Dry eye in the upper blepharoplasty patient: a study comparing orbicularis-sparing versus orbicularis-excising techniques.

PURPOSE: To compare subjective and objective dry eye syndrome (DES) metrics preoperatively and postoperatively in patients undergoing bilateral upper eyelid blepharoplasty (ULB) using orbicularis-sparing versus orbicularis-excising techniques. METHODS: A double-blind, randomized clinical trial was conducted on patients without prior DES or other severe conditions who presented to our institution between 2017 and 2019 for routine functional ULB. Patients were randomized into two treatment arms: bilateral ULB using the orbicularis-sparing technique or bilateral ULB using the orbicularis-excising technique. One subjective and seven objective DES assessments were performed on all patients preoperatively and 1 month and 1 year after surgery. RESULTS: A total of 63 patients were recruited for the study. Standard Patient Evaluation of Eye Dryness (SPEED) scores decreased in both treatment groups at 1 month and 1 year postoperatively. This change did not significantly vary based on surgical technique. Objective DES assessments were not significantly changed at both postoperative time points for either group. There was a correlation between the severity of preoperative DES symptoms and the subjective improvement of DES symptoms postoperatively in both groups. CONCLUSIONS: ULB with an orbicularis-sparing or orbicularis-excising technique does not worsen subjective or objective DES metrics and so, surgeons may confidently use either surgical technique. These findings may impact postoperative expectations for surgeons and patients alike.

An Efficacy Study of Voice Quality Using Cepstral Analyses of Phonation in Parkinson's Disease before and after SPEAK-OUT!®.

INTRODUCTION: SPEAK-OUT!® is a behavioral treatment for hypokinetic dysarthria in persons with Parkinson's disease (PD) that has become an alternative to the gold-standard Lee Silverman Voice Treatment (LSVT) in recent years. Acoustic evaluation of the efficacy of SPEAK-OUT!® therapy has focused on prosody. The purpose of this study was to investigate SPEAK-OUT!® efficacy in terms of vocal quality and its impact on quality of life. Vocal quality was measured acoustically using cepstral peak prominence (CPP) analysis and the Acoustic Voice Quality Index (AVQI) and perceptually using clinical ratings of speech performance. Impact on quality of life was measured with the Voice Handicap Index (VHI) and Voice-Related Quality of Life (V-RQOL). An additional goal of this study was to investigate whether dysarthria severity and disease duration were predictive of changes in voice quality due to SPEAK-OUT!®. METHODS: Pre- and post-therapy data included PD participants' acoustic and perceptual ratings of audio recordings. Demographic data included age, sex, diagnosis, duration of PD, and severity of dysarthria. RESULTS: Participants achieved significant improvement in the vowel and sentence CPP smoothed (CPPS) mean score as well as in their AVQI score post SPEAK-OUT!® treatment. Improvements in AVQI correlated negatively with disease duration and positively with dysarthria severity. DISCUSSION/CONCLUSION: SPEAK-OUT!® is effective in improving voice quality in patients with hypokinetic dysarthria due to idiopathic PD. Patients with more severe dysarthria and with a shorter disease duration may benefit the most, supporting earlier intervention. As for the type of measurement, AVQI combines acoustics from both vowel and sentence contexts and may therefore be the measure of choice over CPPS (vowel) or CPPS (sentence).

The Impact of the Affordable Care Act on Trauma Outcomes in At-Risk Groups: An Interrupted Time Series Analysis with Control Group.

OBJECTIVE: Analyze the impact of the Affordable Care Act (ACA) on trauma outcomes at a population level and within at-risk subgroups. BACKGROUND: Trauma disproportionately affects the uninsured. Compared to the insured, uninsured patients have worse functional outcomes and increased mortality. The goal of the ACA was to increase access to insurance. METHODS: An interrupted time series was conducted using data from the National Inpatient Sample database between 2011 and 2016. Data from Alberta, Canada was used as a control group. Mortality, length of stay, and probability of discharge home with or without home health care was examined using monthly time intervals, with January 2014 as the intervention time. Single and multiple group interrupted time series were conducted. Subgroup analyses were conducted using income quartiles and race. RESULTS: After the intervention, there was a monthly reduction in mortality of 0.0148% ( P < 0.01) in the American cohort: there was no change in the Canadian cohort. The White subgroup experienced a mortality reduction: the non-White subgroup did not. There was no significant change in length of stay or discharge home rate at a population level. There was a monthly increase in the probability of discharge with home health (0.0247%: P < 0.01); this was present in the lower-income quartiles and both race groups. The White subgroup had a higher rate of utilization of home health pre-ACA, and this discrepancy persisted post-ACA. CONCLUSIONS: The ACA is associated with improved mortality and increased use of home health services. Discrepancies amongst racial groups and income quartiles are present.

There Is No Weekend Effect in the Trauma Patient.

BACKGROUND: The presence of a "weekend effect", that is, increased morbidity/mortality for patients admitted to the hospital on a weekend, has been reported in numerous studies across many specialties. Postulated causes include reduced weekend staffing, increased time between admission and undergoing procedures/surgery, and decreased subspecialty availability. The aim of this study is to evaluate if a "weekend effect" exists in trauma care in the United States. METHODS: Using the 2012-2015 National In-patient Sample database from the Healthcare Cost and Utilization Project, adults with trauma diagnoses who were admitted nonelectively were analyzed. Using logistic and negative binomial regression adjusted for survey-related discharge weights and statistically significant covariables, mortality and length of stay (LOS) were assessed, respectively. Subgroup analysis was conducted using rural, urban teaching, and urban nonteaching hospital-type subgroups. Additional subgroup analysis of patients who required surgery during admission was also performed. RESULTS: A total of 22,451 patients were identified, with 3.94% admitted to rural and 81.42% to urban hospitals. Weekend admission did not have a statistically significant difference in adjusted-mortality (OR 0.928; 95% CI 0.858-1.003; P = 0.059) or LOS (IRR 0.978; 95% CI 0.945-1.011; P = 0.199). There was also no statistically significant increase in mortality or LOS for weekend admits in any of the hospital subgroups. CONCLUSIONS: There does not appear to be a weekend effect for trauma admission. This may be explained by the nature of trauma care in the United States, in which there is often 24-h in-house coverage regardless of day of the week. Replicating a trauma service coverage schedule may help other services decrease the presence of the weekend effect.

Impact of e-cigarette use among a cohort of American Indian cigarette smokers: associations with cigarette smoking cessation and cigarette consumption.

INTRODUCTION: Despite American Indian/Alaska Native (AI/AN) people having the highest prevalence of cigarette smoking nationwide, few studies have evaluated e-cigarette use among AI/AN adults who smoke. The primary objective of this observational pilot cohort study was to determine if e-cigarette use is associated with cigarette smoking cessation or reduction among adult AI individuals who smoke. METHODS: In 2016, we collected baseline survey and biomarker data among AI adults who smoke. The survey included questions about cigarette consumption and use of e-cigarettes and biomarkers, such as salivary cotinine markers and exhaled carbon monoxide. After 18 months, we repeated data collection, and asked about changes in cigarette smoking status and cigarettes per day (CPD). Comparisons between groups were performed using the χ2 test, Fisher's exact test or Wilcoxon rank-sum test. RESULTS: Of 375 baseline participants, 214 (57.07%) returned for follow-up and were included in analyses. Of these, 20 (9.3%) reported having stopped cigarette smoking and had biochemical verification of cigarette smoking abstinence. Among those who quit smoking, 15% were baseline e-cigarette users; while among those who continued to smoke at follow-up, about 11% were baseline e-cigarette users. This difference was not statistically significant (p=0.48). Among all those who continued to smoke at follow-up, there was no overall decrease in CPD, nor a significant difference in change in CPD between baseline e-cigarette users and non-users (p=0.98). CONCLUSIONS: E-cigarette use at baseline was not associated with smoking cessation or a change in CPD in this cohort of AI adults who smoke after an 18-month follow-up period.

Vaping patterns, nicotine dependence and reasons for vaping among American Indian dual users of cigarettes and electronic cigarettes.

BACKGROUND: The American Cancer Society discourages the dual use of electronic cigarettes (ECs) and cigarettes because such use has not resulted in reduced exposures to the harmful effects of smoking. American Indian (AI) people have the highest prevalence of smoking and of EC use in the United States, but very little is known about dual EC and cigarette use in AI communities. METHODS: In 2016, 375 adult AI in Oklahoma who smoked cigarettes completed a survey about EC use (vaping). We describe vaping patterns, nicotine dependence, and reasons for EC use among the subset of 44 (12%) current dual EC users. To differentiate habitual EC users from occasional or merely curious users, we defined dual use as using ECs on some days or every day in the past 30 days. RESULTS: About one-third of dual users vaped ten or more times daily. About two-thirds used a tank product. Eleven percent used ECs without nicotine and another 9% were unsure of the nicotine content. A minority (40%) enjoyed vaping more than smoking, and most (76%) would smoke first on days they did both. Thirty-one percent vaped within 5 min of waking and another 24% within 30 min. Although the two-item heaviness of use index did not differ significantly between smoking and vaping, the ten-item Penn State Dependence Index (PSDI) suggested greater dependence on smoking than vaping (11.02 vs. 6.42, respectively; p < .0001). The most common reasons for vaping were to reduce smoking (79%), enjoyment of flavors (78%), and ability to vape where smoking is not allowed (73%). Perceptions of less harm to others (69%) or to self were the next most common (65%). Fewer than half used ECs to reduce stress, for affordability, or because others used them. CONCLUSIONS: Nearly 20% of dual users used ECs either without nicotine or without knowing if the product contained nicotine. The PSDI indicated greater dependence on smoking than vaping. Reasons for vaping were nearly equal between smoking reduction and enjoying flavors. Understanding patterns of dual use will inform future efforts to address nicotine dependence for AI communities with high prevalence of smoking.

Perceptions of Smoking and Vaping on Weight Control Among Adult American Indians Who Smoke.

Interest in electronic cigarette (EC) use, or vaping, to help control weight is increasing. Many American Indian (AI) populations have a high prevalence of smoking, obesity, and EC use, but their perceptions of EC use for weight control are unknown. In Oklahoma in 2016, 375 AI adults who smoke completed a survey including perceptions about smoking and EC effects on weight control. Only 24% believed that smoking helps control weight, and 8% believed that vaping helps control weight. Perceptions differed by EC use, with ever users more often than never users perceiving that smoking (30% vs 12%, respectively; p < .01) and vaping (10% vs 5%; p = .04) help to control weight. Sex, age group (18-44 years vs 45 + years), education (high school graduate/equivalent vs less than high school), smoking cessation attempt in past year, and likelihood to quit in 6 months were not associated with weight control perceptions for either smoking or vaping. Uncertainty regarding EC effects on weight control was less common among EC ever users compared to never users (41% vs 53%, respectively; p = .04). Most people who did not believe or were uncertain that smoking controls weight also did not believe or were uncertain that vaping controls weight. However, only a minority (29%) of people who believed smoking controls weight also believed that vaping controls weight. Among adult AI who smoke, both smoking and vaping were infrequently perceived as helping to control weight, but such perceptions were reported more frequently among those who ever used ECs.

Diabetes-related events in adolescents and young adults: opportunities for psychosocial interventions.

This study was conducted to evaluate predictive factors of diabetes-related emergency room (ER) visits and hospitalizations among adolescents and young adults (AYA) with type 1 diabetes (T1D). Baseline demographic, medical, and psychosocial variables were collected for 177 AYA with T1D. Medical records were reviewed to identify ER visits and hospitalizations related to diabetes. Those with diabetes-related events had significantly higher hemoglobin A1c (A1c) values at baseline (p = 0.0001) and during an average 3.36 years of follow-up (p < 0.0001). Participants with events were more likely to have Medicaid or no insurance vs. private insurance (p = 0.0006) and were more likely to be on multiple daily injections vs. insulin pumps (p = 0.0159). Participants with events reported greater diabetes impact on their lives and their parents reported less autonomy in AYA with events (p = 0.0435). These results suggest that when participants were transferring from pediatric to adult care services, factors such as A1c, insurance status and diabetes treatment are associated with diabetes-related events. Further research is needed to elucidate a causative relationship and develop focused interventions to reduce diabetes-related events during this high-risk time. Autonomy should be further explored to determine its role in diabetes-related events during this transition period.

Improving cancer care for American Indians with cervical cancer in the Indian Health Service (IHS) system - Navigation may not be enough.

OBJECTIVES: Patient navigation programs have been shown to positively impact cancer outcomes for minority populations. Little is known regarding the effects of these programs on American Indian (AI) populations. The purpose of this study is to characterize the impact of a patient navigation program on AI cervical cancer patients at a tertiary care center. METHODS: A retrospective review of all AI cervical cancer patients receiving navigation services and a cohort of AI patients treated prior to navigation services was performed. Additional comparisons were made between those with and without Indian Health Service (IHS) funding. Summary statistics were used to describe demographic, clinical characteristics, treatment, and survivorship across groups. RESULTS: Of 55 patients identified, 34 received navigation and 21 did not. In navigated patients, median age was 46years (27-80years) compared with 42years (17-68years) in pre-navigation patients (p=0.53). There was no difference between stage at diagnosis (p=0.73). No difference was noted in treatment received between groups (p=0.48). Distance traveled for treatment between groups did not differ (p=0.46). Median time to initiation of treatment was not different between groups, 30.5days vs. 27.5days (p=0.18). Among patients with IHS funding, navigation services did not alter time to initiation of treatment (p=0.57), and there was no difference in completion of prescribed therapy between groups (92% navigated vs 100% pre-navigation). CONCLUSIONS: Navigation services for AI cervical cancer patients did not alter initiation or completion of treatment. Navigation programs may provide less tangible benefits to AI cervical cancer patients and further study is warranted.

Prosodic Improvement in Persons with Parkinson Disease Receiving SPEAK OUT!® Voice Therapy.

BACKGROUND/AIMS: Hypokinetic dysarthria in Parkinson disease (PD) hinders the ability to verbally communicate and interferes with activities of daily living. SPEAK OUT!® is a therapy program designed to improve functional communicative ability. In contrast to the Lee Silverman Voice Treatment program, SPEAK OUT!® promotes speaking with intent to effect loud speech. This study evaluated the efficacy of SPEAK OUT!® in persons with idiopathic PD in 3 domains: self-reported voice handicap, clinical ratings of dysarthria and prosody, and acoustic analysis of prosody. PARTICIPANTS AND METHODS: Pre-/post-therapy data included PD participants' scores on the Voice Handicap Index (VHI) and the Voice-Related Quality of Life (V-RQOL) questionnaire, audio recordings, perceptual evaluation scores, and demographic data, such as age, sex, handedness, diagnosis, and onset of PD. RESULTS: Participants achieved a statistically and clinically significant improvement in speech intensity, pitch range, normalized pairwise variability index for pitch, sustained vowel duration, reading intelligibility, and vocal quality after SPEAK OUT!® training, consistent with both of the self-report voice scores, i.e., the VHI and the V-RQOL, and with the perceptual speech evaluation scores. Longer PD duration was associated with lowered efficacy. CONCLUSIONS: SPEAK OUT!® is effective and should be administered as early as possible after disease onset.

Acetazolamide: A New Treatment for Visual Vertigo.

Visual vertigo is a disorder characterised by symptoms of dizziness, vertigo, unsteadiness, disorientation, and general discomfort induced by visual triggers. It is currently treated with vestibular rehabilitation therapy, with no effective pharmacotherapy available for treatment-resistant cases. The objective of this study was to evaluate the efficacy of oral acetazolamide in improving symptoms of visual vertigo. A comparative case series of adult patients clinically diagnosed with visual vertigo was conducted from January 1992 to May 2015. Patients without a full neurologic or otorhinolaryngologic work-up, negative magnetic resonance imaging (MRI), and an organic cause for their symptoms were excluded. The identified patients were then contacted by phone to complete a voluntary symptom survey. Main outcome was the subjective reported percentage in symptom improvement. Secondary outcomes were subjective improvement by symptom triggers. The participants were retrospectively divided into three groups based on their treatment with acetazolamide: currently on acetazolamide, terminated acetazolamide, or never initiated acetazolamide. Fifty-seven patients met the inclusion criteria and were willing to complete the phone survey (19 currently on acetazolamide, 27 terminated acetazolamide, and 11 never initiated therapy). Overall symptomatic improvement was reported by 18 (94.7%) patients currently on acetazolamide, 18 (66.7 %) who terminated acetazolamide, and 5 (45.5%) who never initiated therapy, varying significantly by group (p = 0.0061). Greatest improvement was reported in symptoms triggered by being a passenger in a car. These results show that acetazolamide has a positive association with improvement of symptoms of visual vertigo.

The pro-inflammatory effect of obesity on high grade serous ovarian cancer.

INTRODUCTION: Obesity is a known generator of chronic inflammation but has an uncertain role in ovarian carcinogenesis and survival. Pro-inflammatory cytokines have previously been associated with poor outcomes. Given the established links, we sought to determine whether obesity and pro-inflammatory cytokines affect platinum sensitivity. METHODS: A retrospective review was performed of patients undergoing primary debulking surgery (PDS) for high grade serous ovarian cancer (HGSC) who had available pre-operative serum. Oncologic and treatment characteristics were recorded and analyzed using SAS version 9.3. Bioplex reagent kit was used to measure serum cytokine concentrations. RESULTS: 86 patients met study criteria. Most were Caucasian (88%) and non-diabetic (92%). All patients had advanced stage (III/IV) disease and received chemotherapy after PDS. In univariate analysis, lower VEGF (p=0.013) was associated with longer overall survival (OS). Low IL-8 level (p=0.053) was marginally associated with platinum resistant disease. After adjusting for covariates including residual disease and maintenance therapy, IL-8 was no longer associated with platinum sensitive status (p=0.13), VEGF remained associated with OS (low vs. high HR 0.3, 95% CI 0.1-0.8, p=0.018), and higher IL-12 was associated with longer PFS (HR 0.4, 95% CI 0.2-0.9, p=0.031). CONCLUSION: In HGSC, pro-inflammatory cytokines are influenced by obesity, as differing inter-cytokine correlations were observed based on BMI, possibly due to dysregulation between cytokines in the setting of obesity. Differences in survival and platinum sensitivity were not noted. Future studies are warranted to determine whether obesity may be a modifiable risk factor for poorer outcomes due to differing immune response.

The Collaboverse: A Collaborative Data-Sharing and Speech Analysis Platform.

PURPOSE: Collaboration in the field of speech-language pathology occurs across a variety of digital devices and can entail the usage of multiple software tools, systems, file formats, and even programming languages. Unfortunately, gaps between the laboratory, clinic, and classroom can emerge in part because of siloing of data and workflows, as well as the digital divide between users. The purpose of this tutorial is to present the Collaboverse, a web-based collaborative system that unifies these domains, and describe the application of this tool to common tasks in speech-language pathology. In addition, we demonstrate its utility in machine learning (ML) applications. METHOD: This tutorial outlines key concepts in the digital divide, data management, distributed computing, and ML. It introduces the Collaboverse workspace for researchers, clinicians, and educators in speech-language pathology who wish to improve their collaborative network and leverage advanced computation abilities. It also details an ML approach to prosodic analysis. CONCLUSIONS: The Collaboverse shows promise in narrowing the digital divide and is capable of generating clinically relevant data, specifically in the area of prosody, whose computational complexity has limited widespread analysis in research and clinic alike. In addition, it includes an augmentative and alternative communication app allowing visual, nontextual communication.

Burn Injuries From TikTok Challenges: A Brief Report.

Social media (e.g., TikTok) challenge is a relatively new phenomenon wherein a user creates and posts videos performing an often-dangerous task. The ease of access and availability of social media in recent times make teens and young adults susceptible to these viral Internet challenges and accidental injury. The severity, morbidity, and mortality of burn injuries from social media challenges have not readily been documented in the medical literature. In this brief report, we present three cases of accidental burns after attempting social media challenges involving boiling water or flame. The injuries ranged from superficial partial thickness burns to 24% total body surface area (TBSA) full thickness burns. Online challenges show the potential for severe injury and disability and underlie the importance of awareness and education of the public, further research into the usage of TikTok and other media platforms, and early referral to the American Burn Association recognized center.

Fracture related infection and sepsis in orthopedic trauma: A review.

Trauma is a leading cause of death in the United States for people under 45. Amongst trauma-related injuries, orthopedic injuries represent a significant component of trauma-related morbidity. In addition to the potential morbidity and mortality secondary to the specific traumatic injury or injuries sustained, sepsis is a significant cause of morbidity and mortality in trauma patients as well, and infection related to orthopedic trauma can be especially devastating. Therefore, infection prevention and early recognition of infections is crucial to lowering morbidity and mortality in trauma. Risk factors for fracture-related infection include obesity, tobacco use, open fracture, and need for flap coverage, as well as fracture of the tibia and the degree of contamination. Timely administration of prophylactic antibiotics for patients presenting with open fractures has been shown to decrease the risk of fracture-related infection, and in patients that do experience sepsis from an orthopedic injury, prompt source control is critical, which may include the removal of implanted hardware in infections that occur more than 6 weeks from operative fixation. Given that orthopedic injury constitutes a significant proportion of traumatic injuries, and will likely continue to increase in number in the future, surgeons caring for patients with orthopedic trauma must be able to promptly recognize and manage sepsis secondary to orthopedic injury.

Determining Risk Factors for Detachment After Endothelial Keratoplasties: Nine-Year Review of a Single Institution.

PURPOSE: To determine roles of patient history, donor tissue characteristics, tissue preparation methods, and surgeon technique for graft detachment requiring rebubbling after Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) procedures. METHODS: Retrospective analysis of all eyes undergoing first-time DSAEK or DMEK at the study institution between 2013 and 2022. Data were collected regarding recipients' history, donors' medical history, tissue preparation methods, intraoperative details, and postoperative clinical outcomes. Multivariate statistical analysis was conducted to identify risk factors for graft detachment necessitating rebubbling. RESULTS: Of 1240 eyes meeting inclusion criteria, 746 (60.2%) underwent DSAEK, and 494 (39.8%) underwent DMEK. DSAEK procedures had 12.5% rebubbling rate, whereas DMEK procedures had 18.4% rebubbling rate (P = 0.005). Sub50-DSAEK (<50 µm) grafts had 16.0% rebubble rate, whereas sub100-DSAEK (51-99 µm) and >100 µm DSAEKs had rebubble rate of 9.9% and 9.5%, respectively (P = 0.006). Significant risk factors for DSAEK graft detachment included history of retinal surgery (OR = 2.59), preloaded tissue (OR = 2.70), forceps insertion (OR = 2.33), use of sub50-DSAEK lenticules versus sub100-DSAEK (OR = 2.44) and >100 µm DSAEK (OR = 2.38) lenticules, and donor history of noninsulin-dependent diabetes mellitus (OR = 4.18). DMEK risk factors included recipient history of cancer (OR = 2.51) and use of higher SF6 gas concentration (OR = 1.09). Although rebubbled DMEK eyes had comparable refractive outcomes to nonrebubbled eyes (P >0.05), rebubbled DSAEK eyes had worse refractive outcomes at all time points (P < 0.05). CONCLUSIONS: Graft detachments in DSAEK and DMEK are influenced by various factors, including donor tissue characteristics, tissue preparation, and surgical technique. Identifying and understanding these factors can potentially improve postoperative outcomes.

Accuracy of a commonly used mobile ophthalmology application's vision assessment tools in measuring five vision assessment parameters.

BACKGROUND/OBJECTIVES: The use of mobile ophthalmology applications (MOA) is increasing, but many of these tools have not been validated. This study was performed to assess the accuracy of a popular MOA, Eye Handbook, in measuring five commonly-tested vision assessment parameters (distance visual acuity (DVA), near visual acuity (NVA), colour vision testing (CVT), contrast sensitivity (CS), and pupillary distance (PD)) was compared with traditional vision assessment methods (TVAM) [i.e. Snellen chart, Rosenbaum near card, Ishihara, Pelli Robson test, etc.] performed in the eye clinic setting. SUBJECTS/METHODS: Prospective crossover clinical trial of 129 patients meeting inclusion criteria. RESULTS: Participants averaged significantly better DVA (p = 0.0008), NVA (p < 0.0001), and CVT (p = 0.0105) in the MOA than the TVAM, but all three MOA assessments were predictive of the TVAM values. CS was significantly better with the MOA (p < 0.0001). Linear regression and Spearman correlation tests were applied to assess the effect of CS on NVA, which showed no clear relationship between the difference in NVA and the difference in CS. PD using the two methods was in agreement with no significant difference (p = 0.2889). CONCLUSION: The studied MOA offers an effective means of measuring four common vision parameters: DVA, NVA, CVT, and PD. The MOA can potentially be used by eye care providers, health care providers, and patients, both as a screening tool with correction factor and to monitor ocular pathologies. Atypical MOA measurements should prompt testing in the clinic with formal TVAMs.

An Exploratory and Qualitative Analysis of Self-Reported Evaluations for Fever.

Background: Despite the high prevalence of post-operative fever, a variety of approaches are taken as to the components of a fever evaluation, when it should be undertaken, and when empiric antibiotic agents should be started. Hypothesis: There is a lack of consensus surrounding many common components of a post-operative fever evaluation. Patients and Methods: The Surgical Infection Society membership was surveyed to determine practices surrounding evaluation of post-operative fever. Eight scenarios were posed in febrile (38.5°C), post-operative general surgery or trauma patients, with 19 possible components of work-up (physical examination, complete blood count [CBC], fungal biomarkers, lactate and procalcitonin [PCT] concentrations, cultures, imaging) and management (antibiotic agents). Each scenario was then re-considered for intensive care unit (ICU) patients (intubated/unstable hemodynamics). Agreement on a parameter (<1/4 or >3/4 of respondents) achieved consensus, positive or negative. Parameters between had equipoise; α was set at 0.05. Results: Among the examined scenarios, only CBC and physical examination received positive consensus across most scenarios. Blood/urine cultures, imaging, lactate, inflammatory biomarkers, and the empiric administration of antibiotic agents did not reach consensus; support was variable depending on the clinical scenario, illness severity, and the individual preferences of the answering clinician. The qualitative portion of the survey identified "fever threshold and duration," "clinical suspicion," and "physiologic manifestation" as the most important factors for deciding about the initiation of a fever evaluation and the potential empiric administration of antibiotic agents. Conclusions: There is consensus only for physical and examination routine laboratory work when initiating the evaluation of febrile post-operative patients. However, there are multiple components of a fever evaluation that individual respondents would select depending on the clinical scenario and severity of illness. Parameters demonstrating equipoise are potential candidates for formal guidance or pragmatic prospective trials.

Self-Reported Diagnosis and Management of Surgical Site Infection Highlights Lack of Objective Measures and Treatment Guidance.

Background: There is little guidance regarding empiric therapy for superficial surgical site infections (SSIs). Management of incisions with signs of SSI lacks consensus and management is variable among individual surgeons. Methods: The Surgical Infection Society was surveyed regarding management of SSIs. Cases were provided with varying wound descriptions, initial wound class (WC), post-operative day, and presence of a prosthesis. Responses were in multiple-choice format; statistics: χ2; α = 0.05. Results: Seventy-eight members responded. For appearance scenarios, respondents believed that both mild erythema (55%) and clear drainage (64%) could be observed, whereas substantial (>3 cm) erythema or purulence should be treated with complete (22% and 50%) or partial (55% and 40%) opening of the incision. Degree of erythema did not influence administration of antibiotic agents, but purulence was more likely than clear drainage to be treated with antibiotics (38% vs. 6%; p < 0.001). There were no differences based on WC, except that clean cases were more likely than higher WC scenarios to be treated with gram-positive coverage alone (WC 1 [26%] vs. 2 [10%] vs. 3 [13%] vs. 4 [4%]; p < 0.001). Post-operative day (POD) three appeared to be an inflection point for more aggressive treatment of suspected incisional SSI, with fewer (POD 0 [86%] vs. POD day 3 [54%]; p < 0.001) reporting observation. Respondents were more likely to obtain imaging, start broad-spectrum antibiotic agents, and return to the operating room for purulence in the presence of a mesh. Conclusions: Presented with escalating possibility of SSI, respondents reported lower rates of observation, increased use of antibiotic agents, and increased surgical drainage. Many scenarios lack consensus regarding appropriate therapy. The complete elimination of SSIs is unlikely to be accomplished soon, and this study provides a framework for understanding how surgeons approach SSIs, and potential areas for further research or pragmatic guidance.

Different Surgeon, Different Closure: Lack of Consensus on Appropriate Closure Technique for Various Case Scenarios.

Background: Many techniques for closure of surgical incisions are available to the surgeon, but there is minimal guidance regarding which technique(s) should be utilized at the conclusion of surgery and under what circumstances. Hypothesis: Management of incisions at the conclusion of surgery lacks consensus and varies among individual surgeons. Methods: The Surgical Infection Society membership was surveyed on the management of incisions at the conclusion of surgery. Several case scenarios were provided to test the influences of operation type, intra-operative contamination, and hemodynamic stability on incision management (e.g., close fascia or skin, use of incision/wound vacuum-assisted closure [VAC] device). Responses by two-thirds of participants were required to achieve consensus. Data analysis by χ2 test and logistic regression, a = 0.05. Response heterogeneity was quantified by the Shannon index (SI). Results: Among 78 respondents, consensus was achieved for elective splenectomy (91% close skin/dry dressing). Open appendectomy and left colectomy/end-colostomy had the greatest heterogeneity (SI, 1.68 and 1.63, respectively). During trauma laparotomy, the majority used damage control for hemodynamic instability (53%-67%) but not for hemodynamically stable patients (0%-1.3%; p < 0.001). Additional consensus was achieved for close skin/dry dressing for hemodynamically stable trauma splenectomy patients (87%) and fascia open/wound VAC for hemodynamically unstable colon resection/anastomosis (67%). Fecal diversion for rectal injury and colon resection/anastomosis (both when hemodynamically stable) had high heterogeneity (SI, 1.56 and 1.48, respectively). In penetrating trauma, sentiment was for more use of wet-to-dry dressings and incision/wound VAC with increased contamination in hemodynamically stable patients. Conclusions: Damage control was favored in hemodynamically unstable trauma patients, with use of wet-to-dry dressings and incision/wound VAC with spillage after penetrating trauma. However, most scenarios did not achieve consensus. High variability of practices regarding incision management at the conclusion of surgery was confirmed. Prospective studies and evidence-based guidance are needed to guide decision making at end-operation.