NOM of splenic injuries for hemodynamically stable patients with benign abdomens as it accounts for consistently shorter hospital length of stay, fewer complications, and lower mortality than OM. For hemodynamically unstable patients, management continues to be intervention with surgery. More studies are needed to further investigate outcomes of post-splenectomy patients based on grade of injury, hemodynamic status, type of procedure (i.e., SAE), and failure of NOM in order to provide additional evidence and improve outcomes for this patient population.

The Impact of Hospital/University Affiliation on Research Productivity Among US-Based Authors in the Fields of Trauma, Surgical Critical Care, Acute Care, and Emergency General Surgery.

BACKGROUND: Research productivity is critical to academic surgery and essential for advancing surgical knowledge and evidence-based practice. We aim to determine if surgeon affiliation with top US universities/hospitals (TOPS) is associated with increased research productivity measured by numbers of peer-reviewed publications in PubMed (PMIDs). METHODS: A bibliometric analysis was performed for PMIDs. Affiliated authors who published in trauma surgery (TS), surgical critical care (SCC), acute care surgery (ACS), and emergency general surgery (EGS) were evaluated for publications between 2015 and 2019, and lifetime productivity. Our analysis included 3443 authors from 443 different institutions. Our main outcome was PMIDs of first author (FA) and senior author (SA) in each field (2015-2019) and total lifetime publications. RESULTS: Significant differences exist between PMIDs from TOPS vs non-TOPS in FA-TS (1.34 vs 1.23, P = .001), SA-TS (1.71 vs 1.46, P < .001), total SA-PMIDs (44.10 vs 26.61, P < .001), and SA-lifetime PMIDs (90.55 vs 59.03, P < .001). There were no significant differences in PMIDs for FA or SA-SCC, FA or SA-ACS, FA or SA-EGS, FA-total PMIDs 2015-2019, or FA-lifetime PMIDs (P > .05 for all). CONCLUSION: There were significantly higher TS PMIDs among FAs and SAs affiliated with top US institutions in 2015-2019, along with higher total PMIDs (2015-2019) and lifetime PMIDs. These findings are of significance to future graduate medical applicants and academic surgeons who need to make decisions about training and future career opportunities.

SARS-CoV-2 pharmacologic therapies and their safety/effectiveness according to level of evidence.

INTRODUCTION: There is a pressing need for COVID-19 transmission control and effective treatments. We aim to evaluate the safety and effectiveness of SARS-CoV-2 pharmacologic therapies as of August 2, 2020 according to study level of evidence. METHODS: PubMed, ScienceDirect, Cochrane Library, JAMA Network and PNAS were searched. The following keywords were used: ((COVID-19) OR (SARS-CoV-2)) AND ((((((therapeutics) OR (treatment)) OR (vaccine)) OR (hydroxychloroquine)) OR (antiviral)) OR (prognosis)). Results included peer-reviewed studies published in English. RESULTS: 15 peer-reviewed articles met study inclusion criteria, of which 14 were RCTs and one was a systematic review with meta-analysis. The following pharmacologic therapies were evaluated: chloroquine (CQ), hydroxychloroquine (HCQ), antivirals therapies, plasma therapy, anti-inflammatories, and a vaccine. CONCLUSION: According to level 1 evidence reviewed here, the most effective SARS-Co-V-2 pharmacologic treatments include remdesivir for mild to severe disease, and a triple regimen therapy consisting of lopinavir-ritonavir, ribavirin and interferon beta-1b for mild to moderate disease. Also, dexamethasone significantly reduced mortality in those requiring respiratory support. However, there is still a great need for detailed level 1 evidence on pharmacologic therapies.

A systematic review of the causes and prevention strategies in reducing gun violence in the United States.

BACKGROUND: Approximately 100 lives are lost each day as a result of gun violence in the United States (US) with civilian mass shootings increasing annually. The gun violence rate in the US is almost 20 times higher than other comparable developed countries and has the most gun ownership per capita of any nation in the world. Understanding the causes and risk factors are paramount in understanding gun violence and reducing its incidence. METHODS: A literature search of all published articles relating to gun violence and mass shootings in the US was conducted using the Medline and PMC databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used in conducting this study. Rayyan statistical software was utilized for analysis. Statistical significant was defined as p < .05. RESULTS: Of the initial 2304 eligible manuscripts identified, 22 fulfilled our selection criteria. A variety of common causal and contributory factors were identified including but not limited to mental illness, suicidal ideation, intimate partner violence, socioeconomic status, community distress, family life, childhood trauma, current or previous substance abuse, and firearm access. CONCLUSION: Gun violence is pervasive and multi-factorial. Interventions aimed at reducing gun violence should be targeted towards the most common risk factors cited in the literature such as access, violent behavioral tendencies due to past exposure or substance abuse, and mental illness including suicidal ideation.

Uncommon Presentation of Severe Empyema of the Gallbladder: Case Report and Literature Review.

BACKGROUND Empyema of the gallbladder is a complication of cholecystitis that can develop into sepsis if not treated promptly. Signs and symptoms of gallstone disease are nausea/vomiting, right upper quadrant tenderness, and a history of gallstone disease. With persistence of the obstruction, inflammation and bacterial overgrowth within the gallbladder lumen and tissue may lead to eventual venous congestion, pressure necrosis and even empyema of the gallbladder. CASE REPORT A 60-year old male presented with complaints of mild mid-epigastric pain radiating to the back. He denied previous similar history. CT and ultrasound of the abdomen revealed acute cholecystitis. During surgery, it was clear that the imaging did not accurately represent the severity of the infection and he was diagnosed with gallbladder empyema. Surgery was difficult but was successfully finished. The patient's symptoms and laboratory results normalized by post-operative day 3 and he was discharged. He had no further complications during 2-week follow up. CONCLUSIONS Physicians should keep the abnormal presentations of gallbladder empyema in mind and prepare themselves for a presentation different from imaging during surgery. Several prognostic factors including gallbladder wall thickness, gender, white cell count and diabetes mellitus have been associated with severe complicated cholecystitis and empyema of the gallbladder.

Disparities in Adult and Pediatric Trauma Outcomes: a Systematic Review and Meta-Analysis.

BACKGROUND: Although safeguards requiring emergency care are provided regardless of a patient's payor status, disparate outcomes have been reported in trauma populations. The purpose of this systematic review and meta-analysis was to determine whether race/ethnicity or insurance status had an effect on mortality and to systematically present the literature in the adult and pediatric trauma populations during the last decade. METHODS: An online search of PubMed, Cochrane Library, Google Scholar, and SAGE Journals was performed for publications from January 2009 to March 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. The GRADE Working Group criteria were utilized to assess the evidence quality. A meta-analysis was conducted to compare mortality between insured/uninsured and Caucasian/non-Caucasian patients. RESULTS: Our search revealed 680 publications that qualified for evaluation. Of these, 41 were included in the final analysis. Twenty-six studies included adults only, nine studies included pediatric patients only, and six studies evaluated both. Twelve studies evaluated the effects of race/ethnicity, 18 examined insurance status, and 11 investigated both. Uninsured patients had 22% greater odds of death than insured patients (OR 1.22; CI 1.21-1.24). Non-Caucasian patients had 18% greater risk of death than Caucasian patients (OR 1.18; CI 1.17-1.20). CONCLUSION: Both the adult and pediatric trauma populations suffer outcome disparities based on race/ethnicity and insurance status. Overall, patients without insurance coverage and minority groups (i.e., non-Caucasians) had worse outcomes, as measured by odds of death and all-cause mortality.