bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Implementation of Lean Six Sigma Principles to Improve the Value of Care Delivery for Total Joint Arthroplasty Patients: The Perioperative Institute of Surgical Excellence Experience
Authors: El-Othmani Mouhanad M. , Crespi Zachary , Pallekonda Vinay , Sayeed Zain , Saleh Khaled J. 
Published: November 2020

Background:
With the projected increase in the volume of total joint arthroplasty (TJA), minimizing variations in surgery times, hospital length of stay (LOS), discharge dispositions, and inhospital complication rates would help reduce costs and improve the quality of care. As the move toward bundle payment models gains further traction, providers will be reimbursed based on the quality and cost associated with the surgical episode. As such, it remains critical to design and implement high-quality cost-effective perioperative delivery care models. Lean Six Sigma (LSS) methodology has been well described in the healthcare field as a superior strategy in designing processes aimed at reducing waste while minimizing error rates. We present an institutional experience with the design and implementation of a LSS quality improvement process specific to the TJA pathway, with a hypothesis of expected decrease in case cancellation rate, inhospital LOS, 30-day readmissions, and inpatient rehabilitation utilization after program implementation.

Methods:
In 2017, the Perioperative Institute of Surgical Excellence (PISE) program for lower limb TJA was designed and implemented at our institution over a 4-month duration. The program was designed following LSS principles as a low-cost easily adoptable model with a goal to reduce hospital LOS, case cancellation rate, 30-day readmissions, and inpatient rehabilitation utilization.

Results:
A total of 328 patients (128 total hip arthroplasty and 200 total knee arthroplasty) were included in PISE compared with a total of 255 patients (106 total hip arthroplasty and 149 total knee arthroplasty) for the preimplementation cohort. After implementation of the model, and compared with a similar 4-month preimplementation duration, the pilot results revealed an increase in monthly case load by 28.6%, decrease in the 30-day readmission rate by 1.16%, inpatient rehabilitation utilization by 60%, a reduction of the average LOS by 0.8 days, and a case cancellations decrease by 51%.

Conclusion:
The implementation of the pilot protocol for PISE within our institution was successful in decreasing LOS, inpatient rehabilitation utilization, 30-day readmission, and case cancellation. Further assessment is needed to ascertain sustainability of the protocol over a longer duration and generalizability of the results at different institutions and surgeons.
Cognitive Biases in Orthopaedic Surgery
Authors: Janssen Stein J. , Teunis Teun , Ring David , Parisien Robert C. 
Published: November 2020

Introduction:
Cognitive biases are known to affect all aspects of human decision-making and reasoning. Examples include misjudgment of probability, preferential attention to evidence that confirms one's beliefs, and preference for certainty. It is not known whether cognitive biases influence orthopaedic surgeon decision-making. This study measured the influence of a few cognitive biases on orthopaedic decision-making in hypothetical vignettes. The questions we addressed were as follows: Do orthopaedic surgeons display the cognitive biases of base rate neglect and confirmation bias in hypothetical vignettes? Can anchoring and framing biases be demonstrated?

Methods:
One hundred ninety-six orthopaedic surgeons completed a survey consisting of three vignettes evaluating base rate neglect, five evaluating confirmation bias, and two separate vignettes each randomly exposing half of the group to different anchors and frames.

Results:
For the three vignettes evaluating base rate neglect, 43% (84 of 196) chose answers consistent with base rate neglect in vignette 1, 88% (173 of 196) in vignette 2, and 35% (69 of 196) in vignette 3. Regarding confirmation bias, 51% (100 of 196) chose an answer consistent with confirmation bias for vignette 1, 11% (22 of 196) for vignette 2, 22% (43 of 196) for vignette 3, 22% (44 of 196) for vignette 4, and 29% (56 of 196) for vignette 5. There was a measurable anchoring heuristic (56% versus 34%; a difference of 22%) and framing effect (77% versus 61%; a difference of 16%).

Conclusion:
The influence of cognitive biases can be documented in patient vignettes presented to orthopaedic surgeons. Strategies can anticipate cognitive bias and develop practice debiasing strategies to limit potential error.
Anxiety and Depression Impact on Inhospital Complications and Outcomes After Total Knee and Hip Arthroplasty: A Propensity Score-Weighted Retrospective Analysis
Authors: Zalikha Abdul Kareem , Karabon Patrick , Hajj Hussein Inaya , El-Othmani Mouhanad M. 
Published: November 2020

Introduction:
The purpose of this study was to assess the impact of anxiety and depression on immediate inhospital outcomes and complications after total joint arthroplasty of the hip (total hip arthroplasty [THA]) and knee (total knee arthroplasty [TKA]) using a large national registry.

Methods:
Data from the National Inpatient Sample was used to identify all patients undergoing TKA and THA between 2006 and 2015. Patients were divided in four groups based on a concomitant diagnosis of depression, anxiety, depression plus anxiety, and neither depression nor anxiety (control group). Propensity score analysis was performed to determine whether these psychiatric comorbidities were risk factors for inhospital economic, disposition, and complication outcomes.

Results:
A total of 5,901,057 TKAs and 2,838,742 THAs were performed in our study period. The relative percentage of patients with anxiety and depression undergoing these procedures markedly increased over time. All three psychiatric comorbidity groups were markedly associated with an increased risk of postoperative anemia and were markedly associated with other inhospital complications compared with the control group. Notable associations were also found between the study groups and total charges, length of stay, and disposition.

Discussion:
Anxiety and depression are major risk factors for inhospital complications and are markedly associated with economic and disposition outcomes after TKA and THA. The relative proportion of patients with anxiety and depression undergoing these procedures is rapidly increasing. It is critical for clinicians to remain aware of these risk factors, and attention should be directed on the development of standardized perioperative optimization protocols and medication management for these patients.

Level of Evidence:
Level III, retrospective study
Should Insulin-dependent Diabetic Patients Be Screened for Malnutrition Before Total Joint Arthroplasty? A Cohort at Risk
Authors: Schneider Andrew M. , Brown Nicholas M. 
Published: November 2020

Introduction:
The association of malnutrition in the morbidly obese cohort has led to recommendations for preoperative screening before total joint arthroplasty (TJA). However, despite the connection between diabetes and poor nutrition, preoperative screening in the diabetic cohort has not been closely examined. This study compared malnutrition risk between diabetic patients and morbidly obese patients undergoing TJA and investigated the association of malnutrition on 30-day postoperative TJA outcomes in the diabetic cohort.

Methods:
The National Surgical Quality Improvement Program database was queried, and primary TJA patients were identified for inclusion. Patients were stratified by body mass index and diabetes, and outcomes were reported as two composite groups: complications and infections in the 30-day postoperative period. Univariate and multivariate regressions were used for the analysis.

Results:
Patients with insulin-dependent diabetes mellitus (IDDM) were at a high risk of being malnourished in both the morbidly obese and nonmorbidly obese populations (frequencies of 11.9% and 9.9%, respectively). Patients with IDDM, but without morbid obesity, were 1.5x more often malnourished than morbidly obese patients without diabetes mellitus (9.9% versus 6.4%, respectively, P < 0.001). In a multivariate analysis among patients with co-occurring diabetes and malnutrition, patients with IDDM were at greatest risk for postoperative complications and infection (odds ratio 2.081 [1.652, 2.621]; P < 0.001 and odds ratio 1.894 [1.231, 2.913]; P = 0.004, respectively).

Discussion:
Patients with IDDM are at high risk for malnutrition, and increased vigilance should be maintained in this cohort before TJA to optimize outcomes. Future studies should further investigate the utility of preoperative malnutrition screening in this cohort.
MRI Characteristics of Adverse Local Tissue Reactions Associated With Intraoperative Tissue Damage and Poor Revision Surgery Outcomes: A Systematic Review
Authors: Xiong Liang , Smith Evan J. , Klemt Christian , Barghi Ameen , Padmanabha Anand , Kwon Young-Min 
Published: November 2020

Background:
Metal artifact reductions sequence (MARS) MRI has been established as a cross-sectional imaging modality for diagnosis of adverse local tissue reaction (ALTR). This study aims to evaluate the current literature regarding the characteristics of MARS MRI associated with intraoperative tissue necrosis and postoperative complications in patients undergoing revision THA because of ALTR.

Methods:
We systematically searched the literature that included reporting MRI characteristics of ALTR in failed THA and their correlation with intraoperative findings and postoperative outcomes.

Results:
A total of 617 studies were assessed, and 15 studies met the inclusion criteria. Synovial wall thickness correlated with increasing ALVAL grade, however, weakly with tissue necrosis. Synovial composition of mixed or solid features and the presence of abductor disruption correlated with complications and tissue necrosis. Tissue edema was a poor predictor of aseptic lymphocyte-dominant vasculitis-associated lesion (ALVAL) grade or tissue necrosis.

Discussion:
MARS MRI synovial composition including mixed and solid features and the presence of abductor disruption provide the best prognostic characteristics associated with intraoperative soft-tissue necrosis and revision surgery outcome. These prognostic characteristics on MRI may assist surgeons with improved criteria for intervention and preoperative patient counseling.
The Readability of Online Educational Materials for Femoroacetabular Impingement Syndrome
Authors: Kiapour Ata M. , Otoukesh Babak , Hosseinzadeh Shayan 
Published: November 2020

Although the readability of online materials has been thoroughly studied across different orthopaedic surgery disorders, inadequacy in information exists regarding the readability of the websites pertaining to femoroacetabular impingement (FAI). Given its high prevalence and the importance of providing appropriate online education materials in its prognosis, the primary aim of this study was to assess the readability of web-based patient education materials regarding this disease. “Femoroacetabular impingement,” “FAI,” and “hip impingement” were used as search queries in this study. Readability was evaluated based on five established algorithms, and the readability of contents was compared by website type and also search query. In this study of 59 unique websites on FAI, using five different validated readability formulas, we demonstrated that none of the top 30 webpages were written at the recommended reading level. They were found through three different search queries on the three most used search engines. Current FAI online education materials accessible to patients are written above the recommended levels, and it seems that to improve equity and accessibility in healthcare, universities, hospitals, and healthcare professional societies have a responsibility to ensure that the online materials are provided at more appropriate levels. Early detection and treatment of FAI play a key role in preventing the progression to hip osteoarthritis. Thus, providing appropriate online education materials is of great importance in this prevention by increasing patients' understanding of the disease and the advantages and disadvantages of the treatment options.

Level of Evidence:
Level III
Inequality of Chronic Non-Communicable Diseases Across Various Wealth Groups of India: Results from Latest Cross-Sectional Survey
Authors: Akif Mustafa , Salman Ansari 
Published: November 2020

Background: Non-communicable diseases are the major contributor to mortality and morbidity all over the world including India. About 60% (5.87 million) of all deaths in India are attributed to NCDs. In the present study we have tried to analyze the socioeconomic inequality in the prevalence of the selected four NCDs (Diabetes, Hypertension, Thyroid disorder and Obesity) among the Indian population while paying special attention to urban rural differentials.
Data and Methods: The data of NFHS-4 (2015-16), were used for the present study. To find out the level of inequalities concentration curve and its associated concentration index (CI) were calculated for the selected NCDs. For further clarification odds ratios were calculated using binary logistic regression.
Results: Socioeconomic inequalities were found in the prevalence of all the four selected NCDs. According to the values of CI, highest inequality was in the prevalence of obesity (CI=0.44, p=0.00) and lowest for hypertension (CI=0.06, p=0.00). The values of CI and odds ratios for rural and urban areas are depicting that in both the areas the NCDs are disproportionately concentrated among the rich population.
Conclusion: There is a need of potential target based approach to fight against NCDs keeping the high risk groups in mind.
From in vitro towards in situ: structure‐based investigation of ABC exporters by electron paramagnetic resonance spectroscopy
Authors: Bordignon Enrica , Seeger Markus A. , Galazzo Laura , Meier Gianmarco 
Published: November 2020

ATP‐binding cassette (ABC) exporters have been studied now for more than four decades, and recent structural investigation has produced a large number of protein database entries. Yet, important questions about how ABC exporters function at the molecular level remain debated, such as which are the molecular recognition hotspots and the allosteric couplings dynamically regulating the communication between the catalytic cycle and the export of substrates. This conundrum mainly arises from technical limitations confining all research to in vitro analysis of ABC transporters in detergent solutions or embedded in membrane‐mimicking environments. Therefore, a largely unanswered question is how ABC exporters operate in situ, namely in the native membrane context of a metabolically active cell. This review focuses on novel mechanistic insights into type I ABC exporters gained through a unique combination of structure determination, biochemical characterization, generation of conformation‐specific nanobodies/sybodies and double electron–electron resonance.
Monte Carlo simulation of 6‐MV dynamic wave VMAT deliveries by Vero4DRT linear accelerator using EGSnrc moving sources
Authors: Rostamzadeh Maryam , Ishihara Yoshitomo , Nakamura Mitsuhiro , Popescu I. Antoniu , Mestrovic Ante , Gete Ermias , Fedrigo Roberto , Bergman Alanah Mary 
Published: November 2020

AbstractThe commissioning and benchmark of a Monte Carlo (MC) model of the 6‐MV Brainlab‐Mitsubishi Vero4DRT linear accelerator for the purpose of quality assurance of clinical dynamic wave arc (DWA) treatment plans is reported. Open‐source MC applications based on EGSnrc particle transport codes are used to simulate the medical linear accelerator head components. Complex radiotherapy irradiations can be simulated in a single MC run using a shared library format combined with BEAMnrc “source20.” Electron energy tuning is achieved by comparing measured vs simulated percentage depth doses (PDDs) for MLC‐defined field sizes in a water phantom. Electron spot size tuning is achieved by comparing measured and simulated inplane and crossplane beam profiles. DWA treatment plans generated from RayStation (RaySearch) treatment planning system (TPS) are simulated on voxelized (2.5 mm3) patient CT datasets. Planning target volume (PTV) and organs at risk (OAR) dose–volume histograms (DVHs) are compared to TPS‐calculated doses for clinically deliverable dynamic volumetric modulated arc therapy (VMAT) trajectories. MC simulations with an electron beam energy of 5.9 MeV and spot size FWHM of 1.9 mm had the closest agreement with measurement. DWA beam deliveries simulated on patient CT datasets results in DVH agreement with TPS‐calculated doses. PTV coverage agreed within 0.1% and OAR max doses (to 0.035 cc volume) agreed within 1 Gy. This MC model can be used as an independent dose calculation from the TPS and as a quality assurance tool for complex, dynamic radiotherapy treatment deliveries. Full patient CT treatment simulations are performed in a single Monte Carlo run in 23 min. Simulations are run in parallel using the Condor High‐Throughput Computing software1 on a cluster of eight servers. Each server has two physical processors (Intel Xeon CPU E5‐2650 0 @2.00 GHz), with 8 cores per CPU and two threads per core for 256 calculation nodes.
Neuropsychiatric comorbidities in Huntington’s and Parkinson’s Disease: A United States claims database analysis
Authors: Ishihara Lianna , Oliveri David , Wild Edward J. 
Published: November 2020

AbstractObjectiveHuntington’s disease is a rare, genetic, neurodegenerative disease characterized by a triad of cognitive, behavioral, and motor symptoms. The condition gradually results in increasing disability, loss of independence, and ultimately death. Our objective was to use United States claims data (which offer valuable insight into the natural history of disease) to compare the prevalent comorbidities of people with Huntington’s disease against matched controls with Parkinson’s disease or with no major neurodegenerative diseases (general population controls). We also assess medication use in people with Huntington’s disease.MethodsThis was a retrospective, observational study using data from the IBM MarketScan® Databases. Cases and controls were matched 1:1, and comorbidities were analyzed in each group during 2017. Medications were also assessed in the Huntington’s disease cohort. Eligible cases had ≥ 2 diagnostic codes for Huntington’s disease; controls had ≥ 2 codes for Parkinson’s disease (with no record of Huntington’s disease), or, for general population controls, no record of Huntington’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, or dementia.ResultsA total of 587 matched individuals were assessed in each cohort. Depression and anxiety were more common in Huntington’s disease versus Parkinson’s disease (odds ratios: 1.51 and 1.16, respectively). Other conditions more common in Huntington’s disease included dementia, communication/speech problems, dysphagia, and falls. The use of antidepressant (59.9%) and antipsychotic (39.5%) medications was frequent among Huntington’s disease cases.InterpretationThese data highlight the prevalence of psychiatric, cognitive, communication, swallowing, and mobility problems in people with Huntington’s disease, underscoring the need for holistic expert care of these individuals.
Synthesis of Metallocene Analogues of the Phenethylamine and Tetrahydroisoquinoline Scaffolds via Regioselective Ring Opening of 2‐Aryl‐N‐sulfonyl Aziridines
Authors: González‐Pelayo Silvia , Bernardo Olaya , Borge Javier , López Luis A. 
Published: November 2020

AbstractThe Lewis (or Brønsted) acid‐catalyzed reaction of 2‐aryl‐N‐sulfonyl aziridines with ferrocene and ruthenocene provided new amino‐functionalized metallocene derivatives arising from a regioselective ring opening of the aziridine. The functionalized metallocene derivatives available by this methodology are suitable precursors for the stereoselective synthesis of metallocene analogues of the relevant tetrahydroisoquinoline motif by a Pictet‐Spengler type reaction. These isoquinoline analogues are also accessible by a TfOH‐catalyzed three‐component reaction of 2‐aryl‐N‐sulfonyl aziridines, ferrocene (or ruthenocene) and formaldehyde.magnified image
Small herbaria contribute unique biogeographic records to county, locality, and temporal scales
Authors: Marsico Travis D. , Krimmel Erica R. , Carter J. Richard , Gillespie Emily L. , Lowe Phillip D. , McCauley Ross , Morris Ashley B. , Nelson Gil , Smith Michelle , Soteropoulos Diana L. , Monfils Anna K. 
Published: November 2020

PremiseWith digitization and data sharing initiatives underway over the last 15 years, an important need has been prioritizing specimens to digitize. Because duplicate specimens are shared among herbaria in exchange and gift programs, we investigated the extent to which unique biogeographic data are held in small herbaria vs. these data being redundant with those held by larger institutions. We evaluated the unique specimen contributions that small herbaria make to biogeographic understanding at county, locality, and temporal scales.MethodsWe sampled herbarium specimens of 40 plant taxa from each of eight states of the United States of America in four broad status categories: extremely rare, very rare, common native, and introduced. We gathered geographic information from specimens held by large (≥100,000 specimens) and small (<100,000 specimens) herbaria. We built generalized linear mixed models to assess which features of the collections may best predict unique contributions of herbaria and used an Akaike information criterion‐based information‐theoretic approach for our model selection to choose the best model for each scale.ResultsSmall herbaria contributed unique specimens at all scales in proportion with their contribution of specimens to our data set. The best models for all scales were the full models that included the factors of species status and herbarium size when accounting for state as a random variable.ConclusionsWe demonstrated that small herbaria contribute unique information for research. It is clear that unique contributions cannot be predicted based on herbarium size alone. We must prioritize digitization and data sharing from herbaria of all sizes.
4D‐Printing of Photoswitchable Actuators
Authors: Lu Xili , Ambulo Cedric P. , Wang Suitu , Rivera‐Tarazona Laura K. , Kim Hyun , Searles Kyle , Ware Taylor H. 
Published: November 2020

AbstractShape‐switching behavior, where a transient stimulus induces an indefinitely stable deformation that can be recovered on exposure to another transient stimulus, is critical to building smart structures from responsive polymers as continue power is not needed to maintain deformations. Herein, we 4D‐print shape‐switching liquid crystalline elastomers (LCEs) functionalized with supramolecular crosslinks, dynamic covalent crosslinks, and azobenzene. The salient property of shape‐switching LCEs is that light induces long‐lived, deformation that can be recovered on‐demand by heating. UV‐light isomerizes azobenzene from trans to cis, and temporarily breaks the supramolecular crosslinks, resulting in a programmed deformation. After UV, the shape‐switching LCEs fix more than 90 % of the deformation over 3 days by the reformed supramolecular crosslinks. Using the shape‐switching properties, we print Braille‐like actuators that can be photoswitched to display different letters. This new class of photoswitchable actuators may impact applications such as deployable devices where continuous application of power is impractical.