bluuebunny/crossref_metadata_2025 huggingface dataset:
Liquid Biopsy of HPV DNA in Cervical Cancer
Authors: Cheung Tak Hong , Yim So Fan , Yu Mei Yun , Worley Michael J. , Fiascone Stephen J. , Chiu Rossa W. K. , Lo Keith W. K. , Siu Nelson S. S. , Wong Martin C. S. , Yeung Apple C. M. , Wong Raymond R. Y. , Chen Zi Gui , Elias Kevin M. , Chung Tony K. H. , Berkowitz Ross S. , Wong Yick Fu , Chan Paul K. S.
Published: July 2019

(Abstracted from J Clin Virol 2019;114:32–36)

Despite the introduction of the human papillomavirus (HPV) vaccine, 2 HPV subtypes, HPV16 and HPV18, are responsible for greater than 70% of cervical cancers. Posttreatment surveillance for patients with cervical cancer currently involves physical examination and imaging studies.
A Randomized Trial of Prophylactic Antibiotics for Miscarriage Surgery
Authors: Lissauer David , Wilson Amie , Hewitt Catherine A. , Middleton Lee , Bishop Jonathan R. B. , Daniels Jane , Merriel Abi , Weeks Andrew , Mhango Chisale , Mataya Ronald , Taulo Frank , Ngalawesa Theresa , Chirwa Agatha , Mphasa Colleta , Tambala Tayamika , Chiudzu Grace , Mwalwanda Caroline , Mboma Agnes , Qureshi Rahat , Ahmed Iffat , Ismail Humera , Oladapo Olufemi T. , Mbaruku Godfrey , Chibwana Jerome , Watts Grace , Simon Beatus , Ditai James , Otim Tom Charles , Acam JaneFrances , Ekunait John , Unzia Hellen , Iyaku Margaret , Makiika Joshua J. , Zamora Javier , Roberts Tracy , Goranitis Ilias , Bar-Zeev Sarah , Desmond Nicola , Arulkumaran Sabaratnam , Bhutta Zulfiqar A. , Gulmezoglu Ahmet M. , Coomarasamy Arri
Published: July 2019

(Abstracted from N Engl J Med 2019;380:1012–1021)

Ten percent to 20% of pregnancies end in spontaneous abortion. Products of conception are retained in some cases of spontaneous abortion, and surgical intervention is needed for their removal.
Oral Gonadotropin-Releasing Hormone Antagonist Relugolix Compared With Leuprorelin Injections for Uterine Leiomyomas: A Randomized Controlled Trial
Authors: Osuga Yutaka , Enya Kazuaki , Kudou Kentarou , Tanimoto Masataka , Hoshiai Hiroshi
Published: July 2019

(Abstracted from Obstet Gynecol 2019;133:423–433)

Uterine leiomyomas occur in approximately 20% to 40% of women. A major symptom in women with fibroids is persistent heavy menstrual bleeding, resulting in anemia with fatigue and reduced quality of life.
Association of Long-term Child Growth and Developmental Outcomes With Metformin vs Insulin Treatment for Gestational Diabetes
Authors: Landi Suzanne N. , Radke Sarah , Engel Stephanie M. , Boggess Kim , Stürmer Til , Howe Anna S. , Funk Michele Jonsson
Published: July 2019

(Abstracted from JAMA Pediatr 2019;173(2):160–168)

Gestational diabetes mellitus (GDM) is a common pregnancy complication, characterized by relative insulin deficiency and insulin resistance, leading to maternal hyperglycemia. Oral hypoglycemic agents, such as metformin, have emerged as an option for GDM management.
Prenatal Exome Sequencing Analysis in Fetal Structural Anomalies Detected by Ultrasonography (PAGE): A Cohort Study
Authors: Lord Jenny , McMullan Dominic J. , Eberhardt Ruth Y. , Rinck Gabriele , Hamilton Susan J. , Quinlan-Jones Elizabeth , Prigmore Elena , Keelagher Rebecca , Best Sunayna K. , Carey Georgina K. , Mellis Rhiannon , Robart Sarah , Berry Ian R. , Chandler Kate E. , Cilliers Deirdre , Cresswell Lara , Edwards Sandra L. , Gardiner Carol , Henderson Alex , Holden Simon T. , Homfray Tessa , Lester Tracy , Lewis Rebecca A. , Newbury-Ecob Ruth , Prescott Katrina , Quarrell Oliver W. , Ramsden Simon C. , Roberts Eileen , Tapon Dagmar , Tooley Madeleine J. , Vasudevan Pradeep C. , Weber Astrid P. , Wellesley Diana G. , Westwood Paul , White Helen , Parker Michael , Williams Denise , Jenkins Lucy , Scott Richard H. , Kilby Mark D. , Chitty Lyn S. , Hurles Matthew E. , Maher Eamonn R.
Published: July 2019

(Abstracted from Lancet 2019;393:747–757)

Fetal structural anomalies, detected by ultrasonography, have a range of genetic causes, including chromosomal aneuploidy, copy number variations (CNVs), and pathogenic sequence variants in developmental genes. Conventional prenatal cytogenetic analysis was historically the first-line method to investigate these anomalies, but chromosomal microarray analysis has been adopted more recently, as this test is able to detect smaller, but significant, CNVs.
Routine First-Trimester Screening for Fetal Trisomies in Twin Pregnancy: Cell-free DNA Test Contingent on Results From Combined Test
Authors: Galeva S. , Konstantinidou L. , Gil M. M. , Akolekar R. , Nicolaides K. H.
Published: July 2019

(Abstracted from Ultrasound Obstet Gynecol 2019;53(2):208–213)

In singleton pregnancies, screening for the major trisomies using a combination of fetal nuchal translucency (NT) thickness, serum β-human chorionic gonadotropin, and pregnancy-associated plasma protein A can detect approximately 90% of cases of trisomy 13, 18, or 21, at a false-positive rate of 5%. In twin pregnancies, use of the combined test can achieve a similar detection rate (DR) for trisomy 21, but with a higher false-positive rate of about 6%.
Extended In Vitro Culture of Human Embryos Demonstrates the Complex Nature of Diagnosing Chromosomal Mosaicism From a Single Trophectoderm Biopsy
Authors: Popovic M. , Dhaenens L. , Taelman J. , Dheedene A. , Bialecka M. , De Sutter P. , de Sousa Lopes S. M. Chuva , Menten B. , Heindryckx B.
Published: July 2019

(Abstracted from Hum Reprod 2019;34(4):758–769)

The development of preimplantation genetic testing (PGT-A) in conjunction with assisted reproductive technology has led to valuable analysis of the high frequency of chromosomal abnormalities observed in human embryos. While mosaic embryos may lead to healthy live births, the likelihood of poor clinical outcomes is much greater when compared with euploid blastocyst development.
Induction of Labour at 41 Weeks Versus Expectant Management Until 42 Weeks (INDEX): Multicentre, Randomised Non-inferiority Trial
Authors: Keulen Judit K. J. , Bruinsma Aafke , Kortekaas Joep C. , van Dillen Jeroen , Bossuyt Patrick M. M. , Oudijk Martijn A. , Duijnhoven Ruben G. , van Kaam Anton H. , Vandenbussche Frank P. H. A. , van der Post Joris A. M. , Mol Ben Willem , de Miranda Esteriek
Published: July 2019

(Abstracted from BMJ 2019;364:l344)

Postterm pregnancy, defined as a pregnancy extended to or beyond 42 weeks, is associated with increased perinatal morbidity and mortality. The risk of adverse perinatal outcome increases gradually after 40 weeks, even though favorable perinatal outcomes between 40 and 42 weeks are good in high-resource settings.
The Growth-Restricted Fetus: Risk of Mortality by Each Additional Week of Expectant Management
Authors: Pilliod Rachel A. , Page Jessica M. , Sparks Teresa N. , Caughey Aaron B.
Published: July 2019

(Abstracted from J Matern Fetal Neonatal Med 2019;32(3):442–447)

Pregnancies diagnosed as having fetal growth restriction (FGR) are defined as those where the estimated fetal weight by ultrasound is less than the 10th percentile. Several studies have shown an association between FGR fetuses and stillbirth, with the risk of stillbirth inversely proportional to the degree of growth restriction.
Association of Adverse Perinatal Outcomes of Intrahepatic Cholestasis of Pregnancy With Biochemical Markers: Results of Aggregate and Individual Patient Data Meta-analyses
Authors: Ovadia Caroline , Seed Paul T. , Sklavounos Alexandros , Geenes Victoria , Di Illio Chiara , Chambers Jenny , Kohari Katherine , Bacq Yannick , Bozkurt Nuray , Brun-Furrer Romana , Bull Laura , Estiú Maria C. , Grymowicz Monika , Gunaydin Berrin , Hague William M. , Haslinger Christian , Hu Yayi , Kawakita Tetsuya , Kebapcilar Ayse G. , Kebapcilar Levent , Kondrackienė Jūratė , Koster Maria P. H. , Kowalska-Kańka Aneta , Kupčinskas Limas , Lee Richard H. , Locatelli Anna , Macias Rocio I. R. , Marschall Hanns-Ulrich , Oudijk Martijn A. , Raz Yael , Rimon Eli , Shan Dan , Shao Yong , Tribe Rachel , Tripodi Valeria , Abide Cigdem Yayla , Yenidede Ilter , Thornton Jim G. , Chappell Lucy C. , Williamson Catherine
Published: July 2019

(Abstracted from Lancet 2019;393(10174):899–909)

Intrahepatic cholestasis of pregnancy (ICP) affects less than 0.1% to 0.2% of pregnant women. It is diagnosed in women with gestational pruritus and increased serum bile acids and can be complicated by preterm labor, fetal asphyxia, meconium-stained amniotic fluid, and stillbirth.
A 12-Month Clinical Durability of Effectiveness and Safety Evaluation of a Vaginal Bowel Control System for the Nonsurgical Treatment of Fecal Incontinence
Authors: Richter Holly E. , Dunivan Gena , Brown Heidi W. , Andy Uduak , Dyer Keisha Y. , Rardin Charles , Muir Tristi , McNevin Shane , Paquette Ian , Gutman Robert E. , Quiroz Lieschen , Wu Jennifer
Published: July 2019

(Abstracted from Female Pelvic Med Reconstr Surg 2019;25:113–119)

Fecal incontinence (FI) is a common debilitating condition in women that impacts their quality of life. Inability to control bowel movements is embarrassing and can lead to social isolation.
Insect sting allergy: new guidelines from the European and USA consensus groups: algorithms and recommendations
Authors: Golden David B.K.
Published: July 2019

Purpose of review

Guidelines on insect sting allergy and venom immunotherapy (VIT) have been updated. This review describes the evolution of these guidelines and their similarities and differences.

Recent findings

The US and European guidelines show the evolution of guideline development in the grading of recommendations and the transparency of the evaluation of evidence. The US and European guidelines on VIT are similar in most areas and complimentary in others. The European guidelines are limited to VIT and are based on a published systematic review; the US practice parameters cover all areas of the diagnosis and management of insect sting allergy and do not use the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.

There is general agreement that both children and adults with cutaneous systemic reactions do not require VIT, and that there is minimal risk associated with β-blockers and angiotensin-converting enzyme inhibitors during VIT. There are minor differences in the details of VIT dose, regimen, and choice of venom, but agreement on the duration and risk factors for relapse after VIT. The US and European guidelines are complementary in their discussion of the relation of mastocystosis and insect sting anaphylaxis and the value of measuring basal serum tryptase.

The updated guidelines on insect sting allergy from the US and European groups differ in scope, with a somewhat different focus in specific areas but are complementary overall. Where they overlap, there are relatively few differences in recommendations, and these are subtle. The US practice parameter offers an annotated algorithm for the evaluation and treatment of patients with reactions to insect stings.
What Do I Do When Something Goes Wrong? Teaching Medical Students to Identify, Understand, and Engage in Reporting Medical Errors
Authors: Ryder Hilary F. , Huntington Jonathan T. , West Alan , Ogrinc Greg
Published: July 2019

Problem

Identifying and processing medical errors are overlooked components of undergraduate medical education. Organizations and leaders advocate teaching medical students about patient safety and medical error, yet few feasible examples demonstrate how this teaching should occur. To provide students with familiarity in identifying, reporting, and analyzing medical errors, the authors developed the interactive patient safety reporting curriculum (PSRC), requiring clinical students to engage intellectually and emotionally with personally experienced events in which the safety of one of their patients was compromised.

Approach

In 2015, the authors incorporated the PSRC into the third-year internal medicine clerkship. Students completed a structured written report, analyzing a patient safety incident they experienced. The report focused on severity of outcome, root cause(s) analysis, system-based prevention, and personal reflection. The report was bookended by 2 interactive, case-based sessions led by faculty with expertise in patient safety, quality improvement, and medical errors.

Outcomes

Students accurately analyzed the severity of the outcome, and their reports directly led to 2 formal root cause analyses and 4 system-based improvements.

Next Steps

The time- and resource-efficient PSRC allows students to apply patient safety knowledge to a medical error they experienced in a way that can directly affect care delivery. This model—interactive learning sessions coupled with engaging in a personally experienced case—can be implemented in various settings. Educators seeking to use student-experienced events for learning should not discount the emotional effects of those events on medical students.
Achieving Gender and Social Equality: More Than Gender Parity Is Needed
Authors: Raj Anita , Kumra Tina , Darmstadt Gary L. , Freund Karen M.
Published: July 2019

In this Perspective, the authors review Association of American Medical Colleges data on gender parity and intersectionality, consider the literature on gender parity in academic medicine and the underlying gender norms that explain these statistics, and offer recommendations for moving past indicators of parity to achieve gender and social equality.

Improvements in gender parity among medical school graduates have not translated to gender parity among practicing physicians or medical school faculty, particularly for racial/ethnic minorities. Further, gender parity does not correspond to gender equality, such that gender-based disparities in salaries and advancement persist. In addition, social norms related to traditional gender role expectations reinforce existing biases and lead to sexual harassment and discrimination against women in the workplace.

Building on their analysis of existing data and the literature, the authors offer concrete recommendations to achieve gender equality in academic medicine that not only improve parity but also support policies and practices to address the norms that further bias and discrimination. These recommendations include the collection, monitoring, and open reporting of data on salaries as well as on sex and race/ethnicity; stronger policies related to family leave and sexual discrimination and harassment; and accountability structures to ensure that policies are enforced. While these efforts alone cannot eliminate gender inequalities, academic medicine should be at the forefront of creating a climate in medicine that is supportive of gender equality as part of their larger goal of promoting social equality.
Securing a Network for a Research-Intensive, Referral Academic Medical Center: University of Kentucky HealthCare as a Case Study
Authors: Edwards Robert L. , Birdwhistell Mark D. , Zembrodt James W. , Newman Mark F. , Karpf Michael
Published: July 2019

Over the last 15 years, UK HealthCare, the clinical enterprise of the University of Kentucky, has undertaken 3 clinical strategic plans to secure its position as a research-intensive, referral academic medical center. The first plan, titled Securing the Traditional Marketplace (2005–2010), focused on building advanced subspecialty programs on campus while pursuing partnerships with providers in UK HealthCare’s traditional marketplace, eastern Kentucky. The second plan, Expanding the Footprint (2010–2015), recognized that UK HealthCare needed to cover a population base of 5 to 10 million people to support its subspecialty programs. These 2 strategic plans were successful and achieved 4 outcomes: a doubling of annual discharges, a dramatic increase of transfers/external referrals, a significant increase in the case mix index, and impressive growth in subspecialty programs. The third clinical strategic plan, Preparing for Change (2015–2020), has expanded UK HealthCare’s gains in the face of rapidly changing reimbursement systems and delivery models. The pillars of this plan are responding to consumerism, strengthening hallmark programs through service lines, “hard wiring” relationships with partnering organizations including establishing the Kentucky Health Collaborative, and building infrastructure to deal with risk-based reimbursement. UK HealthCare is trying to spearhead a rational system of care for Kentucky rather than a system that rations care. Halfway through the third clinical strategic plan, UK HealthCare has seen increased discharges, transfers, and clinical expansion in its hallmark programs, building evidence that well-thought business practices can lead to improved public policy.
Beyond Better, Safer, Cheaper Health Care: What’s Ultimately at Stake?
Authors: Souba Wiley , Tsai Antonius
Published: July 2019

Health care reform continues to be controversial and divisive and takes its toll on physicians, patients, and national unity. An emphasis on efficiency and profit that depersonalizes human interactions hampers building physician–patient relationships grounded in compassion and trust. The authors argue that health care reform will be more effective if it is grounded in and anchored by a physician–patient relationship that is relationally transformative rather than transactionally commercial. This health care paradigm shift, from the “transactional getting” to the “relational giving,” must be physician led. The authors propose 3 next steps. First, establishing discourse “ensembles” will foster conversations where new ideas can emerge and percolate and where participants can renew their collective stand for the humanitarian side of the healing relationship. Second, ensemble unity and effectiveness will be enhanced by the so-called inward journey of leadership. Without that journey, we cannot fully connect with the suffering of others, and we lack the wisdom and will to tackle our health care challenges. Third, to begin the process of solidifying this humanistic foundation, transformative leadership becomes essential. In contrast to transactional leadership, which motivates physicians by seducing their self-interests, transformative (relational) leadership connects physicians with their deeply held values that embody what it means to be a physician and what it means to be human. A shared, collective view of what’s at stake if we settle for purely transactional medicine would help create the necessary physician alignment and commitment to reposition medicine as a profession that values service above reward.
The Sooner the Better: High-Value Care Education in Medical School
Authors: Erath Alexandra , Mitchell Margaret , Salwi Sanjana , Liu Yangzi , Sherry Alexander
Published: July 2019

Over the last decade in the United States, a national emphasis on controlling health care costs has prompted the medical community to embrace the ideal of high-value care (HVC), with value defined as health outcomes achieved per dollar spent. Despite increasing recognition of its importance as a skill for the modern physician, the practice of HVC remains a relatively new concept. Integrating HVC into medical education has been heterogeneous at best, with the majority of current HVC education thus far implemented at the postgraduate level. The authors present the unique benefits of the earlier introduction of HVC training at the medical school level, including ease of standardization across programs, a synergy in learning the value of an intervention alongside its other innate qualities, and the establishment of a foundational HVC education to allow for specialty-specific value training during residency. In this Invited Commentary, the authors offer practical recommendations for the incorporation of HVC training into medical schools’ curricula, with special attention to correlating specific education strategies with the preclerkship, clerkship, and elective years of medical school.
Patient Shadowing: A Useful Research Method, Teaching Tool, and Approach to Student Professional Development for Premedical Undergraduates
Authors: Wilson Jason W. , Baer Roberta D. , Villalona Seiichi
Published: July 2019

Problem

Questions have been raised about whether undergraduate institutions are effectively preparing premedical students in the sociobehavioral and cognitive reasoning content found on the revised Medical College Admission Test, providing opportunities to understand and apply these sociobehavioral and cognitive reasoning concepts in real-world scenarios, and offering career exploration opportunities.

Approach

The Research in Physician–Patient Interactions course is a 15-week course designed for premedical students and taught through the collaboration of an emergency medicine physician and an applied medical anthropologist. As of January 2016, the course is offered each spring at the University of South Florida, Tampa, Florida. The course provides opportunities for patient and physician shadowing within the anthropological methodological framework of participant observation. Other qualitative research methods are also taught, and students complete a group patient experience quality improvement project.

Outcomes

Thematic analysis of students’ field notes and reflection essays and follow-up communications with course alumni revealed 3 salient themes regarding the utility of patient shadowing as a research method that provides unique types of qualitative data, as a teaching tool for premedical students to understand the perspectives of patients, and as an approach to developing the professional skills necessary in health care, such as effective communication styles, establishment of rapport, and empathy.

Next Steps

Similar courses should be offered at other universities to premedical students. While it appears that patient shadowing experiences have a great impact during premedical education, there may also be value in integrating a similar experience into medical school and residency training.
A Prospective Multicenter Study Evaluating Endoscopy Competence Among Gastroenterology Trainees in the Era of the Next Accreditation System
Authors: Han Samuel , Obuch Joshua C. , Duloy Anna M. , Keswani Rajesh N. , Hall Matt , Simon Violette , Ezekwe Eze , Menard-Katcher Paul , Patel Swati G. , Aagard Eva , Brimhall Bryan , Ahmad Asyia , Alghamdi Saad , Brown Michael D. , Broy Charles , Carlin Linda , Chugh Priyanka , Connolly Sean E. , Cooley D. Matthew , Cowley Kevin , Di Palma Jack A. , Early Dayna S. , Ellert Swan , Gaumnitz Eric A. , Ghassemi Kevin A. , Lebovics Edward , Lee Robert H. , Lunsford Tisha , Massaad Julia , Mittal Mohit , Morigeau Kirsten , Pietrak Stanley , Piper Michael , Shah Anand S. , Shapiro Alan , Sonnier William , Sorrell Cari , Vignesh Shivakumar , Woolard Shani , Wani Sachin
Published: July 2019

Purpose

The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy.

Method

During academic year 2016–2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis.

Results

Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills.

Conclusions

This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.
Teaching Systems Improvement to Early Medical Students: Strategies and Lessons Learned
Authors: Harbell Monica W. , Li Descartes , Boscardin Christy , Pierluissi Edgar , Hauer Karen E.
Published: July 2019

Purpose

Despite increasing emphasis in medical school education on quality and systems improvement, many medical schools lack sufficient faculty with expertise to teach systems improvement. Using the pedagogical content knowledge framework, this study explores how faculty engage students in systems improvement work and faculty perceptions of the outcomes for the health system and students.

Method

In May–June 2017, the authors interviewed 12 of 13 invited faculty with experience in teaching and engaging first-year medical students in systems improvement work, the course of students’ systems improvement work over time, the impact of students’ projects on health systems, and students’ learning and attitudes about systems improvement. The authors conducted qualitative analysis iteratively with data collection to sufficiency.

Results

Six emergent themes characterized faculty’s approach to guiding students in systems improvement work: faculty–student relationship, faculty role, student role, faculty–student shared responsibility for projects, faculty and student content knowledge, and project outcomes. The faculty–student relationship was foundational for successful systems improvement work. Faculty roles included project selection, project management, and health systems interactions. Students engaged in systems improvement as their faculty leveraged their knowledge and skills and created meaningful student roles. Faculty and students shared responsibility and colearned systems improvement content knowledge. Faculty defined successful outcomes as students’ learning about the systems improvement process and interprofessional collaboration.

Conclusions

Findings highlight the critical importance of pedagogical content knowledge to engage early learners in systems improvement work, understand their learning interests and needs, and manage their projects longitudinally.
Examinee Cohort Size and Item Analysis Guidelines for Health Professions Education Programs: A Monte Carlo Simulation Study
Authors: Aubin André-Sébastien , Young Meredith , Eva Kevin , St-Onge Christina
Published: July 2019

Purpose

Using item analyses is an important quality-monitoring strategy for written exams. Authors urge caution as statistics may be unstable with small cohorts, making application of guidelines potentially detrimental. Given the small cohorts common in health professions education, this study’s aim was to determine the impact of cohort size on outcomes arising from the application of item analysis guidelines.

Method

The authors performed a Monte Carlo simulation study in fall 2015 to examine the impact of applying 2 commonly used item analysis guidelines on the proportion of items removed and overall exam reliability as a function of cohort size. Three variables were manipulated: Cohort size (6 levels), exam length (6 levels), and exam difficulty (3 levels). Study parameters were decided based on data provided by several Canadian medical schools.

Results

The analyses showed an increase in proportion of items removed with decreases in exam difficulty and decreases in cohort size. There was no effect of exam length on this outcome. Exam length had a greater impact on exam reliability than did cohort size after applying item analysis guidelines. That is, exam reliability decreased more with shorter exams than with smaller cohorts.

Conclusions

Although program directors and assessment creators have little control over their cohort sizes, they can control the length of their exams. Creating longer exams makes it possible to remove items without as much negative impact on the exam’s reliability relative to shorter exams, thereby reducing the negative impact of small cohorts when applying item removal guidelines.
The AAMC Standardized Video Interview and the Electronic Standardized Letter of Evaluation in Emergency Medicine: A Comparison of Performance Characteristics
Authors: Hopson Laura R. , Regan Linda , Bond Michael C. , Branzetti Jeremy , Samuels Elizabeth A. , Naemi Bobby , Dunleavy Dana , Gisondi Michael A.
Published: July 2019

Purpose

To compare the performance characteristics of the electronic Standardized Letter of Evaluation (eSLOE), a widely used structured assessment of emergency medicine (EM) residency applicants, and the Association of American Medical Colleges (AAMC) Standardized Video Interview (SVI), a new tool designed by the AAMC to assess interpersonal and communication skills and professionalism knowledge.

Method

The authors matched EM residency applicants with valid SVI total scores and completed eSLOEs in the 2018 Match application cycle. They examined correlations and group differences for both tools, United States Medical Licensing Examination (USMLE) Step exam scores, and honor society memberships.

Results

The matched sample included 2,884 applicants. SVI score and eSLOE global assessment ratings demonstrated small positive correlations approaching r = 0.20. eSLOE ratings had higher correlations with measures of academic ability (USMLE scores, academic honor society membership) than did SVI scores. Group differences were minimal for the SVI, with scores slightly favoring women (d = −0.21) and US-MD applicants (d = 0.23–0.42). Group differences in eSLOE ratings were small, favoring women over men (approaching d = −0.20) and white applicants over black applicants (approaching d = 0.40).

Conclusions

Small positive correlations between SVI score and eSLOE global assessment ratings, alongside varying correlations with academic ability indicators, suggest these are complementary tools. Findings suggest the eSLOE is subject to similar sources and degrees of bias as other common assessments; these group differences were not observed with the SVI. Further examination of both tools is necessary to understand their ability to predict clinical performance.
Driving Pressure Is Associated with Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome
Authors: Bellani Giacomo , Grassi Alice , Sosio Simone , Gatti Stefano , Kavanagh Brian P. , Pesenti Antonio , Foti Giuseppe
Published: July 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Driving pressure, the difference between plateau pressure and positive end-expiratory pressure (PEEP), is closely associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). Although this relationship has been demonstrated during controlled mechanical ventilation, plateau pressure is often not measured during spontaneous breathing because of concerns about validity. The objective of the present study is to verify whether driving pressure and respiratory system compliance are independently associated with increased mortality during assisted ventilation (i.e., pressure support ventilation).

Methods

This is a retrospective cohort study conducted on 154 patients with ARDS in whom plateau pressure during the first three days of assisted ventilation was available. Associations between driving pressure, respiratory system compliance, and survival were assessed by univariable and multivariable analysis. In patients who underwent a computed tomography scan (n = 23) during the stage of assisted ventilation, the quantity of aerated lung was compared with respiratory system compliance measured on the same date.

Results

In contrast to controlled mechanical ventilation, plateau pressure during assisted ventilation was higher than the sum of PEEP and pressure support (peak pressure). Driving pressure was higher (11 [9–14] vs. 10 [8–11] cm H2O; P = 0.004); compliance was lower (40 [30–50] vs. 51 [42–61] ml · cm H2O-1; P < 0.001); and peak pressure was similar, in nonsurvivors versus survivors. Lower respiratory system compliance (odds ratio, 0.92 [0.88–0.96]) and higher driving pressure (odds ratio, 1.34 [1.12–1.61]) were each independently associated with increased risk of death. Respiratory system compliance was correlated with the aerated lung volume (n = 23, r = 0.69, P < 0.0001).

Conclusions

In patients with ARDS, plateau pressure, driving pressure, and respiratory system compliance can be measured during assisted ventilation, and both higher driving pressure and lower compliance are associated with increased mortality.
Postoperative Delirium Is Associated with Long-term Decline in Activities of Daily Living
Authors: Shi Zhongyong , Mei Xinchun , Li Cheng , Chen Yupeng , Zheng Hailin , Wu Yujie , Zheng Hui , Liu Liang , Marcantonio Edward R. , Xie Zhongcong , Shen Yuan
Published: July 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Postoperative delirium is one of the most common complications in the elderly surgical population. However, its long-term outcomes remain largely to be determined. Therefore a prospective cohort study was conducted to determine the association between postoperative delirium and long-term decline in activities of daily living and postoperative mortality. The hypothesis in the present study was that postoperative delirium was associated with a greater decline in activities of daily living and higher mortality within 24 to 36 months after anesthesia and surgery.

Methods

The participants (at least 65 yr old) having the surgeries of (1) proximal femoral nail, (2) hip replacement, or (3) open reduction and internal fixation under general anesthesia were enrolled. The Confusion Assessment Method algorithm was administered to diagnose delirium before and on the first, second, and fourth days after the surgery. Activities of daily living were evaluated by using the Chinese version of the activities of daily living scale (range, 14 to 56 points), and preoperative cognitive function was assessed by using the Chinese Mini-Mental State Examination (range, 0 to 30 points). The follow-up assessments, including activities of daily living and mortality, were conducted between 24 and 36 months after anesthesia and surgery.

Results

Of 130 participants (80 ± 6 yr, 24% male), 34 (26%) developed postoperative delirium during the hospitalization. There were 32% of the participants who were lost to follow-up, resulting in 88 participants who were finally included in the data analysis. The participants with postoperative delirium had a greater decline in activities of daily living (16 ± 15 vs. 9 ± 15, P = 0.037) and higher 36-month mortality (8 of 28, 29% vs. 7 of 75, 9%; P = 0.009) as compared with the participants without postoperative delirium.

Conclusions

Postoperative delirium was associated with long-term detrimental outcomes, including greater decline in activities of daily living and a higher rate of postoperative mortality.
Assessment of Common Criteria for Awake Extubation in Infants and Young Children
Authors: Templeton T. Wesley , Goenaga-Díaz Eduardo J. , Downard Martina G. , McLouth Christopher J. , Smith Timothy E. , Templeton Leah B. , Pecorella Shelly H. , Hammon Dudley E. , O’Brien James J. , McLaughlin Douglas H. , Lawrence Ann E. , Tennant Phillip R. , Ririe Douglas G.
Published: July 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children.

Methods

This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success.

Results

Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100).

Conclusions

Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.
Genetic Analysis of Patients Who Experienced Awareness with Recall while under General Anesthesia
Authors: Sleigh Jamie W. , Leslie Kate , Davidson Andrew J. , Amor David J. , Diakumis Peter , Lukic Vesna , Lockhart Paul J. , Bahlo Melanie
Published: July 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Intraoperative awareness with recall while under apparently adequate general anesthesia is a rare, unexplained, and often very distressing phenomenon. It is possible that a relatively small number of genetic variants might underlie the failure of general anesthetic drugs to adequately suppress explicit memory formation and recall in the presence of apparently adequate anesthesia concentrations.

Methods

The authors recruited 12 adult patients who had experienced an episode of intraoperative awareness with recall (compared with 12 controls), performed whole exome sequencing, and applied filtering to obtain a set of genetic variants that might be associated with intraoperative awareness with recall. The criteria were that the variant (1) had a minor allele frequency less than 0.1% in population databases, (2) was within exonic or splicing regions, (3) caused a nonsynonymous change, (4) was predicted to be functionally damaging, (5) was expressed in the top 50% of genes expressed in the brain, and (6) was within genes in Kyoto Encyclopedia of Genes and Genomes pathways associated with general anesthesia, drug metabolism, arousal, and memory.

Results

The authors identified 29 rare genetic variants in 27 genes that were absent in controls and could plausibly be associated with this disorder. One variant in CACNA1A was identified in two patients and two different variants were identified in both CACNA1A and CACNA1S. Of interest was the relative overrepresentation of variants in genes encoding calcium channels and purinergic receptors.

Conclusions

Within the constraints of the filtering process used, the authors did not find any single gene variant or gene that was strongly associated with intraoperative awareness with recall. The authors report 27 candidate genes and associated pathways identified in this pilot project as targets of interest for future larger biologic and epidemiologic studies.
Successful Reduction in Electrode-Related Pressure Ulcers During EEG Monitoring in Critically Ill Neonates
Authors: Mietzsch Ulrike , Cooper Kristin L. , Harris Mandy L.
Published: July 2019

Background:

Neonates are at a high risk for pressure ulcers (PU) due to skin immaturity and exposure to various medical devices. The prevalence of PU in the neonatal intensive care unit is estimated to be 23%, with 80% of those being related to medical devices, including electroencephalographic (EEG) electrodes. Proposed mechanisms involve prolonged pressure to the electrodes and chemical reactions to conductive agents.

Purpose:

The object of this quality improvement project was to reduce PU in neonates during continuous EEG (cEEG) monitoring by 50% within 12 months and 75% within 18 months. A secondary objective was to eliminate electrode-related infections by 12 months. Balancing measures included gestational age at the time of monitoring, integrity of the EEG setup, and cost effectiveness. The process measure was adherence to the skin-monitoring tool kit.

Methods:

A multiple Plan-Do-Study-Act cycle method was used. All neonates monitored with cEEG were included. The monitoring tool kit was used to document the condition of scalp and EEG electrodes before, during, and after cEEG.

Results:

In the preproject period, 8.5% (9/106) of monitored patients developed PU, and 22.2% (2/9) of those developed infections. During the project period, 3.5% (7/198) of monitored patients developed PU and no infections were observed. During monitoring, 21 patients showed skin irritation, and timely intervention resulted in resolution in more than 90% of the cases and prevented progression into PU. Silver/silver chloride–plated electrodes, when exposed to external heat sources, can cause burns, resembling PU.

Implications for Practice:

Intervention at the electrode level together with skin inspection successfully reduces PU in neonates. Silver/silver chloride–plated electrodes should be avoided in neonates.

Implications for Research:

Further research is needed to identify the optimal electrode for neonatal EEG.
Ethical, Policy, and Practice Implications of Nurses' Experiences With Assisted Death
Authors: Pesut Barbara , Thorne Sally , Greig Madeleine , Fulton Adam , Janke Robert , Vis-Dunbar Mathew
Published: July 2019

The conceptualization of assisted death as an act performed by physicians has resulted in a lack of attention to nurses' roles and experiences with the processes that surround an assisted death. In this article, we synthesize evidence from 6 articles focusing on the experiences of 55 nurses from Canada, Belgium, and the Netherlands, with relevant ethical and policy implications derived from the literature. Nurses have a central role in negotiating inquiries about assisted death and in providing wraparound care for patients, families, and other health care providers. This role is impactful for nurses and requires significant personal and professional moral work.
A retrospective comparative study of patient satisfaction following ambulatory outpatient and inpatient total shoulder arthroplasty
Authors: Nelson Clay G. , Murphy William G. , Mulligan Ryan P. , Brolin Tyler J. , Azar Frederick M. , Throckmorton Thomas W.
Published: July 2019

Background:

Little is known about patient perceptions of outpatient total shoulder arthroplasty (TSA). We evaluated patient-reported satisfaction with TSA in a freestanding ambulatory surgery center (ASC) and an inpatient (INPT) setting.

Methods:

Patients were mailed a survey regarding hospital admission, surgical site infections, and medical problems after surgery, as well as their satisfaction with the surgery and location. Patients were asked if, given the opportunity, they would change the location of their surgery.

Results:

Thirty-five patients with ASC surgery and 46 with INPT surgery completed the survey. Satisfaction regarding location and outcomes of surgery was similar, with no differences in readmission rates, need for medical care after surgery, or surgical site infections. A high percentage of patients in the INPT group would have changed their surgery location to an ASC setting.

Conclusions:

Patients were very satisfied with TSA, as well as the environment of their surgery (ASC or INPT). If given a choice, however, the ASC group preferred having their surgery in the ASC setting, while a high percentage of patients in the INPT group would have preferred to change to an ASC setting.

Level of Evidence:

Level III. Retrospective comparative study.
Hook Plate Fixation for Acute Unstable Distal Clavicle Fracture: A Systematic Review and Meta-analysis
Authors: Asadollahi Saeed , Bucknill Andrew
Published: July 2019

Objectives:

To compare the outcome of hook plate fixation with other techniques in surgical fixation of acute unstable distal clavicle fractures.

Data Sources:

In July 2018, a systematic search of electronic databases (PubMed, Medline, Embase, and Cochrane databases for systematic reviews) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Articles were limited to English language.

Study Selection:

Studies were included if they compared the results of hook plate fixation of acute unstable distal clavicle fracture in adults with other surgical techniques.

Data Extraction:

Data on the study setting, functional outcome, union, and complication rates were extracted. A quality assessment was performed using the Newcastle–Ottawa Scale.

Data Synthesis:

Eleven studies were found that met the inclusion criteria. Six hundred thirty-four patients were pooled using a random effects model. There were 397 male and 237 female patients. Primary outcome measure was functional result, and the secondary outcome measures were union and complication rates. There was no significant difference between the functional outcome and union rate between hook plate fixation, coracoclavicular (CC) stabilization, and locking plate fixation. Hook plate fixation resulted in a higher Constant–Murley score compared with tension band wiring (TBW) [odds ratio (OR), 3.52; 95% confidence interval (CI), 0.79–6.26]. It was also associated with a higher complication rate compared with CC stabilization (OR, 3.68; 95% CI, 1.19–11.33) and the locking plate (OR, 5.19; 95% CI, 1.58–17.06). Compared with TBW, hook plate fixation was associated with a lower complication rate (OR, 0.28; 95% CI, 0.10–0.77).

Conclusions:

Hook plate fixation achieves a similar functional outcome and union rate compared with CC stabilization and locking plate fixation. However, it has a superior functional result compared with TBW. The complication rate is higher compared with CC stabilization and locking plate fixation and is lower compared with TBW.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.