bluuebunny/crossref_metadata_2025_split huggingface dataset:
Assessing the Effectiveness of Using Mechanistic Concept Maps in Case-Based Collaborative Learning
Authors: Fischer Krisztina , Sullivan Amy M. , Krupat Edward , Schwartzstein Richard M. 
Published: September 2018

Problem
Despite the advantages of using mechanistic concept maps (MCMs)—diagrams created individually or collaboratively by a team to foster inductive analysis of a clinical problem—in individual learning, very little is known about their benefits in collaborative learning.

Approach
First-year medical and dental students (n = 170) were assigned to one of four learning groups in the Homeostasis I course, Harvard Medical School, February–March 2016. One group (n = 43) was randomly assigned to the MCM intervention; students in the remaining groups (n = 127) served as controls. Outcomes included pre- and postcourse surveys on, among other things, reasoning skills, attitudes toward teamwork, and tolerance of ambiguity; final exam scores; and qualitative responses to three open-ended questions on students’ perceptions of the effects of MCMs on their learning.

Outcomes
Response rates for pre- and postcourse surveys were 87/170 (51%) and 91/170 (54%). Compared with students in the control groups, students in the MCM group reported better reasoning skills (P = .01) and attitudes toward teamwork (P = .02). There were no significant differences in final exam scores between the groups. Students in the intervention group found MCMs more helpful in conceptual learning than their own notes and flashcards (P = .0001) or the readiness assessment quizzes (P = .0009). Qualitative analysis indicated MCM students routinely overcame team-learning obstacles through strategies aimed at prioritizing collaborative inductive reasoning.

Next Steps
Ongoing studies are evaluating the contextual elements and best practices for optimal employment of MCMs in promoting collaborative inductive reasoning.
Debt and the Emerging Physician Workforce: The Relationship Between Educational Debt and Family Medicine Residents’ Practice and Fellowship Intentions
Authors: Phillips Julie P. , Peterson Lars E. , Fang Bo , Kovar-Gough Iris , Phillips Robert L. 
Published: September 2018

Purpose
Educational debt is increasing and may affect physicians’ career choices. High debt may influence family medicine residents’ initial practice setting and fellowship training decisions, adversely affecting the distribution of primary care physicians. The purpose of this study was to determine whether debt was associated with graduating family medicine residents’ practice and fellowship intentions.

Method
The authors completed a cross-sectional secondary analysis of 2014 and 2015 American Board of Family Medicine (ABFM) examination registration questionnaire data and ABFM administrative data. They used multivariate logistic regression to determine whether educational debt was associated with graduating residents’ practice (ownership and type) and fellowship intentions.

Results
Most residents (89.7%; 3,368) intended to pursue an employed position, but this intention was not associated with their debt. Residents with high debt ($150,000–$249,999) had lower odds of intending to work for a government organization (odds ratio [OR] 0.57; confidence interval [CI] 0.41–0.79). Those with high or very high debt (> $250,000) had lower odds of choosing academic practice (OR 0.55, CI 0.36–0.85 and OR 0.62, CI 0.40–0.96, respectively) or a geriatrics fellowship (OR 0.36, CI 0.20–0.67 and OR 0.29, CI 0.15–0.55, respectively).

Conclusions
High educational debt may contribute to national shortages of academic primary care physicians and geriatricians. Existing National Health Service Corps loan repayment opportunities may not offer adequate incentives to primary care physicians with high debt. The medical community should advocate for policies that better align financial incentives with workforce needs.
The Effects of Motor Imagery on Pain and Range of Motion in Musculoskeletal Disorders
Authors: Yap Benjamin Wei Da , Lim Edwin Choon Wyn 
Published: September 2018

Introduction:
In recent years, there has been an increase in the use of motor imagery (MI) in the rehabilitation of musculoskeletal pain conditions. Across the literature, most reviews have yet to consider Laterality Judgement Task training as a form of MI method. This review aimed to evaluate the effectiveness of using MI as an adjunct to standard rehabilitation on the improvement of pain and range of motion parameters when managing patients with musculoskeletal pain conditions.

Methods:
Searches of 8 major electronic databases were conducted. Data for pain and range of motion were extracted. Meta-analyses (where possible) with either a fixed or random-effect(s) model, standardized mean differences (SMDs), and tests of heterogeneity were performed.

Results:
Eight clinical controlled trials were identified and included in the meta-analyses. When compared with standard rehabilitation alone, the adjunctive role of MI provided superior pain relief (pooled SMD, −2.25; 95% confidence interval, −4.11 to −0.4; P=0.02), and greater improvement in range of motion (pooled SMD, 3.04; 95% confidence interval, 0.66-5.43; P=0.01) in chronic musculoskeletal pain disorders.

Discussion:
The results suggest that MI may be effective for pain relief and improvement in range of motion among chronic musculoskeletal pain conditions, although conclusion is based on a limited certainty of evidence as assessed using the GRADES (Grading of Recommendation, Assessment, Development and Evaluation) approach.
Associations Between Musculoskeletal Pain Experience and Pressure and Cold Pain Sensitivity
Authors: Waller Robert , Smith Anne J. , O’Sullivan Peter B. , Slater Helen , Sterling Michele , Straker Leon M. 
Published: September 2018

Objectives:
To investigate the cross-sectional associations between musculoskeletal pain experience and measures of pressure and cold pain sensitivity in young adults from the Western Australian Pregnancy Cohort (Raine) Study.

Participants and Methods:
In total, 917 participants were eligible for analysis if they provided data pertaining to musculoskeletal pain status at the 22-year follow-up and had data for at least 1 valid pain sensitivity test. Standardized protocols were used to assess pressure pain threshold (4 sites: lumbar spine, tibialis anterior, upper trapezius, and wrist) and cold pain threshold (wrist). Four pain experience groups (“No pain” [n=562, 61.3%], “Low” [n=84, 9.2%], “Medium” [n=147, 16.0%], “High” [n=124, 13.5%]) were determined by latent class analysis using parameters of pain chronicity, frequency, intensity, and number of pain areas. Variables considered as confounders included sex, age, ethnicity, waist-hip ratio, psychological symptoms, sleep quality, physical activity, sedentary behavior, smoking, and income.

Results:
There were no associations between pain experience and pressure pain sensitivity after adjusting for confounders. The “Medium” and “High” pain experience groups demonstrated heightened cold pain sensitivity compared with the “No pain” group (P=0.023), adjusted for sex and smoking.

Discussion:
This study provides the most extensive investigation of the relationship between musculoskeletal pain experience and pressure and cold pain sensitivity in young adults. Heightened cold pain sensitivity in those classified as “Medium” and “High” pain experience may suggest altered nociceptive processing and has implications for clinical management.
Evaluation of Digital Face Recognition Technology for Pain Assessment in Young Children
Authors: Sakulchit Teeranai , Kuzeljevic Boris , Goldman Ran D. 
Published: September 2018

Objectives:
Accurate assessment of pain in young children is challenging. An Emotion Application Programing Interface (API) can analyze and report 8 emotions from facial images. Each emotion ranges between 0 (no correlation) to 1 (greatest correlation). We evaluated correlation between the Emotion API with the FLACC scale (face, lets, activity, cry, and consolability) among children younger than 6 years old during blood sampling.

Methods:
Prospective pilot exploratory study in children during blood sampling. Pictures with facial expressions were uploaded to Emotion API program. Primary outcome was the correlation coefficient between FLACC scale and emotions. Secondary outcomes included maximal correlation of each emotion for 3 pictures—before, during and after needle penetration; and the average of each emotion for 9 pictures—4 before, 1 during and 4 after needle penetration to the skin.

Results:
A total of 77 children were included. During needle penetration, SADNESS was significantly correlated (0.887, P<0.05), and NEUTRAL was negative correlated with the FLACC scale (−0.841; P<0.05). The maximal correlation of each emotion showed increase in SADNESS and decrease in NEUTRAL emotions during, compared to before, needle penetration. Similar findings were observed when the average of each emotion was compared during to before needle penetration.

Discussion:
During a blood test procedure, young children show higher SADNESS and lower NEUTRAL emotions as reported by the Emotion API. This software program may be useful in reporting emotions related to pain in young children, and more research is needed to compare its validity, reliability and real-time application compared to the FLACC scale.
Trends in Fellow Education Research Among Obstetric and Gynecologic Subspecialties
Authors: Buckheit Caledonia , Willis-Gray Marcella , Dotters-Katz Sarah 
Published: September 2018

OBJECTIVE:
To evaluate the frequency at which fellow education-related abstracts are presented at national meetings and compare presentation rates before and after the accreditation transition.

METHODS:
This cross-sectional study evaluated abstracts from the five most recent national meetings of the Society for Maternal-Fetal Medicine (SMFM), the Society of Gynecologic Oncology, the American Society for Reproductive Medicine (ASRM), the American Urogynecologic Society (AUGS), and the Council on Resident Education in Obstetrics and Gynecology (CREOG) and Association of Professors of Gynecology and Obstetrics (APGO). Three independent reviewers assessed abstracts for education-specific content. Abstracts were included if two or greater reviewers identified them as related to fellow education. Descriptive statistics were used for data analysis.

RESULTS:
Fourteen thousand six hundred thirty abstracts were presented at obstetric and gynecologic subspecialty meetings between 2012 and 2017. Of these, 29 (0.20%) pertained to fellows' education. The percent of total abstracts that were fellow-related remained relatively constant over time. Of the four subspecialties, the AUGS presented fellow education research almost five times more frequently than ASRM (P<.01) or SMFM (P<.01). Over the study period, 1,283 abstracts were presented at the CREOG and APGO meeting, with four (0.31%) pertaining to fellows' education. At the CREOG and APGO meeting, fellow-related abstracts did not appear to increase over the period studied.

CONCLUSION:
Research regarding fellows' education is rarely presented at national meetings, representing less than 1% of all abstracts, and has not substantially increased since the transition to the Accreditation Council for Graduate Medical Education.
Validation of a Simulation Model for Laparoscopic Myomectomy Developed with 3D-Printed Molds
Authors: Singleton Miller , Behr Amanda , Braun Kelli , Stager Robert 
Published: September 2018

PURPOSE:
To develop a model that can be used by Ob-Gyn residents when performing simulation for laparoscopic myomectomy.

BACKGROUND:
Laparoscopic myomectomy (LM) is a challenging procedure encountered by Ob-Gyn residents during residency training. Limited commercial simulation products exist but are cost-prohibitive for consistent use.

METHODS:
Uterine and fibroid molds were generated using Pixelogic® Z-brush design software and printed from a 3D printer using polylactic acid filament. Smooth-On® Dragon Skin silicone of varying densities was used for the uterus and fibroids. The model consisted of a uterine body with four fundal subserosal fibroids – two placed anteriorly and two placed posteriorly—fallopian tubes, and round ligaments. Residents evaluated the model and its effectiveness in simulating LM upon simulation completion.

RESULTS:
Five uterine models with four fibroids each were constructed for a total cost of $318 (printed molds, silicone, and pigment); replacement models cost $30 (silicone and pigment only). The model functioned well within the trainer box using surgical instruments and suture; however, the base of the fibroid adhered to the myometrium making excision of the entire specimen difficult. All residents (N=13) used the model. Residents felt the model was realistic (4/5), helps develop skills needed for LM (4.5/5), and will increase resident competency in laparoscopy (4.8/5).

DISCUSSION:
Our model provides a realistic simulation of LM at low cost. One model can be used by up to four residents. We can repair previously used models with silicone allowing them to be reused. We have updated the model to decrease fibroid adherence to the myometrium and facilitate complete excision.
Acute Respiratory Distress Syndrome After Uterine Artery Embolization
Authors: Nguyen Dong Bach , How Jeffrey , Ziegler Cleve , Madar Jaclyn 
Published: September 2018

INTRODUCTION:
Although uterine artery embolization has been established as a less invasive alternative to hysterectomy or myomectomy for the treatment of uterine leiomyomas, it is not devoid of life-threatening complications.

CASE:
We present the case of a 44-year-old patient who developed a severe systemic inflammatory response and acute respiratory distress syndrome 5 weeks after uterine artery embolization of a large multileiomyomatous uterus. Deterioration of her clinical status prompted an emergency hysterectomy that led to rapid improvement.

CONCLUSION:
Although fatalities from septicemia after uterine artery embolization have been reported, aseptic inflammatory responses to uterine degeneration can also lead to multiorgan failure. With recent studies refuting uterine size and leiomyoma location as risk factors, further research is needed to help select appropriate uterine artery embolization candidates.
Cervical Pessary Compared With Vaginal Progesterone for Preventing Early Preterm Birth
Authors: Cruz-Melguizo Sara , San-Frutos Luis , Martínez-Payo Cristina , Ruiz-Antorán Belén , Adiego-Burgos Begoña , Campillos-Maza José Manuel , García-González Celso , Martínez-Guisasola Javier , Pérez-Carbajo Esther , Teulón-González María , Avendaño-Solá Cristina , Pérez-Medina Tirso ,   on behalf of the PESAPRO Study Group
Published: September 2018

OBJECTIVE:
To compare the effectiveness of a cervical pessary and vaginal progesterone to prevent spontaneous preterm births in pregnant women with cervical lengths 25 mm or less as measured by transvaginal ultrasonography.

METHODS:
This was a multicenter, open-label, randomized, noninferiority trial. Women with singleton pregnancies and a short cervix (25 mm or less) measured transvaginally at the second-trimester ultrasonogram were invited to participate. They were computer-randomized (one to one) into cervical pessary placement or treatment with vaginal progesterone (200 mg/24 hours). The primary outcome was spontaneous preterm delivery before 34 weeks of gestation. The noninferiority margin was set at 4% with a 0.025 one-sided α level and a statistical power of 80%. That is, if the 95% CI upper bound exceeded 4%, the pessary could not be deemed noninferior. A sample size of 254 women was required to show noninferiority of the pessary to progesterone.

RESULTS:
The trial was conducted from August 2012 to April 2016 with the participation of 27 Spanish hospitals. A total of 254 patients were enrolled and 246 included in the intention-to-treat analysis. Demographic and baseline characteristics were similar across groups. The rate of spontaneous delivery before 34 weeks of gestation was 14% (n=18/127) in the pessary group and 14% (n=17/119) in the progesterone group with a risk difference of −0.11% (95% CI −8.85% to 8.62%; P=.99), that is, noninferiority was not shown for the pessary. The incidence of increased vaginal discharge (87% vs 71%, P=.002) and discomfort (27% vs 3%, P<.001) was significantly higher in the pessary group.

CONCLUSION:
A cervical pessary was not noninferior to vaginal progesterone for preventing spontaneous birth before 34 weeks of gestation in pregnant women with short cervixes.

CLINICAL TRIAL REGISTRATION:
EU Clinical Trials Register, 2012-000241-13; ClinicalTrials.gov, NCT01643980.
Innate immunity and Toll-like receptor signaling in the pathogenesis of scleroderma: advances and opportunities for therapy
Authors: Brown Max , O’Reilly Steven 
Published: September 2018

Purpose of reviewSystemic sclerosis (SSc) is an autoimmune connective tissue disease in which inflammation and cytokine dysregulation leads to skin fibrosis. Toll-like receptors (TLRs) are conserved pattern recognition receptors, recognizing pathogens danger-associated molecular patterns (DAMPs) that elicit a cascade of proinflammatory signaling. Recently, TLRs have been found to be critically important in SSc pathogenesis, with increased levels of the TLRs and their ligands present in the disease. Animal models have also been pivotal in delineating the role of these innate immune receptors in SSc. This current review examines the role of TLRs and the most recent evidence of the role of DAMPs and how these may be exploited therapeutically.Recent findingsIncreasingly, studies have demonstrated the key roles of TLR4 and other intracellular TLRs in mediating fibrosis in SSc patients and animal models. TLR4 activation appears a key point and novel DAMPs, expressed upon tissue damage, appear critical in mediating the profibrotic effect through a downstream enhancement of transforming growth factor β. Deletion of Tenascin-C or a splice variant of fibronectin ameliorates animal models of skin fibrosis. Intracellular, nucleic acid sensing, TLR8 is critical in activating macrophages to secrete profibrotic molecules. The mechanism involves histone modification through epigenetic modifying enzymes.SummaryTLRs are key therapeutic targets in SSc.
Malnutrition and the Orthopaedic Trauma Patient: A Systematic Review of the Literature
Authors: Ernst Alexandra , Wilson Jacob M. , Ahn Jaimo , Shapiro Marc , Schenker Mara L. 
Published: September 2018

Objectives:
To evaluate the available literature for associations between nutrition and outcomes after operative treatment of long bone and long bone periarticular fractures.

Data Sources:
Systematic review of English-language articles in the MEDLINE, Embase, PubMed, and Cochrane computerized literature databases (through December 2015) using PRISMA guidelines.

Study Selection:
Randomized controlled trials, quasi-randomized controlled trials, case–control studies, and cohort studies (retrospective and prospective) involving long bone and long bone periarticular fractures that included the effect of nutritional status on fracture union, time to union, and any related soft-tissue complication were eligible for review.

Data Extraction:
Two authors independently extracted data from the selected studies using a standardized data collection form with predefined data fields for demographics, interventions, study methods, complications, and management outcomes.

Data Synthesis:
Although one of the original aims of the study was to conduct a meta-analysis, the available literature did not offer sufficient data for meta-analysis.

Conclusions:
Although our systematic review demonstrates a possible role for oral nutritional supplementation and vitamin supplementation in the orthopaedic trauma patient, there remains a need for well-designed trials to clarify this role. There is likely benefit to multidisciplinary approaches to nutritional optimization in the orthopaedic trauma patient, and this should be explored further in forthcoming work.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Clamshell Osteotomy for Acute Fractures in the Malunion Setting: A Technical Note
Authors: Pires Robinson Esteves , Gausden Elizabeth B. , Sanchez Gustavo Tadeu , Wajnsztejn André , Teixeira Thiago Martins , Soares Marcelo da Silva , Pesantez Rodrigo , Lorich Dean G. 
Published: September 2018

Summary:
Surgical management of lower extremity malunions and acute fractures in the setting of lower extremity deformities presents a unique challenge for orthopaedic surgeons. The objective of this study was to evaluate the outcomes of using the clamshell osteotomy in patients with acute fractures involving a malunion or deformity. A retrospective review of the cases performed by various orthopaedic traumatologists at 4 different trauma centers was performed to identify cases using the clamshell osteotomy from January 2012 to January 2016. Nine clamshell osteotomy cases were identified, 4 presenting fractures in the setting of previous malunions. All osteotomies healed within 15 months (average 6.8 ± 4.4 SD). In this multicenter case series, we demonstrate that using clamshell osteotomies can result in excellent outcomes for permitting intramedullary nailing of acute fractures in patients with lower extremity deformity.
International Orthopaedic Multicenter Study in Fracture Care: Coordinating a Large-Scale Multicenter Global Prospective Cohort Study
Authors: Sprague Sheila , McKay Paula , Li Chuan Silvia , Ivers Rebecca , Moroz Paul J. , Jagnoor Jagnoor , Bhandari Mohit , Miclau Theodore ,   on behalf of the INORMUS Investigators
Published: September 2018

Summary:
Traditionally, the orthopaedic trauma literature has been dominated by small studies that were largely single-center initiatives. More recently, there has been a paradigm shift toward larger, multicenter studies because the orthopaedic community embraced the concepts of evidence-based medicine and the need for high-quality research to guide clinical practice. The International Orthopaedic Multicenter Study in Fracture Care is a large multicenter international cohort study in musculoskeletal trauma in Africa, Asia, and Latin America. This is the first study of this magnitude within the global orthopaedic trauma community. The International Orthopaedic Multicenter Study in Fracture Care study has provided an opportunity to form new international collaborative relationships and to develop new research capacity and global collaborative relationships that will provide the foundation for future studies in injury prevention and management.

Levels of Evidence:
IV.