Early pneumonia diagnosis decreases ventilator-associated pneumonia rates in trauma population.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a source of morbidity and mortality for trauma patients. Aspiration events are also common because of traumatic brain injury, altered mental status, or facial trauma. In patients requiring mechanical ventilation, early pneumonias (EPs) may be erroneously classified as ventilator associated. METHODS: A prospective early bronchoscopy protocol was implemented from January 2020 to January 2022. Trauma patients intubated before arrival or within 48 hours of admission underwent bronchoalveolar lavage (BAL) within 24 hours of intubation. Patients with more than 100,000 colony-forming units on BAL were considered to have EP. RESULTS: A total of 117 patients underwent early BAL. Ninety-three (79.5%) had some growth on BAL with 36 (30.8%) meeting criteria for EP. For the total study population, 29 patients (24.8%) were diagnosed with VAP later in their hospital course, 12 of which had previously been diagnosed with EP. Of EP patients (n = 36), 21 (58.3%) were treated with antibiotics based on clinical signs of infection. Of EP patients who had a later pneumonia diagnosed by BAL (n = 12), seven (58.3%) grew the same organism from their initial BAL. When these patients were excluded from VAP calculation, the rate was reduced by 27.6%. Patients with EP had a higher rate of smoking history (41.7% vs. 19.8%, p < 0.001) compared with patients without EP. There was no difference in median hospital length of stay, intensive care unit length of stay, ventilator days, or mortality between the two cohorts. CONCLUSION: Early pneumonia is common in trauma patients intubated within the first 48 hours of admission and screening with early BAL identifies patients with aspiration or pretraumatic indicators of pneumonia. Accounting for these patients with early BAL significantly reduces reported VAP rates. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Localized opacification of hydrophilic acrylic intraocular lenses after procedures using intracameral injection of air or gas.

PURPOSE: To describe clinical and laboratory findings in a series of cases of intraocular lens (IOL) opacification after procedures involving intracameral injections of air or gas. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. DESIGN: Experimental study. METHODS: Seven hydrophilic acrylic IOLs explanted after Descemet-stripping endothelial keratoplasty (DSEK) or Descemet-stripping automated endothelial keratoplasty (DSAEK) because of a localized central optic opacification associated with decrease in visual acuity and complaints of foggy vision were analyzed. The explanted IOLs were sent to our laboratory in the dry state or in fixative by the explanting surgeons. They underwent pathological and histochemical evaluation (alizarin red and von Kossa method). Light scattering measurements were also performed on the surface of 1 explant using Scheimpflug photography. A questionnaire was sent to the surgeons to obtain information pertinent to each case. RESULTS: The 7 explanted IOLs were represented by 6 hydrophilic acrylic designs from 5 manufacturers. Gross and light microscopy showed that granular deposits were densely distributed in an overall round pattern within the margins of the capsulorhexis or the pupil on the anterior surface/subsurface of the IOLs. The granules stained positive for calcium (alizarin red and von Kossa method). Light scattering on the anterior optic surface was very high (228 versus 13 computer-compatible tapes on a control IOL). CONCLUSIONS: A localized pattern of calcification was seen on the anterior surface/subsurface of various hydrophilic acrylic IOLs. Surgeons should be aware of this phenomenon following DSEK/DSAEK procedures in pseudophakic patients with hydrophilic acrylic IOLs. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

The long-term results of keratoplasty in eyes with a glaucoma drainage device.

PURPOSE: To study the outcome of penetrating keratoplasty (PK) in eyes with a glaucoma drainage device (GDD). DESIGN: Retrospective case-controlled study. METHODS: We reviewed all patients who underwent PK from December 1986 to September 2002 at the University of California, Davis (n = 1,974). We identified 33 patients (40 grafts) who were treated with a GDD and followed up for 6 months or more after PK. Graft survival and glaucoma control were compared with grafts in patients without glaucoma (n = 40) and patients with medically controlled glaucoma (n = 17). Kaplan-Meier survival analysis, log rank test, repeated-measures analysis of variance (ANOVA), Fisher exact test, and chi(2) were used in group comparisons. Multivariate analysis was performed using the Cox proportional hazards model. RESULTS: The percentages of clear grafts in the glaucoma drainage device group were 58.5% and 25.8% at 1 and 2 years, respectively. At these time points, glaucoma was controlled in 74.0% and 63.1% of the eyes, respectively. Both medically controlled glaucoma patients and nonglaucomatous patients had higher graft survival percentages at comparable time points. The presence of a GDD was an important factor influencing graft survival (Hazard ratio = 6.8). CONCLUSION: A GDD implant is an independent risk factor for graft failure. Although these devices are effective in controlling intraocular pressure (IOP) in the majority of eyes in the presence of PK, corneal graft clarity is often compromised.

Central retinal artery occlusion and disc edema in a child.

Obstruction of the retinal arterial system is most commonly associated with elderly patient populations. The major etiologic factor in adults has been attributed to emboli from atherosclerotic vascular disease of the carotid arteries, with about 75% of patients over the age of 40 years demonstrating this finding. Conversely, arterial obstruction in young patients is rarely secondary to atheromatous disease and has a variety of causative factors.(1) We describe an unusual case of a previously healthy 8-year-old boy who developed a unilateral central retinal artery occlusion in conjunction with marked optic disc edema. The etiology of these pathologic lesions was attributed to a viral-like syndrome. Vision rapidly deteriorated to no light perception and remained unchanged despite treatment.

Ocular findings in Jacobsen syndrome.

PURPOSE: To discuss the ophthalmic findings and their clinical significance in 10 new cases of Jacobsen syndrome (mental retardation, craniofacial anomalies, congenital heart defects, and blood dyscrasias) and to review the ophthalmic findings in all previously reported cases in the literature. METHODS: Ten new cases of Jacobsen syndrome were collected and studied prospectively for detection of abnormal ophthalmologic examination findings. A total of 63 previously reported cases were identified from Medline and analyzed for ophthalmologic abnormalities. RESULTS: The most common ophthalmologic findings in the new cases of Jacobsen syndrome included strabismus (90.0%), refractive error (90.0%), and ptosis (70.0%). Facial dysmorphism was also common and included hypertelorism, epicanthal folds, and down-slanting palpebral fissures. Uncommon ophthalmic findings included 5 patients with retinal vascular tortuosity, 1 with glaucoma, and 3 with amblyopia. In 63 cases reviewed, 36 reported ophthalmologic abnormalities. The most common findings included facial anomalies and ptosis. Only 5 of the 63 patients had evidence of strabismus, and none were reported to have retinal vascular tortuosity. CONCLUSIONS: To prevent unnecessary vision loss in children with Jacobsen syndrome, proper screening for amblyogenic factors is imperative. We recommend a baseline complete ophthalmologic examination with subsequent follow-up examinations depending on the particular findings noted during the initial screening visit.

A report of canine tooth syndrome.

The authors describe the case of a 5-year-old girl traumatized from a dog bite to the superior aspect of the orbit in the right eye. The dog's canine tooth penetrated deep into the posterior orbit and severed the attachment of the superior oblique muscle from the globe posterior to the trochlea. The management and clinical course of the patient are described and photographs documenting the initial ocular damage and postoperative course are provided. In addition, the entity known as 'canine tooth syndrome' is reviewed.