bluuebunny/crossref_metadata_2025 huggingface dataset:
Bio-Key Based AES for Personalized Image Cryptography
Authors: Vijayarajan R , Gnanasivam P , Avudaiammal R
Published: March 2019

In the era of multimedia technologies and rapidly growing multimedia contents, secured information transfer needs to be ensured through robust cryptography techniques. This paper presents a bio-key-generation scheme in the local environment to transfer multimedia content over vulnerable networks. To encrypt the images, one user has to ensure his/her authentication and further needs to provide a secret key for bio-key generation. Secret key aids to fetch biometric features for key formation and key expansion. Thus, the user receives an expanded key from the template database to perform encryption of a plain image. Once the cipher image is delivered to the network, the user has to repeat the same steps for decryption. This paper experiments the proposed bio-key-generation scheme with advanced encryption standard algorithm. This encryption strategy can also be used to encrypt confidential or personal images in various digital systems such as mobile phones, personal digital gadgets and so on. Various analyses ensure the robustness and the performance of the bio-key-based AES encryption scheme. Entropy, correlation coefficient, number of pixel change rate and unified average changing intensity are evaluated to ensure the effectiveness of the proposed method over other key-based encryption techniques.
Carbon monoxide improves haemodynamics during extracorporeal resuscitation in pigs
Authors: Wollborn Jakob , Steiger Christoph , Ruetten Eva , Benk Christoph , Kari Fabian A , Wunder Christian , Meinel Lorenz , Buerkle Hartmut , Schick Martin A , Goebel Ulrich
Published: March 2019

Aims

Heart disease of different aetiology remains the leading cause of cardiac arrest (CA). Despite efforts to improve the quality of cardiopulmonary resuscitation (CPR), subsequent myocardial and systemic damage after CA still present a major long-term burden. Low-dose carbon monoxide (CO) is known to exert protective effects in cardiovascular pathophysiology but clinical applications are challenged by unfavourable delivery modes. We tested the hypothesis that extracorporeal resuscitation (E-CPR) in combination with controlled fast onset CO delivery results in improved cardiac physiology and haemodynamics. Damage-associated molecular pattern (DAMP) signalling may be part of the molecular mechanism.

Methods and results

In an established porcine model, E-CPR was performed. While E-CPR leads to similar results as compared to a conventional CPR strategy, CO delivery in combination with E-CPR demonstrated significant cardioprotection. Cardiac performance analysis using echocardiography and thermodilution techniques showed a CO-dependent improved cardiac function compared to severe myocardial dysfunction in CPR and E-CPR (left ventricular ejection fraction: Sham 49 ± 5; CPR 26 ± 2; E-CPR 25 ± 2; CO-E-CPR 31 ± 4; P < 0.05). While sublingual microcirculation was significantly compromised in CPR and E-CPR, CO delivery demonstrated a significant improvement in microvascular function (microvascular flow index: Sham 2.9 ± 0.1; CPR 2.2 ± 0.1; E-CPR 1.8 ± 0.1; CO-E-CPR 2.7 ± 0.1; P < 0.01). Histological and serological myocardial damage markers were significantly reduced (hsTroponin-T Sham 0.01 ± 0.001; CPR 1.9 ± 0.2; E-CPR 3.5 ± 1.2; CO-E-CPR 0.5 ± 0.2 ng/mL; P < 0.05). DAMP signalling was decreased ipse facto leading to influence of cardioprotective heat shock and cyclooxygenase response.

Conclusions

CO treatment restores myocardial function and improves systemic macro- and microhaemodynamics in E-CPR through a reduction in DAMPs.
Randomized trial of ticagrelor vs. aspirin in patients after coronary artery bypass grafting: the TiCAB trial
Authors: Schunkert Heribert , Boening Andreas , von Scheidt Moritz , Lanig Clarissa , Gusmini Friederike , de Waha Antoinette , Kuna Constantin , Fach Andreas , Grothusen Christina , Oberhoffer Martin , Knosalla Christoph , Walther Thomas , Danner Bernhard C , Misfeld Martin , Zeymer Uwe , Wimmer-Greinecker Gerhard , Siepe Matthias , Grubitzsch Herko , Joost Alexander , Schaefer Andreas , Conradi Lenard , Cremer Jochen , Hamm Christian , Lange Rüdiger , Radke Peter W , Schulz Rainer , Laufer Günther , Grieshaber Philippe , Pader Philip , Attmann Tim , Schmoeckel Michael , Meyer Alexander , Ziegelhöffer Tibor , Hambrecht Rainer , Kastrati Adnan , Sandner Sigrid E
Published: March 2019

Aims

The antiplatelet treatment strategy providing optimal balance between thrombotic and bleeding risks in patients undergoing coronary artery bypass grafting (CABG) is unclear. We prospectively compared the efficacy of ticagrelor and aspirin after CABG.

Methods and results

We randomly assigned in double-blind fashion patients scheduled for CABG to either ticagrelor 90 mg twice daily or 100 mg aspirin (1:1) once daily. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), repeat revascularization, and stroke 12 months after CABG. The main safety endpoint was based on the Bleeding Academic Research Consortium classification, defined as BARC ≥4 for periprocedural and hospital stay-related bleedings and BARC ≥3 for post-discharge bleedings. The study was prematurely halted after recruitment of 1859 out of 3850 planned patients. Twelve months after CABG, the primary endpoint occurred in 86 out of 931 patients (9.7%) in the ticagrelor group and in 73 out of 928 patients (8.2%) in the aspirin group [hazard ratio 1.19; 95% confidence interval (CI) 0.87–1.62; P = 0.28]. All-cause mortality (ticagrelor 2.5% vs. aspirin 2.6%, hazard ratio 0.96, CI 0.53–1.72; P = 0.89), cardiovascular death (ticagrelor 1.2% vs. aspirin 1.4%, hazard ratio 0.85, CI 0.38–1.89; P = 0.68), MI (ticagrelor 2.1% vs. aspirin 3.4%, hazard ratio 0.63, CI 0.36–1.12, P = 0.12), and stroke (ticagrelor 3.1% vs. 2.6%, hazard ratio 1.21, CI 0.70–2.08; P = 0.49), showed no significant difference between the ticagrelor and aspirin group. The main safety endpoint was also not significantly different (ticagrelor 3.7% vs. aspirin 3.2%, hazard ratio 1.17, CI 0.71–1.92; P = 0.53).

Conclusion

In this prematurely terminated and thus underpowered randomized trial of ticagrelor vs. aspirin in patients after CABG no significant differences in major cardiovascular events or major bleeding could be demonstrated.

ClinicalTrials.gov Identifier

NCT01755520.
Population growth of an endangered pinniped—the New Zealand sea lion (Phocarctos hookeri)—is limited more by high pup mortality than fisheries bycatch
Authors: Hamilton Sheryl , Baker G Barry
Published: March 2019

The endangered New Zealand sea lion, Phocarctos hookeri is killed as incidental bycatch in a trawl fishery operating near their second largest population on Campbell Island in New Zealand’s sub-Antarctic. Using the Potential Biological Removal (PBR) procedure to assess the sustainability of this bycatch for the sea lion population on Campbell Island indicated that annual bycatch estimates, particularly following the implementation of bycatch mitigation measures, are below the PBR threshold of 25 (derived using a precautionary approach). Preliminary Population Viability Analysis (PVA) modelling supported the finding that current bycatch levels, especially given a strong male bias (98%) in bycatch, are sustainable for this population. Models showed that reducing pup mortality through management actions, such as installing ramps in wallows where large numbers of pups drown, would lead to increased population growth. While obtaining more accurate data on population status and demographic parameters for the Campbell Island population should be a priority, this will take many years of research. The PBR and PVA tools demonstrate that contemporary conservation management should continue to focus on increasing pup survival while maintaining mitigation approaches that have reduced bycatch to low levels, together with high observer coverage to sustain confidence in annual bycatch estimates.
Management of cervical aortic arch complicated by multiple aneurysms
Authors: Shayan Gulidanna , Shao Jiang , Wang Yuewei , Si Loubin , Shen Junyue , Chen Yu , Liu Bao , Zheng Yuehong
Published: March 2019

OBJECTIVES

Cervical aortic arch with aneurysm formation is considered an extremely rare condition. Here, we summarize our experience in treating 8 patients. We validated extra-anatomic ascending-to-infrarenal abdominal aorta bypass through the retroperitoneal cavity without circulatory arrest as an alternative treatment for patients with a tortuous arch that was unsuitable for endovascular repair.

METHODS

From March 2015 to April 2018, 8 patients (7 women; median age 46 years) diagnosed with cervical aortic arch complicated with aneurysm formation were treated at Peking Union Medical College Hospital and the Affiliated Hospital of Qingdao University. After assessment of the anatomical characteristics, 4 patients underwent endovascular repair. Three patients with a tortuous aortic arch and saccular aneurysm formation between the left common carotid artery and the left subclavian artery were treated with an extra-anatomic ascending-to-infrarenal abdominal aorta bypass and aneurysm indwelling. One patient refused surgical intervention and is being followed up on a yearly basis at our outpatient clinic. No circulatory arrest was required during surgery.

RESULTS

No severe postoperative complications were observed during follow-up (6–36 months). Postoperative computed tomography angiography revealed patent blood flow in the prosthetic aortic graft bypass. No endoleak, migration or stenosis of the stent grafts was observed in patients following endovascular repair. The left subclavian artery was preserved in 3 patients. Follow-up computed tomography angiography revealed satisfactory postoperative results in all patients, with no signs of aortic dilation or coarctation.

CONCLUSIONS

Ascending-to-infrarenal abdominal aorta bypass through the retroperitoneal cavity is a safe and effective treatment for cervical aortic arch with a tortuous aorta complicated by aneurysm formation and coarctation.
Digital Breast Tomosynthesis: What Have We Learned?
Authors: Butler Reni , Conant Emily F , Philpotts Liane
Published: March 2019

Digital breast tomosynthesis (DBT) is increasingly recognized as a superior breast imaging technology compared with 2D digital mammography (DM) alone. Accumulating data confirm increased sensitivity and specificity in the screening setting, resulting in higher cancer detection rates and lower abnormal interpretation (recall) rates. In the diagnostic environment, DBT simplifies the diagnostic work-up and improves diagnostic accuracy. Initial concern about increased radiation exposure resulting from the DBT acquisition added onto a 2D mammogram has been largely alleviated by the development of synthesized 2D mammography (SM). Continued research is underway to reduce artifacts associated with SM, and improve its comparability to DM. Breast cancers detected with DBT are most often small invasive carcinomas with a preponderance for grade 1 histology and luminal A molecular characteristics. Recent data suggest that higher-grade cancers are also more often node negative when detected with DBT. A meta-analysis of early single-institution studies of the effect of DBT on interval cancers has shown a modest decrease when multiple data sets are combined. Because of the greater conspicuity of lesions on DBT imaging, detection of subtle architectural distortion is increased. Such findings include both spiculated invasive carcinomas and benign etiologies such as radial scars. The diagnostic evaluation of architectural distortion seen only with DBT can pose a challenge. When no sonographic correlate can be identified, DBT-guided biopsy and/or localization capability is essential. Initial experience with DBT-guided procedures suggests that DBT biopsy equipment may improve the efficiency of percutaneous breast biopsy with less radiation.
Pearls and Pitfalls of Contrast-Enhanced Mammography
Authors: Phillips Jordana , Fein-Zachary Valerie J , Slanetz Priscilla J
Published: March 2019

Contrast-enhanced mammography (CEM) is a promising new imaging modality that uses a dual-energy acquisition to provide both morphologic and vascular assessment of breast lesions. Although no official BI-RADS lexicon exists, interpretation entails using the mammographic BI-RADS lexicon in combination with that for breast MRI. CEM has comparable performance to breast MRI, with sensitivity of 93–100% and specificity of 80–94%. Currently FDA approved for diagnostic imaging, this technology can be helpful in determining disease extent in patients with newly diagnosed breast malignancy, monitoring response to neoadjuvant therapy, identifying mammographically occult malignancies, and diagnostic problem-solving. Studies are ongoing about its role in screening, especially in women with dense breasts or at elevated risk. There are some challenges to successful implementation into practice, but overall, patients tolerate the study well, and exam times are less than the full breast MRI protocol.
Proof Paradoxes and Normic Support: Socializing or Relativizing?
Authors: Di Bello Marcello
Published: March 2019

Smith (2018) argues that, unlike other forms of evidence, naked statistical evidence fails to satisfy normic support. This is his solution to the puzzles of statistical evidence in legal proof. This paper focuses on Smith’s claim that DNA evidence in cold-hit cases does not satisfy normic support. I argue that if this claim is correct, virtually no other form of evidence used at trial can satisfy normic support. This is troublesome. I discuss a few ways in which Smith can respond.
Hybrid symplectic integrators for planetary dynamics
Authors: Rein Hanno , Hernandez David M , Tamayo Daniel , Brown Garett , Eckels Emily , Holmes Emma , Lau Michelle , Leblanc Réjean , Silburt Ari
Published: March 2019

Hybrid symplectic integrators such as MERCURY are widely used to simulate complex dynamical phenomena in planetary dynamics that could otherwise not be investigated. A hybrid integrator achieves high accuracy during close encounters by using a high-order integration scheme for the duration of the encounter while otherwise using a standard second-order Wisdom–Holman scheme, thereby optimizing both speed and accuracy. In this paper we reassess the criteria for choosing the switching function that determines which parts of the Hamiltonian are integrated with the high-order integrator. We show that the original motivation for choosing a polynomial switching function in MERCURY is not correct. We explain the nevertheless excellent performance of the MERCURY integrator and then explore a wide range of different switching functions including an infinitely differentiable function and a Heaviside function. We find that using a Heaviside function leads to a significantly simpler scheme compared to MERCURY , while maintaining the same accuracy in short-term simulations.
Serotonin Receptor 1A Variation Is Associated with Anxiety and Agonistic Behavior in Chimpanzees
Authors: Staes Nicky , Sherwood Chet C , Freeman Hani , Brosnan Sarah F , Schapiro Steven J , Hopkins William D , Bradley Brenda J
Published: March 2019

Serotonin is a neurotransmitter that plays an important role in regulating behavior and personality in humans and other mammals. Polymorphisms in genes coding for the serotonin receptor subtype 1A (HTR1A), the serotonin transporter (SLC6A4), and the serotonin degrading enzyme monoamine oxidase A (MAOA) are associated with anxiety, impulsivity, and neurotic personality in humans. In primates, previous research has largely focused on SLC6A4 and MAOA, with few studies investigating the role of HTR1A polymorphic variation on behavior. Here, we examined variation in the coding region of HTR1A across apes, and genotyped polymorphic coding variation in a sample of 214 chimpanzees with matched measures of personality and behavior. We found evidence for positive selection at three amino acid substitution sites, one in chimpanzees-bonobos (Thr26Ser), one in humans (Phe33Val), and one in orangutans (Ala274Gly). Investigation of the HTR1A coding region in chimpanzees revealed a polymorphic site, where a C/A single nucleotide polymorphism changes a proline to a glutamine in the amino acid sequence (Pro248Gln). The substitution is located in the third intracellular loop of the receptor, a region important for serotonin signal transduction. The derived variant is the major allele in this population (frequency 0.67), and is associated with a reduction in anxiety, decreased rates of male agonistic behavior, and an increase in socio-positive behavior. These results are the first evidence that the HTR1A gene may be involved in regulating social behavior in chimpanzees and encourage further systematic investigation of polymorphic variation in other primate populations with corresponding data on behavior.
Nonsteroidal anti-inflammatory drug use and risk of acute kidney injury and hyperkalemia in older adults: a population-based study
Authors: Nash Danielle M , Markle-Reid Maureen , Brimble Kenneth S , McArthur Eric , Roshanov Pavel S , Fink Jeffrey C , Weir Matthew A , Garg Amit X
Published: March 2019

Background

Clinical guidelines caution against nonsteroidal anti-inflammatory drug (NSAID) use in older adults. The study objective was to quantify the 30-day risk of acute kidney injury (AKI) and hyperkalemia in older adults after NSAID initiation and to develop a model to predict these outcomes.

Methods

We conducted a population-based retrospective cohort study in Ontario, Canada from 2007 to 2015 of patients ≥66 years. We matched 46 107 new NSAID users with 46 107 nonusers with similar baseline health. The primary outcome was 30-day risk of AKI and secondary outcomes were hyperkalemia and all-cause mortality.

Results

NSAID use versus nonuse was associated with a higher 30-day risk of AKI {380 [0.82%] versus 272 [0.59%]; odds ratio (OR) 1.41 [95% confidence interval (CI) 1.20–1.65]} and hyperkalemia [184 (0.40%) versus 123 (0.27%); OR 1.50 (95% CI 1.20–1.89); risk difference 0.23% (95% CI 0.13–0.34)]. There was no association between NSAID use and all-cause mortality. A prediction model incorporated six predictors of AKI or hyperkalemia: older age, male gender, lower baseline estimated glomerular filtration rate, higher baseline serum potassium, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use or diuretic use. This model had moderate discrimination [C-statistic 0.72 (95% CI 0.70–0.74)] and good calibration.

Conclusions

In older adults, new NSAID use compared with nonuse was associated with a higher 30-day risk of AKI and hyperkalemia but not all-cause mortality. Prescription NSAID use among many older adults may be safe, but providers should use caution and assess individual risk.
Quantitative easing in a monetary union
Authors: Saraceno Francesco , Tamborini Roberto
Published: March 2019

The long season of unconventional monetary policies in advanced economies seems to be coming to an end. How can quantitative easing (QE) be effective where conventional monetary policy fails? How does it work in the peculiar environment of a monetary union? We study this latter case modelling a monetary union as the aggregate of two countries characterized by New Keynesian output and inflation relationships, with a Tobinian money market equation. QE is operated by the single central bank by expanding money supply in exchange for risky assets throughout the union. We assess the stabilization capacity of QE under different types of symmetric and asymmetric shocks, in which case fiscal accommodation at the country level should also intervene.
A Matter of Life or Death: A Survey Experiment on the Perceived Legitimacy of Political Decision-Making on Euthanasia
Authors: Christensen Henrik Serup , Himmelroos Staffan , Setälä Maija
Published: March 2019

Most representative democracies seem to experience dwindling levels of legitimacy in the eyes of citizens. Nevertheless, it remains unclear what people want from parliamentary decision-making. In this study, we test the impact of outcome favourability, actor involvement and justifications on the perceived legitimacy of a parliamentary decision-making process on euthanasia in Finland. We do so with the help of a survey experiment (n = 1243), where respondents were exposed to a vignette where the treatments varied randomly. The results suggest that outcome favourability is of primary importance, but the involvement of experts and citizens also boost legitimacy in the eyes of citizens. Justifications, or presenting arguments for the decisions, does not enhance legitimacy and may even cause a backfire mechanism where the difference between getting and not getting the preferred outcome is amplified.
Incidence, risk factors, and outcomes of pulmonary hypertension in preterm infants with bronchopulmonary dysplasia
Authors: MacKenzie Katelyn , Cunningham Kathy , Thomas Sumesh , Mondal Tapas , el Helou Salhab , Shah Prakesh S , Mukerji Amit
Published: March 2019

Objectives

To determine the incidence and risk factors for pulmonary hypertension (PH) in preterm infants with moderate to severe bronchopulmonary dysplasia (BPD) and to compare short-term outcomes.

Methods

Preterm infants <32 weeks gestation born August 2013 through July 2015 with moderate to severe BPD at 36 weeks postmenstrual age were categorized into BPD-PH (exposure) and BPD-noPH (control) groups.

Results

Of 92 infants with BPD, 87 had echocardiographic assessment, of whom 24 (28%) had PH. On multiple logistic regression after adjustment for gestational age and sex, no significant risk factors for PH were identified based on data from this cohort. There were no differences in resource utilization or clinical outcomes including survival to discharge.

Conclusion

Approximately one out of four patients with moderate to severe BPD were identified as having PH. No significant risk factors for PH were identified. No differences in outcomes were identified for those with and without PH.
Synergistic effect of immunotherapy and radiotherapy in non-small cell lung cancer: current clinical trials and prospective challenges
Authors: Yang Hui , Jin Tao , Li Mengqian , Xue Jianxin , Lu Bo
Published: March 2019

Lately, the success of ICIs has drastically changed the landscape of cancer treatment, and several immune checkpoint inhibitors (ICIs) have been approved by the US Food and Drug Administration (FDA) for advanced non-small cell lung cancer (NSCLC). However, numerous patients are resistant to ICIs and require additional procedures for better efficacy results. Thus, combination therapy is urgently needed to strengthen the anti-tumor immunity. A variety of preclinical and clinical studies combining ICIs with radiotherapy (RT) have demonstrated that the combination could induce synergistic effects, as RT overcomes the resistance to ICIs. However, the underlying mechanism of the synergistic effect and the optimal arrangement of the combination therapy are indecisive now. Hence, this review was conducted to provide an update on the current clinical trial results and highlighted the ongoing trials. We also discussed the optimal parameters in clinical trials, including radiation dose, radiation fractionation, radiation target field, and sequencing of combination therapy. In this review, we found that combination therapy showed stronger anti-tumor immunity with tolerable toxicities in clinical trials. However, the best combination mode and potential biomarkers for the target patients in combination therapy are still unclear.
VitisMethods to Understand and Develop Strategies for Diagnosis and Sustainable Control of Grapevine Trunk Diseases
Authors: Reis P. , Pierron R. , Larignon P. , Lecomte P. , Abou-Mansour E. , Farine S. , Bertsch C. , Jacques A. , Trotel-Aziz P. , Rego C. , Fontaine F.
Published: March 2019

Vitis vinifera is affected by many diseases every year, depending on causal agents, susceptibility of cultivars, and climate region. Some are caused by a single agent, such as gray mold caused by Botrytis cinerea or powdery mildew caused by Erysiphe necator. Others result from the actions of a complex of pathogens such as grapevine trunk diseases (GTDs). GTDs are presently among the most devastating diseases in viticulture worldwide because both the economic losses and the long-term sustainability of vineyards are strongly affected. The complexity of GTDs results from the diversity of associated fungi, the undetermined period of latency within the vine (asymptomatic status), the erratic foliar symptom expression from one year to the next, and, probably correlated with all of these points, the lack of efficient strategies to control them. Distinct methods can be beneficial to improve our knowledge of GTDs. In vitro bioassays with cell suspensions, calli, foliar discs, full leaves, or plantlets, and in vivo natural bioassays with cuttings, grafted plants in the greenhouse, or artificially infected ones in the vineyard, can be applied by using progressive integrative levels of in vitro and in vivo, depending on the information searched. In this review, the methods available to understand GTDs are described in terms of experimental procedures, main obtained results, and deliverable prospects. The advantages and disadvantages of each model are also discussed.
Global Epidemiology of Use of and Disparities in Caesarean Sections
Authors: Boerma Ties , Ronsmans Carine , Melesse Dessalegn Y. , Barros Aluisio J. D. , Barros Fernando C. , Juan Liang , Moller Ann-Beth , Say Lale , Hosseinpoor Ahmad Reza , Yi Mu , de Lyra Rabello Neto Dácio , Temmerman Marleen
Published: March 2019

(Abstracted from Lancet 2018;392(10155):1341–1348)

Cesarean delivery can save women's and infants' lives and should be universally accessible. However, the large increase in cesarean delivery use, often for nonmedical indications, is of concern given the risks for both women and children.
Association of Prenatal Maternal Depression and Anxiety Symptoms With Infant White Matter Microstructure
Authors: Dean Douglas C. , Planalp Elizabeth M. , Wooten William , Kecskemeti Steven R. , Adluru Nagesh , Schmidt Cory K. , Frye Corrina , Birn Rasmus M. , Burghy Cory A. , Schmidt Nicole L. , Styner Martin A. , Short Sarah J. , Kalin Ned H. , Goldsmith H. Hill , Alexander Andrew L. , Davidson Richard J.
Published: March 2019

(Abstracted from JAMA Pediatr 2018;172(10):973–981)

Depression and anxiety are common during pregnancy. These disorders are estimated to affect 7% to 20% of pregnant women; however, many women reach only a subclinical threshold and are not formally diagnosed.
Personalised Perioperative Care by E-Health After Intermediate-Grade Abdominal Surgery: A Multicentre, Single-Blind, Randomised, Placebo-Controlled Trial
Authors: van der Meij Eva , Anema Johannes R. , Leclercq Wouter K. G. , Bongers Marlies Y. , Consten Esther C. J. , Schraffordt Koops Steven E. , van de Ven Peter M. , Terwee Caroline B. , van Dongen Johanna M. , Schaafsma Frederieke G. , Meijerink Wilhelmus J. H. J. , Bonjer Hendrik J. , Huirne Judith A. F.
Published: March 2019

(Abstracted from Lancet 2018;392:51–59)

Instructing and guiding patients are essential for successful recovery after surgery. Because of efficiency-driven, shortened hospital stays, the amount of time health care professionals spend, before and after surgery with their patients, has been reduced.
Donor Spermatogenesis in De Novo Formed Seminiferous Tubules From Transplanted Testicular Cells in Rhesus Monkey Testis
Authors: Shetty Gunapala , Mitchell Jennifer M. , Lam Truong Nguyen Anh , Wu Zhuang , Zhang Jie , Hill Lorraine , Tailor Ramesh C. , Peters Karen A. , Penedo Maria Cecilia , Orwig Kyle E. , Meistrich Marvin L.
Published: March 2019

(Abstracted from Hum Reprod 2018;33:2249–2255)

Cytotoxic cancer treatments, including chemotherapy and radiotherapy, cause damage to spermatogenic stem cells (SSCs), jeopardizing the fertility of young men of reproductive age. One potential method for future production of sperm in this population is SSC transplantation.
A Further Examination of Previous and Future Policy Opportunities of the Educational Commission for Foreign Medical Graduates
Authors: Dauphinee W. Dale
Published: March 2019

The Educational Commission for Foreign Medical Graduates (ECFMG) has a distinguished history of providing high-quality, innovative products and services to international medical graduates (IMGs) seeking to study and practice medicine in the United States. In 2010, the ECFMG board introduced a policy stating that, starting in 2023, all IMGs applying to the ECFMG for credentialing must have graduated from a medical school that has been accredited by an internationally recognized accrediting body akin to the Liaison Committee on Medical Education in the United States or the World Federation for Medical Education. In this issue of Academic Medicine, Tackett reviews the reasons for the policy and its adoption worldwide. After eight years, the number of schools meeting the new standard is modest. He is concerned about the negative effect a continuing low rate of adoption will have on U.S. postgraduate medical education programs and workforce supply. The author of this Invited Commentary offers three perspectives: an overview of the ECFMG’s successes, alternative measurement tools to ensure the quality of IMGs entering the United States, and frameworks by which an organization like the ECFMG can refine its policy positions and processes for the future. Academia can expect the ECFMG, given its history of successful collaboration and public accountability, to continue using best practices and to adjust policies according to evidence. As a publicly accountable authority, the ECFMG should debrief key stakeholders on current policies, track IMG practice patterns, and share the resulting data with stakeholders to inform their IMG-related planning decisions.
Geographic Distribution of Regional Quota Program Graduates of Japanese Medical Schools: A Nationwide Cohort Study
Authors: Matsumoto Masatoshi , Kashima Saori , Owaki Tetsuhiro , Iguchi Seitaro , Inoue Kazuo , Tazuma Susumu , Maeda Takahiro
Published: March 2019

Purpose

To show the practice location of graduates from two Japanese programs recruiting physicians to rural areas: a regional quota program of medical schools and a prefecture scholarship program (a prefecture is an administrative geographic division). Graduates of each program must work in a designated rural prefecture for a fixed period.

Method

A nationwide cohort study was conducted for three groups of participants graduating between 2014 and 2016: quota graduates without scholarship (quota alone), nonquota graduates with scholarship (scholarship alone), and quota graduates with scholarship. A questionnaire was sent via medical school or prefecture office to each potential subject to collect baseline individual data, including home prefecture and graduation year. Data were connected through physician identification number to the Physician Census 2016 of the Ministry of Health, Labour and Welfare to identify the subjects’ practice location and compared with data for other physicians in the census. Comparisons were conducted with Mann-Whitney and chi-square tests.

Results

The proportion of physicians working in nonmetropolitan municipalities for quota alone (185/244; 75.8%), scholarship alone (305/363; 84.0%), and quota with scholarship (341/384; 88.8%) was significantly higher than for other physicians (13,299/22,906; 58.1%). Median population density of the municipalities where subjects worked for quota alone (1,042.4 persons per square kilometer), scholarship alone (613.5), and quota with scholarship (547.4) was significantly lower than that for other physicians (3,214.0). These disparities increased with number of years since graduation.

Conclusions

The regional quota and prefecture scholarship programs succeeded in producing physicians who practiced in rural areas of Japan.
Exemplary Learning Environments for the Health Professions: A Vision
Authors: van Schaik Sandrijn M. , Reeves Susan A. , Headrick Linda A.
Published: March 2019

In this article, the authors propose a vision for exemplary learning environments in which everyone involved in health professions education and health care collaborates toward optimal health for individuals, populations, and communities. Learning environments in the health professions can be conceptualized as complex adaptive systems, defined as a collection of individual agents whose actions are interconnected and follow a set of shared “simple rules.” Using principles from complex adaptive systems as a guiding framework for the proposed vision, the authors postulate that exemplary learning environments will follow four such simple rules: Health care and health professions education share a goal of improving health for individuals, populations, and communities; in exemplary learning environments, learning is work and work is learning; exemplary learning environments recognize that collaboration with integration of diverse perspectives is essential for success; and the organizations and agents in the learning environments learn about themselves and the greater system they are part of in order to achieve continuous improvement and innovation. For each of the simple rules, the authors describe the details of the vision and how the current state diverges from this vision. They provide actionable ideas about how to reach the vision using specific examples from the literature. In addition, they identify potential targets for assessment to monitor the success of learning environments, including outcome measures at the individual, team, institutional, and societal levels. Such measurements can ensure optimal alignment between health professions education and health care and inform ongoing improvement of learning environments.
Cadaver Rounds: A Comprehensive Exercise That Integrates Clinical Context Into Medical Gross Anatomy
Authors: Meredith M. Alex , Clemo H. Ruth , McGinn Melissa J. , Santen Sally A. , DiGiovanni Susan R.
Published: March 2019

Problem

The purpose of medical schools is to train students to care for patients; however, the temporal and conceptual gap between course work and patient care may induce students to undervalue preclinical course work, thereby decreasing learning and retention. Bringing clinical context into preclinical courses reduces this problem, and many preclinical programs incorporate “cameo” appearances of clinical material. In contrast, the authors describe a comprehensive program at Virginia Commonwealth University School of Medicine that uses the cadaver as the students’ first patient to embed clinical context within preclinical anatomy.

Approach

As the students’ first patient, cadavers undergo modified physical exams, whole-body computed tomography scans, and pathology sample analysis. Students log daily dissection observations onto a “patient chart.” Group findings are integrated, on a self-directed basis, into a final grand rounds–style presentation (“Cadaver Rounds”) requiring students to synthesize longitudinally collected observations into a plausible clinical condition likely experienced by the cadaver-patient when alive. The entire exercise uses few additional contact hours (about six) and runs concurrently with the existing medical curriculum.

Outcomes

According to course surveys used to assess students’ perceptions of the relevance and effectiveness of Cadaver Rounds (2015–2017), the students’ experience was highly positive. Participation by faculty and clinicians has been enthusiastic.

Next Steps

The authors hope both to identify additional authentic clinical tasks to import into the dissection lab and to partner with other programs to adopt and evaluate this clinically centered approach to anatomy.
School Absence Associated With Childhood Pain in the United States
Authors: Groenewald Cornelius B. , Giles Marian , Palermo Tonya M.
Published: March 2019

Objective:

The objective of this study was to estimate the national burden of school absenteeism associated with pain among 6 to 17-year-old children in the United States.

Methods:

Data were analyzed from a large, nationally representative sample from the 2012 National Health Interview Survey. Associations between pain and school absence were analyzed using multivariate negative binomial models controlling for sociodemographic and clinical characteristics.

Results:

The sample contained 8641 participants, of whom 30.3% reported pain over the preceding 12 months. Mean number of parent-reported school days missed across the entire sample was 3 per child; however pain was associated with an additional 1.5 reported missed school days per child. Furthermore, pain was associated with higher rates of chronic absenteeism (missing >15 d of school): 6.1% of children with pain was chronically absent as compared with 1.3% of children without pain. Extrapolated to the nation, childhood pain in the United States was associated with 22.2 million additional days of missed school, whereas childhood asthma, in comparison, was associated with 8 million additional days of school missed.

Discussion:

Associations between pain and school absenteeism highlight the need for interventions aimed at improving school attendance among children with pain.
Does postoperative alignment affect union in distal femoral fractures?
Authors: Long Charles Wyatt , Seligson David , Douglas Lonnie Rhea
Published: March 2019

Background:

Distal femoral shaft fractures can be hard to treat. Recently, a meta-analysis concluded that healing rates of distal femoral fractures are suboptimal, and further research is needed. The purpose of our study was to evaluate if postoperative alignment affected union rates of distal femoral fractures.

Methods:

Eighty-nine distal femoral fractures from the University of Louisville met inclusion and exclusion criteria. We used the Fracture and Dislocation Classification Compendium-2018 to classify fractures. Radiographs were evaluated for fracture location, alignment, and for healing. All statistical tests had a level of significance of 0.05. Statistical tests included a chi squared analysis, a t-test for two independent samples for proportions, and Fisher’s exact tests.

Results:

Chi squared analysis showed a statistically significant difference in healing of fractures with anatomic alignment versus those with nonanatomic alignment (χ2=18.241, P<0.001). The t-test of two independent samples for proportions showed that the 51% increase in healing of fractures with anatomic alignment was statistically significant (P<0.002, 95% CI 0.22, 0.80). Fisher’s exact test for specific fracture types also showed statistical significance (P<0.01).

Conclusions:

Proper anatomical alignment during surgical fixation of infraisthmal and supracondylar fractures is strongly associated with increased rates of fracture healing. Likewise, there is a strong association between nonanatomic alignment and nonunion. A prospective study examining the effect of alignment on union, regardless of fixation method, is reasonable and recommended.
Is open reduction necessary for pediatric T-condylar fractures of the humerus?
Authors: Kaçmaz İsmail Eralp , Basa Can Doruk , Zhamilov Vadym , Reisoğlu Ali , Akan İhsan , Ağuş Haluk
Published: March 2019

The aim of this study was to investigate the outcomes of closed reduction and percutaneous pinning (Kirschner wire fixation) as a less invasive method for the treatment of pediatric T-condylar fractures of the humerus compared with open reduction and pinning. Among pediatric patients who were diagnosed with T-condylar fractures of the humerus between 2010 and 2017, those who underwent closed reduction and percutaneous pinning were retrospectively evaluated. The surgical technique used was to restore joint alignment through closed reduction and then to insert a pin parallel to the joint surface to stabilize the intercondylar fracture. Then, the supracondylar fracture was fixed with crossed pins. At 1-year follow-up, rotation, angulation, and joint range of motion were evaluated. Patient satisfaction was assessed subjectively using the visual analogue scale. Early and late postoperative Baumann angles were measured. All patients were male, and the mean age was 10.8 ± 4.6 years. The mean follow-up duration was 16.5 ± 7.2 months, and the mean union duration was 7.4 ± 2.3 weeks. None of the patients had any rotational deformities, but two had 5° of varus, one had 5° of valgus, two had a flexion contracture of 10°, and one had a flexion contracture of 40°. The only complication observed was a pin-tract infection, which developed in one patient. The mean visual analogue scale score was 9.25 ± 1. In pediatric patients with T-condylar humerus fractures, closed reduction and percutaneous pinning may be a good alternative to open reduction and pinning, because it is less invasive and does not cause additional complications
The modified Kostuik transilial bar technique has acceptable results in neuromuscular spinal deformity correction
Authors: Ozdemir Haci M. , Demirkale Ismail , Ozdemir Mahmut , Aksekili Mehmet A.E.
Published: March 2019

The aim of this study is to evaluate the results of the modified Kostuik transilial bar technique for neuromuscular scoliosis (NS). We reviewed the records of 21 patients treated for NS with this instrumentation. There were 14 females and seven males, with an average age of 15.6 years (range: 9–21 years). We determined patients’ demographics, correction ratio of both curve and pelvic obliquity, loss of correction, screw loosening at first sacral vertebra, and clinical outcomes. Mean follow-up was 56 months (range: 34–96 months). There were no reoperations, no screw breakage, and no significant loss of correction. The mean preoperative coronal Cobb angle was 71.4°±8.7°, the initial postoperative measurements had a mean Cobb angle of 19.2°±7.2°, and at the last follow-up, the mean Cobb angle was 23.6°±6.9° (P<0.001). Pelvic obliquity decreased from 27.7°±12.4° to 9.1°±5.3° at follow-up and to 11.9°±6.3° at the last follow-up (P<0.001). The preoperative pelvic obliquity angle was significantly higher at the patients with screw loosening (P=0.016). There was one established as well as one possible pseudoarthrosis in our patients. The new technique does appear to possibly become an alternative to conventional lumbosacral fixation techniques. Integration of the bar with pipe-type connector onto the long spinal instrumentation with oblique connectors can prevent the most unenviable complications such as wide exposure, hardware prominence, reoperation, and pseudoarthrosis.
Prevalence of Cozen’s Phenomenon of the Proximal Tibia
Authors: Yang Brian W. , Shore Benjamin J. , Rademacher Emily , May Collin , Watkins Colyn J. , Glotzbecker Michael P.
Published: March 2019

Background:

There has been little investigation into the epidemiology of Cozen’s phenomenon, genu valgum as a complication of proximal tibial metaphysis fractures. In this study, we present a large case series of proximal tibia fractures in children to describe the prevalence, epidemiology, and characteristics associated with Cozen’s phenomenon following proximal tibial fracture in children.

Methods:

We searched the orthopedic database at our institution for all patients aged 1 to 8 years old with proximal tibia fractures presenting for initial fracture management between January 1, 2014 and December 31, 2017. Demographic data, mechanism of injury, fracture characteristics, and the presence of a concurrent fibula fracture were determined from the medical records. Initial and follow-up valgus angulation was measured as the angle between a line perpendicular to the proximal tibial physis and a line drawn along the axis of the tibia. Differences in the rate of valgus angulation by mechanism of injury and fracture type were compared.

Results:

In total, 181 fractures in 181 patients were included in our study (98 male, 83 female). The average age at injury was 4.55 years (range, 1.02 to 7.95 y); 140 patients (77.3%, 140/181) had initial valgus angulation of <4 degrees; 20 of these patients (14.3%, 20/140) developed angulation of at least 4 degrees at some point during follow-up at an average of 0.8 months (range, 0.2 to 1.9 mo); 4 patients (20.0%, 4/20) with <4 degrees of initial angulation had persistent valgus angulation of 5 degrees at latest follow-up. Two of these patients were not scheduled to return because the provider did not determine the valgus angulation to be clinically meaningful. The 2 other patients were asymptomatic and continued to receive nonoperative management. No patients in our series required surgical correction of valgus deformity.

Conclusions:

Cozen’s phenomenon is an uncommon complication of proximal tibial metaphysis fractures. Eliminating unnecessary radiographs and clinical visits for our pediatric trauma patients will improve the quality and value of care delivery.

Level of Evidence:

Level IV.
Is There Value in Radiology Reads for Pediatric Supracondylar Fractures in the Outpatient Clinic?
Authors: Du Jerry Y. , Tamer Pierre , Wang Joanne H. , Liu Raymond W.
Published: March 2019

Background:

Increased health care costs have driven assessment of value of common practices. The Joint Commission mandates the dual interpretation of musculoskeletal radiographs by radiologists and orthopedic surgeons in hospital-based clinic settings. However, the value of this practice has come under question. The purpose of this study was to investigate whether radiologist interpretations change orthopedists’ management during follow-up of pediatric supracondylar humerus fractures.

Methods:

A retrospective review was performed of pediatric elbow fractures at a single institution from January 2012 to December 2015. Patients with supracondylar humerus fractures and at least one clinic follow-up were included. For each radiograph, the orthopedic surgeon and radiologist interpretations were reviewed and a determination was made as to whether the radiologist interpretation affected management of the patient. In films with disagreement of displacement, Baumann angle and posterior displacement based on Gartland classification with Wilkins and Leitch modifications were measured. Timing of final radiologist and orthopedic interpretations were also assessed. Finally, billing charges of radiologist interpretations were assessed.

Results:

There were 441 pediatric supracondylar humerus fracture patients included in this study. All 441 patients had at least 1 clinic follow-up, 397 patients had at least 2 clinic follow-ups, and 123 patients had at least 3 clinic follow-ups, with a total of 716 elbow radiographs obtained. There were 17 cases (2.4%) where orthopedics and radiologist final interpretations disagreed regarding fracture displacement. In no cases did radiologist interpretations change orthopedic management. Radiographs that orthopedics interpreted as displaced were more likely to be posteriorly displaced (80.0% vs. 0.0%; P=0.002). However there was no difference in Baumann angle (P=0.125). Of the 716 films included, 28 radiologist interpretations were performed the day after the clinic visit (4%). Excluding these cases, there was an average of 57±3 minutes between radiograph acquisition and final interpretation. There were 352 cases where final orthopedic note filing time was documented, and 32% of these notes were finalized prior to the final radiologist interpretations. The total charges of radiologist interpretations was $18,772.

Conclusions:

The results of this study suggest that dual-interpretation of radiographs obtained in the follow-up clinic setting does not add value in management of pediatric supracondylar humerus fractures.

Level of Evidence:

Level IV—case series.