bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Sum Score to Define Therapy-Refractory Myasthenia Gravis: A German Consensus
Authors: Schroeter Michael , Berger Benjamin , Blaes Franz , Hagenacker Tim , Jander Sebastian , Kaiser Julia , Kalischewski Petra , Lee De-Hyung , Ruck Tobias , Schara Ulrike , Urban Peter , Meisel Andreas 
Published: February 2021

Background and purpose: In 2017, eculizumab has been approved for treatment-refractory generalised myasthenia gravis (TRgMG). The German Myasthenia Foundation has published a consensus statement on the use of eculizumab, with a recent update. However, a treatment-refractory state is still ill-defined and the term warrants further clarification. We aimed at developing a sum score to operationalise the definition of a TRgMG status, which is easy- to-handle in clinical decision making. Methods: We established a structured consensus process according to the Delphi consensus methodology, with 12 members of the medical advisory board of the German Myasthenia Foundation. Accordingly, 4 consensus rounds were accomplished. Additionally, a literature survey covering the years 2004-2020 was done and relevant information offered to the consensus group. Consensus criteria were predefined. In the consensus process the relative importance of scoring items were to be consented, with a sum score of 20 and above indicating a TRgMG status. Results: The sum score considers the categories disease severity, inefficiency of antecedent therapies, cessation of therapies due to side effects, and long term stay on the intensive care unit. Categories were specified by a total of 13 scoring items. Eventually, the Delphi process developed an unanimous scoring consensus. Conclusion: We suggest a sum score to define treatment refractory state in generalised myasthenia gravis. Beyond clarifying the indication of eculizumab, this easy-to-handle score facilitates clinical decision making and offers new inclusion criteria for clinical studies that explore new therapeutic perspectives in myasthenia gravis treatment.
Stroke case fatality in sub-Saharan Africa: Systematic review and meta-analysis
Authors: Adoukonou Thierry , Kossi Oyéné , Fotso Mefo Pervenche , Agbétou Mendinatou , Magne Julien , Gbaguidi Glwadys , Houinato Dismand , Preux Pierre-Marie , Lacroix Philippe 
Published: February 2021

Background The burden of stroke is high in sub-Saharan Africa; however, few data are available on long-term mortality. Objective To estimate over one-month stroke case fatality in sub-Saharan Africa. Methods A systematic review and meta-analysis were performed according to meta-analysis of observational studies in epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO protocol: CRD42020192439), on five electronic databases (PubMed, Science direct, AJOL, EMBASE, and Web of Sciences). We searched all studies on stroke case fatality over one month in sub-Saharan Africa published between 1st January 2000 and 31st December 2019. Results We included 91 studies with a total of 34,362 stroke cases. The one-month pooled stroke case-fatality rate was 24.1% [95% CI: 21.5–27.0] and 33.2% [95% CI: 23.6–44.5] at one year. At three and five years, the case-fatality rates were respectively 40.1% [95% CI: 20.8–63.0] and 39.4% [95% CI: 14.3–71.5] with high heterogeneity. Hemorrhagic stroke was associated with a higher risk of mortality at one month, but ischemic stroke increased the risk of mortality over six months. Diabetes was associated with poor prognosis at 6 and 12 months with odds ratios of 1.64 [95% CI: 1.22–2.20] and 1.85 [1.25–2.75], respectively. Conclusion The stroke case fatality over one month was very high, compared to case fatalities reported in Western countries and can be explained by a weak healthcare systems and vascular risk factors.
A Review of the Collagen Orientation in the Articular Cartilage
Authors: Bloebaum Roy D. , Wilson Andrew S. , Martin William N. 
Published: February 2021

Objective There has been a debate as to the alignment of the collagen fibers. Using a hand lens, Sir William Hunter demonstrated that the collagen fibers ran perpendicular and later aspects were supported by Benninghoff. Despite these 2 historical studies, modern technology has conflicting data on the collagen alignment. Design Ten mature New Zealand rabbits were used to obtain 40 condyle specimens. The specimens were passed through ascending grades of alcohol, subjected to critical point drying (CPD), and viewed in the scanning electron microscope. Specimens revealed splits from the dehydration process. When observing the fibers exposed within the opening of the splits, parallel fibers were observed to run in a radial direction, normal to the surface of the articular cartilage, radiating from the deep zone and arcading as they approach the surface layer. After these observations, the same samples were mechanically fractured and damaged by scalpel. Results The splits in the articular surface created deep fissures, exposing parallel bundles of collagen fibers, radiating from the deep zone and arcading as they approach the surface layer. On higher magnification, individual fibers were observed to run parallel to one another, traversing radially toward the surface of the articular cartilage and arcading. Mechanical fracturing and scalpel damage induced on the same specimens with the splits showed randomly oriented fibers. Conclusion Collagen fiber orientation corroborates aspects of Hunter’s findings and compliments Benninghoff. Investigators must be aware of the limits of their processing and imaging techniques in order to interpret collagen fiber orientation in cartilage.
Addressing Anxiety and Fear during the Female Pelvic Examination
Authors: O’Laughlin Danielle J. , Strelow Brittany , Fellows Nicole , Kelsey Elizabeth , Peters Sonya , Stevens Joy , Tweedy Johanna 
Published: February 2021

To review the anxiety and fear risk factors, pathophysiology, symptoms, screening and diagnosis while highlighting treatment considerations for women undergoing a pelvic examination. Methods: We reviewed the literature pertaining to anxiety and fear surrounding the pelvic examination to help guide health care providers’ on available screening options and to review options for individualized patient management. Results: Anxiety and fear are common before and during the pelvic examination. In fact, the pelvic exam is one of the most common anxiety-provoking medical procedures. This exam can provoke negative physical and emotional symptoms such as pain, discomfort, anxiety, fear, embarrassment, and irritability. These negative symptoms can interfere with preventative health screening compliance resulting in delayed or avoided care and significant health consequences. Conclusion: Assessing women for anxiety related to pelvic examinations may help decrease a delay or avoidance of examinations. Risk factor and symptom identification is also a key component in this. General anxiety questionnaires can help identify women with anxiety related to pelvic examinations. Strategies to reduce anxiety, fear and pain during a pelvic examination should routinely be implemented, particularly in women with high-risk factors or those identified with screening techniques as having anxiety, fear or pain with examinations. Treatment options should be targeted at understanding the patient’s concerns, starting conversations about pelvic examinations early, educating patient’s about the examination and offering the presence of a chaperone or support person. During an examination providers should ensure the patient is comfortable, negative phrases are avoided, the correct speculum size is utilized and proper lubrication, draping, dressing and positioning are performed. Treating underlying gynecologic or mental health conditions, consideration of cognitive behavioral therapy and complementary techniques such as lavender aromatherapy and music therapy should also be considered when appropriate.
Interbundle Impingement Pressure in Individualized and Nonindividualized Double-Bundle Anterior Cruciate Ligament Reconstruction: A Cadaveric Study
Authors: Wu Bing , Liang Daqiang , Yang Lei , Li Sheng , Qiu Zhihe , Qin Qihuang , Liang Xinzhi , Liu Haifeng , Ouyang Kan , Xiong Jianyi , Wang Daping , Lu Wei , Zhong Mingjin , Li Ying , Li Hao , Feng Wenzhe , Chen Kang , Peng Liangquan , Zhu Weiming 
Published: February 2021

Background: Graft impingement is one of the main concerns in double-bundle anterior cruciate ligament reconstruction (DB-ACLR). Impingement between the anteromedial (AM) and posterolateral (PL) bundles has been postulated to cause graft deterioration or rerupture, but this has not been thoroughly investigated, and the interbundle impingement pressure (IIP) has not been well researched. Purpose: To determine the IIP between the AM and PL bundles in the native anterior cruciate ligament (ACL) and in DB-ACLR with individualized and nonindividualized double-tunnel placement. Study Design: Controlled laboratory study. Methods: A total of 30 fresh-frozen, nonpaired, human cadaveric knees were randomly divided into 3 groups of 10 knees: native intact ACL (NI group), DB-ACLR tunnel placement using the preserved remnant procedure (individualized reconstruction) (PR group), and DB-ACLR tunnel placement using the bony landmark procedure (nonindividualized reconstruction) (BL group). Pressure sensors were inserted between the AM and PL bundles. The knee was moved passively from full extension to full flexion, and the IIP between the 2 ACL bundles was measured every 15°. Similarly, the impingement pressure was measured between the ACL and intercondylar roof and between the ACL and posterior cruciate ligament (PCL). Results: No significant differences were found in the maximum, mean, or minimum ACL-roof and ACL-PCL impingement pressures among the 3 groups. The IIP significantly increased when the knee joint was flexed >120° in all 3 groups ( P < .001). Compared with the other 2 groups, the BL group had significantly higher maximum and mean IIP throughout the range of knee movement ( P < .001) and from maximum extension to 120° of flexion ( P < .001). The BL group also had significantly higher minimum IIP than the other 2 groups when knee flexion was >120° ( P < .001). No significant differences were seen in maximum, minimum, or mean IIP between the NI and PR groups. Conclusion: The PR procedure (individualized DB-ACLR) was more consistent with the interbundle biomechanical conditions of the native ACL, whereas the BL procedure (nonindividualized DB-ACLR) had higher maximum and mean IIP. The IIP was higher than the ACL–intercondylar roof or ACL-PCL pressures, and it increased significantly when knee flexion was >120°. Clinical Relevance: These data suggest that surgeons can perform individualized DB-ACLR using preserved remnants for tunnel placement as impingement-free DB-ACLR.
Restoring RUNX1 deficiency in RUNX1 familial platelet disorder by inhibiting its degradation
Authors: Krutein Michelle C. , Hart Matthew R. , Anderson Donovan J. , Jeffery Jasmin , Kotini Andriana G. , Dai Jin , Chien Sylvia , DelPriore Michaela , Borst Sara , Maguire Jean Ann , French Deborah L. , Gadue Paul , Papapetrou Eirini P. , Keel Siobán B. , Becker Pamela S. , Horwitz Marshall S. 
Published: February 2021

Abstract
RUNX1 familial platelet disorder (RUNX1-FPD) is an autosomal dominant disorder caused by a monoallelic mutation of RUNX1, initially resulting in approximately half-normal RUNX1 activity. Clinical features include thrombocytopenia, platelet functional defects, and a predisposition to leukemia. RUNX1 is rapidly degraded through the ubiquitin-proteasome pathway. Moreover, it may autoregulate its expression. A predicted kinetic property of autoregulatory circuits is that transient perturbations of steady-state levels result in continued maintenance of expression at adjusted levels, even after inhibitors of degradation or inducers of transcription are withdrawn, suggesting that transient inhibition of RUNX1 degradation may have prolonged effects. We hypothesized that pharmacological inhibition of RUNX1 protein degradation could normalize RUNX1 protein levels, restore the number of platelets and their function, and potentially delay or prevent malignant transformation. In this study, we evaluated cell lines, induced pluripotent stem cells derived from patients with RUNX1-FPD, RUNX1-FPD primary bone marrow cells, and acute myeloid leukemia blood cells from patients with RUNX1 mutations. The results showed that, in some circumstances, transient expression of exogenous RUNX1 or inhibition of steps leading to RUNX1 ubiquitylation and proteasomal degradation restored RUNX1 levels, thereby advancing megakaryocytic differentiation in vitro. Thus, drugs retarding RUNX1 proteolytic degradation may represent a therapeutic avenue for treating bleeding complications and preventing leukemia in RUNX1-FPD.
Index of microcirculatory resistance predicts long term cardiac systolic function in patients with STEMI undergoing primary PCI
Authors: Qi Yu , Gu Rong , Xu Jiamin , Kang Lina , Liu Yihai , Wang Lian , Chen Jianzhou , Zhang Jingmei , Wang Kun 
Published: February 2021

Abstract
Background
To evaluate the predictive value of the index of microcirculatory resistance (IMR) for long-term cardiac systolic function after primary percutaneous coronary intervention (pPCI) in patients with acute anterior wall ST-segment elevation myocardial infarction (STEMI).

Methods
A total of 53 acute anterior wall STEMI patients were included and followed up within 1-year. IMR was measured to evaluate the immediate intraoperative reperfusion. IMR > 40 U was defined as the high IMR group and ≤ 40 U was defined as the low IMR group. Left ventricular ejection fraction (LVEF) was measured by echocardiography at 24 h, 1 month, 3 months, and 1 year after PCI to analyze the correlation between IMR and cardiac systolic function. Heart failure was estimated according to classification within one year.

Results
The ratio of TMPG (TIMI myocardial perfusion grade) 3 (85.7% vs. 52%, p = 0.015) and STR (ST-segment resolution) > 70% (82.1% vs. 48%, p = 0.019) were significantly higher in the low IMR group. The LVEF in the low IMR group was significantly higher than that in the high IMR group at 3 months (43.06 ± 2.63% vs. 40.20 ± 2.67%, p < 0.001) and 1 year (44.16 ± 2.40% vs. 40.13 ± 3.48%, p < 0.001). IMR was negatively correlated with LVEF at 3 months (r = − 0.1014, p = 0.0040) and 1 year (r = − 0.1754, p < 0.0001).

Conclusions
The IMR showed significant negative correlation with the LVEF value after primary PCI. The high IMR is a strong predictor of heart failure within 1 year after anterior myocardial infarction.
Effect of remote online exam delivery on student experience and performance in applied knowledge tests
Authors: Jaap Alan , Dewar Avril , Duncan Colin , Fairhurst Karen , Hope David , Kluth David 
Published: February 2021

AbstractBackgroundThe use of remote online delivery of summative assessments has been underexplored in medical education. Due to the COVID-19 pandemic, all end of year applied knowledge multiple choice question (MCQ) tests at one UK medical school were switched from on campus to remote assessments.MethodsWe conducted an online survey of student experience with remote exam delivery and compared test performance in remote versus invigilated campus-based forms of similar assessments for Year 4 and 5 students across two academic years.ResultsVery few students experienced technical or practical problems in completing their exam remotely. Test anxiety was reduced for some students but increased for others. The majority of students preferred the traditional setting of invigilated exams in a computer lab, feeling this ensured an even playing field for all candidates. Mean score was higher for Year 4 students in the remotely-delivered versus campus-based form of the same exam (76.53% [SD 6.57] vs. 72.81% [6.64];t438.38 = 5.94,p = 0.001;d = 0.56), whereas candidate performance was equivalent across both forms for Year 5 students.ConclusionsRemote online MCQ exam delivery is an effective and generally acceptable approach to summative assessment, and could be used again in future without detriment to students if onsite delivery is not possible.
The effect of salinity on Enterocytozoon hepatopenaei infection in Penaeus vannamei under experimental conditions
Authors: Aranguren Caro L. F. , Alghamdi F. , De Belder K. , Lin J. , Mai H. N. , Millabas J. , Alrehaili Y. , Alazwari A. , Algetham S. , Dhar A. K. 
Published: February 2021

Abstract
Background
Enterocytozoon hepatopenaei (EHP) is an enteric pathogen that affects Penaeus vannamei and Penaeus monodon shrimp in many SE Asian countries. In the western hemisphere, EHP was reported for the first time in 2016 in farmed P. vannamei in Venezuela. Anecdotal evidence suggests that EHP is more prevalent in grow-out ponds where the salinity is high (> 15 parts per thousand (ppt)) compared to grow-out ponds with low salinities (< 5 ppt). Considering that P. vannamei is an euryhaline species, we were interested in knowing if EHP can propagate in P. vannamei in low salinities.

Results
In this study, we described an experimental infection using fecal strings as a source inoculum. Specific Pathogen Free (SPF) P. vannamei were maintained at three different salinities (2 ppt, 15 ppt, and 30 ppt) while continuously challenged using feces from known EHP-infected P. vannamei over a period of 3 weeks. The fecal strings, used as a source of EHP inocula in the challenges, was sufficient to elicit an infection in shrimp maintained at the three salinities. The infectivity of EHP in shrimp reared at 2 ppt, 15 ppt, and 30 ppt salinities was confirmed by PCR and histopathology. The prevalence and the severity of the EHP infection was higher at 30 ppt than at 2 ppt and 15 ppt.

Conclusion
The data suggests that fecal strings are a reliable source of EHP inoculum to conduct experimental challenges via the fecal-oral route. An EHP infection can occur at a salinity as low as 2 ppt, however, the prevalence and the severity of the EHP infection is higher at a salinity of 30 ppt.
Chiropractic students’ cognitive dissonance to statements about professional identity, role, setting and future: international perspectives from a secondary analysis of pooled data
Authors: Swain Michael S. , Gliedt Jordan A. , de Luca Katie , Newell Dave , Holmes Michelle 
Published: February 2021

Abstract
Background
Chiropractic students demonstrate philosophically opposing views about the chiropractic profession. The primary aim was to describe chiropractic students’ responses to statements about chiropractic identity, role, setting, and future direction. A secondary aim was to describe the frequency of internally conflicting responses.

Methods
Three datasets from Europe, North America, and Australia/New Zealand were pooled in a secondary data analysis. Chiropractic students from 25 chiropractic training institutions completed interrelating surveys (combined response rate 21.9%) between 2013 and 2018. The survey instrument investigated student viewpoints about chiropractic professional identity, role, practice setting and future direction of chiropractic practice. Student attitudes about chiropractic were described using weighted proportions to adjust for unequal population sampling across the three geographical regions. The frequency of concordant and discordant student responses was described by combining identity items with items that explored responses about practice role, setting and future direction. The relationship between student characteristics (age, sex, education, association membership and geographical region) and ideologically conflicting responses were assessed using the Chi-squared test and Cramér’s V.

Results
Data from 2396 student chiropractors (50.8% female; from Europe 36.2%, North America 49.6% and Australia/New Zealand 14.5%) were analysed. For identity, nearly half of the chiropractic students (weighted 45.1%) agreed that it is important for chiropractors to hold strongly to the traditional chiropractic theory that adjusting the spine corrects “dis-ease” and agreed (weighted 55.5%) that contemporary and evolving scientific evidence is more important than traditional chiropractic principles. The frequency of discordant (ideologically conflicting) student responses ranged from 32.5% for statements about identity versus role, to 51.4% for statements about identity versus future. There was no association between student age, sex and internally conflicting responses. Chiropractic students’ professional association membership status, pre-chiropractic education and geographical region were associated with ideologically conflicting responses.

Conclusions
Chiropractic students in this analysis show traditional and progressive attitudes towards the chiropractic profession. Individual student responses frequently contradict in terms of professional ideology, but most (approximately half) students demonstrate concordant progressive and mainstream attitudes. Ideological conflict may raise concerns about some students’ ability to learn and make clinical judgements, and potential for disharmony in the chiropractic fraternity.
The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study
Authors: He Qiao , Wang Wen , Zhu Shichao , Wang Mingqi , Kang Yan , Zhang Rui , Zou Kang , Zong Zhiyong , Sun Xin 
Published: February 2021

Abstract
Background
Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection (HAI) in intensive care units (ICUs). Ventilator-associated event (VAE), a more objective definition, has replaced traditional VAP surveillance and is now widely used in the USA. However, the adoption outside the USA is limited. This study aims to describe the epidemiology and clinical outcomes of VAEs in China, based on a prospectively maintained registry.

Methods
An observational study was conducted using an ICU-HAI registry in west China. Patients that were admitted to ICUs and underwent mechanical ventilation (MV) between April 1, 2015, and December 31, 2018, were included. The characteristics and outcomes were compared between patients with and without VAEs. The rates of all VAEs dependent on different ICUs were calculated, and the pathogen distribution of patients with possible VAP (PVAP) was described.

Results
A total of 20,769 ICU patients received MV, accounting for 21,723 episodes of mechanical ventilators and 112,697 ventilator-days. In all, we identified 1882 episodes of ventilator-associated condition (VAC) events (16.7 per 1000 ventilator-days), 721 episodes of infection-related ventilator-associated complications (IVAC) events (6.4 per 1000 ventilator-days), and 185 episodes of PVAP events (1.64 per 1000 ventilator-days). The rates of VAC varied across ICUs with the highest incidence in surgical ICUs (23.72 per 1000 ventilator-days). The median time from the start of ventilation to the onset of the first VAC, IVAC, and PVAP was 5 (3–8), 5 (3–9), and 6 (4–13) days, respectively. The median length of hospital stays was 28.00 (17.00–43.00), 30.00 (19.00–44.00), and 30.00 (21.00–46.00) days for the three VAE tiers, which were all longer than that of patients without VAEs (16.00 [12.00–23.00]). The hospital mortality among patients with VAEs was more than three times of those with non-VAEs.

Conclusions
VAE was common in ICU patients with ≥ 4 ventilator days. All tiers of VAEs were highly correlated with poor clinical outcomes, including longer ICU and hospital stays and increased risk of mortality. These findings highlight the importance of VAE surveillance and the development of new strategies to prevent VAEs.