bluuebunny/crossref_metadata_2025_split huggingface dataset:
Student Perspectives on the “Step 1 Climate” in Preclinical Medical Education
Authors: Chen David R. , Priest Kelsey C. , Batten Jason N. , Fragoso Ligia E. , Reinfeld Bradley I. , Laitman Benjamin M. 
Published: January 2019

The United States Medical Licensing Examination Step 1 was implemented in the 1990s as the most recent version of the National Board of Medical Examiners’ preclinical licensing examination originally created in the late 1960s. For the purposes of state licensure, the exam is pass/fail, but the Step 1 numeric score has in recent years become central to the residency application and selection process. Consequently, a medical student’s Step 1 score is increasingly viewed as a key outcome of preclinical medical education.
In this Invited Commentary, students from various institutions across the country draw on their shared experiences to argue that the emphasis on Step 1 for residency selection has fundamentally altered the preclinical learning environment, creating a “Step 1 climate.” The authors aim to increase awareness of the harms and unintended consequences of this phenomenon in medical education. They outline how the Step 1 climate negatively impacts education, diversity, and student well-being, and they urge a national conversation on the elimination of reporting Step 1 numeric scores.
Residency Program Factors Associated With Depressive Symptoms in Internal Medicine Interns: A Prospective Cohort Study
Authors: Pereira-Lima Karina , Gupta Rahael R. , Guille Constance , Sen Srijan 
Published: January 2019

Purpose
To investigate the associations between program-level variables such as organizational structure, workload, and learning environment and residents’ development of depressive symptoms during internship.

Method
Between 2012 and 2015, 1,276 internal medicine interns from 54 U.S. residency programs completed the Patient Health Questionnaire-9 (PHQ-9) before internship, and then quarterly throughout the internship. The training environment was assessed via a resident questionnaire and average weekly work hours. The authors gathered program structural variables from the American Medical Association Fellowship and Residency Electronic Interactive Database (FREIDA online) and program research rankings from Doximity. Associations between program-level variables and change in depressive symptoms were determined using stepwise linear regression modeling.

Results
Mean program PHQ-9 scores increased from 2.3 at baseline to 5.9 during internship (mean difference 3.6; SD 1.4; P < .001), with the mean increase ranging from −0.3 to 8.8 (interquartile range 1.1) among included programs. In multivariable models, faculty feedback (β = −0.37; 95% CI: −0.62, −0.12; P = .005), learning experience in inpatient rotations (β = −0.28; 95% CI: −0.54, −0.02; P = .030), work hours (β = 0.34; 95% CI: 0.13, 0.56; P = .002), and research ranking position (β = −0.25; 95% CI: −0.47, −0.03; P = .036) were associated with change in depressive symptoms.

Conclusions
Poor faculty feedback and inpatient learning experience, long work hours, and high institutional research rankings were associated with increased depressive symptoms among internal medicine interns. These factors may be potential targets for interventions to improve wellness and mental health among these professionals.
Distal Nail Target and Alignment of Distal Tibia Fractures
Authors: Brinkmann Elyse , DiSilvio Frank , Tripp Michael , Bernstein Mitchell , Summers Hobie , Lack William D. 
Published: January 2019

Objectives:
To assess the relationship between the distal nail target and postoperative alignment for distal tibia fractures treated with intramedullary nailing.

Design:
Retrospective cohort study.

Setting:
A single level 1 trauma center.

Patients/Participants:
One hundred thirty distal tibia fractures treated with intramedullary nailing over a 10-year period.

Main Outcome Measurements:
Malalignment >5 degrees.

Results:
Thirty-eight cases (29.2%) of malalignment >5 degrees included valgus (19 cases, 14.6%), procurvatum (13 cases, 10.0%), recurvatum (1 case, 0.8%), and combined valgus with procurvatum (5 cases, 3.8%). Medially directed nails demonstrated relative valgus (mean lateral distal tibia angle 86.4 vs. 89.4 degrees, P < 0.01) and more frequent coronal malalignment (24 of 78, 30.8% vs. 0 of 52, 0%, P < 0.01). Anteriorly directed nails demonstrated relative procurvatum (mean anterior distal tibia angle 82.8 vs. 80.9 degrees, P < 0.01) and more frequent sagittal malalignment (15 of 78, 19.2% vs. 3 of 52, 5.8%, P = 0.03). Malalignment was less common for nails targeting the central or slightly posterolateral plafond (0 of 30, 0% vs. 38 of 100, 38%), P < 0.01. Multivariate analysis demonstrated the distal nail target (P = 0.03), fracture within 5 cm of the plafond (P = 0.01), as well as night and weekend surgery (P = 0.03) were all independently associated with malalignment.

Conclusions:
Alignment of distal tibia fractures is sensitive to both injury and treatment factors. Nails should be targeted centrally or slightly posterolaterally to minimize malalignment.

Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Frailty and Malnutrition Are Associated With Inpatient Postoperative Complications and Mortality in Hip Fracture Patients
Authors: Wilson Jacob M. , Boissonneault Adam R. , Schwartz Andrew M. , Staley Christopher A. , Schenker Mara L. 
Published: January 2019

Objective:
To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients.

Design:
Retrospective observational cohort study.

Setting:
Urban, American College of Surgeons–Verified, Level-1, Trauma Center.

Patients/Participants:
Three hundred seventy-seven consecutive patients with isolated hip fractures.

Intervention:
N/A.

Main Outcome Measures:
On admission, albumin and total lymphocyte count (TLC) levels and complication data were collected. Additionally, mFI scores were calculated. Statistical analysis was then used to analyze the association between frailty, malnutrition, and postoperative complications.

Results:
Overall, 62.6% and 17.5% of patients were malnourished as defined by TLC of <1500 cells per cubic millimeter and albumin of <3.5 g/dL, respectively. Both TLC (P = 0.024; r = −0.12) and albumin (P < 0.001; r = −0.23) weakly correlated with frailty. Combining malnutrition and frailty revealed predictive synergy. Albumin of <3.5 g/dL and mFI of ≥0.18 in the same patient resulted in a positive predictive value of 69% and a likelihood ratio of 4 (2.15–7.43) for postoperative complications. Similarly, the combination of hypoalbuminemia and frailty resulted in a positive predictive value of 23.3% and likelihood ratio of 8.52 (P < 0.001) for mortality.

Conclusions:
When patients are frail and malnourished, there is a risk elevation beyond that of frailty or malnutrition in isolation. This high-risk cohort can be easily identified at admission with routine laboratory values and clinical history. There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor.

Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Hospital Mechanical Ventilation Volume and Patient Outcomes: Too Much of a Good Thing?
Authors: Mehta Anuj B. , Walkey Allan J. , Curran-Everett Douglas , Matlock Daniel , Douglas Ivor S. 
Published: January 2019

Objectives:
Prior studies investigating hospital mechanical ventilation volume-outcome associations have had conflicting findings. Volume-outcome relationships within contemporary mechanical ventilation practices are unclear. We sought to determine associations between hospital mechanical ventilation volume and patient outcomes.

Design:
Retrospective cohort study.

Setting:
The California Patient Discharge Database 2016.

Patients:
Adult nonsurgical patients receiving mechanical ventilation.

Interventions:
The primary outcome was hospital death with secondary outcomes of tracheostomy and 30-day readmission. We used multivariable generalized estimating equations to determine the association between patient outcomes and hospital mechanical ventilation volume quartile.

Measurements and Main Results:
We identified 51,689 patients across 274 hospitals who required mechanical ventilation in California in 2016. 38.2% of patients died in the hospital with 4.4% receiving a tracheostomy. Among survivors, 29.5% required readmission within 30 days of discharge. Patients admitted to high versus low volume hospitals had higher odds of death (quartile 4 vs quartile 1 adjusted odds ratio, 1.40; 95% CI, 1.17–1.68) and tracheostomy (quartile 4 vs quartile 1 adjusted odds ratio, 1.58; 95% CI, 1.21–2.06). However, odds of 30-day readmission among survivors was lower at high versus low volume hospitals (quartile 4 vs quartile 1 adjusted odds ratio, 0.77; 95% CI, 0.67–0.89). Higher hospital mechanical ventilation volume was weakly correlated with higher hospital risk-adjusted mortality rates (ρ = 0.16; p = 0.008). These moderately strong observations were supported by multiple sensitivity analyses.

Conclusions:
Contrary to previous studies, we observed worse patient outcomes at higher mechanical ventilation volume hospitals. In the setting of increasing use of mechanical ventilation and changes in mechanical ventilation practices, multiple mechanisms of worse outcomes including resource strain are possible. Future studies investigating differences in processes of care between high and low volume hospitals are necessary.
National Performance on the Medicare SEP-1 Sepsis Quality Measure
Authors: Barbash Ian J. , Davis Billie , Kahn Jeremy M. 
Published: January 2019

Objectives:
The Centers for Medicare and Medicaid Services requires hospitals to report compliance with a sepsis treatment bundle as part of its Inpatient Quality Reporting Program. We used recently released data from this program to characterize national performance on the sepsis measure, known as SEP-1.

Design:
Cross-sectional study of United States hospitals participating in the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program linked to Centers for Medicare and Medicaid Services’ Healthcare Cost Reporting Information System.

Setting:
General, short-stay, acute-care hospitals in the United States.

Measurements and Main Results:
We examined the hospital factors associated with reporting SEP-1 data, the hospital factors associated with performance on the SEP-1 measure, and the relationship between SEP-1 performance and performance on other quality measures related to time-sensitive medical conditions. A total of 3,283 hospitals were eligible for the analysis, of which 2,851 (86.8%) reported SEP-1 performance data. SEP-1 reporting was more common in larger, nonprofit hospitals. The most common reason for nonreporting was an inadequate case volume. Among hospitals reporting SEP-1 performance data, overall bundle compliance was generally low, but it varied widely across hospitals (mean and sd: 48.9% ± 19.4%). Compared with hospitals with worse SEP-1 performance, hospitals with better SEP-1 performance tended to be smaller, for-profit, nonteaching, and with intermediate-sized ICUs. Better hospital performance on SEP-1 was associated with higher rates of timely head CT interpretation for stroke patients (rho = 0.16; p < 0.001), more frequent aspirin administration for patients with chest pain or heart attacks (rho = 0.24; p < 0.001) and shorter median time to electrocardiogram for patients with chest pain (rho = –0.12; p < 0.001).

Conclusions:
The majority of eligible hospitals reported SEP-1 data, and overall bundle compliance was highly variable. SEP-1 performance was associated with structural hospital characteristics and performance on other measures of hospital quality, providing preliminary support for SEP-1 performance as a marker of timely hospital sepsis care.
What Does the Word “Treatable” Mean? Implications for Communication and Decision-Making in Critical Illness
Authors: Batten Jason N. , Kruse Katherine E. , Kraft Stephanie A. , Fishbeyn Bela , Magnus David C. 
Published: January 2019

Objectives:
To explore how nonphysicians and physicians interpret the word “treatable” in the context of critical illness.

Design:
Qualitative study using in-depth interviews.

Setting:
One academic medical center.

Subjects:
Twenty-four nonphysicians (patients and community members) purposively sampled for variation in demographic characteristics and 24 physicians (attending physicians and trainees) purposively sampled from four specialties (critical care, palliative care, oncology, and surgery).

Interventions:
None.

Measurements and Main Results:
We identified two distinct concepts that participants used to interpret the word “treatable”: 1) a “good news” concept, in which the word “treatable” conveys a positive message about a patient’s future, thereby inspiring hope and encouraging further treatment and 2) an “action-oriented” concept, in which the word “treatable” conveys that physicians have an action or intervention available, but does not necessarily imply an improved prognosis or quality of life. The overwhelming majority of nonphysicians adopted the “good news” concept, whereas physicians almost exclusively adopted the “action-oriented” concept. For some nonphysicians, the word “treatable” conveyed a positive message about prognosis and/or further treatment, even when this contradicted previously stated negative information.

Conclusions:
Physician use of the word “treatable” may lead patients or surrogates to derive unwarranted good news and false encouragement to pursue treatment, even when physicians have explicitly stated information to the contrary. Further work is needed to determine the extent to which the word “treatable” and its cognates contribute to widespread decision-making and communication challenges in critical care, including discordance about prognosis, misconceptions that palliative treatments are curative, and disputes about potentially inappropriate or futile treatment.
Modeling the Complex Exposure History of Smoking in Predicting Bladder Cancer
Authors: van Osch Frits H. M. , Vlaanderen Jelle , Jochems Sylvia H. J. , Bosetti Cristina , Polesel Jerry , Porru Stefano , Carta Angela , Golka Klaus , Jiang Xuejuan , Stern Mariana C. , Zhong Wei-De , Kellen Eliane , Pohlabeln Hermann , Tang Li , Marshall James , Steineck Gunnar , Karagas Margaret R. , Johnson Kenneth C. , Zhang Zuo-Feng , Taylor Jack A. , La Vecchia Carlo , Bryan Richard T. , van Schooten Frederik J. , Wesselius Anke , Zeegers Maurice P. 
Published: January 2019

Background:
Few studies have modeled smoking histories by combining smoking intensity and duration to show what profile of smoking behavior is associated with highest risk of bladder cancer. This study aims to provide insight into the association between smoking exposure history and bladder cancer risk by modeling both smoking intensity and duration in a pooled analysis.

Methods:
We used data from 15 case–control studies included in the bladder cancer epidemiology and nutritional determinants study, including a total of 6,874 cases and 17,727 controls. To jointly interpret the effects of intensity and duration of smoking, we modeled excess odds ratios per pack–year by intensity continuously to estimate the risk difference between smokers with long duration/low intensity and short duration/high intensity.

Results:
The pattern observed from the pooled excess odds ratios model indicated that for a fixed number of pack–years, smoking for a longer duration at lower intensity was more deleterious for bladder cancer risk than smoking more cigarettes/day for a shorter duration. We observed similar patterns within individual study samples.

Conclusions:
This pooled analysis shows that long duration/low intensity smoking is associated with a greater increase in bladder cancer risk than short duration/high intensity smoking within equal pack–year categories, thus confirming studies in other smoking-related cancers and demonstrating that reducing exposure history to a single metric such as pack–years was too restrictive.
A Novel and Highly Potent Urotensin II Receptor Antagonist Inhibits Urotensin II–Induced Pressure Response in Mice
Authors: Nishi Mina , Yonesu Kiyoaki , Tagawa Hideki , Kato Mikio , Marumoto Shinji , Nagayama Takahiro 
Published: January 2019

Abstract:
This study was designed to characterize the pharmacological profile of DS37001789, which is a structurally novel piperazine derivative that acts as urotensin II (U-II) receptor antagonist. DS37001789 inhibited [125I]-U-II binding to human GPR14, U-II receptor, with an IC50 value 0.9 nM. Its potency was superior to that of ACT-058362, a nonpeptide U-II receptor antagonist whose IC50 was 120 nM. Human U-II–induced vascular contraction was blocked by DS37001789. The dose–response curve of DS37001789 in rats and monkeys did not show species differences, and it shifted to the right without any effects on the maximum vascular response. Moreover, orally administered DS37001789 dose-dependently prevented human U-II–induced blood pressure elevation in mice, and this effect was significant at dose and higher dose (30 and 100 mg/kg), and its potency was superior to that of ACT-058362 (100 mg/kg). These results suggest that DS37001789 is a highly potent U-II receptor antagonist both in vitro and in vivo, with no marked species difference. DS37001789 would be a useful tool to clarify the physiological roles of U-II/GPR14 system. In addition, it can serve as a novel therapeutic agent for diseases in which the U-II/GPR14 system is upregulated, such as hypertension, heart failure, renal dysfunction, and diabetes.
A meta-analysis of efficacy and safety of sorafenib versus other targeted agents for metastatic renal cell carcinoma
Authors: Wang Hai-Tao , Xia Ming 
Published: January 2019

Abstract

Background:
Molecular targeted therapies were found to be efficacious and safer in the treatment of metastatic renal cell carcinoma (mRCC). Sorafenib is the first target agent (TA) to report a benefit in this disease and has largely established a prominent role in progression-free survival (PFS). However, there have been conflicting results across the trials that evaluated the efficacy of sorafenib.

Objective:
The aim of the study was to perform a meta-analysis to compare the efficacy and safety of sorafenib in first-line treatments of mRCC.

Methods:
We searched online electronic databases: PubMed, Embase, and the Cochrane Library updated on September 2017. Trials on the efficacy of sorafenib in first-line treatments of advanced RCC were included, of which the primary outcomes were objective response rate (ORR), PFS, overall survival (OS), and grade 3/4 adverse events (AEs).

Results:
A total of 5 trials were included in this analysis. The group of AEs showed significantly improved PFS (odds ratio [OR] = 0.78, 95% confidence interval [CI] = 0.70–0.86, P < .001), as well with the ORR (OR = 1.89, 95%CI = 1.38–2.59, P < .0001) compared with sorafenib. However, there was no significant difference in OS (OR = 0.97, 95%CI = 0.78–1.22, P = .82).

Conclusion:
Sorafenib did not achieve efficacy and safety benefit in patients with mRCC compared with those treated with TAs. The role of sorafenib in first-line treatments of mRCC may change in favor of newer drugs. More research is needed to confirm whether these new TAs could replace sorafenib as the gold standard in the future.
Hand tendinopathy risk factors in Taiwan
Authors: Shen Po-Chuan , Chang Po-Chun , Jou I-Ming , Chen Chung-Hwan , Lee Fang-Hsin , Hsieh Jeng-Long 
Published: January 2019

Abstract
De Quervain's disease, carpal tunnel syndrome (CTS), and trigger finger (digit) are three common pathological conditions of the hand. They are considered overuse syndromes and occur predominantly in females. The prevalence rate and cause-specific risks of these three tendinopathies have not yet been clarified. Data from 41,871 cases listed in the Taiwan National Health Insurance Research Database (NHIRD) from 2010 to 2014 were analyzed. The prevalence rate of these 3 conditions by age, sex, and the risk factors of female-dominant diseases (e.g., osteoporosis, rheumatoid arthritis [RA], and tendinopathy), diabetes mellitus, and hormone antagonist treatment was evaluated. We found that 1.59% of the population developed CTS, 0.49% developed de Quervain's, and 1.07% developed trigger finger. Cases were more likely to develop the three hand tendinopathies if they were female, between 50 and 59 years old, and, according to a multivariate analysis, comorbid with RA, diabetes, using hormone antagonists. Our findings should provide an understanding of the risk factors associated with hand tendinopathy.
High percentage atypical hepatocellular carcinoma in chronic hepatitis B patients treated with nucleos(t)ide analogs
Authors: Lin Ching-Chung , Bair Ming-Jong , Liu Chia-Yuan , Lin Ze-Yu , Chen Chih-Jen , Chen Ming-Jen , Chu Cheng-Hsin , Wang Horng-Yuan , Shih Shou-Chuan , Wang Tsang-En 
Published: January 2019

Abstract
Nucleos(t)ide analogs are used for preventing liver cirrhosis in chronic hepatitis B patients, but the risk factors of hepatocellular carcinoma (HCC) in these patients remain unclear. We designed this retrospective cohort study, the aim is to determine the risk factors for HCC development and its image presentation under nucleos(t)ide analogs treatment.
In this study, patients were treated with lamivudine (LAM), entecavir 0.5 mg (ETV), or telbivudine (LdT), and followed-up for at least 2 years to detect HCC and its presentation. Assessment of the risk factors for HCC included age, sex, HBeAg, viral load, liver cirrhosis, current and previous medications, and liver function tests.
Totally, 396 patients were recruited, and 18 patients developed HCC. The mean time from the treatment to HCC development was 28.5 ± 16.7 months. The clinical characteristics in HCC and no-HCC groups showed significant differences among age (52.8 ± 6.1 vs 47.1 ± 12.6 years, P <.01), baseline alanine transaminase (ALT) levels (161.4 ± 177.3 vs 361.7 ± 496.3, P <.01), and baseline liver cirrhosis (72.2% vs 29.9%, P <.01). In patients aged ≥45 years, the hazard ratio of HCC was 10.2 and liver cirrhosis was 4.1. Majority of HCCs developed in the right liver (14/18), were single numbered (13/18), had tumor size about 1.9 ± 0.7 cm, were classified as T1 (14/18, TNM staging), and the atypical image occupied 88% of the HCC cases.
The patients aged ≧45 years on long-term nucleos(t)ide analog therapy, and with baseline liver cirrhosis were at a high risk of HCC. Regular alpha-fetoprotein (AFP) assessment and image study of these patients are the gold standards for early HCC detection in patients with high percentage atypical HCC appearances.