bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Physician–Investigator Workforce: Looking Ahead
Authors: Andriole Dorothy A. , Wolfson Rachel K. 
Published: January 2021

Support of the U.S. health professions investigator workforce is critically important to the continued advancement of health care nationally. Physician–investigators comprise one segment of this health professions investigator workforce, which also includes investigators in the nursing, pharmacy, and dentistry professions, and others. Among physician health professionals in particular, the term “physician–investigator” has been described as encompassing physicians engaged in research in various ways including “clinical researchers” (physicians with clinical duties who do clinical, patient-centered research), “clinician–scientists” (physicians with clinical roles who perform research in laboratories or using computational tools), and “physician–scientists” (physicians focused on research with little or no clinical activity). Broadly defined, physician–investigators are included in various groups of researchers described in several articles recently published in Academic Medicine; these articles provide details on a range of approaches, with supporting outcomes data, being taken to train, support, and retain physicians in the health professions investigator workforce.
The authors of this commentary examine selected literature, including several articles in this issue among others, along with Association of American Medical Colleges data, to offer observations about programs that train physician–investigators. Evidence-informed single-program approaches for early-career researchers can sustain continued research interest and foster the career development of the emerging physician–investigator workforce. Collaborative multi-institutional approaches offer the benefit of multisite work to power outcomes studies and to increase generalizability beyond a specific institutional program. System-wide institutional approaches may be particularly critical in supporting physician–investigators across all career stages. Although the articles discussed in this commentary are largely (although not exclusively) focused on various initiatives and programs designed to develop and sustain the physician–investigator workforce, such initiatives and programs may have value in addressing shared challenges of developing, supporting, and retaining the broader investigator workforce across all health professions.
Surgical Site Infection Following Primary Definitive Fusion for Pediatric Spinal Deformity
Authors: Watanabe Kei , Yamaguchi Toru , Suzuki Satoshi , Suzuki Teppei , Nakayama Keita , Demura Satoru , Taniguchi Yuki , Yamamoto Takuya , Sugawara Ryo , Sato Tatsuya , Fujiwara Kenta , Murakami Hideki , Akazawa Tsutomu , Kakutani Kenichiro , Hirano Toru , Yanagida Haruhisa , Watanabe Kota , Matsumoto Morio , Uno Koki , Kotani Toshiaki , Takeshita Katsushi , Ohara Tetsuya , Kawakami Noriaki 
Published: January 2021

Study Design.
A retrospective multicenter study.

Objective.
To determine the surgical site infection (SSI) rate, associated risk factors, and causative pathogens in pediatric patients with spinal deformity.

Summary of Background Data.
There have been no extensive investigations of the risk factors for SSI in Japan.

Methods.
Demographic data, radiographic findings, and the incidence of SSI were retrospectively analyzed in 1449 pediatric patients who underwent primary definitive fusion surgery for spinal deformity at any of 15 institutions from 2015 to 2017. SSI was defined according to the US Centers for Disease Control and Prevention guideline.

Results.
The incidence of all SSIs was 1.4% and that of deep SSIs was 0.76%. The most common pathogenic microbes were methicillin-resistant staphylococci (n = 5) followed by gram-negative rods (n = 4), methicillin-sensitive staphylococci (n = 1), and others (n = 10). In univariate analysis, younger age, male sex, a diagnosis of kyphosis, type of scoliosis, American Society of Anesthesiologists (ASA) class ≥3, mental retardation urinary incontinence, combined anterior-posterior fusion, greater magnitude of kyphosis, three-column osteotomy, use of blood transfusion, and number of antibiotic administration were associated with the likelihood of SSI (all P < 0.05). Multivariate logistic regression analysis identified the following independent risk factors for SSI: syndromic scoliosis etiology (vs. idiopathic scoliosis; adjusted odds ratio [OR] 16.106; 95% confidence interval [CI] 2.225–116.602), neuromuscular scoliosis etiology (vs. idiopathic scoliosis; adjusted OR 11.814; 95% CI 1.109–125.805), ASA class 3 (vs. class 2; adjusted OR 15.231; 95% CI 1.201–193.178), and administration of antibiotic therapy twice daily (vs. three times daily; adjusted OR 6.121; 95% CI 1.261–29.718).

Conclusion.
The overall infection rate was low. The most common causative bacteria were methicillin-resistant followed by gram-negative rods. Independent risk factors for SSI in pediatric patients undergoing spinal deformity surgery were scoliosis etiology, ASA class 3, and administration of antibiotic therapy twice daily.

Level of Evidence: 3
Physical Functioning in Adolescents with Idiopathic Scoliosis
Authors: Alamrani Samia , Rushton Alison B. , Gardner Adrian , Bini Elena , Falla Deborah , Heneghan Nicola R. 
Published: January 2021

Study Design.
A systematic review.

Objective.
To summarize evidence on measurement properties of Outcome Measures (OM) used to assess physical functioning in adolescents with idiopathic scoliosis (AIS).

Summary of Background Data.
The AIS is a common spine deformity in those aged 10 to 18 years old. Associated health problems (e.g., back pain) significantly impact the quality of life (QoL). One important domain in QoL is physical functioning, which can be measured with patient-reported outcome measures (PROM), performance-based outcome measures (PBOM), and body structure and function OM. Adequate measurement properties of OM are important for precision in research and practice.

Methods.
A two-staged search strategy was performed on electronic databases up to December 2019. Search one revealed a list of OM was used for physical functioning assessment in AIS. Search two identified studies that evaluated the measurement properties of OM in AIS; using the list identified in search one. Two independent reviewers determined study eligibility, risk of bias assessment (COnsensus-based Standards for the selection of health Measurement INstruments [COSMIN] checklist), and performed data extraction. The level of evidence was established using a modified GRADE approach.

Results.
Search one yielded: 28 PROM, 20 PBOM, and 10 body structure and function OM. Search two revealed: 16 measurement properties studies for PROM, one for PBOM, and three for body structure and function measures. Construct validity, reliability, and responsiveness of most PROM has been established in AIS, but not content validity or internal consistency (moderate evidence). Construct validity was sufficient for the Timed Up and Go test and body structure and function measures (very low to low evidence).

Conclusion.
Currently, physical functioning is evaluated with a variety of measures in AIS. The majority of measurement properties studies evaluated PROM with a paucity of information on measurement properties of PBOM and body structure and function OM. Based on COSMIN methodology, none of the OM identified in this review can be recommended with confidence in individuals with AIS.

Level of Evidence: 2
Significant Sleep Dysregulation in a Toddler With Developmental Delay
Authors: Stein Martin T. , Owens Judith , Abbott Myles 
Published: January 2021

CASE:
Derrick's parents made an appointment with a new pediatrician for a second opinion about disordered sleep. Now 22-months old, he was evaluated at 18 months of age for developmental delay when he was found to have “a regulatory disorder associated with delays in language and motor development, hypotonia and significant sleep problems.” The parents are now most concerned about his sleeping pattern. Prolonged sleep onset and frequent night awaking occur each night since 6-months of age. These problems are more severe in the past few months when he awakes screaming and cannot be settled. The awakening episodes occur 2 to 4 times each night when “he screams and thrashes his body for up to an hour.” Daytime tantrums increased. After the parents read a book about sleep in young children, they provided a calm atmosphere at bedtime including a dark room and singing a quiet lullaby. When these changes did not alter sleep, they purchased a vibrating mattress which was also unsuccessful.
Derrick was born full term after an uncomplicated prenatal and perinatal course. He sat at 10 months, crawled at 12 months, and walked at 18 months. He currently drinks from a sippy cup and he can use a utensil to eat. He has few words saying only “no” and “mama” in the past month. Imitation of some words occurred recently. He has responded to simple directions in the past 2 months. Derrick passed the newborn audiology screen. He does not have difficulty swallowing and he does not drool. He plays with many different toys and he plays in parallel with his older brother who also experienced delays in motor and language development. His brother is now doing very well in school. There is no family history of cognitive delay, seizure disorder, cerebral palsy, early developmental delay (other than the brother) or a significant sleep problem.

Physical examination:
head circumference, length and weight (75th percentile). He had mild generalized hypotonia, mild weakness, 2+ symmetrical deep tendon reflexes, and absence of ankle clonus. His gait was slightly wide based, steady, and without a limp. Neither ataxia nor drooling was observed. He was easily engaged in play with the examiner without evidence of irritability. The remainder of the examination was normal.
Can a Pediatrician Effectively Treat a 9-Year-Old Obese Girl?
Authors: Rhee Kyung (Kay) , Boutelle Kerri , McKenna Matthew , Stein Martin T. 
Published: January 2021

CASE:
Maria is a 9-year-old Latina girl who was followed up by her pediatrician since birth with normal developmental milestones, good school achievement, and without significant medical problems. She was not in the pediatric office for the past 3 years. At the age of 9 years, she presented for a health supervision visit. Her pediatrician looked at her growth chart-90 pounds (95th percentile) and height 52 inches (50th percentile)-that confirmed a clinical impression of obesity on physical examination. Her body mass index was 23.4 (>95th percentile for age).
During 10 years in primary care pediatric practice, the pediatrician typically prescribed a management plan for obese school-aged and adolescent patients that started with parent and child education about potential health problems associated with obesity followed by a recommendation to decrease the caloric intake and encourage active exercise each day. She then arranged for follow-up visits to monitor weight and adherence to the management plan. However, a moment of self-refection suggested that most of her patients did not follow her advice in a sustained way. Obesity persisted in most cases. The pediatrician wondered if there was an alternative-better yet, evidence-based—approach to pediatric obesity that might provide a better outcome.
Sudden Onset of Refusal to Eat on Waking After a Nightmare in a 6-Year-Old Girl
Authors: Zaccagnino Maria , Gahagan Sheila , Spencer Andrea , Jellinek Michael , Stein Martin T. 
Published: January 2021

CASE:
Bridgette is a 6-year-old girl, who presented with sudden onset of refusal to eat or drink. The only precipitating event was a nightmare the previous night. She described a dream in which her mother and maternal aunt, dressed as witches, and father and maternal uncle, appearing as bats, wanted to kill her by making her eat and drink from a cauldron. Bridgette stated, “I can't eat anymore, I'm afraid of dying.” Bridgette's eating pattern and behavior were described as previously normal. Motor, social, and language milestones were also normal. Her parents reported that she occasionally refused nonpreferred foods, and they believed that her food intake had decreased at age 4 years. She was a full-term infant without perinatal problems and breast fed until 8 months. Her medical history was significant for strabismus surgery, before 6 months. Her mental health history revealed mildly depressed mood and irritability related to teasing at school after her strabismus surgery. Her parents described her as “always looking for attention.” Her teachers reported that she had normal intelligenceand described her behavior as shy, slightly withdrawn, and distrustful. Social history revealed an only child of married parents without marital or work-related problems. Bridgette went to her maternal grandmother's home after school and during school holidays.
Her parents pleaded with her to eat, but she refused. She was evaluated at urgent care where her physical examination was described as normal. Her body mass index was above the 97th percentile (3 SD above the mean). The parents were described as fearful and despairing. Laboratory tests included a complete blood count with differential, an electroencephalogram, and a computed tomography scan, all of which were normal. Intravenous fluids were administered on the day of presentation and the following day. She continued to refuse to eat or drink, and after 2 days, she was hospitalized for nasogastric tube feeding.
An Ethical Conflict Between Parents and Clinician in a Child with a Language Delay
Authors: Gupta Vidya Bhushan , Brosco Jeffrey P. , Patel Nidhip , Braddock Adam , Stein Martin T. 
Published: January 2021

CASE: A developmental-behavioral pediatrician evaluated a 2-year-old child for developmental delays. He determined that the child had mild expressive language delays; the child had an intelligible vocabulary of 20 words and at least 20 other words that he said unclearly. He said a few contracted 2-word phrases, such as “gimme” and “its ok.” He was shy and generally clung to his parents who spoke softly and very little. His development in all other domains was normal. Hearing evaluation and the neurological examination were normal.
The pediatrician provided suggestions to the parents in order to stimulate language and scheduled a follow-up appointment in 3 months. The parents asked him to refer the child for early intervention and write a letter to the US Immigration and Naturalization Service. They asked that the letter state that the child had a disabling condition and returning the child and his family to their country of origin would cause permanent harm to the child. The parents then gave the pediatrician a draft of a letter that had been prepared by an immigration lawyer.
The physician explained to the parents that the child had a mild expressive language delay and that he would like to see the child again in 3 months before deciding on early intervention. He advised them to obtain a copy of his medical note from the medical records department. The parents insisted that he write the letter and got upset and called him “heartless” when the physician refused to write the letter.
Reconstruction of Severe Palm Injury with Sensate Medial Plantar Artery Flap and Nerve Grafting
Authors: Padovano William M. , Hill Elspeth J. R. , Felder John M. 
Published: January 2021

Summary:
A 28-year-old, healthy man presented with an abrasion injury of the left palm, including a full-thickness glabrous skin defect, an open injury of the carpal tunnel with 50% transection of the median nerve, and a multilevel traction/avulsion injury of the thenar motor branch. He underwent repair with a free medial plantar artery flap, nerve transfer of the palmar cutaneous nerve to the medial plantar cutaneous nerve, grafting of the median nerve, and direct neurotization of the thenar muscles via an end-to-side nerve graft from the median nerve. At 8 months postoperative, both donor and recipient areas had healed completely, and the patient had regained meaningful 2-point discrimination of the palm and fingers, achieved innervation of the thenar muscles, and returned to work as a cook.
Subtotal Mandible Reconstruction with a Free Fibula Flap and No Skin Incisions
Authors: Lim Soobin , Mulloy Clairissa D. , Stern-Buchbinder Zachary , St. Hilaire Hugo , Stalder Mark W. 
Published: January 2021

Summary:
Resection of large mandibular tumors followed by primary reconstruction using free tissue transfer is typically accomplished using transcutaneous cervical incisions, which provide access for ablation as well as inset of the osseous free flap. This approach offers wide exposure; however, it subjects the patient to potential facial scarring, marginal mandibular nerve injury, lip deformity/incompetence, formation of orocutaneous fistulae, as well as functional impairments to speech, mastication, and deglutition. To reduce morbidity and to preserve aesthetics, a transoral approach can be used in cases that do not require a neck dissection. This technique can be coupled with transoral dissection of the facial vessels for intraoral microanastomoses to avoid extraoral incisions altogether. We present a case of a large 17.2 cm subtotal mandibulectomy and 3-segment fibular free flap reconstruction using virtual surgical planning, with patient-specific cutting guides and reconstruction plate performed entirely transorally without any skin incisions. Although technically challenging, this is a safe and effective technique for large segmental mandibular defects, which provides superior cosmetic and functional outcomes.
Intraoperative Autoderm Decontamination for Use in Immediate Single-stage Direct-to-implant Breast Reconstruction
Authors: Diaz-Abele Julian , Padalko Adam , Dalke Kimberly , Brichacek Michal , Buchel Edward W. 
Published: January 2021

Background:
Acellular dermal matrix (ADM) in direct-to-implant breast cancer reconstruction is the standard of care due to superior cosmetic results and decreased capsular contracture, but can be cost prohibitive. Although more economical, using patient’s own dermis (“Autoderm”) instead of ADM has undescribed sterility. Sterility is essential, as bacterial contamination may cause infection and capsular contraction. This study aimed to determine the sterility and optimal decontamination protocol of Autoderm.

Methods:
A prospective controlled study of 140 samples from 20 DIEP (deep inferior epigastric perforator) breast cancer reconstruction patients was performed. Seven de-epithelialized dermal samples (2 × 1 cm) per patient were collected from excess abdominal tissue (6 decontamination protocols and one control). Samples were submerged in povidone-iodine, chlorhexidine, or cefazolin/tobramycin/bacitracin for 15 minutes; half of the samples were agitated (150 rpm) for 15 minutes, and half were not. The control was normal saline without agitation. The solution was removed, and the tissue was sent for aerobic colony count cultures. Patient’s demographic data and complications were also collected.

Results:
Of 140 samples, 3 of 20 non-agitated povidone-iodine and 1 of 20 control samples had aerobic bacterial growth. All of the other 100 samples from 5 experimental groups (povidone-iodine + agitation, chlorhexidine ± agitation, and cefazolin/tobramycin/bacitracin ± agitation) had no aerobic bacterial growth.

Conclusions:
This study suggests povidone-iodine + agitation, chlorhexidine ± agitation, and cefazolin/tobramycin/bacitracin ± agitation are effective at sterilizing de-epithelialized dermis, whereas povidone-iodine without agitation and saline are ineffective. Autoderm with the appropriate decontamination protocol may be a potential sterile alternative to ADM.
Education during Surgical Outreach Trips in Vietnam: A Qualitative Study of Surgeon Learners
Authors: Billig Jessica I. , Nasser Jacob S. , Chung William H. J. , Huynh Kristine A. , Chung Kevin C. 
Published: January 2021

Background:
Visiting educator trips teach surgical care in low-resource settings to develop sustainable global surgery. Surgery has been integral in these volunteer activities, but it is unknown whether surgeon learners receive suitable education during these trips. We sought to describe the educational experiences of surgeon learners during a visiting educator trip to better understand the perceptions of surgical outreach education.

Methods:
We conducted semistructured interviews of 18 surgeon learners participating in a visiting educator trip to 2 hospitals in Thai Nguyen, Vietnam. Each interview was conducted in Vietnamese, translated into English, and transcribed. Narratives were content coded using thematic analyses.

Results:
We identified 3 main themes. First, participants noted the value in surgical outreach and believed that these trips provided a thorough understanding of surgical care from patient evaluation to complications management. Second, participants described key barriers to education. Participants desired to focus on “learning one topic in depth” rather than learning in breadth. Furthermore, they described the paucity of translated resources, a lack of English proficiency, and rudimentary translator services. Finally, participants provided substantive guidance in improving surgical outreach education, specifically regarding the limited nature of current international partnerships to foster long-term, sustainable relationships.

Conclusions:
Although Vietnamese surgeon learners felt that visiting educator trips were beneficial, they recognized important areas for improvement. The language barrier was a major impediment to effective learning with materials and lectures commonly provided in English, highlighting the need for improved language concordance. Additionally, participants desired continued relationships with the visiting surgeons to build long-term collaboration.
Open-label Venous Leg Ulcer Pilot Study Using a Novel Autolologous Homologous Skin Construct
Authors: Armstrong David G. , Orgill Dennis P. , Galiano Robert D. , Glat Paul M. , Carter Marissa J. , Zelen Charles M. 
Published: January 2021

Background:
Venous leg ulcers (VLUs) are often refractory to compression therapy, and their prevalence is increasing. An autologous homologous skin construct (AHSC) that uses the endogenous regenerative capacity of healthy skin has been developed to treat cutaneous defects, with a single application. The ability of AHSC to close VLUs with a single treatment was evaluated in an open-label, single-arm feasibility study to test the hypothesis that AHSC treatment will result in wound closure by providing healthy autologous tissue to the wound bed.

Methods:
Ten VLUs were treated with a single application of AHSC. A 1.5 cm2 full-thickness skin harvest from the proximal calf was collected and sent to a Food and Drug Administration–registered facility, where it was processed into AHSC and returned to the provider within 48 hours. AHSC was spread evenly across the wound and dressed with silicone. The primary endpoint was wound closure rate at 12 weeks. Wound closure was followed with 3-dimensional planimetry, and closure was confirmed by a panel of plastic surgeons. Additional endpoints followed for 12 weeks included graft take, harvest site closure, adverse event rate, complications, and patient-reported pain.

Results:
All 10 VLUs demonstrated successful graft take as evidenced by graft persisting in wound and harvest site closure. Eight VLUs exhibited complete closure within 12 weeks. One VLU that failed to heal with a prior split thickness skin graft closed within 13.5 weeks with AHSC. The mean time of closure was 34 days (95% confidence interval, 14–53). Pain improved by closure confirmation visit. There was 1 serious adverse event unrelated to the product or procedure.

Conclusion:
This pilot study demonstrated that AHSC may be a viable single-application topical intervention for VLUs and warrants further investigation in larger, controlled studies.