bluuebunny/crossref_metadata_2025_split huggingface dataset:
Delay in Antibiotic Administration Is Associated With Mortality Among Septic Shock Patients With Staphylococcus aureus Bacteremia*
Authors: Corl Keith A. , Zeba Fatima , Caffrey Aisling R. , Hermenau Matthew , Lopes Vrishali , Phillips Gary , Merchant Roland C. , Levy Mitchell M. , LaPlante Kerry L. 
Published: December 2019

Objectives:
The relationship between the timing of antibiotics and mortality among septic shock patients has not been examined among patients specifically with Staphylococcus aureus bacteremia.

Design:
Retrospective analysis of a Veterans Affairs S. aureus bacteremia database.

Setting:
One-hundred twenty-two hospitals in the Veterans Affairs Health System.

Patients:
Patients with septic shock and S. aureus bacteremia admitted directly from the emergency department to the ICU from January 1, 2003, to October 1, 2015, were evaluated.

Interventions:
Time to appropriate antibiotic administration and 30-day mortality.

Measurements and Main Results:
A total of 506 patients with S. aureus bacteremia and septic shock were included in the analysis. Thirty-day mortality was 78.1% for the entire cohort and was similar for those participants with methicillin-resistant S. aureus and methicillin-sensitive S. aureus bacteremia. Our multivariate analysis revealed that, as compared with those who received appropriate antibiotics within 1 hour after emergency department presentation, each additional hour that passed before appropriate antibiotics were administered produced an odds ratio of 1.11 (95% CI, 1.02–1.21) of mortality within 30 days. This odds increase equates to an average adjusted mortality increase of 1.3% (95% CI, 0.4–2.2%) for every hour that passes before antibiotics are administered.

Conclusions:
The results of this study further support the importance of prompt appropriate antibiotic administration for patients with septic shock. Physicians should consider acting quickly to administer antibiotics with S. aureus coverage to any patient suspected of having septic shock.
Efficacy and safety of chimeric antigen receptor-T cells in the treatment of B cell lymphoma: a systematic review and meta-analysis
Authors: Zheng Xiao-Hong , Zhang Xi-You , Dong Qian-Qian , Chen Feng , Yang Shou-Bo , Li Wen-Bin 
Published: December 2019

Abstract

Background
Conventional treatment has limited efficacy in relapsed/refractory B-cell lymphoma. Since chimeric antigen receptor T-cell (CAR-T) technology has shown high safety and results in high remission rates, we investigated its efficacy and safety in B-cell lymphoma treatment and analyzed potential affecting factors to provide evidence for therapeutic strategies and applications.

Methods
We searched databases including PubMed, Embase, and Cochrane up to July 2019. Meta-analysis 1 was conducted to study the efficacy of CAR-T cell for treating B-cell lymphoma, measuring the response rate and complete remission rate as outcomes. Sub-group analysis was performed for age, pathological type, target antigen, co-stimulatory molecule, and conditioning chemotherapy. Meta-analysis 2 was undertaken on the safety of the treatment with the incidence rate of toxicity (cytokine-releasing syndrome [CRS], neurotoxicity) as an outcome.

Results
Seventeen studies were included in the systematic review and meta-analysis. It was found that CAR-T cells had good therapeutic effects in the following cases: B-cell lymphoma (patients ≥65 years old); diffuse large B-cell lymphoma pathological type; patients with treatment target antigen other than CD19; patients treated with co-stimulatory molecules other than CD28, including 4-1BB+CD28 or 4-1BB; and patients treated with cyclophosphamide/fludarabine pre-treatment protocol conditioning chemotherapy. Although the CRS and neurotoxicity incidences were high, most were reversible with minimal risk of death.

Conclusion
CAR-T cell treatment is safe for clinical application; however, toxicity effects should be monitored.
FACTORS ASSOCIATED WITH THE USE OF 360-DEGREE LASER RETINOPEXY DURING PRIMARY VITRECTOMY WITH OR WITHOUT SCLERAL BUCKLE FOR RHEGMATOGENOUS RETINAL DETACHMENT AND IMPACT ON SURGICAL OUTCOMES (PRO STUDY REPORT NUMBER 4)
Authors: Wang Jay C. , Ryan Edwin H. , Ryan Claire , Kakulavarapu Srividya , Mardis Patrick J. , Rodriguez Marianeli , Stefater James A. , Forbes Nora J. , Gupta Omesh , Capone Antonio , Emerson Geoffrey G. , Joseph Daniel P. , Eliott Dean , Yonekawa Yoshihiro ,   For the Primary Retinal Detachment Outcomes (PRO) Study Group
Published: December 2019

Purpose:
To determine factors associated with 360-degree laser retinopexy (360LR) during primary pars plana vitrectomy ± scleral buckle for rhegmatogenous retinal detachment (RRD) and its impact on surgical outcomes.

Methods:
This is a multicenter, retrospective, interventional study. Patients undergoing primary pars plana vitrectomy or primary pars plana vitrectomy + scleral buckle for noncomplex primary RRD in 2015 were evaluated. Primary outcomes were single surgery anatomical success (SSAS) and final anatomical success. Secondary outcomes included final logarithm of the minimum angle of resolution visual acuity, epiretinal membrane formation, cystoid macular edema development, and number of subsequent vitrectomies. Multivariate regressions were performed.

Results:
Two thousand two hundred and forty-eight surgeries by 61 surgeons were included; of which, 516 underwent 360LR. Younger age (P = 0.01), more retinal breaks (P = 0.01), more extensive RRD (P < 0.001), and surgeon ID (P < 0.001) were significantly associated with 360LR. No significant associations between 360LR and single surgery anatomical success (P = 0.44), epiretinal membrane formation (P = 0.14), cystoid macular edema development (P = 0.28), or number of subsequent vitrectomies (P = 0.41) were found. Controlling for case complexity, 360LR was significantly associated with lower final anatomical success (P < 0.001) and worse final logarithm of the minimum angle of resolution visual acuity (P < 0.001).

Conclusion:
Multiple factors influenced whether 360LR was performed during primary pars plana vitrectomy ± scleral buckle for RRD. However, 360LR was not associated with improved surgical outcomes, and in fact, it may be associated with poorer outcomes.
Extracorporeal support to achieve lung-protective and diaphragm-protective ventilation
Authors: Spinelli Elena , Carlesso Eleonora , Mauri Tommaso 
Published: December 2019

Purpose of review
Extracorporeal support allows ultraprotective controlled and assisted ventilation, which can prevent lung and diaphragm injury. We focused on most recent findings in the application of extracorporeal support to achieve lung protection and diaphragm- protection, as well as on relevant monitoring.

Recent findings
A recent randomized trial comparing the efficacy of extracorporeal support as a rescue therapy to conventional protective mechanical ventilation was stopped for futility but post hoc analyses suggested that extracorporeal support is beneficial for patients with very severe acute respiratory distress syndrome. However, the optimal ventilation settings during extracorporeal support are still debated. It is conceivable that they should enable the highest amount of CO2 removal with lowest mechanical power.
Extracorporeal CO2 removal can minimize acidosis and enable the use of ultra-protective lung ventilation strategies when hypoxemia is not a major issue. Moreover, it can protect lung and diaphragm function during assisted ventilation through control of the respiratory effort.
Lung mechanics, gas exchange, diaphragm electrical activity, ultrasound, electrical impedance tomography could be integrated into clinical management to define lung and diaphragm protection and guide personalized ventilation settings.

Summary
Technological improvement and the latest evidence indicate that extracorporeal support may be an effective tool for lung and diaphragm protection.
Effects of 2 Forms of Practice Facilitation on Cardiovascular Prevention in Primary Care
Authors: Persell Stephen D. , Liss David T. , Walunas Theresa L. , Ciolino Jody D. , Ahmad Faraz S. , Brown Tiffany , French Dustin D. , Hountz Randy , Iversen Karen , Lindau Stacy T. , Lipiszko Dawid , Makelarski Jennifer A. , Mazurek Kathryn , Murakami Linda , Peprah Yaw , Potempa Jennifer , Rasmussen Luke V. , Wang Andrew , Wang Jesi , Yeh Chen , Kho Abel N. 
Published: December 2019

Background:
Effective quality improvement (QI) strategies are needed for small practices.

Objective:
The objective of this study was to compare practice facilitation implementing point-of-care (POC) QI strategies alone versus facilitation implementing point-of-care plus population management (POC+PM) strategies on preventive cardiovascular care.

Design:
Two arm, practice-randomized, comparative effectiveness study.

Participants:
Small and mid-sized primary care practices.

Interventions:
Practices worked with facilitators on QI for 12 months to implement POC or POC+PM strategies.

Measures:
Proportion of eligible patients in a practice meeting “ABCS” measures: (Aspirin) Aspirin/antiplatelet therapy for ischemic vascular disease, (Blood pressure) Controlling High Blood Pressure, (Cholesterol) Statin Therapy for the Prevention and Treatment of Cardiovascular Disease, and (Smoking) Tobacco Use: Screening and Cessation Intervention, and the Change Process Capability Questionnaire. Measurements were performed at baseline, 12, and 18 months.

Results:
A total of 226 practices were randomized, 179 contributed follow-up data. The mean proportion of patients meeting each performance measure was greater at 12 months compared with baseline: Aspirin 0.04 (95% confidence interval: 0.02–0.06), Blood pressure 0.04 (0.02–0.06), Cholesterol 0.05 (0.03–0.07), Smoking 0.05 (0.02–0.07); P<0.001 for each. Improvements were sustained at 18 months. At 12 months, baseline-adjusted difference-in-differences in proportions for the POC+PM arm versus POC was: Aspirin 0.02 (−0.02 to 0.05), Blood pressure −0.01 (−0.04 to 0.03), Cholesterol 0.03 (0.00–0.07), and Smoking 0.02 (−0.02 to 0.06); P>0.05 for all. Change Process Capability Questionnaire improved slightly, mean change 0.30 (0.09–0.51) but did not significantly differ across arms.

Conclusion:
Facilitator-led QI promoting population management approaches plus POC improvement strategies was not clearly superior to POC strategies alone.
Depression and Uptake of Oral Anticoagulation Therapy in Patients With Atrial Fibrillation
Authors: Fenger-Grøn Morten , Vestergaard Claus H. , Frost Lars , Davydow Dimitry S. , Parner Erik T. , Christensen Bo , Ribe Anette R. 
Published: December 2019

Background:
Oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF) is a highly important preventive intervention, perhaps especially in those with comorbid depression, who have a worse prognosis. However, OAT may pose particular challenges in depressed patients.

Objectives:
To assess whether AF patients with depression have lower OAT uptake.

Methods:
This nationwide register-based 2005–2016 cohort study of all Danes with AF and OAT indication (CHA2DS2VASc stroke risk score ≥2) assessed OAT initiation within 90 days in those with incident AF (N=147,162) and OAT prevalence in those with prevalent AF (N=192,656). The associations of depression with both outcomes were estimated in regression analyses with successive adjustment for socioeconomic characteristics and somatic and psychiatric comorbidity.

Results:
Comorbid depression was significantly associated with lower frequency of OAT initiation in incident AF patients {adjusted proportion differences (aPDs): −6.6% [95% confidence interval (CI), −7.4 to −5.9]} and lower prevalence of OAT [aPD: −4.2% (95% CI, −4.7 to −3.8)] in prevalent AF patients. Yet, the OAT uptake increased substantially during the period, particularly in depressed patients [aPD for OAT prevalence in 2016: −0.8% (95% CI, −1.6 to −0.0)].

Conclusions:
Comorbid depression was associated with a significantly lower OAT uptake in patients with AF, which questions whether depressed patients receive sufficient support to manage this consequential cardiac condition. However, a substantial increase in the overall OAT uptake and a decrease of the depression-associated deficit in OAT were seen over the period during which OAT was developed through the introduction of new oral anticoagulation therapy.
Technology and precision therapy delivery in childhood cancer
Authors: Tydings Caitlin , Kim AeRang 
Published: December 2019

Purpose of review
The purpose of this review is to describe current advances in pediatric precision therapy through innovations in technology and engineering. A multimodal approach of chemotherapy, surgery and/or radiation therapy has improved survival outcomes for pediatric cancer but with significant early and late toxicities. The pediatric population is particularly vulnerable given their age during treatment. Advances in precision interventions discussed include image guidance, ablation techniques, radiation therapy and novel drug delivery mechanisms that offer the potential for more targeted approach approaches with improved efficacy while limiting acute and late toxicities.

Recent findings
Image-guidance provides improved treatment planning, real time monitoring and targeting when combined with ablative techniques and radiation therapy. Advances in drug delivery including radioisotopes, nanoparticles and antibody drug conjugates have shown benefit in adult malignancies with increasing use in pediatrics. These therapies alone and combined may lead to augmented local antitumor effect while sparing systemic exposure and potentially limiting early and late toxicities.

Summary
Pediatric cancer medicine often requires a multimodal approach, each with early and late toxicities. Precision interventions and therapies offer promise for more targeted approaches in treating pediatric malignancies and require further investigation to determine long-term benefit.
Assessment of HPV Risk Type in H&E-stained Biopsy Specimens of the Cervix by Microscopy Image Analysis
Authors: Konstantinou Christos , Kostopoulos Spiros , Glotsos Dimitris , Kalatzis Ioannis , Asvestas Pantelis , Ravazoula Panagiota , Michail George , Cavouras Dionisis , Sakellaropoulos George 
Published: December 2019

Objectives:The objective of this study was (a) to identify, by computer processing of digitized images of hematoxylin and eosin (H&E)-stained biopsy material of the cervix, differences in the structure of nuclei between high-risk (HR) and low-risk (LR) human papillomavirus virus (HPV) types and (b) to assess the HPV risk type by designing a decision-support system (DSS).Materials and Methods:Clinical material comprised H&E-stained biopsies from squamous intraepithelial lesions of 55 patients with polymerase chain reaction-verified HR-HPV (26 patients) or LR-HPV (29 patients) infection. From each patient’s biopsy specimen, we digitized 1 region of interest, guided by the expert physician. After the segmentation of nuclei, we quantified from each nucleus 77 textural and morphologic features. We represented each patient by a 77-feature vector, the feature means of all nuclei, and we created 2 classes for HR-HPV and LR-HPV types. We carried out (a) a statistical analysis to determine features with statistically significant differences between the 2 classes and (b) a discriminant analysis, by designing a DSS, to estimate the HPV risk type.Results:Statistical analysis revealed 40 features with between-classes statistically significant differences and discriminant analysis showed that the best DSS design achieved a high accuracy of about 93% in identifying the HPV risk type on data not used in the design of the DSS.Conclusions:Nuclei of HR-HPV types were of higher intensity, contained larger structures, had higher edges, were coarser, rougher, had higher contrast, were larger, and attained more irregular shapes. The proposed DSS indicates that discrimination of HPV risk type from images of H&E-stained biopsy material of the cervix is promising.
Flap Reconstruction of the Hand
Authors: Wink Jason D. , Gandhi Rikesh A. , Ashley Blair , Levin L. Scott 
Published: December 2019

Learning Objectives:
After studying this article, the participant should: 1. Be familiar with local, regional, and free flaps for reconstruction of the hand. 2. Be able to identify potential sources of tissue for vascularized coverage using an algorithmic approach to provide stable and functional reconstruction of the hand. 3. Recognize the controversies and complications unique to flap reconstruction of the hand.

Summary:
The goal of this continuing medical education module is to provide the practicing reconstructive surgeon with a framework in which to think about reconstruction of the hand. The hand has unique functional and aesthetic characteristics that must be considered when choosing the optimal methods for reconstruction. There are a number of reliable local and regional flaps that can be used to treat the hand requiring soft-tissue coverage and/or vascularized bone graft. The “reconstructive ladder,” originally described by Mathes and Nahai, is based on the principle of using the simplest approach that adequately restores form and ideally optimizes function. In cases where the simplest techniques prove to be inadequate, local and regional flaps and, ultimately, microsurgical tissue transfer should be considered.
Initial Opioid Prescriptions Predict Continued Narcotic Use: Analysis of 24,594 Reduction Mammaplasty Patients
Authors: Merola David , Calotta Nicholas A. , Lu Zhen A. , Lifchez Scott D. , Aliu Oluseyi , Coon Devin 
Published: December 2019

Background:
The objective of this study was to establish whether a particular perioperative opioid regimen was associated with a higher risk of opioid refilling in the reduction mammaplasty patient population.

Methods:
A retrospective cohort study was conducted on subjects that underwent bilateral reduction mammaplasty with no history of opioid use in the year before surgery. Patients were followed for a period of 4 months after surgery. Multivariable logistic regression was used to establish factors associated with prescription refilling. Predictive probabilities of opioid refilling, given various perioperative opioid regimens, were explored.

Results:
A total of 24,594 subjects met all criteria for inclusion in the study, 13 percent of whom demonstrated continued opioid use following surgery. The probability of refill in patients receiving 15 to 59 daily morphine milligram equivalents perioperatively was significantly lower than in those receiving less than 15 daily morphine milligram equivalents (e.g., 15 mg of codeine every 4 hours) or more than 60 daily morphine milligram equivalents (e.g., 10 mg of oxycodone every 6 hours).

Conclusions:
The probability of refilling prescription opioids is increased by nonmodifiable risk factors, such as age. However, modifiable risk factors exist as well, most notably the amount of narcotic prescribed during the perioperative period. Overprescribing was found to be common in the reduction mammaplasty patient population. Limiting outpatient opioid exposure to a range of 15 to 59 daily morphine milligram equivalents (e.g., 5 mg of hydrocodone every 6 hours) during the perisurgical period may reduce the probability that the surgeon will need to prescribe further narcotics. Further studies are needed to validate our findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Risk, III.
An Evaluation of Race Disparities in Academic Plastic Surgery
Authors: Smith Brandon T. , Egro Francesco M. , Murphy Carolyn P. , Stavros Alexander G. , Nguyen Vu T. 
Published: December 2019

Background:
Academic plastic surgery has a history of underrepresentation of ethnic and racial minority groups. Recent policy shifts by national medical groups and plastic surgery societies have focused on reversing these inequalities. This study seeks to measure ethnic and racial representation at academic and leadership positions following recent changes.

Methods:
A cross-sectional study was conducted in June of 2018, measuring ethnic and racial diversity of U.S. academic plastic surgery faculty. Among faculty, career qualifications, years of experience, faculty positions, and leadership ethnicity were compared.

Results:
A total of 930 academic plastic surgeons were included in the study. Classified collectively as nonwhite, this group graduated more recently than other academic plastic surgeons (2006 versus 2001; p < 0.0001) and had greater rates of clinical fellowship attainment (OR, 1.62; 95 percent CI, 1.16 to 2.26). Nonwhite individuals were less likely to be employed in the full professor position compared with their white colleagues (OR, 0.6; 95 percent CI, 0.42 to 0.88; p = 0.0077). However, after adjustment for differences in years of postresidency experience, this disparity was no longer significant (OR, 1.06; 95 percent CI, 0.62 to 1.83; p = 0.82), indicating the importance of current cohort experience differences. Assessment of program leadership found that nonwhite chairs employed significantly more nonwhite faculty (42.5 percent versus 20.9 percent; p < 0.0001).

Conclusions:
Academic plastic surgery continues to face disparities in representation of both ethnic and racial minorities. Current inequalities are most severe at senior academic positions and may be linked to cohort experience differences along with leadership and promotion biases.
Population-Based Health Utility Assessment of Migraine Headache Symptoms before and after Surgical Intervention
Authors: Torabi Radbeh , Bourn Lynn , Veith Jacob , Wisecarver Ian , Briley Kenneth , Bartow Matthew , Austen William G. , Tessler Oren 
Published: December 2019

Background:
Approximately 30 million Americans suffer from migraine headaches. The primary goals of this study are to (1) use Migraine-Specific Symptoms and Disability criteria and Migraine Headache Index to describe the symptomatic improvement following decompressive surgery for refractory migraines, and (2) use the average Migraine Headache Index preoperatively and postoperatively for health utility assessment from a healthy patient’s perspective.

Methods:
The Migraine-Specific Symptoms and Disability criteria and the Migraine Headache Index were used to characterize migraine symptoms in the authors’ patient population before and after decompressive surgery. Healthy individuals were randomized to a scenario in which they assumed either the preoperative or postoperative average patient symptom profile described by the authors’ migraine patients. Health utility assessments were used to quantify the evaluation of health states the authors’ patients experienced before and after surgical migraine therapy.

Results:
Twenty-five patients underwent surgery for migraine headaches. The Migraine-Specific Symptoms and Disability questionnaire showed a significant decrease in both frequency of headaches per month (p < 0.0001) and overall pain score (p = 0.007). The Migraine Headache Index demonstrated a statistically significant improvement (p = 0.03). Healthy individuals in the preoperative group had significantly lower utility scores compared with the postoperative group in all of the health utility assessments completed for migraine symptoms.

Conclusion:
This is the first study to use health utility assessments to attest the efficacy of decompressive therapy by demonstrating the population perspective, which perceived a significant improvement in quality of life following the surgical treatment of migraines in the authors’ patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.