bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cluster analysis to define distinct clinical phenotypes among septic patients with bloodstream infections
Authors: Guilamet Maria Cristina Vazquez , Bernauer Michael , Micek Scott T. , Kollef Marin H. 
Published: April 2019

Abstract
Prior attempts at identifying outcome determinants associated with bloodstream infection have employed a priori determined classification schemes based on readily identifiable microbiology, infection site, and patient characteristics. We hypothesized that even amongst this heterogeneous population, clinically relevant groupings can be described that transcend old a priori classifications.
We applied cluster analysis to variables from three domains: patient characteristics, acuity of illness/clinical presentation and infection characteristics. We validated our clusters based on both content validity and predictive validity.
Among 3715 patients with bloodstream infections from Barnes-Jewish Hospital (2008–2015), the most stable cluster arrangement occurred with the formation of 4 clusters. This clustering arrangement resulted in an approximately uniform distribution of the population: Cluster One “Surgical Outside Hospital Transfers” (21.5%), Cluster Two “Functional Immunocompromised Patients” (27.9%), Cluster Three “Women with Skin and Urinary Tract Infection” (28.7%) and Cluster Four “Acutely Sick Pneumonia” (21.8%). Staphylococcus aureus distributed primarily to Clusters Three (40%) and Four (25%), while nonfermenting Gram-negative bacteria grouped mainly in Clusters Two and Four (31% and 30%). More than half of the pneumonia cases occurred in Cluster Four. Clusters One and Two contained 33% and 31% respectively of the individuals receiving inappropriate antibiotic administration. Mortality was greatest for Cluster Four (33.8%, 27.4%, 19.2%, 44.6%; P < .001), while Cluster One patients were most likely to be discharged to a nursing home.
Our results support the potential for machine learning methods to identify homogenous groupings in infectious diseases that transcend old a priori classifications. These methods may allow new clinical phenotypes to be identified potentially improving the severity staging and development of new treatments for complex infectious diseases.
Liuwei Dihuang Decoction for primary osteoporosis
Authors: Liu Yu , Wang Ping , Shi Xiuqun , Li Huijin , Zhang Xionghui , Zeng Shenghu , Xu Zhoufa , Lai Dongqing , Zhang Minling 
Published: April 2019

Abstract

Background:
Primary osteoporosis (POP) is one kind of global disease, as a serious threat to human health. Liuwei Dihuang Decoction (LWDHD) has been recommended to treat osteoporosis alone or combined with medicine in China; however, its efficacy is unclear. The object of this systematic review and meta-analysis is to evaluate the efficacy and safety of LWDHD in the management of POP.

Methods:
We will search The Cochrane Library, Medline, PubMed, Elsevier, Springer, Web of Science, Ovid, WHO ICTRP, CNKI, CBM, VIP, and WanFang Database from their inception to February 2019. All randomized controlled trials (RCTs) of LWDHD for the treatment of POP will be included. The language is limited to Chinese and English. The fracture incidence will be accepted as the primary outcomes. Data synthesis, subgroup analysis, sensitivity analysis will be performed by using RevMan V.5.3.5 software.

Results:
A high-quality synthesis of current evidence for the treatment of POP with LWDHD will be provided from efficacy and safety.

Conclusion:
This systematic review will generate evidence for judging whether LWDHD is an effective and safe intervention for POP or not.

PROSPERO registration number:
PROSPERO CRD 4201926066.
Case report of long-term survival with metastatic triple-negative breast carcinoma
Authors: Chue Ben Man-Fai , La Course Bryce Douglas 
Published: April 2019

Abstract

Rationale:
Breast cancer is the most common as well as one of the most devastating cancers among women in the United States. Prognosis is poor for patients with metastatic breast cancer, especially for patients with so-called “triple-negative” disease. The lack of effective therapies for metastatic triple-negative breast cancer outlines the need for novel and innovative treatment strategies.

Patient concerns:
A 58-year-old underwent a mastectomy which revealed a recurrent triple-negative breast carcinoma. Afterward, she presented with a growing mass in her left axilla and chest wall. A computed tomography scan showed axillary and supraclavicular adenopathy, nodules in the left upper and lower lobe of the lungs, and 2 areas of disease in the liver. A bone scan showed lesions in the ribs.

Diagnosis:
The patient was diagnosed with a recurrent metastatic triple-negative breast carcinoma that spread to the lung, liver, and bones.

Interventions:
The patient was treated with metronomic chemotherapy, sequential chemotherapy regimens, and immunotherapy.

Outcomes:
The patient is now over 15 years out from her diagnosis of metastatic disease without any evidence of recurrent disease, likely due to the patient's treatment strategy which included sequential metronomic chemotherapy regimens and immunotherapy.

Lessons:
Sequential metronomic chemotherapy regimens in combination with immunotherapy might be an effective treatment option for patients with metastatic triple-negative breast cancer. We hope that this case can provide some guidance for the treatment of metastatic triple-negative breast cancer and motivate research that can potentially lead to more cases of long-term survival for patients who develop this dismal disease.
A very rare presentation of reoperation combined both old Monteggia fracture and secondary distal radioulnar joint dislocation in adult
Authors: Zhang Yanchao , Xiao Wan’an , Li Jianjun 
Published: April 2019

Abstract

Rationale:
The old Monteggia fracture is an uncommon lesion pattern in adult, which may lead to the potential complications such as recurrent dislocation of the radial head, heterotopic ossification of the elbow, nerve palsy, malunion of the ulna, and residual forearm deformity. However, the secondary distal radioulnar joint (DRUJ) dislocation is rarely reported in the similar lesion. Here we present a unique reoperation of old Monteggia fracture combined with secondary DRUJ disruption after the initial operation failure.

Patient concerns:
A 38-year-old male presented to our hospital outpatient office complaining of left elbow stiffness and ongoing wrist dysfunction with a history of injury to the left forearm caused by a forklift accident that occurred 5 months previously.

Diagnosis and interventions:
At the local hospital, the patient underwent successively fasciotomy and decompression, ulnar open reduction, and internal fixation due to osteofascial compartment syndrome and a misdiagnosed ulnar fracture. Upon examination, the secondary dorsal dislocation of the DRUJ was obvious both clinically and radiographically. We performed a revision surgery called ulnar osteotomy, radioulnar ligament repair, and temporary fixation of the DRUJ with a Kirschner wire.

Outcomes:
The patient received a satisfactory result without observed redislocation and relapse according to the 1-year follow-up.

Lessons:
Considering the notoriously poor outcomes, the importance of early recognition and accurate treatment should be emphasized repeatedly in similar lesions. Paying close and continuous attention to the clinical and radiographic examinations of the elbow and wrist joint is necessary to avoid misdiagnosis and missed diagnosis.
Progressive sacroiliitis due to accessory sacroiliac joint mimicking ankylosing spondylitis
Authors: Song Ran , Lee Soyun , Lee Sang-hoon 
Published: April 2019

Abstract

Rationale:
An accessory sacroiliac (SI) joint usually has little clinical significance. However, severe arthritic changes can cause chronic buttock or low back pain and can be misdiagnosed as another disease presenting with sacroiliitis such as ankylosing spondylitis (AS).

Patient concerns:
A 33-year-old woman was diagnosed with AS due to chronic buttock pain and progressive sacroiliitis on plain X-ray and magnetic resonance imaging (MRI). Her buttock and low back pain gradually worsened despite proper treatment for AS.

Diagnosis:
Computed tomography revealed an accessory SI joint with arthritic changes.

Interventions:
Nonsteroidal anti-inflammatory drugs (NSAIDs) and restricted movement were prescribed.

Outcomes:
The symptoms were controlled with NSAIDs, rest, and restriction of excessive movement. The medication could be stopped after the pain subsided.

Lessons:
An accessory SI joint can be a cause of chronic back pain and can be misdiagnosed as AS with sacroiliitis when progressive arthritic changes are observed. Therefore, additional imaging studies other than conventional X-ray or MRI may be required for accurate diagnosis.
Clinical features, surgical management, and long-term prognosis of intraventricular meningiomas
Authors: Chen Cheng , Lv Liang , Hu Yu , Yin Senlin , Zhou Peizhi , Jiang Shu 
Published: April 2019

Abstract
Intraventricular meningiomas are rather rare and only represent a small proportion of all intracranial meningiomas. Data are still limited toward this peculiar entity and surgical resection remains challenging for neurosurgeons. The purpose of present study is to demonstrate clinical features, surgical treatment, and potential risk factors determined long-term prognosis of intraventricular meningiomas.
A total of 89 surgically treated and histopathologically confirmed intraventricular meningiomas were identified in our institution from 2008 to 2018. Clinical features, neuroimaging findings, surgical records, and prognosis data were extracted and reviewed retrospectively. Group comparison and recurrence-free survival analysis were performed.
Female predominance was well established with a sex radio of 2.1:1. Raised intracranial pressure and decline of visual acuity were 2 chief symptoms that patients generally complained of. Preoperative magnetic resonance imaging (MRI) scans were performed in all patients and there was a trend toward lateral ventricular meningiomas were larger in size than others (P = .07). Superior parietal lobule and temporal approach were widely adopted and lateral/4th ventricular meningiomas were more easily to acquire total tumor resection as compared with 3rd ventricular meningiomas (P = .03). After an average follow-up of 57.3 months, 6 patients experienced recurrence of disease in our series. Individuals with subtotal resection (P < .001) and higher World Health Organization classification (P = .001) were more prone to relapse.
Intraventricular meningiomas presented with a wide variety of symptoms. Surgery remained 1st treatment of choice and optimal surgical approach should be planned individually based on preoperative MRI evaluation. Patients underwent subtotal tumor resection and with malignant tumor nature should be carefully monitored during follow-up.
A meta-analysis on the prognosis of exosomal miRNAs in all solid tumor patients
Authors: Zhou Jiupeng , Guo Hui , Yang Yuanli , Zhang Yongfeng , Liu Heng 
Published: April 2019

Abstract

Background:
It has been reported that the encapsulated miRNAs from exosomes are potential biomarkers of tumors prognosis. Yet, the results are controversial, so it is obliged to do a meta-analysis to reach a definite conclusion.

Materials and methods:
Studies were searched for published in PubMed, Embase, and Web of Science databases until April 20, 2018. A meta-analysis was conducted to appraise the role of exosomal miRNAs in prognosis of cancer patients.

Results:
The different exosomal miRNAs expression was remarkably related to overall survival (OS) (hazard ratio [HR] = 2.02, 95% confidence interval [CI]: 1.84–2.21) and disease-free survival (DFS) (HR = 2.43, 95% CI: 1.86–3.17) of cancer patients. High exosomal miR-21 expression was associated with poor OS (HR = 2.59; 95% CI: 1.71–3.90) and DFS (HR = 1.84; 95% CI: 1.37–2.47). High exosomal miR-451a expression was associated with poor OS (HR = 4.81; 95% CI: 2.33–9.93) and DFS (HR = 2.64; 95% CI: 1.62–4.31). High exosomal miR-1290 expression was associated with poor OS (HR = 1.73; 95% CI: 1.29–2.33). Low exosomal miR-638 expression was associated with poor OS (HR = 2.25; 95% CI: 1.46–3.46).

Conclusion:
The expression levels of exosomal miRNAs, particularly miR-21, miR-451a, miR-1290, and miR-638 could strongly predict prognosis of solid tumor patients and might be a potential target for tumor treatment.
Comparison of risk scores and shock index in hemodynamically stable patients presenting to the emergency department with nonvariceal upper gastrointestinal bleeding
Authors: Jung Dae Ho , Ko Byuk Sung , Kim Youn-Jung , Kim Won Young 
Published: April 2019

Objective
Risk assessment in nonvariceal upper gastrointestinal bleeding (UGIB) is not well validated and remains unclear in hemodynamically stable patients at emergency department admission. We compared the prognostic value of risk-scoring systems for predicting adverse outcomes in patients with nonvariceal UGIB and normotension.

Participants and methods
A single-center prospective observational study was carried out. Patients with consecutive nonvariceal UGIB, presenting with normotension (systolic blood pressure ≥90 mmHg) to the emergency department, were included. We compared the areas under the curves (AUC) of Glasgow Blatchford score (GBS), the pre-endoscopy Rockall score, AIMS65, the shock index, and the modified shock index with respect to adverse outcomes defined as embolization, surgery, ICU admission, rebleeding, and in-hospital mortality.

Results
In total, 1233 patients were included. Adverse outcomes occurred in 165 (13.4%) patients; in-hospital mortality was 1.2%. AUC of the GBS for adverse outcome was higher than that of the shock index, but not significantly different (0.647 vs. 0.569, P=0.23). AUC values of the modified shock index, AIMS65, and the pre-endoscopy Rockall score were 0.565, 0.593, and 0.533, respectively. The cut-off value of the GBS (≥8) was associated with 85% sensitivity and 35% specificity for predicting adverse outcome.

Conclusion
Pre-existing risk scores have shown suboptimal predictive ability for adverse events in normotensive patients with nonvariceal UGIB. The GBS (≥8) might help to identify patients prone to adverse events; however, further studies with risk scores or new scores are needed because of the low accuracy of these scores.
Costs and Trends of Emergency Department Utilization Pre-ACA and Post-ACA
Authors: Vernon Marlo , Goggans Steven , De Leo Gianluca , Heboyan Vahé 
Published: April 2019

Background:
A high volume of emergency department (ED) visits in the rural United States may be the result of barriers to accessing primary care. The Affordable Care Act (ACA) increased the number of insured, which may improve patient access to primary care and therefore reduce ED utilization. The objective of this study is to estimate the trends and cost of ED utilization pre-ACA and post-ACA implementation in a rural United States.

Data and Methods:
We use 2009–2013 ED utilization data from a rural Georgia hospital to estimate trends and costs by demographic characteristics, referring source, and payor information. T tests and log-linear regression models are used to assess the sociodemographic factors impacting ED inflation-adjusted costs before (2009–2010) and after ACA (2011–2013) implementation.

Results:
During 2009–2013, 39,970 ED encounters were recorded with an average cost (AC) of $2002 per visit. Results indicate that during pre-ACA, on average, 8702 encounters were recorded per year with an AC of $1759. During post-ACA, there were 7521 annual visits, with an annual AC of $2241. Regression model results indicate that AC were significantly higher for men, older adults, nonblack patients, those with private insurance, and during the post-ACA period.

Conclusions:
Results suggest that post-ACA, declining ED visits may be due to more patients with insurance accessing primary care instead of ED. We further hypothesize that increased AC during this period may be due to ED visits being of an emergent nature, which require more resources to treat. Further comprehensive investigation is warranted to study the impact of ACA on ED utilization for nonemergency purposes among rural and nonrural hospitals.
Maryland’s Global Hospital Budgets
Authors: Beil Heather , Haber Susan G. , Giuriceo Katherine , Amico Peter , Morrison Marisa , Beadles Christopher , Berzin Olivia , Cole-Beebe Maggie , Greenwald Leslie , Jiang Linda , Perry Rebecca , Wright Alton 
Published: April 2019

Background:
Global budgets have been proposed as a way to control health care expenditures, but experience with them in the United States is limited. Global budgets for Maryland hospitals, the All-Payer Model, began in January 2014.

Objectives:
To evaluate the effect of hospital global budgets on health care utilization and expenditures.

Research Design:
Quantitative analyses used a difference-in-differences design modified for nonparallel baseline trends, comparing trend changes from a 3-year baseline period to the first 3 years after All-Payer Model implementation for Maryland and a matched comparison group.

Subjects:
Hospitals in Maryland and matched out-of-state comparison hospitals. Fee-for-service Medicare beneficiaries residing in Maryland and comparison hospital market areas.

Measures:
Medicare claims were used to measure total Medicare expenditures; utilization and expenditures for hospital and nonhospital services; admissions for avoidable conditions; hospital readmissions; and emergency department visits. Qualitative data on implementation were collected through interviews with senior hospital staff, state officials, provider organization representatives, and payers, as well as focus groups of physicians and nurses.

Results:
Total Medicare and hospital service expenditures declined during the first 3 years, primarily because of reduced expenditures for outpatient hospital services. Nonhospital expenditures, including professional expenditures and postacute care expenditures, also declined. Inpatient admissions, including admissions for avoidable conditions, declined, but, there was no difference in the change in 30-day readmissions. Moreover, emergency department visits increased for Maryland relative to the comparison group.

Conclusions:
This study provides evidence that hospital global budgets as implemented in Maryland can reduce expenditures and unnecessary utilization without shifting costs to other parts of the health care system.
Medicare Beneficiaries With a Specialist as Their Personal Doctor Report Better Experiences With Care
Authors: Collins Rebecca L. , Elliott Marc N. , Burkhart Q , Haviland Amelia , Gaillot Sarah , Orr Nate , Friedberg Mark W. 
Published: April 2019

Background:
Health plans often require that patients have a personal doctor. Older adults rely on specialists for much of their care and may use a specialist in this role, but little is known about how many or which Medicare beneficiaries use specialists as their personal doctor and how their care experiences differ from others’.

Objective:
To examine the prevalence and characteristics of Medicare beneficiaries with a specialist as a personal doctor and compare their patient experiences and immunization to other beneficiaries’.

Research Design:
Logistic regression predicted having a specialist as a personal doctor from beneficiary characteristics. Doubly-robust models compared 7 patient experience and 2 immunization measures for beneficiaries with and without a specialist as their personal doctor. Interactions of a specialist indicator and beneficiary characteristics tested for moderators.

Study Population:
A total of 227,642 Medicare beneficiaries aged 65+ who reported having a personal doctor on the 2014 Medicare CAHPS survey.

Results:
In total, 20% of beneficiaries reported that their personal doctor was a specialist, fewer than previously reported for the most frequently visited physician (43%); beneficiaries who were older, less healthy, less educated, racial/ethnic minorities, had fee-for-service coverage, or had lower income were more likely to do so. They also reported better patient experiences than those with nonspecialist personal physicians on 6 of 7 measures and more immunizations; the largest difference was for care coordination. Having a specialist personal doctor was associated with particularly positive patient experience for low income, Black, Hispanic, and less healthy beneficiaries.

Conclusion:
Future research should investigate whether specialists as personal doctors may reduce patient-experience disparities for vulnerable patients.
Influence of Peer Physicians on Intensity of End-of-Life Care for Cancer Decedents
Authors: Keating Nancy L. , O’Malley Alistair James , Onnela Jukka-Pekka , Gray Stacy W. , Landon Bruce E. 
Published: April 2019

Background:
The intensity of end-of-life care varies substantially both within and between areas. Differing practice patterns of individual physicians are likely influenced by their peers.

Objective:
To assess whether intensity of end-of-life care previously provided by a physician’s peers influences patterns of care at the end-of-life for that physician’s patients.

Research Design:
Observational study.

Subjects:
A total of 185,947 fee-for-service Medicare enrollees with cancer who died during 2006–2010 who were treated by 26,383 physicians.

Measures:
Spending in the last month of life, >1 emergency room visit, >1 hospitalization, intensive care unit admission in the last month of life, chemotherapy within 2 weeks of death, no/late hospice, terminal hospitalization.

Results:
Mean (SD) spending in the last month of life was $16,237 ($17,124). For each additional $1000 of spending for a peer physician’s patients in the prior year, spending for the ego physician’s patients was $83 higher (P<0.001). Among physicians with peers both in and out of their practice, more of the peer effect was explained by physicians outside of the practice ($72 increase for each $1000 increase by peer physicians’ patients, P<0.001) than peer physicians in the practice ($27 for each $1000 increase by within-practice peer physicians’ patients, P=0.01). Results were similar across the other measures of end-of-life care intensity.

Conclusions:
Physician’s peers exert influence on the intensity of care delivered to that physician’s patients at the end-of-life. Physician education efforts led by influential providers and provider organizations may have potential to improve the delivery of high-value end-of-life care.
An update in the management of pediatric sarcoma
Authors: Sandler Gideon , Yokoi Akiko , Hayes-Jordan Andrea 
Published: April 2019

Purpose of review
Nonrhabdomyosarcoma soft tissue sarcoma (NRSTS) is a rare subgroup of malignancy in childhood that is composed of a variety of soft tissue and bony tumors. Prognosis for resectable localized disease is usually good and improved with systemic treatment. However, survival from locally advanced and metastatic disease remains poor. There have been numerous preclinical and clinical studies to define histopathology, biology, and genetic alteration of sarcomas. The purpose of this review is to clarify the progress in the management of NRSTS.

Recent findings
Genomic analysis, including the use of next-generation sequencing, has revealed fusion transcripts or specific genetic alterations which provide diagnostic biomarkers and potential targets for novel therapies.

Summary
Most cases are sporadic, but some are associated with genetic predispositions. Most present as a painless mass and diagnosis is frequently delayed because of a low index of suspicion. There is a wide array of histopathological subtypes. Investigations usually involve core, incisional or excisional biopsy for tissue diagnosis, and cross-sectional and nuclear imaging for staging. Management of pediatric sarcoma is largely dependent on the patient's histopathological diagnosis, age, disease stage, and co-morbidities but usually involves a combination of systemic and local therapies. Preclinical studies and phase I/II trials of newer targeted therapies are ongoing.