bluuebunny/crossref_metadata_2025 huggingface dataset:
Initial Management of Traumatic Digit Amputations: A Retrospective Study of Functional Outcomes
Authors: Oni Georgette , Buntic Rudolph , Malata Charles , Buncke Gregory , Ngaage Ledibabari
Published: March 2018

Background Traumatic amputation of one or more digits can have a serious detrimental effect on social and economic standings which can be mitigated by successful replantation. Little has been recorded on preoperative management before replantation and how this affects the outcomes of the replanted digit.

Methods A retrospective cohort study was conducted and data collected over an 18-month period. Three protocols for preoperative management were examined: minimal (basic wound management), complete Buncke (anticoagulation, dry dressing on amputate placed on indirect ice and absence of a digital block), and incomplete (any two or three criteria from complete Buncke in addition to the minimal) protocols. Data was collected on survival rate, secondary operations, and complication rate. Function was defined by sensation, range of movement, and strength.

Results Seventy four of 177 digits were replanted with an overall survival rate of 86.5%. The rates for minimal, incomplete, and complete protocols were 95%, 87%, and 91%, respectively, and not significantly different. The complication rate was significantly different between the complete (20%) and minimal (60%) protocols (p = 0.0484). Differences in sensation and grip strength were statistically significant between protocols (p = 0.0465 and p = 0.0430, respectively). Anticoagulation, no digital block and dry gauze all showed reduced complication rates in comparison to their counterparts.

Conclusions The Buncke protocol, which includes anticoagulation, no digital block, and dry gauze, was found to significantly reduce the complication rate which suggests that it prevents compromise of tissue integrity. Significant differences were found between protocols for sensation and grip strength. A higher-powered study is needed to investigate the effects of preoperative management on complication rates and functional outcomes.
Is There Any Difference in Risk Factors between Male and Female Patients in New-Onset Atrial Fibrillation after Coronary Artery Bypass Grafting?
Authors: Erdil Nevzat , Colak Mehmet , Disli Olcay , Battaloglu Bektas , Colak Cemil , Akça Barış
Published: March 2018

Background We aimed to investigate the risk factors of post-coronary artery bypass grafting (CABG) atrial fibrillation (AF) in male and female patients without any history of AF, to identify the sex-specific risk factors, and to examine the effect of sex-specific risk factors on the overall population.

Methods This retrospective study was conducted using the hospital database with 4,758 patients who underwent CABG surgery. Among them, 2,836 patients with complete data participated in this study. The female patients were divided into two groups as patients who developed new-onset AF after CABG and those who did not. The relationship between the patients' variables and risk factors of post-CABG AF was examined.

Results The overall incidence of post CABG AF was 12.9% (386/2,836). Sex-specific incidence of AF was similar: 3.2% (91/690) and 12.9% (277/2146) in female and male patients, respectively (p = 0.849). Multiple analysis revealed the independent risk factors for male and female patients, respectively: mean age (odds ratio [OR] = 1.057, OR = 1,076), age over 65 years (OR = 2.156, OR = 2.736), the European System For Cardiac Operative Risk Evaluation Scores (EuroSCORE) (OR = 1.13, OR = 1.218), COPD (OR = 1.589, OR = 1.789), BUN level (OR = 1.026, OR = 1.019), mean cardiopulmonary bypass (CPB) time (OR = 1.007, OR = 1.010), prolonged CPB time (OR = 1.604, OR = 2.309), mean cross-clamp time (OR = 1.009, OR = 1.017), need of inotropic support (OR = 2.249, OR = 2.731), and mean mechanical ventilation time (VT) (OR = 1.026, OR = 1.027).

Low left ventricular ejection fraction (LVEF) (OR = 1.419), left ventricular (LV) aneurysm repair (OR = 1.533), carotid artery disease (OR = 1.750), prolonged VT (OR = 1.729), and use of intra-aortic balloon pump (IABP) (OR = 2.436) were found to be the risk factors only for male AF patients.

Unstable angina (OR = 1.969), right coronary artery (RCA) disease (OR = 2), prolonged cross-clamp time (OR = 2.152), and the number of grafts per operation (OR = 1.298) were found to be the risk factors only for female AF patients.

Conclusion This study suggests that predictors of AF in the overall population may be due to isolated patient groups. Multiple regression analysis and artificial intelligence modelling should be performed on large-scale, isolated groups to make strong AF prediction.
Red Blood Cell Transfusions Affect Intestinal and Cerebral Oxygenation Differently in Preterm Infants with and without Subsequent Necrotizing Enterocolitis
Authors: Kuik Sara , Van Braeckel Koenraad , Hulscher Jan , Bos Arend , Kooi Elisabeth , van der Laan Michelle , Kalteren Willemien
Published: March 2018

Objective To assess intestinal and cerebral oxygenation during and after red blood cell (RBC) transfusions in preterms with or without subsequent transfusion-associated necrotizing enterocolitis (TANEC).

Study Design In preterms of < 32 weeks' gestational age, we measured intestinal and cerebral regional tissue oxygen saturation (rintSO2, rcSO2) and their variabilities using near-infrared spectroscopy during and after transfusions. We compared eight infants who developed TANEC 6 to 48 hours after RBC transfusions with 16 controls.

Results In TANEC infants, rcSO2 was lower during and after RBC transfusions than in controls, median (interquartile range) 55% (50–62) versus 72% (65–75), p < 0.01. There were no differences regarding rintSO2. Individual rintSO2 and rcSO2 ranges were smaller after transfusions in TANEC infants, 28% (9–36) versus 49% (40–65), p < 0.01, and 17% (14–33) versus 36% (26–57), p = 0.01, as was short-term rintSO2 variability. For each 10% higher rcSO2, the risk of developing TANEC decreased (odds ratio 0.09; 95% confidence interval 0.01–0.63). The smaller the rintSO2 range after transfusion, the higher the risk of developing TANEC.

Conclusion In preterm infants lower rcSO2, but not rintSO2, values during and after RBC transfusions are associated with TANEC. Lower rintSO2 and rcSO2 variabilities after RBC transfusions may represent a diminished capacity for vascular adaptation, possibly leading to TANEC.
Incident Risk Factors and Major Bleeding in Patients with Atrial Fibrillation Treated with Oral Anticoagulants: A Comparison of Baseline, Follow-up and Delta HAS-BLED Scores with an Approach Focused on Modifiable Bleeding Risk Factors
Authors: Chao Tze-Fan , Lin Yenn-Jiang , Chang Shih-Lin , Lo Li-Wei , Hu Yu-Feng , Tuan Ta-Chuan , Liao Jo-Nan , Chung Fa-Po , Chen Tzeng-Ji , Lip Gregory , Chen Shih-Ann
Published: March 2018

Aim When assessing bleeding risk in patients with atrial fibrillation (AF), risk stratification is often based on the baseline risks. We aimed to investigate changes in bleeding risk factors and alterations in the HAS-BLED score in AF patients. We hypothesized that a follow-up HAS-BLED score and the ‘delta HAS-BLED score’ (reflecting the change in score between baseline and follow-up) would be more predictive of major bleeding, when compared with baseline HAS-BLED score.

Methods and Results A total of 19,566 AF patients receiving warfarin and baseline HAS-BLED score ≤2 were studied. After a follow-up of 93,783 person-years, 3,032 major bleeds were observed. The accuracies of baseline, follow-up, and delta HAS-BLED scores as well as cumulative numbers of baseline modifiable bleeding risk factors, in predicting subsequent major bleeding, were analysed and compared. The mean baseline HAS-BLED score was 1.43 which increased to 2.45 with a mean ‘delta HAS-BLED score’ of 1.03. The HAS-BLED score remained unchanged in 38.2% of patients. Of those patients experiencing major bleeding, 76.6% had a ‘delta HAS-BLED’ score ≥1, compared with only 59.0% in patients without major bleeding (p < 0.001). For prediction of major bleeding, AUC was significantly higher for the follow-up HAS-BLED (0.63) or delta HAS-BLED (0.62) scores, compared with baseline HAS-BLED score (0.54). The number of baseline modifiable risk factors was non-significantly predictive of major bleeding (AUC = 0.49).

Conclusion In this ‘real-world’ nationwide AF cohort, follow-up HAS-BLED or ‘delta HAS-BLED score’ was more predictive of major bleeding compared with baseline HAS-BLED or the simple determination of ‘modifiable bleeding risk factors’. Bleeding risk in AF is a dynamic process and use of the HAS-BLED score should be to ‘flag up’ patients potentially at risk for more regular review and follow-up, and to address the modifiable bleeding risk factors during follow-up visits.
Perioperative Complications of Surgery for Hypertrophic Pyloric Stenosis
Authors: Kelay Arun , Hall Nigel
Published: March 2018

Pyloromyotomy is the tried and tested surgical procedure for successful operative treatment of pyloric stenosis. Over time, the operative approach has evolved to take advantage of cosmetically superior incisions and more recently minimally invasive surgery. During and following surgery, complications are uncommon. The specific complications of an inadequate pyloromyotomy requiring repeated procedure and mucosal perforation during an overzealous pyloromyotomy represent the ends of a spectrum within which sits the perfect procedure. Here, we discuss these specific complications together with the other potential complications following surgery for hypertrophic pyloric stenosis, including anesthetic considerations.
The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Short Version)
Authors: Sidhu Paul , Cantisani Vito , Dietrich Christoph , Gilja Odd , Saftoiu Adrian , Bartels Eva , Bertolotto Michele , Calliada Fabrizio , Clevert Dirk-André , Cosgrove David , Deganello Annamaria , D’Onofrio Mirko , Drudi Francesco , Freeman Simon , Harvey Christopher , Jenssen Christian , Jung Ernst-Michael , Klauser Andrea , Lassau Nathalie , Meloni Maria , Leen Edward , Nicolau Carlos , Nolsoe Christian , Piscaglia Fabio , Prada Francesco , Prosch Helmut , Radzina Maija , Savelli Luca , Weskott Hans-Peter , Wijkstra Hessel
Published: March 2018

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.
Sizing and placement of solar photovoltaic plants by using time-series historical weather data
Authors: Ali Abid , Mohd Nor Nursyarizal , Ibrahim Taib , Fakhizan Romlie Mohd
Published: March 2018

The integration of distribution generation (DG) in distribution networks with improper planning adversely influences the quality of the electrical networks. Conventionally, the outputs from the intermittent DGs, such as solar photovoltaic (PV) plants, are assumed dispatchable. The intermittency of solar irradiance on the outputs of the PV modules has been ignored in most studies on the sizing and placement of DGs. By looking at this problem, this paper presents the sizing and placement of a distributed solar photovoltaic plant (DSPP) by using time series historical weather data. To predict the output from the PV modules, 15 years of solar data were modeled with the aid of a beta probability density function. The total energy loss index was formulated as the main objective function, and the optimization problem was solved by mixed integer optimization by using genetic algorithm. By adopting a time-varying commercial load, the proposed algorithm was applied on IEEE 33 bus and IEEE 69 bus distribution networks. The numerical studies on the two distribution networks show the advantages of the proposed approach for minimizing the total energy losses and improving the bus voltage profiles. It was revealed that up to 38% of the total energy losses in distribution networks could be reduced at sites with solar insolation of 5.65 peaks sun hours. In contrast to existing methods, planning for DGs by using weather data provided more realistic results for DSPP in distribution networks.
Dispersion characteristics of anisotropic unmagnetized ultra-relativistic transverse plasma wave with arbitrary electron degeneracy
Authors: Sarfraz M. , Farooq H. , Abbas G. , Noureen S. , Iqbal Z. , Rasheed A.
Published: March 2018

Thermal momentum space anisotropy is ubiquitous in many astrophysical and laboratory plasma environments. Using Vlasov-Maxwell's model equations, a generalized polarization tensor for a collisionless ultra-relativistic unmagnetized electron plasma is derived. In particular, the tensor is obtained by considering anisotropy in the momentum space. The integral of moments of Fermi-Dirac distribution function in terms of Polylog functions is used for describing the border line plasma systems (TeTFe≈1) comprising arbitrary electron degeneracy, where Te and TFe, are thermal and Fermi temperatures, respectively. Furthermore, the effects of variation in thermal momentum space anisotropy on the electron equilibrium number density and the spectrum of electromagnetic waves are analyzed.
Label-free extraction of extracellular vesicles using centrifugal microfluidics
Authors: Yeo Joo Chuan , Kenry  , Zhao Zhihai , Zhang Pan , Wang Zhiping , Lim Chwee Teck
Published: March 2018

Extracellular vesicles (EVs) play an important role as active messengers in intercellular communication and distant microenvironment modeling. Increasingly, these EVs are recognized as important biomarkers for clinical diagnostics. However, current isolation methods of EVs are time-consuming and ineffective due to the high diffusive characteristics of nanoparticles coupled with fluid flow instability. Here, we develop a microfluidic CEntrifugal Nanoparticles Separation and Extraction (µCENSE) platform for the rapid and label-free isolation of microvesicles. By utilizing centrifugal microhydrodynamics, we subject the nanosuspensions between 100 nm and 1000 nm to a unique fluid flow resulting in a zonal separation into different outlets for easy post-processing. Our centrifugal platform utilizes a gentle and efficient size-based separation without the requirements of syringe pump and other accessories. Based on our results, we report a high separation efficiency of 90% and an extraction purity of 85% within a single platform. Importantly, we demonstrate high EV extraction using a table top centrifuge within a short duration of eight minutes. The simple processes and the small volume requirement further enhance the utility of the platform. With this platform, it serves as a potential for liquid biopsy extraction and point-of-care diagnostics.
Hybrid reflections from multiple x-ray scattering in epitaxial bismuth telluride topological insulator films
Authors: Morelhão Sérgio L. , Kycia Stefan , Netzke Samuel , Fornari Celso I. , Rappl Paulo H. O. , Abramof Eduardo
Published: March 2018

Epitaxial films of bismuth telluride topological insulators have received increasing attention due to their potential applications in spintronic and quantum computation. One of the most important properties of epitaxial films is the presence of interface defects due to the lateral lattice mismatch since electrically active defects can drastically compromise device performance. By describing hybrid reflections in hexagonal bismuth telluride films on cubic substrates, in-plane lattice mismatches were characterized with accuracy at least 20 times better than using other X-ray diffraction methods, providing clear evidence of 0.007% lateral lattice mismatch, consistent with stress relaxation associated with van der Waals gaps in the film structure.
A rapid and meshless analytical model of acoustofluidic pressure fields for waveguide design
Authors: O'Rorke Richard , Collins David , Ai Ye
Published: March 2018

Acoustofluidics has a strong pedigree in microscale manipulation, with particle and cell separation and patterning arising from acoustic pressure gradients. Acoustic waveguides are a promising candidate for localizing force fields in microfluidic devices, for which computational modelling is an important design tool. Meshed finite element analysis is a popular approach for this, yet its computation time increases rapidly when complex geometries are used, limiting its usefulness. Here, we present an analytical model of the acoustic pressure field in a microchannel arising from a surface acoustic wave (SAW) boundary condition that computes in milliseconds and provide the simulation code in the supplementary material. Unlike finite element analysis, the computation time of our model is independent of microchannel or waveguide shape, making it ideal for designing and optimising microscale waveguide structures. We provide experimental validation of our model with cases including near-field acoustic patterning of microparticles from a travelling SAW and two-dimensional patterning from a standing SAW and explore the design of waveguides for localised particle or cell capture.
Abstracts presented at the Association for Medical Education and Research in Substance Abuse (AMERSA) 41st Annual Conference, Washington, DC, USA, November 2017
Authors: Gordon Adam J.
Published: March 2018

The 41st annual meeting of the Association for Medical Education and Research in Substance Abuse (AMERSA) was held in Washington, DC, USA, in November 2017. Contained in this paper are the abstracts of scientific work presented at the conference.
Abstracts presented at the International Society of Addiction Medicine (ISAM) 19th Annual Meeting, Abu Dhabi, United Arab Emirates, October 2017
Authors: Gordon Adam J.
Published: March 2018

The 19th Annual Meeting of the International Society of Addiction Medicine (ISAM) was held in Abu Dhabi, United Arab Emirates, in October 2017. Contained in this paper are the abstracts of scientific work presented at the conference.
Unveiling skin macrophage dynamics explains both tattoo persistence and strenuous removal
Authors: Baranska Anna , Shawket Alaa , Jouve Mabel , Baratin Myriam , Malosse Camille , Voluzan Odessa , Vu Manh Thien-Phong , Fiore Frédéric , Bajénoff Marc , Benaroch Philippe , Dalod Marc , Malissen Marie , Henri Sandrine , Malissen Bernard
Published: March 2018

Here we describe a new mouse model that exploits the pattern of expression of the high-affinity IgG receptor (CD64) and allows diphtheria toxin (DT)–mediated ablation of tissue-resident macrophages and monocyte-derived cells. We found that the myeloid cells of the ear skin dermis are dominated by DT-sensitive, melanin-laden cells that have been missed in previous studies and correspond to macrophages that have ingested melanosomes from neighboring melanocytes. Those cells have been referred to as melanophages in humans. We also identified melanophages in melanocytic melanoma. Benefiting of our knowledge on melanophage dynamics, we determined the identity, origin, and dynamics of the skin myeloid cells that capture and retain tattoo pigment particles. We showed that they are exclusively made of dermal macrophages. Using the possibility to delete them, we further demonstrated that tattoo pigment particles can undergo successive cycles of capture–release–recapture without any tattoo vanishing. Therefore, congruent with dermal macrophage dynamics, long-term tattoo persistence likely relies on macrophage renewal rather than on macrophage longevity.
Energy states of the Hulthen plus Coulomb-like potential with position-dependent mass function in external magnetic fields
Authors: Eshghi M , Sever R , Ikhdair S M
Published: March 2018

We need to solve a suitable exponential form of the position-dependent mass (PDM) Schrödinger equation with a charged particle placed in the Hulthen plus Coulomb-like potential field and under the actions of the external magnetic and Aharonov–Bohm (AB) flux fields. The bound state energies and their corresponding wave functions are calculated for the spatially-dependent mass distribution function of interest in physics. A few plots of some numerical results with respect to the energy are shown.
eMolTox: prediction of molecular toxicity with confidence
Authors: Ji Changge , Svensson Fredrik , Zoufir Azedine , Bender Andreas
Published: March 2018

In this work, we present eMolTox, a web server for the prediction of potential toxicity associated with a given molecule. A total of 174 toxicology-related in vitro/vivo experimental datasets were used for model construction and Mondrian conformal prediction was used to estimate the confidence of the resulting predictions. Toxic substructure analysis is also implemented in eMolTox. eMolTox predicts and displays a wealth of information of potential molecular toxicities for safety analysis in drug development.

Availability and implementation

The eMolTox Server is freely available for use on the web at http://xundrug.cn/moltox.

Supplementary information

Supplementary data are available at Bioinformatics online.
Purpose in Life Among Centenarian Offspring
Authors: Marone Sarah , Bloore Katherine , Sebastiani Paola , Flynn Christopher , Leonard Brittany , Whitaker Kelsey , Mostowy Marilyn , Perls Thomas T , Andersen Stacy L
Published: March 2018

Objectives

Purpose in life (PIL), a feeling of meaning and direction in life, is associated with favorable health outcomes including lower mortality and reduced risk of disease, disability, and cognitive impairment. Since centenarian offspring have been shown to have long health spans we sought to examine whether they have higher PIL than individuals without familial longevity.

Method

We compared PIL scores from the Ryff Scales of Psychological Well-Being in centenarian offspring from the New England Centenarian Study (N = 361, mean age = 82.0 years) with 3 referent groups: spouses, birth cohort-matched referents, and Health and Retirement Study (HRS) participants.

Results

Logistic regression analyses adjusted for age, sex, education, and marital status indicated greater odds of high PIL among centenarian offspring compared with spouse (adjusted odds ratio [aOR] = 1.92, 95% confidence interval [CI] = 1.002–3.68, p = .049) and birth cohort referents (aOR = 2.64, 95% CI = 1.36–5.14, p = .004). Offspring had an almost 3 times greater odds of having high PIL than HRS participants (odds ratio [OR] = 2.93, 95% CI = 2.17–3.96, p < .0001).

Discussion

Higher PIL is associated with being an offspring of a long-lived parent and may play a role in the ability to delay age-associated illnesses and functional decline. Increasing purposefulness may be a target for interventions to promote healthy aging.
Chemical pre-processing of cluster galaxies over the past 10 billion years in the IllustrisTNG simulations
Authors: Gupta Anshu , Yuan Tiantian , Torrey Paul , Vogelsberger Mark , Martizzi Davide , Tran Kim-Vy H , Kewley Lisa J , Marinacci Federico , Nelson Dylan , Pillepich Annalisa , Hernquist Lars , Genel Shy , Springel Volker
Published: March 2018

We use the IllustrisTNG simulations to investigate the evolution of the mass–metallicity relation (MZR) for star-forming cluster galaxies as a function of the formation history of their cluster host. The simulations predict an enhancement in the gas-phase metallicities of star-forming cluster galaxies (109 < M* < 1010 M⊙ h−1) at z ≤ 1.0 in comparisons to field galaxies. This is qualitatively consistent with observations. We find that the metallicity enhancement of cluster galaxies appears prior to their infall into the central cluster potential, indicating for the first time a systematic ‘chemical pre-processing’ signature for infalling cluster galaxies. Namely, galaxies that will fall into a cluster by z = 0 show a ∼0.05 dex enhancement in the MZR compared to field galaxies at z ≤ 0.5. Based on the inflow rate of gas into cluster galaxies and its metallicity, we identify that the accretion of pre-enriched gas is the key driver of the chemical evolution of such galaxies, particularly in the stellar mass range (109 < M* < 1010 M⊙ h−1). We see signatures of an environmental dependence of the ambient/inflowing gas metallicity that extends well outside the nominal virial radius of clusters. Our results motivate future observations looking for pre-enrichment signatures in dense environments.
Efficacy of Copper and New Bactericides for Managing Olive Knot in California
Authors: Nguyen K. A. , Förster H. , Adaskaveg J. E.
Published: March 2018

Baseline sensitivities were established for kasugamycin and oxytetracycline for 147 strains of Pseudomonas savastanoi pv. savastanoi collected from olive knots throughout California. Minimum inhibitory concentrations for ≥95% growth inhibition ranged from 1.86 to 11.52 and 0.13 to 0.40 µg/ml for kasugamycin and oxytetracycline, respectively. In copper sensitivity evaluations, 95.3% of the strains collected grew at concentrations of metallic copper equivalent (MCE) of <20 µg/ml, 2.7% grew at MCE between 20 and 30 µg/ml (moderately sensitive), and 2% grew at MCE of 150 µg/ml (resistant). Copper resistance was never reported previously in the olive knot pathogen, and pathogenicity studies confirmed a high virulence of the copper-resistant strains. In comparative field studies, kasugamycin at 200 µg/ml performed equally to the standard copper hydroxide treatment (MCE of 1,260 µg/ml) for reducing knot development on lateral wounds of Arbequina and Manzanillo olive inoculated with a copper-sensitive strain and was better than copper using a highly copper-resistant strain. Oxytetracycline at 200 µg/ml was not as effective as copper or kasugamycin but significantly reduced the disease as compared with the untreated control. Field studies on application timings of copper, kasugamycin, and copper-kasugamycin mixtures to inoculated wounds indicated that treatments within 24 h of inoculation resulted in higher disease control than applications at later times. In greenhouse trials, copper or copper-kasugamycin applied to wounds 7 days before inoculation persisted and reduced knot incidence by >50%. Our findings indicate that kasugamycin is an effective bactericide for controlling olive knot and that the time of any bactericide application after inoculation is critical in managing the disease.
Sandifer syndrome
Authors: Moore Debora M. , Rizzolo Denise
Published: March 2018

Sandifer syndrome is a rare complication of gastroesophageal reflux disease that may be more common than reported. This syndrome was first mentioned more than 50 years ago with minimal documentation in the medical literature. Because of the presentation, the patient may be referred for lengthy, expensive, and unnecessary neurologic testing. This may lead to a missed or delayed diagnosis, mismanagement, and the use of inappropriate medication. Providers should be aware of Sandifer syndrome when evaluating a child with torticollis or unusual posturing that is not associated with neuromuscular disease or injury.
Current and Optimal Training in High-Value Care in the Internal Medicine Clerkship: A National Curricular Needs Assessment
Authors: Cayea Danelle , Tartaglia Kim , Pahwa Amit , Harrell Heather , Shaheen Amy , Lang Valerie J.
Published: March 2018

Purpose

The clinical skills needed to practice high-value care (HVC) are core to all medical disciplines. Medical students form practice habits early, and HVC instruction is essential to this formation. The purpose of this study was to describe the state of HVC instruction and assessment in internal medicine clerkships and identify needs for additional curricula.

Method

In 2014, the Clerkship Directors in Internal Medicine conducted its annual survey of 121 U.S. and Canadian medical schools. The authors evaluated a subset of questions from that survey asking clerkship directors about the perceived importance of HVC instruction, type and amount of formal instruction and assessment, achievement of student competence, prioritization of topics, and barriers to curriculum implementation. Descriptive statistics were used to summarize responses, and chi-square tests were used to examine associations between response categories.

Results

The overall response rate was 77.7% (94/121). The majority (85; 91.4%) agreed that medical schools have a responsibility to teach about HVC across all phases of the curriculum. Of respondents, 31 (32.9%) reported their curricula as having some formal instruction on HVC, and 66 (70.2%) felt the amount was inadequate. Highest-priority topics for inclusion included overuse of diagnostic tests and treatments, defining value and its application to clinical reasoning, and balancing benefit and harm. Only 11 (17.8%) assessed students’ competence in HVC.

Conclusions

Internal medicine clerkship directors reported that HVC is insufficiently taught and assessed in medical school, despite relevance to practice. Developing generalizable curricular materials, faculty development, and dedicated curricular time may enhance HVC education.
About Politeness, Face, and Feedback: Exploring Resident and Faculty Perceptions of How Institutional Feedback Culture Influences Feedback Practices
Authors: Ramani Subha , Könings Karen D. , Mann Karen V. , Pisarski Emily E. , van der Vleuten Cees P.M.
Published: March 2018

Purpose

To explore resident and faculty perspectives on what constitutes feedback culture, their perceptions of how institutional feedback culture (including politeness concepts) might influence the quality and impact of feedback, feedback seeking, receptivity, and readiness to engage in bidirectional feedback.

Method

Using a constructivist grounded theory approach, five focus group discussions with internal medicine residents, three focus group discussions with general medicine faculty, and eight individual interviews with subspecialist faculty were conducted at Brigham and Women’s Hospital between April and December 2016. Discussions and interviews were audiotaped and transcribed verbatim; concurrent data collection and analysis were performed using the constant comparative approach. Analysis was considered through the lens of politeness theory and organizational culture.

Results

Twenty-nine residents and twenty-two general medicine faculty participated in focus group discussions, and eight subspecialty faculty participated in interviews. The institutional feedback culture was described by participants as (1) a culture of politeness, in which language potentially damaging to residents’ self-esteem was discouraged; and (2) a culture of excellence, in which the institution’s outstanding reputation and pedigree of trainees inhibited constructive feedback. Three key themes situated within this broader cultural context were discovered: normalizing constructive feedback to promote a culture of growth, overcoming the mental block to feedback seeking, and hierarchical culture impeding bidirectional feedback.

Conclusions

An institutional feedback culture of excellence and politeness may impede honest, meaningful feedback and may impact feedback seeking, receptivity, and bidirectional feedback exchanges. It is essential to understand the institutional feedback culture before it can be successfully changed.
A Proposal for a Shared Medical School Curricular Ecosystem
Authors: Le Tao T. , Prober Charles G.
Published: March 2018

New digital platforms are transforming learning in higher education and providing high-quality education content at little or no cost. Educators can now reach large, even global audiences. Yet, many medical schools continue to develop and maintain custom but duplicative curricular content despite having limited faculty and financial resources. In addition, medical students are faced with a multitude of potentially unaligned curricula driven by the school, national licensing exams, and the students’ own perceived clinical training needs. The authors propose the creation of a common curricular component ecosystem that is developed around consensus-built foundational learning objectives aligned with core competencies that must be acquired by all students graduating medical school. Identifying and developing common curricula with standardized learning outcomes ideally should involve leading medical education, accreditation, and certification bodies in the United States. Curriculum component standards will be necessary to enable curriculum development, sharing, and adoption at scale. A shared medical curriculum ecosystem would free up faculty time to develop high-value teaching activities at individual medical schools. Students would benefit from a consistent education experience that better aligns with national licensure exams. A shared, core curriculum system could begin to bend the cost curve for medical education in the United States and scale internationally to help address the increasing global shortage of health care workers.
Where Hospital Boards Often Fail: Auditing Leadership Performance
Authors: Friedman Susan Y. , Rabkin Mitchell T.
Published: March 2018

Hospital boards address quality of care and patient safety as well as financial performance through long-accepted practices. By contrast, a hospital’s administrative operations and institutional culture are not usually subject to such detailed scrutiny. Yet, despite a healthy bottom line and patient commendations, hospital personnel can be underperforming, burdened with poor morale, and suffering from less-than-optimal leadership, unwarranted inefficiency, and ethically questionable management practices. The resulting employee dissatisfaction or disengagement can affect productivity, quality, turnover, innovation, patient and donor attraction and retention, public image, etc., and can be missed by an unsuspecting board. While boards do not scrutinize most administrative operations, they do examine financial performance, through review of the independent auditor’s Management Letter. Designed to help the chief financial officer (CFO) improve the efficiency and integrity of the hospital’s financial systems and to recommend improvements to the board for implementation (rather than to assess the CFO’s performance), the Management Letter has no equal with respect to a comparable evaluation of the hospital’s administrative performance and workplace culture. When, as is often the case, there is only superficial review of the chief executive officer, the board has no source of analysis or recommendations to improve the hospital’s institutional environment. In this Invited Commentary, the authors suggest a methodology to provide such a review, leading to a Leadership Letter, and discuss its utility for both nonprofit and for-profit organizations.
A Call for Mixed Methods in Competency-Based Medical Education: How We Can Prevent the Overfitting of Curriculum and Assessment
Authors: Hoang Nam S. , Lau James N.
Published: March 2018

Competency-based medical education (CBME) has been the subject of heated debate since its inception in medical education. Despite the many challenges and pitfalls of CBME that have been recognized by the medical education community, CBME is now seeing widespread implementation. However, the biggest problems with CBME still have not been solved. Two of these problems, reductionism and loss of authenticity, present major challenges when developing curricula and assessment tools.

The authors address these problems by making a call for flexibility in competency definitions and for the use of mixed methods in CBME. First, they present the issue of reductionism and a similar concept from the field of data science, overfitting. Then they outline several solutions, both conceptual and concrete, to prevent undue reductionist tendencies in both competency definitions and in tools of assessment. Finally, they propose the reintroduction of qualitative methods to balance the historically quantitative emphasis of assessment in medical education.

The authors maintain that mixed-methods assessment with multiple assessors in differing contexts can yield a more accurate representation of a medical trainee’s skills and abilities, deter the loss of authenticity, and increase the willingness of medical educators to adopt a feasible form of CBME. Finally, they propose the deployment of dedicated faculty assessors and physician coaches (which will reduce training requirements for other faculty), as well as the use of formal qualitative tools of assessment alongside established quantitative tools, to encourage a truly mixed-methods approach to assessment.
Sodium Channel Nav1.3 Is Expressed by Polymorphonuclear Neutrophils during Mouse Heart and Kidney Ischemia In Vivo and Regulates Adhesion, Transmigration, and Chemotaxis of Human and Mouse Neutrophils In Vitro
Authors: Poffers Marit , Bühne Nathalie , Herzog Christine , Thorenz Anja , Chen Rongjun , Güler Faikah , Hage Axel , Leffler Andreas , Echtermeyer Frank
Published: March 2018

Background

Voltage-gated sodium channels generate action potentials in excitable cells, but they have also been attributed noncanonical roles in nonexcitable cells. We hypothesize that voltage-gated sodium channels play a functional role during extravasation of neutrophils.

Methods

Expression of voltage-gated sodium channels was analyzed by polymerase chain reaction. Distribution of Nav1.3 was determined by immunofluorescence and flow cytometry in mouse models of ischemic heart and kidney injury. Adhesion, transmigration, and chemotaxis of neutrophils to endothelial cells and collagen were investigated with voltage-gated sodium channel inhibitors and lidocaine in vitro. Sodium currents were examined with a whole cell patch clamp.

Results

Mouse and human neutrophils express multiple voltage-gated sodium channels. Only Nav1.3 was detected in neutrophils recruited to ischemic mouse heart (25 ± 7%, n = 14) and kidney (19 ± 2%, n = 6) in vivo. Endothelial adhesion of mouse neutrophils was reduced by tetrodotoxin (56 ± 9%, unselective Nav-inhibitor), ICA121431 (53 ± 10%), and Pterinotoxin-2 (55 ± 9%; preferential inhibitors of Nav1.3, n = 10). Tetrodotoxin (56 ± 19%), ICA121431 (62 ± 22%), and Pterinotoxin-2 (59 ± 22%) reduced transmigration of human neutrophils through endothelial cells, and also prevented chemotactic migration (n = 60, 3 × 20 cells). Lidocaine reduced neutrophil adhesion to 60 ± 9% (n = 10) and transmigration to 54 ± 8% (n = 9). The effect of lidocaine was not increased by ICA121431 or Pterinotoxin-2.

Conclusions

Nav1.3 is expressed in neutrophils in vivo; regulates attachment, transmigration, and chemotaxis in vitro; and may serve as a relevant target for antiinflammatory effects of lidocaine.
Does Equi–Minimum Alveolar Concentration Value Ensure Equivalent Analgesic or Hypnotic Potency?
Authors: Ryu Kyoung-Ho , Song Keulame , Lim Tae-Young , Choi Won-Jun , Kim Yun-Hong , Kim Hyun-Soo
Published: March 2018

Background

Minimum alveolar concentration (MAC) has traditionally been used to compare the potency of volatile anesthetics. However, as it reflects the spinal mechanism of immobility rather than the cerebral mechanism of analgesia and hypnosis, it is doubtful that equi-MAC connotes equivalent analgesic or hypnotic potency. The level of analgesia and hypnosis can be assessed using surgical pleth index and bispectral index (BIS) values, respectively. This study was designed to compare the surgical pleth index and BIS values produced by equi-MAC of desflurane and sevoflurane in patients undergoing single-agent volatile anesthesia.

Methods

Eighty-nine patients were randomly allocated to two groups receiving either desflurane (n = 44) or sevoflurane (n = 45). Anesthesia was only maintained with assigned volatile anesthetic of age-corrected 1.0 MAC. Surgical pleth index values as an analgesic estimate and BIS values as a hypnotic estimate were obtained under standard tetanic stimulation.

Results

Post-stimulation surgical pleth index values (mean ± SD), the primary outcome, were significantly lower for the desflurane group than those for the sevoflurane group (49 ± 10 vs. 64 ± 14, difference, 15 [95% CI, 10 to 20], P < 0.001). The desflurane group showed significantly lower poststimulation BIS values (median [interquartile range]) than the sevoflurane group (36 [31 to 41] vs. 41 [38 to 47], difference, 6 [95% CI, 2 to 9], P = 0.001).

Conclusions

During a steady-state of 1.0 MAC, desflurane and sevoflurane did not cause similar surgical pleth index and BIS values under the standardized nociceptive stimulus. These findings suggest that equi-MAC of desflurane and sevoflurane may not ensure equivalent analgesic or hypnotic potency.
Optimizing Clinical Interpretation of Distortion Product Otoacoustic Emissions in Infants
Authors: Blankenship Chelsea M. , Hunter Lisa L. , Keefe Douglas H. , Feeney M. Patrick , Brown David K. , McCune Annie , Fitzpatrick Denis F. , Lin Li
Published: March 2018

Objectives:

The purpose of this study was to analyze distortion product otoacoustic emission (DPOAE) level and signal to noise ratio in a group of infants from birth to 4 months of age to optimize prediction of hearing status. DPOAEs from infants with normal hearing (NH) and hearing loss (HL) were used to predict the presence of conductive HL (CHL), sensorineural HL (SNHL), and mixed HL (MHL). Wideband ambient absorbance was also measured and compared among the HL types.

Design:

This is a prospective, longitudinal study of 279 infants with verified NH and HL, including conductive, sensorineural, and mixed types that were enrolled from a well-baby nursery and two neonatal intensive care units in Cincinnati, Ohio. At approximately 1 month of age, DPOAEs (1–8 kHz), wideband absorbance (0.25–8 kHz), and air and bone conduction diagnostic tone burst auditory brainstem response (0.5–4 kHz) thresholds were measured. Hearing status was verified at approximately 9 months of age with visual reinforcement audiometry (0.5–4 kHz). Auditory brainstem response air conduction thresholds were used to assign infants to an NH or HL group, and the efficacy of DPOAE data to classify ears as NH or HL was analyzed using receiver operating characteristic (ROC) curves. Two summary statistics of the ROC curve were calculated: the area under the ROC curve and the point of symmetry on the curve at which the sensitivity and specificity were equal. DPOAE level and signal to noise ratio cutoff values were defined at each frequency as the symmetry point on their respective ROC curve, and DPOAE results were combined across frequency in a multifrequency analysis to predict the presence of HL.

Results:

Single-frequency test performance of DPOAEs was best at mid to high frequencies (3–8 kHz) with intermediate performance at 1.5 and 2 kHz and chance performance at 1 kHz. Infants with a conductive component to their HL (CHL and MHL combined) displayed significantly lower ambient absorbance values than the NH group. No differences in ambient absorbance were found between the NH and SNHL groups. Multifrequency analysis resulted in the best prediction of HL for the SNHL/MHL group with poorer sensitivity values when infants with CHL were included.

Conclusions:

Clinical interpretation of DPOAEs in infants can be improved by using age-appropriate normative ranges and optimized cutoff values. DPOAE interpretation is most predictive at higher F2 test frequencies in young infants (2–8 kHz) due to poor test performance at 1 to 1.5 kHz. Multifrequency rules can be used to improve sensitivity while balancing specificity. Last, a sensitive middle ear measure such as wideband absorbance should be included in the test battery to assess possibility of a conductive component to the HL.
Subspecialty Training Among Graduates of Pediatric Orthopaedic Fellowships: An 11-Year Analysis of the Database of American Board of Orthopaedic Surgery
Authors: Hosseinzadeh Pooya , Louer Craig , Sawyer Jeffrey , Flynn John , Albanese Stephen
Published: March 2018

Background:

The field of pediatric orthopaedic surgery is evolving with a reported increase in the number of pediatric orthopaedic fellows being trained as well as an increase in the number of fellows completing additional fellowship training in another subspecialty. The purpose of this study was to examine the historic trends of trainees seeking multiple fellowships within pediatric orthopaedics over an 11-year period using the database of the American Board of Orthopaedic Surgery (ABOS).

Methods:

We queried the ABOS database for fellowship choice of applicants for the ABOS part II oral examination with the self-declared subspecialty of pediatric orthopaedics during the years of 2005 to 2015. Descriptive analysis was performed to determine the percentage of applicants who completed >1 fellowship, and the type of subspecialty fellowship completed. χ2 analysis was used to compare the proportion of multiple fellowship trainees between years.

Results:

From 2005 to 2015, 310 applicants for ABOS part II pediatric subspecialty examination had completed a fellowship in pediatric orthopaedic surgery, with that number increasing from 14 to 43/y over that span. Forty-five trainees (15%) completed 48 additional fellowships over that decade, with 2 recent trainees completing multiple additional fellowships. The most common additional fellowships were sports (n=22, 46%), hand (n=8, 17%), and spine (n=7, 15%). The rate of additional fellowship training increased over 5-fold from 5% in the first 3 years of the study to 28% in the last 2 years of the study (P=0.001).

Conclusions:

The proportion of trainees completing additional subspecialty fellowships in addition to pediatric orthopaedics has risen over the past decade. The precise cause and effect of such change is uncertain and likely multifactorial. Reexamination of our classic training paradigms may be warranted in light of these trends.

Level of Evidence:

Level III.
Liberal Glucose Control in ICU Patients With Diabetes: A Before-and-After Study*
Authors: Luethi Nora , Cioccari Luca , Biesenbach Peter , Lucchetta Luca , Kagaya Hidetoshi , Morgan Rhys , Di Muzio Francesca , Presello Barbara , Gaafar Duaa , Hay Alison , Crisman Marco , Toohey Roisin , Russell Hollie , Glassford Neil J. , Eastwood Glenn M. , Ekinci Elif I. , Deane Adam M. , Bellomo Rinaldo , Mårtensson Johan
Published: March 2018

Objectives:

To assess the feasibility, biochemical efficacy, and safety of liberal versus conventional glucose control in ICU patients with diabetes.

Design:

Prospective, open-label, sequential period study.

Setting:

A 22-bed mixed ICU of a tertiary hospital in Australia.

Patients:

We compared 350 consecutive patients with diabetes admitted over 15 months who received liberal glucose control with a preintervention control population of 350 consecutive patients with diabetes who received conventional glucose control.

Interventions:

Liberal control patients received insulin therapy if glucose was greater than 14 mmol/L (target: 10–14 mmol/L [180–252 mg/dL]). Conventional control patients received insulin therapy if glucose was greater than 10 mmol/L (target: 6–10 mmol/L [108–180 mg/dL]).

Measurements and Main Results:

We assessed separation in blood glucose, insulin requirements, occurrence of hypoglycemia (blood glucose ≤ 3.9 mmol/L [70 mg/dL]), creatinine and white cell count levels, and clinical outcomes. The median (interquartile range) time-weighted average blood glucose concentration was significantly higher in the liberal control group (11.0 mmol/L [8.7–12.0 mmol/L]; 198 mg/dL [157–216 mg/dL]) than in the conventional control group (9.6 mmol/L [8.5–11.0 mmol/L]; 173 mg/dL [153–198 mg/dL]; p < 0.001). Overall, 132 liberal control patients (37.7%) and 188 conventional control patients (53.7%) received insulin in ICU (p < 0.001). Hypoglycemia occurred in 6.6% and 8.6%, respectively (p = 0.32). Among 314 patients with glycated hemoglobin A1c greater than or equal to 7%, hypoglycemia occurred in 4.1% and 9.6%, respectively (p = 0.053). Trajectories of creatinine and white cell count were similar in the groups. In multivariable analyses, we found no independent association between glucose control and mortality, duration of mechanical ventilation, or ICU-free days to day 30.

Conclusions:

In ICU patients with diabetes, during a period of liberal glucose control, insulin administration, and among patients with hemoglobin A1c greater than or equal to 7%, the prevalence of hypoglycemia was reduced, without negatively affecting serum creatinine, the white cell count response, or other clinical outcomes. (Trial Registration: Australian New Zealand Clinical Trials Registry; ACTRN12615000216516).