bluuebunny/crossref_metadata_2025_split huggingface dataset:
Barriers and Facilitators to Self-Directed Learning in Continuing Professional Development for Physicians in Canada: A Scoping Review
Authors: Jeong Dahn , Presseau Justin , ElChamaa Rima , Naumann Danielle N. , Mascaro Colin , Luconi Francesca , Smith Karen M. , Kitto Simon 
Published: April 2018

Purpose
This scoping review explored the barriers and facilitators that influence engagement in and implementation of self-directed learning (SDL) in continuing professional development (CPD) for physicians in Canada.

Method
This review followed the six-stage scoping review framework of Arksey and O’Malley and of Daudt et al. In 2015, the authors searched eight online databases for English-language Canadian articles published January 2005–December 2015. To chart and analyze data from the 17 included studies, they employed a two-step analysis process composed of conventional content analysis followed by directed coding applying the Theoretical Domains Framework (TDF).

Results
Conventional content analysis generated five categories of barriers and facilitators: individual, program, technological, environmental, and workplace/organizational. Directed coding guided by the TDF allowed analysis of barriers and facilitators to behavior change according to two key groups: physicians engaging in SDL, and SDL developers designing and implementing SDL programs. Of the 318 total barriers and facilitators coded, 290 (91.2%) were coded for physicians and 28 (8.8%) for SDL developers. The majority (209; 65.7%) were coded in four key TDF domains: environmental context and resources, social influences, beliefs about consequences, and behavioral regulation.

Conclusions
This scoping review identified five categories of barriers and facilitators in the literature and four key TDF domains where most factors related to behavior change of physicians and SDL developers regarding SDL programs in CPD were coded. There was a significant gap in the literature about factors that may contribute to SDL developers’ capacity to design and implement SDL programs in CPD.
Outpatient Posterior Lumbar Fusion
Authors: Arshi Armin , Park Howard Y. , Blumstein Gideon W. , Wang Christopher , Buser Zorica , Wang Jeffrey C. , Shamie Arya N. , Park Don Y. 
Published: April 2018

Study Design.
A retrospective case-control study.

Objective.
The aim of this study was to determine the nationwide trends and complication rates associated with outpatient posterior lumbar fusion (PLF).

Summary of Background Data.
Outpatient lumbar spine fusion is now possible secondary to minimally invasive techniques that allow for reduced hospital stays and analgesic requirements. Limited data are currently available regarding the clinical outcome of outpatient lumbar fusion.

Methods.
The Humana administrative claims database was queried for patients who underwent one to two-level PLF (CPT-22612 or CPT-22633 AND ICD-9–816.2) as either outpatients or inpatients from Q1 2007 to Q2 2015. The incidence of perioperative medical and surgical complications was determined by querying for relevant International Classification of Diseases and Current Procedural Terminology codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate odds ratios (ORs) of complications among outpatients relative to inpatients undergoing PLF.

Results.
Cohorts of 770 patients who underwent outpatient PLF and 26,826 patients who underwent inpatient PLF were identified. The median age was in the 65 to 69 years age group for both cohorts. The annual relative incidence of outpatient PLF remained stable across the study period (R
2 = 0.03, P = 0.646). Adjusting for age, gender, and comorbidities, patients undergoing outpatient PLF had higher likelihood of revision/extension of posterior fusion [(OR 2.33, confidence interval (CI) 2.06–2.63, P < 0.001], anterior fusion (OR 1.64, CI 1.31–2.04, P < 0.001), and decompressive laminectomy (OR 2.01, CI 1.74–2.33, P < 0.001) within 1 year. Risk-adjusted rates of all other postoperative surgical and medical complications were statistically comparable.

Conclusion.
Outpatient lumbar fusion is uncommonly performed in the United States. Data collected from a national private insurance database demonstrate a greater risk of postoperative surgical complications including revision anterior and posterior fusion and decompressive laminectomy. Surgeons should be cautious in performing PLF in the outpatient setting, as the risk of revision surgery may increase in these cases.

Level of Evidence: 3
Ascorbic Acid Attenuates Multifidus Muscles Injury and Atrophy After Posterior Lumbar Spine Surgery by Suppressing Inflammation and Oxidative Stress in a Rat Model
Authors: Tang Pan , Zhu Ren , Gu Yu , Gu Jia-Ming , Xie Zi-Ang , Xu Jia-Qi , Zhao Xiang-De , Huang Kang-Mao , Wang Ji-Ying , Jiang Xue-Sheng , Fan Shun-Wu , Hu Zhi-Jun 
Published: April 2018

Study Design.
A rat model of multifidus muscles injury and atrophy after posterior lumbar spine surgery.

Objective.
We determined the effect of ascorbic acid (AA) on the postoperative multifidus muscles in rat model.

Summary of Background Data.
Previous studies show oxidative stress and inflammation are two main molecular mechanisms in multifidus muscle injury and atrophy after posterior lumbar surgery. AA may have a protective effect in postoperative multifidus muscles.

Methods.
Rats were divided into sham surgery, control surgery, and surgery plus AA groups. Multifidus muscles of the control and AA groups were excised from the osseous structures. The muscles were retracted continuously for 2 hours. In the sham and AA groups, AA was administered via oral gavage daily in the first week. In each group, the oxidative stress was evaluated by measuring malondialdehyde (MDA) and Total superoxide dismutase (T-SOD). The inflammation, fat degeneration, or fibrosis of multifidus muscle were evaluated by quantitative real-time polymerase chain reaction (q-PCR), histology, or immunohistochemical analysis.

Results.
T-SOD activity was significantly lower in the control group than that in the AA group in the first week. MDA levels were significantly higher in the AA group. Interleukin-6 and tumor necrosis factor-α in multifidus muscles also showed significant differences when treated with AA. The inflammation score on histology was significantly lower in the AA group postoperatively in the first week. In the long run, marker genes for fibrosis and fat degeneration, and fibrosis and fat degeneration scores, were significantly lower in the AA than the control group on days 14 and 28 postoperatively.

Conclusion.
In conclusion, AA attenuated the oxidative stress and inflammation response in the postoperative multifidus muscles, and remarkable differences were observed from the histological assessment and related marker genes expression. Our results provided important insight into the anti-inflammatory and anti-oxidative effects of AA in the postoperative multifidus muscles.

Level of Evidence: N/A
Estimation of Extra Length of Stay Attributable to Hospital-Acquired Infections in Adult ICUs Using a Time-Dependent Multistate Model*
Authors: Ohannessian Robin , Gustin Marie-Paule , Bénet Thomas , Gerbier-Colomban Solweig , Girard Raphaele , Argaud Laurent , Rimmelé Thomas , Guerin Claude , Bohé Julien , Piriou Vincent , Vanhems Philippe 
Published: April 2018

Objectives:
The objective of the study was to estimate the length of stay of patients with hospital-acquired infections hospitalized in ICUs using a multistate model.

Design:
Active prospective surveillance of hospital-acquired infection from January 1, 1995, to December 31, 2012.

Setting:
Twelve ICUs at the University of Lyon hospital (France).

Patients:
Adult patients age greater than or equal to 18 years old and hospitalized greater than or equal to 2 days were included in the surveillance. All hospital-acquired infections (pneumonia, bacteremia, and urinary tract infection) occurring during ICU stay were collected.

Interventions:
None.

Measurements and Main Results:
The competitive risks of in-hospital death, transfer, or discharge were considered in estimating the change in length of stay due to infection(s), using a multistate model, time of infection onset. Thirty-three thousand four-hundred forty-nine patients were involved, with an overall hospital-acquired infection attack rate of 15.5% (n = 5,176). Mean length of stay was 27.4 (± 18.3) days in patients with hospital-acquired infection and 7.3 (± 7.6) days in patients without hospital-acquired infection. A multistate model–estimated mean found an increase in length of stay by 5.0 days (95% CI, 4.6–5.4 d). The extra length of stay increased with the number of infected site and was higher for patients discharged alive from ICU. No increased length of stay was found for patients presenting late-onset hospital-acquired infection, more than the 25th day after admission.

Conclusions:
An increase length of stay of 5 days attributable to hospital-acquired infection in the ICU was estimated using a multistate model in a prospective surveillance study in France. The dose-response relationship between the number of hospitalacquired infection and length of stay and the impact of early-stage hospital-acquired infection may strengthen attention for clinicians to focus interventions on early preventions of hospital-acquired infection in ICU.
Modernizing the Mohs Surgery Consultation: Instituting a Video Module for Improved Patient Education and Satisfaction
Authors: Newsom Emily , Lee Erica , Rossi Anthony , Dusza Stephen , Nehal Kishwer 
Published: April 2018

BACKGROUND
Studies show that patients recall less than half of the information given by their physicians. Use of video in medicine increases patient comprehension and satisfaction and decreases anxiety. However, studies have not elaborated on video content.

OBJECTIVE
To use principles of learning with multimedia to improve the Mohs surgery consultation.

MATERIALS AND METHODS
The authors developed 2 informational videos on Mohs surgery: traditional versus narrative. The focus of the traditional video was purely didactic. The narrative video included patient testimonials, patient–physician interaction, and animations. New Mohs surgery patients viewed either the traditional (n = 40) or the narrative video (n = 40). Existing Mohs surgery patients (n = 40) viewed both videos. Both groups answered questionnaires about their satisfaction.

RESULTS
For new Mohs surgery patients, no significant difference was found between the traditional and the narrative video groups because respondent satisfaction was high for both video formats. For existing Mohs surgery patients, all respondents (100%) reported that videos were helpful for understanding Mohs surgery; however, the majority would recommend the narrative over the traditional format (72.5% vs 27.5%, p = .01).

CONCLUSION
Technology is useful for patient education because all patients preferred seeing a video to no video. Further research is needed to optimize effective multimedia use in patient education.
Effect of Diallyl Trisulfide on Ischemic Tissue Injury and Revascularization in a Diabetic Mouse Model
Authors: Yang Hai-Bing , Liu Hui-Min , Yan Jin-Chuan , Lu Zhao-Yang 
Published: April 2018

Background and Objective:
Allitridin [diallyl trisulfide (DATS)] is an extract from garlic (Allium sativum) that putatively improves endothelial function and is protective against cardiovascular diseases. Endothelial dysfunction after tissue ischemia in diabetic patients is partially due to poor angiogenic response. This study investigated whether DATS may improve angiogenesis in a diabetic mouse model with hind limb ischemia.

Methods:
Streptozotocin was administered by intraperitoneal injection to establish the model of diabetes in male C57BL/6 mice. After 14 days, nondiabetic and diabetic mice (n = 24, each) underwent unilateral hind limb ischemia by femoral artery ligation. The mice were apportioned to 4 groups: nondiabetic treated (or not) with DATS and diabetic treated (or not) with DATS. DATS treatment consisted of a single daily intraperitoneal injection of 500 μg·kg−1·d−1 for 14 days, beginning on the day of induced ischemia. Ischemia was scored by standard criteria. Blood perfusion was determined using thermal infrared imaging. Tissue capillary density and oxidative stress levels were measured by immunohistochemistry and immunofluorescence, respectively. Serum lipids were measured by enzymatic colorimetric assay. Fasting serum insulin was detected using an insulin enzyme-linked immunosorbent assay kit. Nitric oxide (NO) metabolites and protein carbonyls in tissues were determined by enzyme-linked immunosorbent assay. Targeted protein concentrations were measured by western blotting.

Results:
At 14 days after ligation, the ischemic skeletal muscle of the streptozotocin-induced diabetic mice had lower levels of endothelial NO synthase, phosphorylated endothelial NO synthase, and vascular endothelial growth factor compared with nondiabetic group. In addition, the hind limb blood perfusion, capillary density, and NO bioactivity were lower in the diabetic group, whereas oxidative stress and protein carbonyl levels were higher. These changes were ameliorated by DATS treatment.

Conclusions:
DATS treatment of diabetic mice promoted revascularization in ischemic tissue.
Cranial Remodeling Orthosis for Infantile Plagiocephaly Created Through a 3D Scan, Topological Optimization, and 3D Printing Process
Authors: Geoffroy Maya , Gardan Julien , Goodnough Jason , Mattie Johanne 
Published: April 2018

ABSTRACT

Purpose
This article presents a novel design of a cranial remodeling orthosis (CRO) helmet developed through a three-dimensional (3D) scanning and 3D printing process to correct an infantile plagiocephaly.

Materials and Methods
This research merges a handheld scanner, computer-aided engineering (CAE), and fused deposition modeling (FDM) technologies to propose an alternative to traditional plaster casting. The study finds out all criteria that will merge with requirements, 3D scanning, topological optimization into the CAE, and 3D printing to implement the design for manufacturing (DFM) approach to get a reproducible process that is less invasive for the child.

Results
The project identifies the current limitations and creates design requirements and acceptance criteria to define a design and manufacturing process using a topological optimization method. Based on a child's skull 3D scan, the application aims to manufacture a CRO helmet due to clinical criteria by 3D printing. The new design aims to reduce the time from assessment to initial fitting and to reduce the temperature within the CRO. The project has manufactured a CRO helmet by fused depositing modeling in 3D printing to characterize its mechanical behavior and analyze the possible improvements.

Conclusions
Limitations were found in the material used in the 3D printing, and some recommendations are made to improve the method. The DFM approach is useful for improving the final product by considering manufacturing and use constraints as soon as possible in the design stage, such as part orientation, infill density, and topological optimization parameters as well as the practitioner' skills. The main novelty is to have developed a 3D scanning and 3D printing process to correct an infantile plagiocephaly to obtain a CRO helmet responding to use and manufacturing constraints while proposing a suitable organic shape.
Factors Associated With the Benefits of Concurrent Administration of Intratympanic Steroid Injection With Oral Steroids in Patients With Acute Acoustic Trauma
Authors: Chang Young-Soo , Bang Kanghyun , Choi Nayeon , Kim Jong Sei , Lee Gang-Gyu 
Published: April 2018

Objective:
To analyze the factors associated with the benefits of concurrent administration of intratympanic steroid injection (ITSI) and oral steroids in patients with acute acoustic trauma (AAT) incurred during military training.

Study Design:
Retrospective analysis.

Patients:
Nineteen patients eligible under the criteria established concerning treatment for AAT were retrospectively reviewed in this study.

Interventions:
ITSI treatments were administered simultaneously alongside oral prednisolone.

Main Outcome Measures:
Patients were categorized into two groups depending on the time elapsed between exposure to the noise and treatment initiation: 1) “Early Treatment initiation,” defined as the treatment being initiated between 3 and 7 days; and 2) “Delayed treatment initiation,” defined as the treatment being initiated in >7 days. Pure-tone air conduction threshold audiometry, to record the pure-tone average (PTA) at 2, 4, and 8 kHz, was conducted upon each patient's initial visit, and 1 month after starting treatment. The degree of hearing gain (hearing gain [dB] = [initial PTA] – [final PTA]) was calculated and used as the metric for determining the treatment's outcome. The initial PTA and treatment onset were adopted as possible associated factors.

Results:
The mean ages of each group were 22.00 ± 2.12 years and 22.83 ± 2.64 years, respectively (p = 0.28). The initial PTAs were 46.41 ± 12.73 dB and 47.22 ± 14.74 dB, respectively (p = 1.00).
In the multivariable linear regression analysis, the initial PTA and the treatment initiation showed a significant association (R2 = 0.37). The unstandardized regression coefficient of the initial PTA was 0.37 (p = 0.04). Patients with early treatment initiation showed significant improvement in the degree of hearing gain compared with delayed treatment initiation (unstandardized regression coefficient = 12.63, p = 0.01).

Conclusions:
We demonstrated the importance of early treatment onset for maximizing the benefits of concurrent administration of ITSI with oral steroids in patients with AAT suffered during military training. Further evaluation is needed to confirm the factors associated with the efficacy of concurrent ITSI with oral steroids.
Short article: Safety of targeted prophylaxis strategy in patients with resolved hepatitis B virus infection receiving rituximab for immune-mediated diseases
Authors: Spinicci Michele , Emmi Giacomo , Dies Laura , Barilaro Alessandro , Vitiello Gianfranco , Mencarini Jessica , Cavallo Annalisa , Bartoloni Alessandro , Bartalesi Filippo 
Published: April 2018

Objectives
Rituximab (RTX) is a monoclonal antibody that is widely used in hematologic malignancies and immune-mediated diseases (IMID) and has been associated with the risk of hepatitis B virus reactivation (HBVr). Thus, antiviral prophylaxis is recommended before RTX treatment in all patients with chronic hepatitis B virus (HBV) infection and those with resolved infection affected by onco-hematological conditions. By contrast, the correct management of HBsAg-negative/HbcAb-positive patients candidates for RTX-containing regimens for IMID is still debated, owing to few data currently available in this setting.

Patients and methods
We retrospectively evaluated the risk of HBVr in patients with IMID with resolved HBV infection, referred to the Infectious and Tropical Diseases Unit Outpatients Service, Careggi Hospital, Florence, Italy, between September 2013 and September 2017, undergoing RTX without antiviral prophylaxis and followed up by serial serum HBV-DNA monitoring.

Results
Overall, 20 patients with IMID were identified (70% female, with median age of 57 years) and followed up for a median period of 19 months (range: 2–36 months). A single HBVr case, detected in preclinical stage, was observed (1/20, 5%), and targeted prophylaxis was promptly introduced.

Conclusion
The results supported the low to moderate risk of HBVr in HBsAg-negative/HBcAb-positive patients with IMID undergoing RTX, in contrast to what is observed in onco-hematological settings. The targeted prophylaxis strategy, based on serum HBV-DNA serial monitoring, seems a safe option in these patients.
Centers for Disease Control and Prevention Syphilis Summit: Difficult Clinical and Patient Management Issues
Authors: Marra Christina M. , Ghanem Khalil G. 
Published: April 2018

Abstract
Despite over a century of clinical experience in diagnosing and managing patients with syphilis, many thorny clinical questions remain unanswered. We focus on several areas of uncertainty for the clinician: the role of serologic tests in diagnosing syphilis and assessing syphilis treatment responses, and the risk of neurosyphilis and ocular syphilis in patients with syphilis. We also address whether clinical approaches should differ in patients who are, and are not, infected with HIV. The current increases in syphilis rates in the United States and elsewhere underscore our urgent need to definitively address these issues.
Quality Improvement Education in Residency Training
Authors: Massagli Teresa L. , Zumsteg Jennifer M. , Osorio Marisa B. 
Published: April 2018

Abstract
Hospitals and healthcare institutions have strong external and internal pressures to improve patient safety and healthcare quality. Quality improvement education has been mandated for resident physicians by the Accreditation Council for Graduate Medical Education. This review describes didactic and experiential curricula for residents in quality improvement interventions as well as factors that create challenges to implementing such a curriculum and those that foster it. Resident attitudes, faculty capacity, institutional resources, and dedicated time are critical elements influencing the success of quality improvement curricula. Faculty interest in quality improvement could be enhanced by academic recognition of their work. Recommendations to facilitate publication of quality improvement efforts are described.
Clinical Improvements Are Not Explained by Changes in Tendon Structure on Ultrasound Tissue Characterization After an Exercise Program for Patellar Tendinopathy
Authors: van Ark Mathijs , Rio Ebonie , Cook Jill , van den Akker-Scheek Inge , Gaida James E. , Zwerver Johannes , Docking Sean 
Published: April 2018

ObjectivesThe aim of this study was to investigate the effects of a 4-wk in-season exercise program of isometric or isotonic exercises on tendon structure and dimensions as quantified by ultrasound tissue characterization (UTC).DesignThis was a randomized clinical trial. Volleyball and basketball players (16–31 yrs,n= 29) with clinically diagnosed patellar tendinopathy were randomized to a 4-wk isometric or isotonic exercise program. The programs were designed to decrease patellar tendon pain. A baseline and 4-wk UTC scan was used to evaluate change in tendon structure.ResultsNo significant change in tendon structure or dimensions on UTC was detected after the exercise program despite patellar tendinopathy symptoms improving. The percentage and mean cross-sectional area of aligned fibrillar structure (echo types I + II) (Z= −0.414,P= 0.679) as well as disorganized structure (echo types III + IV) (Z= −0.370,P= 0.711) did not change over the 4-wk exercise program. Change in tendon structure and dimensions on UTC did not differ significantly between the groups.ConclusionStructural properties and dimensions of the patellar tendon on UTC did not change after a 4-wk isometric or isotonic exercise program for athletes with patellar tendinopathy in-season, despite an improvement in symptoms. It seems that structural improvements are not required for a positive clinical outcome.