bluuebunny/crossref_metadata_2025_split huggingface dataset:
Who moved my fellow: changes to Accreditation Council for Graduate Medical Education fellowships in pediatric surgery and what may be yet to come
Authors: Alaish Samuel M. , Garcia Alejandro V. 
Published: April 2019

Purpose of review
Over the past 15 years, the Accreditation Council for Graduate Medical Education (ACGME) has significantly altered the regulatory framework governing fellowship training in pediatric surgery. The daily experiences of pediatric surgical trainees have been impacted by these changes, but training program directors and faculty have not developed a consistent approach to managing this shift. This review highlights the changes, which have occurred, analyzes the current state of fellowship training, and proposes potential strategies for management.

Recent findings
The implementation of work hour restrictions, increased supervision requirements, the milestone evaluation program and most recently, enforcement of required critical care experience, have caused significant changes in the curriculum. Pediatric surgical trainees record more total cases, and more minimally invasive surgical (MIS) cases, in particular, than ever before. A subset of this increase may result from trainees performing cases previously assigned to general surgery residents. Teaching cases performed by fellows have decreased. Although the relationship between these shifts in training experience and the didactic curriculum is not clear, we also note that the Pediatric Surgery Certifying Examination failure rate has increased, approaching 20% in recent years.

Summary
It is unclear whether the changes in Pediatric Surgery training programs have been effective, or (conversely) have led to unintended consequences. Paradigm shifts in our training model may be required to address the changes in surgical education and skill acquisition, so that well tolerated, competent and skillful pediatric surgeons continue to enter the workforce.
Pediatric postoperative opioid prescribing and the opioid crisis
Authors: Harbaugh Calista M. , Gadepalli Samir K. 
Published: April 2019

Purpose of review
The purpose of this review is to explore the effects of the opioid crisis on pediatric patients in the postoperative setting and provide recommendations for well-tolerated opioid prescribing practices.

Recent findings
Opioid overdoses have increased among all age groups, predominantly related to overprescribing and accessibility of opioids in the home. Adverse risks of prescribed opioids include respiratory depression, gastrointestinal distress, accidental ingestion, intentional misuse, new chronic use, diversion to another user, and overdose. Well-tolerated opioid prescribing practices include multimodal pain management; prescribing guided by patient need; risk assessment for potential misuse; and comprehensive patient and family education on risks, safe storage, and disposal practices. Evolving state laws will affect varying institutional policies; thus, providers must ensure their prescribing practices are current and compliant.

Summary
All age groups have been affected by the opioid crisis, including children and adolescents. When managing postoperative pain, clinicians must balance appropriate pain management with well-tolerated opioid stewardship to minimize harm related to postoperative care.
Revalidation of a Perioperative Risk Assessment Measure for Skin
Authors: Meehan Anita J. , Beinlich Nancy R. , Bena James F. , Mangira Caroline 
Published: April 2019

Background
Validated perioperative pressure injury (PI) risk assessment measures are few and often cumbersome to complete, leading to missed opportunities to identify and target prevention interventions to those patients at increased risk for developing a postsurgical PI.

Objectives
Previous validation of a six-item perioperative risk assessment measure for skin (PRAMS) was conducted in our community hospital with positive findings. The purpose of this study was to increase generalizability by revalidating the PRAMS in a larger sample.

Methods
This was a retrospective chart review of all surgical patients aged ≥18 years positioned in the supine or lateral position in a Midwest quaternary care, multispecialty, 1,500-bed hospital during a 6-month period (n = 1,526). The intent of the study was to revalidate the PRAMS. The main outcome of interest was the development of PI after surgery. Risk indicators of interest included diabetes, age, surgical time, Braden score, previous surgery, and preexisting PI. The diagnostic ability of any of the risk indicators on the development of a postsurgical PI was evaluated using sensitivity, specificity, and predictive values.

Results
Postsurgical PIs occurred in 121 patients. Comparing current to previous study results, the PRAMS was effective in identifying surgical patients at risk for PI (sensitivity = .98). Those patients with a postsurgical PI had a lower mean Braden score, were more likely to have a preexisting PI, and were more likely to have a previous surgery during the same admission (p < .001 for all risk indicators), comparing favorably to the original study. Patients without risk indicators were unlikely to develop a postsurgical PI (negative predictive value = .98).

Discussion
Results of this validation study demonstrate that the PRAMS is effective in identifying patients who developed a postsurgical PI using information readily available to the perioperative staff.
Proteinuria Is Associated With Increased Risk of Fragility Fracture in Men With or at Risk of HIV Infection
Authors: Gonciulea Anda , Wang Ruibin , Althoff Keri N. , Estrella Michelle M. , Sellmeyer Deborah E. , Palella Frank J. , Lake Jordan E. , Kingsley Lawrence A. , Brown Todd T. 
Published: April 2019

Background:
Proteinuria has been associated with bone loss and fractures in general population, but data in HIV-infected population are lacking.

Setting:
Prospective, multicenter cohort study of men with or at risk of HIV infection.

Methods:
Between 2006 and 2015, urine protein measurements and bone fracture histories were ascertained semiannually in 947 HIV-infected (HIV+) and 969 HIV-uninfected (HIV−) men aged 40 years or older. Proteinuria was defined as protein-to-creatinine ratio ≥200 mg/g at ≥2 consecutive visits. Outcome measures (1) all fractures (excluding fractures of skull, face, and digits) and (2) fragility fractures (fractures of vertebral column, femur, wrist, and humerus). Multivariable Cox proportional hazards models assessed the association between proteinuria and fracture after adjusting for additional risk factors.

Results:
The overall period prevalence of proteinuria was higher among HIV+ than HIV− (29% vs 6%, P < 0.001). Men with proteinuria had a significantly higher risk of fragility fracture compared with men without proteinuria [adjusted hazard ratio (aHR) = 2.29 (1.12–4.66)] and did not differ by HIV serostatus (p-interaction = 0.83). The risk of all fractures was not statistically different between men with or without proteinuria [aHR = 1.31 (0.84–2.05)]. Among HIV+ men, the association between confirmed proteinuria and fragility fracture was attenuated [aHR = 2.12 (0.95–4.73)] after additional adjustment for CD4+ T-cell count/mm3, history of AIDS, the presence of detectable plasma HIV-1 RNA, and cumulative exposure to tenofovir disoproxil fumarate.

Conclusions:
Proteinuria was more common in HIV+ than in HIV− men and was a strong independent risk factor for fragility fracture regardless of HIV serostatus. Proteinuria should prompt consideration of a thorough evaluation for bone disease among HIV+ persons.
Ultrasonic Piezoelectric Bone Surgery Combined With Leukocyte and Platelet-Rich Fibrin and Pedicled Buccal Fat Pad Flap in Denosumab-Related Osteonecrosis of the Jaw
Authors: Şahin Onur , Odabaşi Onur , Ekmekcioğlu Ceren 
Published: April 2019

Abstract
Denosumab is an antiresorptive agent that is found as a humanized antibody, which inhibits the most critical pro-osteoclastogenic factor secreted by the cancer cells and shown to be required for osteoclast formation, function, and development. A severe side effect of denosumab is the osteonecrosis of the jaw (DRONJ). There are only a few studies on DRONJ treatment in the literature. The aim of this case report is to present the successful conservative management of DRONJ observed after tooth extraction at the posterior maxilla following the discontinuation of medication. To our knowledge, this is the first DRONJ case treated with using the ultrasonic piezoelectric bone surgery combined with leukocyte and platelet-rich fibrin (L-PRF) and pedicled buccal fat pad flap (PBFP). Use of ultrasonic bone surgery in combination with L-PRF and PBFP is an alternative treatment method that can be effective in exposed bone coverage and soft tissue healing at the posterior maxillary region in DRONJ patients.
The Use of Virtual Surgical-Guided Osteoplasty for Maxillofacial Brown Tumors
Authors: Wilt Danielle Christina , Kim Beomjune , Zaid Waleed 
Published: April 2019

Abstract
A 28-year-old African American female with end-stage renal disease on dialysis secondary to preeclampsia presented to the office as a referral for large multifocal tumors of maxilla and mandible. Surgical pathology and laboratory findings were supportive of secondary hyperparathyroidism leading to multifocal brown tumors. She underwent osteoplasty after using virtual surgical planning to create stereolithic models to visualize the tumor and fabricate cutting guides to minimize the risk of injury to adjacent nerves and teeth. Brown tumors can be resistant to medical management with unreliable regression in size. With the advent of customized surgical guides, more precise and judicious surgery can be performed on these types of tumors safely.
The Beers criteria: Not just for geriatrics anymore? Analysis of Beers criteria medications in nongeriatric trauma patients and their association with falls
Authors: Maerz Adam H. , Walker Benjamin S. , Collier Bryan R. , Tegge Allison N. , Faulks Emily R. , Bower Katie L. , Nussbaum Michael S. , Lollar Daniel I. , Hamill Mark E. 
Published: April 2019

BACKGROUND
It has been well established that many classes of medications on the Beers list of Potentially Inappropriate Medications (PIMs) are associated with falls and injuries in the geriatric population, but little work has been performed to understand if similar relationships exist among the nongeriatric adult population.

METHODS
A retrospective chart review of 32 months of trauma encounters at our Level I trauma center was performed in nongeriatric adults aged 18 years to 64 years. Encounters were reviewed by mechanism of injury and intake medication reconciliation. The data were then evaluated for associations between PIMs and falls.

RESULTS
Of the 7,897 trauma encounters in the study period, 6,493 had completed medication reconciliation, and 4,154 were between the ages of 18 years and 64 years. There was a statistically significant disproportionate number of those who sustained a fall on psychoactive medications and proton pump inhibitors, and the odds of a trauma patient presenting as a fall were also significantly higher on these select classes of PIMs.

CONCLUSION
The PIMs associated with falls in the geriatric population are also associated with falls in the nongeriatric population. This study supports the judicious prescribing of these medications, as they may have risks beyond what was originally thought.

LEVEL OF EVIDENCE
Prognostic, level IV.
Lead toxicity from retained bullet fragments: A systematic review and meta-analysis
Authors: Apte Anisha , Bradford Kevin , Dente Christopher , Smith Randi N. 
Published: April 2019

BACKGROUND
Firearm injury remains a public health epidemic in the United States. A large proportion of individuals with gunshot wounds subsequently have retained bullet fragments (RBF). There are no standard medical guidelines regarding bullet removal and the full extent of the consequences of RBF remains unknown.

OBJECTIVE
To determine whether there is an association among RBF, elevated blood lead levels (BLL) and lead toxicity in survivors of firearm injury 16 years and older.

METHODS
PubMed, EMBASE, CINAHL, Scopus, Cochrane Library, and Sociological Abstracts electronic databases were searched for all randomized controlled trials, prospective and retrospective cohort, case-control and cross-sectional studies published in the English language between 1988 and 2018. Quality assessment and risk of bias was evaluated using the Newcastle Ottawa Scale. A meta-analysis was performed using a random-effects model.

RESULTS
The search yielded 2,012 articles after removal of duplicates. Twelve were included after full article review. Eleven studies supported an association between elevated BLL and RBF. Bony fractures were associated with increased risk of elevated BLL in three studies. A positive relationship between BLL and the number of RBF was also shown in three studies, with one study demonstrating 25.6% increase in BLL for every natural-log increase in RBF (1–228, p < 0.01). Meta-analysis demonstrated BLL significantly higher in individuals with RBF as compared to controls (5.47 μg/dL, p < 0.01).

CONCLUSION
Patients with bony fractures or multiple RBF, who are at higher risk of elevated BLL, should be monitored for BLL in intervals of 3 months within the first year of injury. For patients who return with BLL above 5 μg/dL, all efforts must be undertaken to remove fragments if there is no potential to worsen the injury.

LEVEL OF EVIDENCE
Systematic review, Meta-analysis, level III.
Pain management in trauma patients affected by the opioid epidemic: A narrative review
Authors: Karamchandani Kunal , Klick John C. , Linskey Dougherty Melissa , Bonavia Anthony , Allen Steven R. , Carr Zyad J. 
Published: April 2019

ABSTRACT
Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use.

LEVEL OF EVIDENCE
Narrative review, moderate to High.
Essentials of emergency transfusion—The complement to stop the bleed
Authors: Lewis Meghan , Shulman Ira , Hudgins Jay , Moore Ernest E. , Inaba Kenji 
Published: April 2019

ABSTRACT
Over the past decade, the shift toward damage control surgery for bleeding trauma patients has come with an increased emphasis on optimal resuscitation. Two lifesaving priorities predominate: to quickly stop the bleed and effectively resuscitate the hemorrhagic shock. Blood is separated into components for efficient storage and distribution; however, bleeding patients require all components in a balanced ratio. A variety of blood products are available to surgeons, and these products have evolved over time. This review article describes the current standards for resuscitation of bleeding patients, including characteristics of all available products. The relevant details of blood donation and collection, blood banking, blood components, and future therapies are discussed, with the goal of guiding surgeons in their emergency transfusion practice.
Beta rhythm events predict corticospinal motor output
Authors: Hussain Sara J , Cohen Leonardo G , Bönstrup Marlene 
Published: April 2019

AbstractThe beta rhythm (15-30 Hz) is a prominent signal of sensorimotor cortical activity. This rhythm is not sustained but occurs non-rhythmically as brief events of a few (1–2) oscillatory cycles. Recent work on the relationship between these events and sensorimotor performance suggests that they are the biologically relevant elements of the beta rhythm. However, the influence of these events on corticospinal excitability, a mechanism through which the primary motor cortex controls motor output, is unknown. Here, we addressed this question by evaluating relationships between beta event characteristics and corticospinal excitability in healthy adults. Results show that the number, amplitude, and timing of beta events preceding transcranial magnetic stimulation (TMS) each significantly predict MEP amplitudes. However, beta event characteristics did not explain additional MEP amplitude variance beyond that explained by mean beta power alone, suggesting that conventional beta power measures and beta event characteristics similarly capture natural variation in human corticospinal excitability. Despite this lack of additional explained variance, these results provide first evidence that endogenous beta oscillatory events shape human corticospinal excitability.
A high throughput multi-locus insecticide resistance marker panel for tracking resistance emergence and spread inAnopheles gambiae
Authors: Lucas Eric R. , Rockett Kirk A. , Lynd Amy , Essandoh John , Grisales Nelson , Kemei Brigid , Njoroge Harun , Hubbart Christina , Rippon Emily J. , Morgan John , Van’t Hof Arjen , Ochomo Eric O. , Kwiatkowski Dominic P. , Weetman David , Donnelly Martin J. 
Published: April 2019

AbstractThe spread of resistance to insecticides in the mosquito vectors of diseases such as malaria and dengue poses a threat to the effectiveness of control programmes, which rely largely on insecticide-based interventions. Monitoring the resistance status of mosquito populations is therefore essential, but obtaining direct phenotypic measurements of resistance is laborious and error-prone. In contrast, high-throughput genotyping offers the prospect of quick and repeatable estimates of resistance, while also allowing the genotypic markers of resistance to be tracked and studied. We developed a panel of 28 known or putative markers of resistance in the major malaria vectorAnopheles gambiae, which we use to test the association of these markers with resistance and to study their geographic distribution. We screened resistance-phenotypedAn.gambiaefrom populations from a wide swathe of Sub-Saharan Africa (Burkina Faso, Ghana, Democratic Republic of Congo (DRC) and Kenya), and found evidence of resistance association for four mutations, including a novel mutation in the detoxification geneGste2(Gste2-119V). We also identified a gene duplication inGste2which combines a resistance-associated mutant form of the gene with its wild-type counterpart, potentially alleviating the costs of resistance. Finally, we describe the distribution of the multiple evolutionary origins ofkdrresistance, finding unprecedented levels of diversity in the DRC. This panel represents the first step towards developing a quantitative predictive genotypic model of insecticide resistance that can be used to screenAn.gambiaepopulations and predict resistance status.
Targeting IL-6 reduces IgM levels and tumor growth in Waldenström macroglobulinemia
Authors: Han Weiguo , Matissek Stephan J. , Jackson David A. , Sklavanitis Brandon , Elsawa Sherine F. 
Published: April 2019

AbstractThe tumor microenvironment (TME) plays an important role in cancer and plays a role in resistance to therapy. In Waldenström macroglobulinemia (WM), a B-cell malignancy characterized by the overproduction of a monoclonal IgM protein, the TME plays an important role in WM biology by secreting cytokines that promote malignant phenotype. In previous work, we have shown that TME-IL-6 promotes WM cell growth and IgM secretion in WM. Tocilizumab/Actemra is an anti-IL-6R antibody, which can competitively block IL-6 binding to the IL-6R. We investigated the efficacy of Tocilizumab in a preclinical mouse model of WM that considers the role of the TME in disease biology. Hairless SCID mice were subcutaneously implanted with BCWM.1 or RPCI-WM1 and bone marrow stromal cells. Groups of mice were treated with Tocilizumab or control antibody three times/week for 5 weeks and the effect on tumor burden and disease biology were evaluated. Although Tocilizumab had no effect on mice survival, there was a reduction in tumor growth rate in mice injected with RPCI-WM1 cells treated with Tocilizumab (p=0.0394). In mice injected with BCWM.1 + stromal cells, there was a significant reduction in human IgM secretion in mice sera with Tocilizumab treatment (p=0.0099). There was no significant change in mice weight suggesting Tocilizumab induced no toxicities to the mice. Taken together, our data suggests that administration of Tocilizumab to tumor bearing mice, results in a significant reduction in tumor volume and IgM secretion. Therefore, the evaluation of the role of Tocilizumab in WM patients may provide therapeutic efficacy by reducing IgM production and slowing the rate of tumor growth.
Scaling of thermal tolerance with body mass and genome size in ectotherms: A comparison between water-and air-breathers
Authors: Leiva Félix P. , Calosi Piero , Verberk Wilco C.E.P. 
Published: April 2019

AbstractGlobal warming appears to favour smaller-bodied organisms, but whether larger species are also more vulnerable to thermal extremes, as suggested for past mass-extinction events, is still an open question. Here, we tested whether interspecific differences in thermal tolerance (heat and cold) of ectotherm organisms are linked to differences in their body mass and genome size (as a proxy for cell size). Since the vulnerability of larger, aquatic taxa to warming has been attributed to the oxygen limitation hypothesis, we also assessed how body mass and genome size modulate thermal tolerance in species with contrasting breathing modes, habitats and life-stages. A database with the upper (CTmax) and lower (CTmin) critical thermal limits and their methodological aspects was assembled comprising more than 500 species of ectotherms. Our results demonstrate that thermal tolerance in ectotherms is dependent on body mass and genome size and these relationships became especially evident in prolonged experimental trials where energy efficiency gains importance. During long-term trials, CTmax was impaired in larger-bodied water-breathers, consistent with a role for oxygen limitation. Variation in CTmin was mostly explained by the combined effects of body mass and genome size and it was enhanced in larger-celled, air-breathing species during long-term trials, consistent with a role for depolarization of cell membranes. Our results highlight the importance of accounting for phylogeny and exposure duration. Especially when considering long-term trials, the observed effects on thermal limits are more in line with the warming-induced reduction in body mass observed during long-term rearing experiments.