bluuebunny/crossref_metadata_2025 huggingface dataset:
The Blessings of Medicine? Patient Characteristics and Health Outcomes in a Ugandan Mission Hospital, 1908–19701
Authors: Doyle Shane , Meier zu Selhausen Felix , Weisdorf Jacob
Published: January 2019

This article sheds new light on the impact and experience of western biomedicine in colonial Africa. We use patient registers from Western Uganda’s earliest mission hospital to explore whether and how Christian conversion and mission education affected African health behaviour. A data set of 18,600 admissions permits analysis of patients’ age, sex, residence, religion, diagnoses, duration of hospitalisation and treatment outcomes. We document Toro Hospital’s substantial geographic reach, trace evolving treatment practices and highlight significant variation in hospital-based disease incidence between the early colonial and early postcolonial periods. We observe no relationship between numeracy and health outcomes, nor religion-specific effects concerning hygiene-related infections. Christian conversion was associated with superior cure rates and shorter length of stay and with lower incidence of skin diseases and sexually transmitted infections (STIs). However, our findings indicate that STI incidence was linked to morality campaigns and that clinicians’ diagnoses were influenced by assumptions around religious groups’ sexual behaviour.
Improving Residency Selection Requires Close Study and Better Understanding of Stakeholder Needs
Authors: Katsufrakis Peter J. , Chaudhry Humayun J.
Published: January 2019

The United States Medical Licensing Examination has long been valued by state medical boards as an evidence-based, objective assessment of an individual’s progressive readiness for the unsupervised practice of medicine. As a secondary use, it is also valued by residency program directors in resident selection. In response to Chen and colleagues’ consideration of changing Step 1 scoring to pass/fail, contextual and germane information is offered in this Invited Commentary, including a discussion of potential consequences, risks, and benefits of such a change. A review of stakeholders involved in the residency application process and their possible reactions to a scoring change precedes a discussion of possible changes to the process—changes that may better address expressed concerns. In addition to pass/fail scoring, these include limiting score releases only to examinees, changing the timing of score releases, increasing the amount and improving the quality of information about residency programs available to applicants, developing additional quantitative measures of applicant characteristics important to residency programs, and developing a rating system for medical school student evaluations. Thoughtful and broad consideration of stakeholders and their concerns, informed by the best evidence available, will be necessary to maximize the potential for improvement and minimize the risk of unintended adverse consequences resulting from any changes to the status quo. An upcoming invitational conference in 2019 that is being organized by several stakeholder organizations is expected to further explore underlying issues and concerns related to these options.
Open Access Medical Journals: Promise, Perils, and Pitfalls
Authors: Baker Eileen F. , Iserson Kenneth V. , Aswegan Andrew L. , Larkin Gregory L. , Derse Arthur R. , Kraus Chadd K.
Published: January 2019

The number of both print and electronic open access (OA) journals has increased dramatically. Although electronic availability of information on the Internet may offer greater potential for information sharing, it also gives rise to “predatory” journals and deceptive publishers. In this Invited Commentary, the authors describe both the opportunities and potential perils that come with OA publications.

Definitions for four models of legitimate OA are provided: the gold model, the green model, the platinum model, and the hybrid model. Benefits and risks of each model are discussed. The authors also distinguish between legitimate OA journals and predatory journals, highlighting several existing tools and resources for distinguishing between the two.

Finally, the authors provide a checklist to help authors evaluate the policies and processes of journals and thereby avoid predatory publications.
Applying the Hedgehog Concept to Transform Undergraduate Medical Education
Authors: Ginzburg Samara B. , Willey Joanne M. , Bates Carole , Santen Sally A. , Battinelli David , Smith Lawrence
Published: January 2019

As the U.S. health care system changes and physician responsibilities shift, medical educators must reconsider how best to prepare medical school graduates for the future practice of medicine. Thoughtful reexamination of the goals of undergraduate medical education (UME) and the roles of educators, medical students, and physicians is warranted to ensure that they align with evolving health care environments and delivery systems. In this Invited Commentary, the authors apply Jim Collins’s “hedgehog concept” from Good to Great—a business-world framework designed to transform companies—to UME. The hedgehog concept is defined by the intersection of an organization’s passion, area of expertise, and economic and resource engines. Focusing on this single concept can guide key decisions, reject what does not align conceptually, and drive overall organizational success. The authors use the hedgehog concept to frame the programmatic development of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell (Zucker SOM), a millennial medical school, as an organization with the passion to develop innovative UME curricula by challenging the status quo; the drive to be the best at leveraging health system resources to train graduates to excel in systems-based care; and the economic and resource engine of faculty time, financial and infrastructure support, and reputation building. The success of this approach is assessed at Zucker SOM through student and graduate outcomes data. The authors suggest that this hedgehog concept is generalizable to other UME programs whose leaders seek to transform medical education to meet 21st-century workforce and health care delivery needs.
Student Perspectives on the “Step 1 Climate” in Preclinical Medical Education
Authors: Chen David R. , Priest Kelsey C. , Batten Jason N. , Fragoso Ligia E. , Reinfeld Bradley I. , Laitman Benjamin M.
Published: January 2019

The United States Medical Licensing Examination Step 1 was implemented in the 1990s as the most recent version of the National Board of Medical Examiners’ preclinical licensing examination originally created in the late 1960s. For the purposes of state licensure, the exam is pass/fail, but the Step 1 numeric score has in recent years become central to the residency application and selection process. Consequently, a medical student’s Step 1 score is increasingly viewed as a key outcome of preclinical medical education.

In this Invited Commentary, students from various institutions across the country draw on their shared experiences to argue that the emphasis on Step 1 for residency selection has fundamentally altered the preclinical learning environment, creating a “Step 1 climate.” The authors aim to increase awareness of the harms and unintended consequences of this phenomenon in medical education. They outline how the Step 1 climate negatively impacts education, diversity, and student well-being, and they urge a national conversation on the elimination of reporting Step 1 numeric scores.
Residency Program Factors Associated With Depressive Symptoms in Internal Medicine Interns: A Prospective Cohort Study
Authors: Pereira-Lima Karina , Gupta Rahael R. , Guille Constance , Sen Srijan
Published: January 2019

Purpose

To investigate the associations between program-level variables such as organizational structure, workload, and learning environment and residents’ development of depressive symptoms during internship.

Method

Between 2012 and 2015, 1,276 internal medicine interns from 54 U.S. residency programs completed the Patient Health Questionnaire-9 (PHQ-9) before internship, and then quarterly throughout the internship. The training environment was assessed via a resident questionnaire and average weekly work hours. The authors gathered program structural variables from the American Medical Association Fellowship and Residency Electronic Interactive Database (FREIDA online) and program research rankings from Doximity. Associations between program-level variables and change in depressive symptoms were determined using stepwise linear regression modeling.

Results

Mean program PHQ-9 scores increased from 2.3 at baseline to 5.9 during internship (mean difference 3.6; SD 1.4; P < .001), with the mean increase ranging from −0.3 to 8.8 (interquartile range 1.1) among included programs. In multivariable models, faculty feedback (β = −0.37; 95% CI: −0.62, −0.12; P = .005), learning experience in inpatient rotations (β = −0.28; 95% CI: −0.54, −0.02; P = .030), work hours (β = 0.34; 95% CI: 0.13, 0.56; P = .002), and research ranking position (β = −0.25; 95% CI: −0.47, −0.03; P = .036) were associated with change in depressive symptoms.

Conclusions

Poor faculty feedback and inpatient learning experience, long work hours, and high institutional research rankings were associated with increased depressive symptoms among internal medicine interns. These factors may be potential targets for interventions to improve wellness and mental health among these professionals.
Distal Nail Target and Alignment of Distal Tibia Fractures
Authors: Brinkmann Elyse , DiSilvio Frank , Tripp Michael , Bernstein Mitchell , Summers Hobie , Lack William D.
Published: January 2019

Objectives:

To assess the relationship between the distal nail target and postoperative alignment for distal tibia fractures treated with intramedullary nailing.

Design:

Retrospective cohort study.

Setting:

A single level 1 trauma center.

Patients/Participants:

One hundred thirty distal tibia fractures treated with intramedullary nailing over a 10-year period.

Main Outcome Measurements:

Malalignment >5 degrees.

Results:

Thirty-eight cases (29.2%) of malalignment >5 degrees included valgus (19 cases, 14.6%), procurvatum (13 cases, 10.0%), recurvatum (1 case, 0.8%), and combined valgus with procurvatum (5 cases, 3.8%). Medially directed nails demonstrated relative valgus (mean lateral distal tibia angle 86.4 vs. 89.4 degrees, P < 0.01) and more frequent coronal malalignment (24 of 78, 30.8% vs. 0 of 52, 0%, P < 0.01). Anteriorly directed nails demonstrated relative procurvatum (mean anterior distal tibia angle 82.8 vs. 80.9 degrees, P < 0.01) and more frequent sagittal malalignment (15 of 78, 19.2% vs. 3 of 52, 5.8%, P = 0.03). Malalignment was less common for nails targeting the central or slightly posterolateral plafond (0 of 30, 0% vs. 38 of 100, 38%), P < 0.01. Multivariate analysis demonstrated the distal nail target (P = 0.03), fracture within 5 cm of the plafond (P = 0.01), as well as night and weekend surgery (P = 0.03) were all independently associated with malalignment.

Conclusions:

Alignment of distal tibia fractures is sensitive to both injury and treatment factors. Nails should be targeted centrally or slightly posterolaterally to minimize malalignment.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Frailty and Malnutrition Are Associated With Inpatient Postoperative Complications and Mortality in Hip Fracture Patients
Authors: Wilson Jacob M. , Boissonneault Adam R. , Schwartz Andrew M. , Staley Christopher A. , Schenker Mara L.
Published: January 2019

Objective:

To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients.

Design:

Retrospective observational cohort study.

Setting:

Urban, American College of Surgeons–Verified, Level-1, Trauma Center.

Patients/Participants:

Three hundred seventy-seven consecutive patients with isolated hip fractures.

Intervention:

N/A.

Main Outcome Measures:

On admission, albumin and total lymphocyte count (TLC) levels and complication data were collected. Additionally, mFI scores were calculated. Statistical analysis was then used to analyze the association between frailty, malnutrition, and postoperative complications.

Results:

Overall, 62.6% and 17.5% of patients were malnourished as defined by TLC of <1500 cells per cubic millimeter and albumin of <3.5 g/dL, respectively. Both TLC (P = 0.024; r = −0.12) and albumin (P < 0.001; r = −0.23) weakly correlated with frailty. Combining malnutrition and frailty revealed predictive synergy. Albumin of <3.5 g/dL and mFI of ≥0.18 in the same patient resulted in a positive predictive value of 69% and a likelihood ratio of 4 (2.15–7.43) for postoperative complications. Similarly, the combination of hypoalbuminemia and frailty resulted in a positive predictive value of 23.3% and likelihood ratio of 8.52 (P < 0.001) for mortality.

Conclusions:

When patients are frail and malnourished, there is a risk elevation beyond that of frailty or malnutrition in isolation. This high-risk cohort can be easily identified at admission with routine laboratory values and clinical history. There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Hospital Mechanical Ventilation Volume and Patient Outcomes: Too Much of a Good Thing?
Authors: Mehta Anuj B. , Walkey Allan J. , Curran-Everett Douglas , Matlock Daniel , Douglas Ivor S.
Published: January 2019

Objectives:

Prior studies investigating hospital mechanical ventilation volume-outcome associations have had conflicting findings. Volume-outcome relationships within contemporary mechanical ventilation practices are unclear. We sought to determine associations between hospital mechanical ventilation volume and patient outcomes.

Design:

Retrospective cohort study.

Setting:

The California Patient Discharge Database 2016.

Patients:

Adult nonsurgical patients receiving mechanical ventilation.

Interventions:

The primary outcome was hospital death with secondary outcomes of tracheostomy and 30-day readmission. We used multivariable generalized estimating equations to determine the association between patient outcomes and hospital mechanical ventilation volume quartile.

Measurements and Main Results:

We identified 51,689 patients across 274 hospitals who required mechanical ventilation in California in 2016. 38.2% of patients died in the hospital with 4.4% receiving a tracheostomy. Among survivors, 29.5% required readmission within 30 days of discharge. Patients admitted to high versus low volume hospitals had higher odds of death (quartile 4 vs quartile 1 adjusted odds ratio, 1.40; 95% CI, 1.17–1.68) and tracheostomy (quartile 4 vs quartile 1 adjusted odds ratio, 1.58; 95% CI, 1.21–2.06). However, odds of 30-day readmission among survivors was lower at high versus low volume hospitals (quartile 4 vs quartile 1 adjusted odds ratio, 0.77; 95% CI, 0.67–0.89). Higher hospital mechanical ventilation volume was weakly correlated with higher hospital risk-adjusted mortality rates (ρ = 0.16; p = 0.008). These moderately strong observations were supported by multiple sensitivity analyses.

Conclusions:

Contrary to previous studies, we observed worse patient outcomes at higher mechanical ventilation volume hospitals. In the setting of increasing use of mechanical ventilation and changes in mechanical ventilation practices, multiple mechanisms of worse outcomes including resource strain are possible. Future studies investigating differences in processes of care between high and low volume hospitals are necessary.
National Performance on the Medicare SEP-1 Sepsis Quality Measure
Authors: Barbash Ian J. , Davis Billie , Kahn Jeremy M.
Published: January 2019

Objectives:

The Centers for Medicare and Medicaid Services requires hospitals to report compliance with a sepsis treatment bundle as part of its Inpatient Quality Reporting Program. We used recently released data from this program to characterize national performance on the sepsis measure, known as SEP-1.

Design:

Cross-sectional study of United States hospitals participating in the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program linked to Centers for Medicare and Medicaid Services’ Healthcare Cost Reporting Information System.

Setting:

General, short-stay, acute-care hospitals in the United States.

Measurements and Main Results:

We examined the hospital factors associated with reporting SEP-1 data, the hospital factors associated with performance on the SEP-1 measure, and the relationship between SEP-1 performance and performance on other quality measures related to time-sensitive medical conditions. A total of 3,283 hospitals were eligible for the analysis, of which 2,851 (86.8%) reported SEP-1 performance data. SEP-1 reporting was more common in larger, nonprofit hospitals. The most common reason for nonreporting was an inadequate case volume. Among hospitals reporting SEP-1 performance data, overall bundle compliance was generally low, but it varied widely across hospitals (mean and sd: 48.9% ± 19.4%). Compared with hospitals with worse SEP-1 performance, hospitals with better SEP-1 performance tended to be smaller, for-profit, nonteaching, and with intermediate-sized ICUs. Better hospital performance on SEP-1 was associated with higher rates of timely head CT interpretation for stroke patients (rho = 0.16; p < 0.001), more frequent aspirin administration for patients with chest pain or heart attacks (rho = 0.24; p < 0.001) and shorter median time to electrocardiogram for patients with chest pain (rho = –0.12; p < 0.001).

Conclusions:

The majority of eligible hospitals reported SEP-1 data, and overall bundle compliance was highly variable. SEP-1 performance was associated with structural hospital characteristics and performance on other measures of hospital quality, providing preliminary support for SEP-1 performance as a marker of timely hospital sepsis care.
What Does the Word “Treatable” Mean? Implications for Communication and Decision-Making in Critical Illness
Authors: Batten Jason N. , Kruse Katherine E. , Kraft Stephanie A. , Fishbeyn Bela , Magnus David C.
Published: January 2019

Objectives:

To explore how nonphysicians and physicians interpret the word “treatable” in the context of critical illness.

Design:

Qualitative study using in-depth interviews.

Setting:

One academic medical center.

Subjects:

Twenty-four nonphysicians (patients and community members) purposively sampled for variation in demographic characteristics and 24 physicians (attending physicians and trainees) purposively sampled from four specialties (critical care, palliative care, oncology, and surgery).

Interventions:

None.

Measurements and Main Results:

We identified two distinct concepts that participants used to interpret the word “treatable”: 1) a “good news” concept, in which the word “treatable” conveys a positive message about a patient’s future, thereby inspiring hope and encouraging further treatment and 2) an “action-oriented” concept, in which the word “treatable” conveys that physicians have an action or intervention available, but does not necessarily imply an improved prognosis or quality of life. The overwhelming majority of nonphysicians adopted the “good news” concept, whereas physicians almost exclusively adopted the “action-oriented” concept. For some nonphysicians, the word “treatable” conveyed a positive message about prognosis and/or further treatment, even when this contradicted previously stated negative information.

Conclusions:

Physician use of the word “treatable” may lead patients or surrogates to derive unwarranted good news and false encouragement to pursue treatment, even when physicians have explicitly stated information to the contrary. Further work is needed to determine the extent to which the word “treatable” and its cognates contribute to widespread decision-making and communication challenges in critical care, including discordance about prognosis, misconceptions that palliative treatments are curative, and disputes about potentially inappropriate or futile treatment.
Modeling the Complex Exposure History of Smoking in Predicting Bladder Cancer
Authors: van Osch Frits H. M. , Vlaanderen Jelle , Jochems Sylvia H. J. , Bosetti Cristina , Polesel Jerry , Porru Stefano , Carta Angela , Golka Klaus , Jiang Xuejuan , Stern Mariana C. , Zhong Wei-De , Kellen Eliane , Pohlabeln Hermann , Tang Li , Marshall James , Steineck Gunnar , Karagas Margaret R. , Johnson Kenneth C. , Zhang Zuo-Feng , Taylor Jack A. , La Vecchia Carlo , Bryan Richard T. , van Schooten Frederik J. , Wesselius Anke , Zeegers Maurice P.
Published: January 2019

Background:

Few studies have modeled smoking histories by combining smoking intensity and duration to show what profile of smoking behavior is associated with highest risk of bladder cancer. This study aims to provide insight into the association between smoking exposure history and bladder cancer risk by modeling both smoking intensity and duration in a pooled analysis.

Methods:

We used data from 15 case–control studies included in the bladder cancer epidemiology and nutritional determinants study, including a total of 6,874 cases and 17,727 controls. To jointly interpret the effects of intensity and duration of smoking, we modeled excess odds ratios per pack–year by intensity continuously to estimate the risk difference between smokers with long duration/low intensity and short duration/high intensity.

Results:

The pattern observed from the pooled excess odds ratios model indicated that for a fixed number of pack–years, smoking for a longer duration at lower intensity was more deleterious for bladder cancer risk than smoking more cigarettes/day for a shorter duration. We observed similar patterns within individual study samples.

Conclusions:

This pooled analysis shows that long duration/low intensity smoking is associated with a greater increase in bladder cancer risk than short duration/high intensity smoking within equal pack–year categories, thus confirming studies in other smoking-related cancers and demonstrating that reducing exposure history to a single metric such as pack–years was too restrictive.
A Novel and Highly Potent Urotensin II Receptor Antagonist Inhibits Urotensin II–Induced Pressure Response in Mice
Authors: Nishi Mina , Yonesu Kiyoaki , Tagawa Hideki , Kato Mikio , Marumoto Shinji , Nagayama Takahiro
Published: January 2019

This study was designed to characterize the pharmacological profile of DS37001789, which is a structurally novel piperazine derivative that acts as urotensin II (U-II) receptor antagonist. DS37001789 inhibited [125I]-U-II binding to human GPR14, U-II receptor, with an IC50 value 0.9 nM. Its potency was superior to that of ACT-058362, a nonpeptide U-II receptor antagonist whose IC50 was 120 nM. Human U-II–induced vascular contraction was blocked by DS37001789. The dose–response curve of DS37001789 in rats and monkeys did not show species differences, and it shifted to the right without any effects on the maximum vascular response. Moreover, orally administered DS37001789 dose-dependently prevented human U-II–induced blood pressure elevation in mice, and this effect was significant at dose and higher dose (30 and 100 mg/kg), and its potency was superior to that of ACT-058362 (100 mg/kg). These results suggest that DS37001789 is a highly potent U-II receptor antagonist both in vitro and in vivo, with no marked species difference. DS37001789 would be a useful tool to clarify the physiological roles of U-II/GPR14 system. In addition, it can serve as a novel therapeutic agent for diseases in which the U-II/GPR14 system is upregulated, such as hypertension, heart failure, renal dysfunction, and diabetes.
A meta-analysis of efficacy and safety of sorafenib versus other targeted agents for metastatic renal cell carcinoma
Authors: Wang Hai-Tao , Xia Ming
Published: January 2019

Background:

Molecular targeted therapies were found to be efficacious and safer in the treatment of metastatic renal cell carcinoma (mRCC). Sorafenib is the first target agent (TA) to report a benefit in this disease and has largely established a prominent role in progression-free survival (PFS). However, there have been conflicting results across the trials that evaluated the efficacy of sorafenib.

Objective:

The aim of the study was to perform a meta-analysis to compare the efficacy and safety of sorafenib in first-line treatments of mRCC.

Methods:

We searched online electronic databases: PubMed, Embase, and the Cochrane Library updated on September 2017. Trials on the efficacy of sorafenib in first-line treatments of advanced RCC were included, of which the primary outcomes were objective response rate (ORR), PFS, overall survival (OS), and grade 3/4 adverse events (AEs).

Results:

A total of 5 trials were included in this analysis. The group of AEs showed significantly improved PFS (odds ratio [OR] = 0.78, 95% confidence interval [CI] = 0.70–0.86, P < .001), as well with the ORR (OR = 1.89, 95%CI = 1.38–2.59, P < .0001) compared with sorafenib. However, there was no significant difference in OS (OR = 0.97, 95%CI = 0.78–1.22, P = .82).

Conclusion:

Sorafenib did not achieve efficacy and safety benefit in patients with mRCC compared with those treated with TAs. The role of sorafenib in first-line treatments of mRCC may change in favor of newer drugs. More research is needed to confirm whether these new TAs could replace sorafenib as the gold standard in the future.
Hand tendinopathy risk factors in Taiwan
Authors: Shen Po-Chuan , Chang Po-Chun , Jou I-Ming , Chen Chung-Hwan , Lee Fang-Hsin , Hsieh Jeng-Long
Published: January 2019

De Quervain's disease, carpal tunnel syndrome (CTS), and trigger finger (digit) are three common pathological conditions of the hand. They are considered overuse syndromes and occur predominantly in females. The prevalence rate and cause-specific risks of these three tendinopathies have not yet been clarified. Data from 41,871 cases listed in the Taiwan National Health Insurance Research Database (NHIRD) from 2010 to 2014 were analyzed. The prevalence rate of these 3 conditions by age, sex, and the risk factors of female-dominant diseases (e.g., osteoporosis, rheumatoid arthritis [RA], and tendinopathy), diabetes mellitus, and hormone antagonist treatment was evaluated. We found that 1.59% of the population developed CTS, 0.49% developed de Quervain's, and 1.07% developed trigger finger. Cases were more likely to develop the three hand tendinopathies if they were female, between 50 and 59 years old, and, according to a multivariate analysis, comorbid with RA, diabetes, using hormone antagonists. Our findings should provide an understanding of the risk factors associated with hand tendinopathy.
High percentage atypical hepatocellular carcinoma in chronic hepatitis B patients treated with nucleos(t)ide analogs
Authors: Lin Ching-Chung , Bair Ming-Jong , Liu Chia-Yuan , Lin Ze-Yu , Chen Chih-Jen , Chen Ming-Jen , Chu Cheng-Hsin , Wang Horng-Yuan , Shih Shou-Chuan , Wang Tsang-En
Published: January 2019

Nucleos(t)ide analogs are used for preventing liver cirrhosis in chronic hepatitis B patients, but the risk factors of hepatocellular carcinoma (HCC) in these patients remain unclear. We designed this retrospective cohort study, the aim is to determine the risk factors for HCC development and its image presentation under nucleos(t)ide analogs treatment.

In this study, patients were treated with lamivudine (LAM), entecavir 0.5 mg (ETV), or telbivudine (LdT), and followed-up for at least 2 years to detect HCC and its presentation. Assessment of the risk factors for HCC included age, sex, HBeAg, viral load, liver cirrhosis, current and previous medications, and liver function tests.

Totally, 396 patients were recruited, and 18 patients developed HCC. The mean time from the treatment to HCC development was 28.5 ± 16.7 months. The clinical characteristics in HCC and no-HCC groups showed significant differences among age (52.8 ± 6.1 vs 47.1 ± 12.6 years, P <.01), baseline alanine transaminase (ALT) levels (161.4 ± 177.3 vs 361.7 ± 496.3, P <.01), and baseline liver cirrhosis (72.2% vs 29.9%, P <.01). In patients aged ≥45 years, the hazard ratio of HCC was 10.2 and liver cirrhosis was 4.1. Majority of HCCs developed in the right liver (14/18), were single numbered (13/18), had tumor size about 1.9 ± 0.7 cm, were classified as T1 (14/18, TNM staging), and the atypical image occupied 88% of the HCC cases.

The patients aged ≧45 years on long-term nucleos(t)ide analog therapy, and with baseline liver cirrhosis were at a high risk of HCC. Regular alpha-fetoprotein (AFP) assessment and image study of these patients are the gold standards for early HCC detection in patients with high percentage atypical HCC appearances.
Effect of subgroup-specific multimodal therapy on chronic spinal back pain and function—a prospective inpatient multicentre clinical trial in Germany
Authors: Steinmetz Anke , Psczolla Matthias , Seidel Wolfram , Niemier Kay , Derlien Steffen , Nisser Jenny
Published: January 2019

Treatment modalities of spinal pain patients are discussed diversely, and different multimodal therapy programs have been developed. Purpose of the present study was to evaluate therapy outcome and effectiveness of an inpatient interdisciplinary and multimodal treatment program.

This prospective multicentre clinical trial has been performed with patients from orthopedic hospitals receiving a functional musculoskeletal therapy pathway. Outcome measures were pain intensity and back-specific function (Oswestry Disability Index) before (T1) and after the intervention (T2) as well as after 6 and 12 months (T3, T4). Statistical approach included parametric (t test) and nonparametric (Wilcoxon-test) tests and the calculation of effect sizes. Additionally, a statistical subgroup analysis based on selected parameters (degree of pain chronicity, gender, and age) was performed using linear mixed models.

In total, 249 patients (42.6% men, 57.4% women) with spinal pain were included, 133 patients were accessible for follow-up at T3 and 106 patients at T4.

Average pain (AP) reduced significantly (P <.001) from T1 to T4 with an effect size of 0.99. Back-specific function also improved (P <.001) over all measuring time points (TP) (effect size: 0.63). Furthermore, the statistical subgroup analysis demonstrated the efficacy of the treatment concept within the subgroup parameters chronicity degree and age.

A functional musculoskeletal therapy pathway including treatment of musculoskeletal dysfunctions appears to be beneficial in terms of treating pain and function. Pain chronicity and age seems to be factors influencing therapy outcome. Further studies are needed to examine the superiority of these inpatient programs for back pain including control groups.
Risk factors of efficacy for patients receiving surgical treatment following terrible triad of the elbow joint
Authors: Chen Hong-Wei , Huang Shu-Ming
Published: January 2019

Background:

This study aims to explore the efficacy of surgical and conservative treatment for elbow joint terrible triad, and evaluate related factors affecting surgical treatment efficacy.

Methods:

Patients with terrible triad of elbow joint (n = 165) were selected, among which 79 cases underwent conservative treatment (the control group) and 86 cases underwent surgical treatment (the experimental group). The range of flexion and extension, range of rotation and Mayo elbow performance score were recorded. In the experimental group, postoperation, according to the Mayo elbow performance score, patients were assigned into the effective group (72 cases) and ineffective group (14 cases). All patients were followed up regularly for 6 to 24 months. X-ray and computed tomography examination were used to examine anterior and posterior elbow joints preoperatively and postoperatively and the degree of arm rotation.

Results:

The range of flexion and extension, range of rotation and Mayo elbow performance score were found to be significantly higher in the experimental group after treatment compared to the experimental group before treatment and in the control group after treatment. Seven days after treatment, compared with the control group, the expressions of interleukin (IL)-6, C-reactive protein, IL-8, and tumor necrosis factor-α in serum decreased, and returned to almost near normal levels in the experimental group. Age, mean operative time, and postoperative immobilization time were significantly different between the effective and ineffective groups. The incidence of joint stiffness, heterotopic ossification, and ulnar nerve symptoms in the effective group were lower than those in the ineffective group. The postoperative immobilization time served a protective factor for the efficacy of surgical treatment of elbow joint terrible triad, while age served as a risk factor.

Conclusion:

The results indicated that surgical treatment regimens for elbow joint terrible triad exhibited better efficacy than conservative treatment regimens, and lower age and longer postoperative immobilization time serve as protective factors for surgical treatment efficacy.
Prognostic role of high neutrophil-to-lymphocyte ratio in breast cancer patients receiving neoadjuvant chemotherapy
Authors: Xue Ling Bo , Liu Yong Hong , Zhang Bo , Yang Yan Fang , Yang Dong , Zhang Li Wei , Jin Jian , Li Jie
Published: January 2019

Background:

We aimed to evaluate the correlation of neutrophil-to-lymphocyte ratio (NLR) with pathological response, disease-free survival (DFS), and overall survival (OS) in patients with breast cancer and under neoadjuvant chemotherapy (NAC).

Materials and methods:

We performed a systematical search using Cochrane Library, ScienceDirect, PubMed, Embase, and Web of Science up to May 2018. On the basis of the data directly obtained from the available studies, the odds ratios (ORs) and their 95% confidence intervals (95% CIs) were pooled on the basis of higher or lower NLR levels.

Results:

The meta-analysis showed that high NLR was significantly associated with poor NAC response (OR = 2.27, 95% CI: 1.46–3.53, P < .001) but not with the DFS (OR = 1.18, 95% CI: 0.78–1.78, P = .435) and OS (OR = 2.781, 95% CI: 0.54–14.32, P = .221).

Conclusion:

Although high NLR was significantly associated with poor pathological response, we were unable to demonstrate the prognostic value of NLR for DFS and OS in patients with breast cancer who were undergoing NAC.
Adenoid cystic carcinoma of the vagina
Authors: Zhang Lan-Zhi , Huang Li-Yan , Huang An-Liang , Liu Jin-Xing , Yang Fan
Published: January 2019

Rationale:

Squamous carcinoma is the most common malignancy of vagina. Adenoid cystic carcinoma (ACC) in the vagina is very rare.

Patient concerns:

In the present study, we present a 45-year-old woman with a palpable swelling in the vagina. The patient reported body paresthesia, chest congestion, expiratory dyspnea, and itching in the thigh root.

Diagnosis:

The ultrasound results revealed inhomogeneous echoes of the muscular layer in the middle and distal of the vagina, and probed a slightly richer blood flow signal. Then biopsy was performed. On microscopic examination, it was observed that tumor cells were arranged in a tubular or cribriform pattern, and exhibited a consistent size, small nuclei, and nuclear fission. The myoepithelium was lined around the glandular cavity, but the myoepithelium was tumorous. Immunohistochemistry was performed for further verification. Vimentin was positive in mesenchyme and CK-P was positive in epithelial cells. P63 and calponin were spotted, which were focal positive around the glandular cavity. Finally, the patient was diagnosed as ACC.

Interventions:

At last, the patient chose chemoradiotherapy, not surgical excision.

Outcomes:

The patient is alive and well 13 months after the initial diagnosis.

Lessons:

ACC in the vagina is extremely rare. To our knowledge, this report is the first case of ACC arising from the vagina in English-language literature. Extensive surgical section of the tumour and chemoradiotherapy are recommended for therapy. Because of rarity, the prognosis of ACC in vagina is not known.
Acquired scoliosis following Nuss procedure for pectus excavatum
Authors: Meng Yichen , Lin Tao , Shao Wei , Gao Rui , Zhou Xuhui
Published: January 2019

Rationale:

Nuss procedure is a safe and popular minimally invasive surgical technique for the correction of pectus excavatum in adolescents. Acquired scoliosis over 50 degrees after Nuss procedure has never been reported.

Patient concerns:

A 14-year-old boy was referred to pediatric surgery for pectus excavatum deformity. He underwent a successful Nuss procedure. At follow up, the patient was noted having an asymmetric back whole spine X-ray showed a right-sided thoracic curve with a Cobb angle of 54 degrees.

Interventions and outcomes:

We obtained a satisfactory result by removing the pectus bar and prescribing the patient a brace.

Lessons:

This report demonstrates that the spine should be evaluated routinely before and after Nuss procedure. Besides, spinal fusion is not recommended for acquired scoliosis following pectus excavatum surgery.
Conventionally fractionated stereotactic radiotherapy (CFRT) in combination with dose-dense temozolomide (TMZ) in relapsed malignant glioma
Authors: Qie Shuai , Yuan Lanhui , Shi Hong-Yun , Zhang Xi , Li Yanhong
Published: January 2019

Rationale:

At present, there is no uniform consensus on the treatment of recurrent glioblastoma, especially the re-irradiation dose and temozolomide (TMZ) dose. The literature on the treatment of recurrent glioblastoma (GBM) by conventionally fractionated stereotactic radiotherapy (CFRT) is even rarer.

Patient concerns:

A 44-year-old woman was admitted to our hospital for residual tumor after reoperation.

Diagnoses:

Postoperative pathological diagnosis was GBM, WHO grade IV. The brain magnetic resonance imaging re-examination showed abnormal enhancement around the local operative region after resection of the left frontal lobe tumor, and there was presence of residual tumor.

Interventions:

The patient was treated with reoperation followed by re-irradiation plus dose-dense TMZ to achieve complete remission.

Outcomes:

Complete remission was observed at the end of radiotherapy and at the 1 month follow-up after radiotherapy.

Lessons:

This study suggests that CFRT plus dose-dense TMZ might be a feasible option for the treatment in relapsed malignant glioma patients with good general condition.
Proximal migration of retained pencil lead along a flexor tendon in the hand
Authors: Hwang Jae Ha , Lee Dong Gyu , Kim Kwang Seog , Lee Sam Yong
Published: January 2019

Rationale:

The hand is the most common site for foreign body injuries. Pencil lead penetration mainly occurs in school-age children.

We report a case of proximal migration of a retained pencil lead in the hand, emphasizing the importance of adequate imaging and prompt removal of the foreign body.

Patient concerns:

We report the case of an 8-year-old boy who visited our outpatient clinic for a retained foreign body in the right palm. Removal was planned under general anesthesia. Black staining from the pencil lead was observed around the tendon sheath in the operative field, but the foreign body itself was not apparent.

Diagnosis:

Intraoperative radiography located the foreign body at the wrist, 5 cm away from the original site. Proximal migration of the retained foreign body was suspected.

Intervention:

Incision was extended toward the wrist and the foreign body was discovered in the flexor sheath at the wrist.

Conclusion:

Foreign bodies may migrate to adjacent tissues, but rarely wander far. Computed tomography is the most useful tool in diagnosing a pencil lead foreign body.

Lessons:

Adequate imaging and prompt removal of the foreign body is important. When a retained foreign body is removed after a delay, the physician must always consider the possibility of foreign body migration.
Urban-rural disparity in cervical cancer in China and feasible interventions for tackling the rural excess
Authors: Wen Xiaoduo , Wen Denggui , Yang Yi , Chen Yuetong , Akazawa Kohei , Liu Yunjiang , Shan Baoen
Published: January 2019

According to GLOBOCAN 2012, age-standardized incidence rate (ASIR) of cervical cancer in developed and less developed countries is 9.9 vs. 15.7 per 100,000 population per year. This disparity is related to inequity in access to screening. Urban rural disparity in access to cervical cancer screening is similar in China. We aim to assess urban rural disparity in ASIR.

Using population-based tumor registration data collected by us in urban Shijiazhuang city (with incidence data available for 1,217,437 women in 2012) and in Shexian County (with incidence data available for 197,416 women since 2000), we compared ASIR of cervical cancer between the two populations in 2012. We also analyzed the trend of biennial ASIR and averaged age at diagnosis of cervical cancer for 2000–2015 in Shexian County during which China was undergoing rapid changes in sexual mores. Finally, using previously published national death survey data, we compared age-standardized mortality rate (ASMR) of cervical cancer between Shijiazhuang city and Shexian County over the periods of 1973–1975 and 1990–1992.

It was found that the ASIR of cervical cancer in rural Shexian County is 3 times higher than in Shijiazhuang city in 2012 (25.0 vs. 8.4 per 100,000 per year, P < .01); and the corresponding ASMR was 2 times higher over the period of 1973–1975 (25.0 vs. 13.0 per 100,000 per year, P < .01) and 8 times higher over the period of 1990–1992 (9.8 vs. 1.2 per 100,000 per year, P < .01). From 2000 to 2015 along with rapid changes in sexual behavior, the biennial ASIR of cervical cancer increased by +3.2% on average, from 19.3 to 28.5 per 100,000 per year (P < .01), and the biennial averaged age at diagnosis decreased from 55.8 to 52.1 (P < .01).

Urban-rural disparity in ASIR of cervical cancer in present study is larger than that reported between developed and less developed countries in GLOBOCAN 2012, in which the disparity is considered “due to differences in access to screening.” As in China, cytologists and infrastructure required for cervical cancer screening are similarly lacking in rural areas, we suggest cytological screening for cervical cancer be strengthened in disadvantaged rural settings.
CDK4/6 inhibition versus mTOR blockade as second-line strategy in postmenopausal patients with hormone receptor-positive advanced breast cancer
Authors: Huang Hong-Wei , Huang Li-Sheng , Xu Qi-Ni , Wang Hong-Biao , Li Xu-Yuan , Lin Jia-Zhou
Published: January 2019

Background:

Cyclin-dependent kinase 4/6 (CDK4/6) inhibitors (palbociclib and abemaciclib) and mammalian target of rapamycin (mTOR) inhibitors (everolimus) are effective agents for restoring endocrine sensitivity in patients with advanced breast cancer progression on prior aromatase inhibitors. We conducted a network meta-analysis to compare these treatments in terms of progression-free survival (PFS), objective response rate (ORR), and clinical benefit rate (CBR).

Methods:

The PubMed and Embase databases were searched for relevant publications between January 2000 and June 2018. Treatments were ranked based on a network meta-analysis. Ranking was determined by P-score. A random-effect model was used when heterogeneity was detected; otherwise, a fixed-effect model was used.

Results:

Six trials comprising 4063 patients formed the comparison network. Compared with everolimus plus exemestane, the combinations of palbociclib or abemaciclib with fulvestrant showed similar efficacies in PFS and no differences in ORR. For the CBR, palbociclib demonstrated improvement, while abemaciclib did not. Incidences of severe adverse events did not significantly differ. A total of 29%, 15.9%, and 4% of patients discontinued everolimus, abemaciclib, and palbociclib, respectively, due to toxicity.

Conclusion:

These results suggest similar efficacies between CDK4/6 inhibition and mTOR blockade; however, CDK4/6 inhibitors were associated with favorable toxicity profiles.
Association between initial opioid use and response to a brief interdisciplinary treatment program in fibromyalgia
Authors: Hwang Jong-moon , Lee Byung-joo , Oh Terry H. , Park Donghwi , Kim Chul-hyun
Published: January 2019

Background:

To evaluate the association between opioid use and treatment outcome (symptom severity, quality of life [QOL]) after a brief interdisciplinary fibromyalgia treatment program (FTP).

Method:

Subjects (n = 971) with fibromyalgia participated in the FTP. They filled out the Fibromyalgia Impact Questionnaire (FIQ) and the Short Form-36 Health Status Questionnaire (SF-36) at baseline and 6 to 12 months after the FTP. Post-treatment changes in FIQ and SF-36 scores were compared after stratifying the participants into opioid user and non-opioid user groups.

Results:

A total of 236 patients (24.3%) were opioid users. Compared with non-opioid users, the opioid users had worse symptom severity measured using FIQ total score (p < .001) and all subscales at baseline and post treatment, as well as worse QOL measured using all SF-36 subscales and physical and mental components. Comparison of least-square means of mean change of QOL between opioid users and non-opioid users after analysis of covariance adjusted patient characteristics and baseline scores showed that the FIQ subscale scores of physical impairment (p < .05), job ability (p < .05), and fatigue (p < .05) were significantly less improved in the opioid users compared with the non-opioid users. Moreover, the SF-36 subscale score of general health perception (p < .05) was significantly less improved in the opioid users compared with non-opioid users. However, post-treatment changes in mean scores for QOL subscale generally did not significantly differ in both groups.

Conclusions:

Opioid use did not affect response to the FTP, as measured using the FIQ total score or SF-36 physical and mental component summary scores. Furthermore, the opioid user group showed less improvement in the FIQ subscale scores of physical impairment, job ability, and fatigue and in the SF-36 subscale scores of general health perception.