bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cost-Effectiveness of Curettage Versus Expectant Management in Women With an Incomplete Evacuation After Misoprostol Treatment for First-Trimester Miscarriage: A Randomized Controlled Trial and Cohort Study
Authors: Lemmers Marike , Verschoor Marianne A. C. , Bossuyt Patrick M. , Huirne Judith A. F. , Spinder Teake , Nieboer Theodoor E. , Bongers Marlies Y. , Janssen Ineke A. H. , Van Hooff Marcel H. A. , Mol Ben W. J. , Ankum Willem M. , Bosmans Judith E. 
Published: July 2018

(Abstracted from Acta Obstet Gynecol Scand 2018;97(3):294–300)
Misoprostol was introduced over 10 years ago as a treatment option for women with first-trimester miscarriages alongside expectant management and curettage. It is an effective treatment for 50% to 85% of these women.
Opioid Utilization Following Lumbar Arthrodesis
Authors: Kalakoti Piyush , Hendrickson Nathan R. , Bedard Nicholas A. , Pugely Andrew J. 
Published: July 2018

Study Design.
A retrospective, observational cohort study.

Objective.
In patients undergoing lumbar spine arthrodesis, we sought to establish perioperative trends in chronic versus naive opioid users (OUs) and identify modifiable risk factors associated with prolonged consumption.

Summary of Background Data.
The morbidity associated with excessive opioid use for chronic conditions continues to climb and has been identified as a national epidemic. Limiting excessive perioperative opioid use after procedures such as lumbar fusion remains a national health strategy.

Methods.
A national commercial claims dataset (2007–2015) was queried for all patients undergoing anterior lumbar interbody fusion (ALIF) and/or lumbar [posterior/transforaminal lumbar interbody fusion (P/TLIF) or posterolateral fusion (PLF)] spinal fusion procedures. Patients were labeled as either an OU (prescription within 3 months pre-surgery) or opioid naive (ON, no prescription). Rates of opioid use were evaluated preoperatively for OU, and longitudinally tracked up to 1-year postoperatively for both OU and ON. Multivariable regression techniques investigated factors associated with opioid use at 1-year following surgery. In addition, a clinical calculator (app) was created to predict 1-year narcotic use.

Results.
Overall, 26,553 patients (OU: 58.3%) underwent lumbar surgery (ALIF: 8.5%; P/TLIF: 43.8%; PLF: 41.5%; ALIF+PLF: 6.2%). At 1-month postop, 60.2% ON and 82.9% OUs had a filled opioid prescription. At 3 months, prescription rates declined significantly to 13.9% in ON versus 53.8% in OUs, while plateauing at 6 to 12-month postoperative period (ON: 8.4–9.6%; OU: 42.1–45.3%). At 1 year, significantly higher narcotic prescription filling rates were observed in OUs than in ON (42.4% vs. 8.6%; P < 0.001). Preoperative opioid use was the strongest driver of 1-year narcotic use following ALIF [odds ratio (OR): 7.86; P < 0.001], P/TLIFs (OR: 4.62; P < 0.001), or PLF (OR: 7.18; P < 0.001).

Conclusion.
Approximately one-third patients chronically use opioids before lumbar arthrodesis and nearly half of the pre-op OUs will continue to use at 1 year. Our findings serve as a baseline in identifying patients at risk for chronic use and alter surgeons to work toward discontinuation of opioids before lumbar spinal surgery.

Level of Evidence: 3
Intraoperative Neuromonitoring (IONM)
Authors: Kumar Naresh , G Vijayaraghavan , Ravikumar Nivetha , Ding Yan , Yin May Lin , Patel Ravish Shammi , Naresh Nandika , Hey Hwee Weng Dennis , Lau Leok-Lim , Liu Gabriel 
Published: July 2018

Study Design.
A retrospective design.

Objective.
We aim to report our experience with multimodal intraoperative neuromonitoring (IONM) in metastatic spine tumor surgery (MSTS).

Summary of Background Data.
IONM is considered as standard of care in spinal deformity surgeries. However, limited data exist about its role in MSTS.

Methods.
A total of 135 patients from 2010 to 2017, who underwent MSTS with IONM at our institute, were studied retrospectively. After excluding seven with no baseline signals, 128 patients were analyzed. The data collected comprised of demographics, pre and postoperative American Spinal Injury Association (ASIA) grades and neurological status, indications for surgery, type of surgical approach. Multimodal IONM included somatosensory-evoked potentials (SSEPs), transcranial electric motor-evoked potentials (tcMEP), and free running electromyography (EMG).

Results.
The 128 patients included 61 males and 67 females with a mean age of 61 years. One hundred sixteen underwent posterior procedures; nine anterior and three both. The frequency of preoperative ASIA Grades were A = 0, B = 0, C = 10, D = 44, and E = 74 patients. In total, 54 underwent MSTS for neurological deficit, 66 for instability pain, and 8 for intractable pain.
Of 128 patients, 13 (10.2%) had significant IONM alerts, representing true positives; 114 true negatives, one false negative, and no false positives. Among the 13 true positives, four (30%) underwent minimally invasive and nine (70%) open procedures. Eight (69.2%) patients had posterior approach. Seven (53.84%) true positive alerts were during decompression, which resolved to baseline upon completion of decompression, while five (38.46%) were during instrumentation, which recovered to baseline after adjusting/downsizing the instrumentation, and one (8.3%) during lateral approach, which reversed after changing the plane of dissection. Of the seven patients without baseline, five were ASIA-A and two were ASIA-C. The sensitivity, specificity, positive, and negative predictive values were 99.1%, 100%, 100%, and 92.9%, respectively.

Conclusion.
Multimodal IONM in MSTS helped in preventing postoperative neurological deficit in 9.4% of patients. Its high sensitivity and specificity to detect intraoperative neurological events envisage its use in ASIA-grade D/E patients requiring instrumented decompression.

Level of Evidence: 3
Lack of Cost Savings for Lumbar Spine Fusions After Bundled Payments for Care Improvement Initiative
Authors: Bronson Wesley H. , Kingery Matthew T. , Hutzler Lorraine , Karia Raj , Errico Thomas , Bosco Joseph , Bendo John A. 
Published: July 2018

Study Design.
Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program.

Objective.
To analyze the effects of the BPCI program on patient outcome metrics and cost data.

Summary of Background Data.
The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present 2 years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution.

Methods.
In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with major complication or comorbidity [MCC]) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same diagnosis related groups (DRGs) from 2009 to 2012 from which the target price was established.

Results.
Three hundred fifty patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared with the baseline cohort, length of stay decreased (4.58 ± 2.51 vs. 5.13 ± 3.75; P = 0.009), readmission rate was unchanged, and discharges with home health aid increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 ± 27,028 vs. $48,913 ± 24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 ± 26,347 vs. $45,934 ± 19,638, P = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (P < 0.001), and the percentage of complex spines increased from 23% to 45% (P < 0.001).

Conclusion.
Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies.

Level of Evidence: 3
Strategy and risk sharing in hospital–postacute care integration
Authors: McHugh John P. , Zinn Jacqueline , Shield Renee R. , Tyler Denise A. , Gadbois Emily A. , Soni Sneha , Mor Vincent 
Published: July 2018

Issue/Trend:
Postacute care has been identified as a primary area for cost containment. The continued shift of payment structures from volume to value has often put hospitals at the forefront of addressing postacute care cost containment. However, hospitals continue to struggle with models to manage patients in postacute care institutions, such as skilled nursing facilities or in home health agencies. Recent research has identified postacute care network development as one mechanism to improve outcomes for patients sent to postacute care providers. Many hospitals, though, have not utilized this strategy for fear of not adhering to Centers for Medicare & Medicaid Services requirements that patients are given choice when discharged to postacute care.

Managerial Approach:
A hospital’s approach to postacute care integration will be dictated by environmental uncertainty and the level of embeddedness hospitals have with potential postacute care partners. Hospitals, though, must also consider how and when to extend shared savings to postacute care partners, which will be based on the complexity of the risk-sharing calculation, the ability to maintain network flexibility, and the potential benefits of preserving competition and innovation among the network members. For hospital leaders, postacute care network development should include a robust and transparent data management process, start with an embedded network that maintains network design flexibility, and include a care management approach that includes patient-level coordination.

Conclusion:
The design of care management models could benefit from elevating the role of postacute care providers in the current array of risk-based payment models, and these providers should consider developing deeper relationships with select postacute care providers to achieve cost containment.
A relational perspective on care coordination
Authors: Ghaffari Affan , Wells Rebecca , Creel Liza , Siañez Mónica 
Published: July 2018

Background:
Care coordination occurs largely through care coordinators’ interactions with patients and community partners to identify and address patients’ individual needs. More frequent and higher-quality communication with each may enhance care coordination effectiveness.

Purpose:
The purpose of this study was to understand (a) how care coordinator perceptions of interactions with patients and community partners, respectively, compared to each other group’s perceptions of their interactions with care coordinators and (2) whether these dynamics between care coordinators and community partners changed over time.

Methodology:
The research context was a comparative case study of provider-based care coordination projects funded through the Texas 1115(a) Medicaid waiver. The Relational Coordination instrument was administered through (a) two waves of in-person interviews with care coordinators (2014–2015 and 2015–2016) at a total of 10 sites across the state, (b) a single 2016 phone survey with 159 patients at nine of those sites, and (c) phone surveys with representatives of the community resources that care coordinators had identified as key partners in 2014–2015 and again in 2015–2016.

Results:
Care coordinators reported more frequently needing both patients and community partners than either other group reported relative to care coordinators. Frequency of need and mutual influence with community partners increased in the first 2 years of the care coordination programs’ implementation. The perceived quality of interactions between care coordinators and both patients and community partners was positive, but with room for improvement.

Conclusion:
Care coordination may entail limited interactions with patients and community partners, especially at program inception. As care coordination programs mature, interactions may become more frequent and influence with partners may expand.

Practice Implications:
Decision makers should support care coordinators in improving the quality of their communication with both patients and community partners, as well as allow time for these relationships to develop.
Indoor and Outdoor Radon Concentration Levels in Lebanon
Authors: Habib Rima R. , Nuwayhid Rida Y. , Hamdan Zena , Alameddine Ibrahim , Katul Gabriel 
Published: July 2018

Abstract
Lebanon’s lung cancer rates, among the highest in the Arab region, contribute to the burden of noncommunicable diseases. A number of studies have shown that lung cancer risk increases when smokers vs. nonsmokers exposed to elevated radon levels are compared. This research employs indoor and outdoor space and time concentration surveys across Lebanon, where the smoking rate among the population is among the highest in the world. The distributional properties of measured radon concentration were shown to be lognormal with median indoor and outdoor concentrations of 17 and 10 Bq m−3, respectively. Standard deviation for indoor concentrations was 1.2 times smaller than its outdoor counterpart, suggesting that weather-related patterns affect outdoor radon concentration variability. No significant spatial association was detected across seasons for indoor and outdoor radon concentrations. Geographical location, proximity to faults, and housing construction material had no significant impact on outdoor and indoor radon concentration variations. When lognormal distributions were used to determine exceedance probability of the recommended reference radon concentration, they were smaller than 0.1%. While exhibiting high seasonal variability, the study shows that radon does not appear to be a public health concern in Lebanon.
Unexpected Cardiac MRI Findings in Patients Presenting to the Emergency Department for Possible Acute Coronary Syndrome
Authors: Ziegler Cole E. , Painter David M. , Borawski Joseph B. , Kim Raymond J. , Kim Han W. , Limkakeng Alexander T. 
Published: July 2018

Background:
Stress cardiac magnetic resonance imaging (CMR) has become increasingly used in patients presenting to the emergency department (ED) with symptoms concerning for acute coronary syndrome (ACS). We hypothesized that CMR detects a number of alternative diagnoses (diagnoses other than ACS that could explain symptoms) and incidental findings in patients presenting to the ED for potential ACS.

Methods:
We prospectively enrolled adult patients who presented to an academic ED from 2011 to 2015 for possible ACS and subsequently had an adenosine stress perfusion CMR as part of their diagnostic evaluation. All medical charts were reviewed to verify accurate prospective data collection and to collect follow-up data.

Results:
A total of 391 patients were included. On stress CMR, abnormalities attributable to coronary artery disease (CAD) were found in 106 (27.1%) of patients. Previously undiagnosed moderate to severe valvular disease was the most common non-CAD cardiac finding, occurring in 20 (5.1%) cases. Other alternative diagnoses were rare with 7 cases of cardiomyopathy, 1 case of aortic aneurysm, 1 case of aortic dissection, 1 case of acute myocarditis, 3 cases of pericarditis, and 2 cases of moderate pleural effusion. Cardiac incidental findings were rare. Extracardiac incidental findings were found in 79 patients (20.2%). Only 18.6% of the patients recommended for follow-up imaging had this completed within 1 year after CMR.

Conclusions:
This experience suggests that stress CMR is useful in not only diagnosing symptomatic CAD but also potentially important non-CAD–related disease. These factors may impact their use in ED-based ACS workups.
Risk of Motor Vehicle Collision or Driving Impairment After Traumatic Brain Injury: A Collaborative International Systematic Review and Meta-Analysis
Authors: Chee Justin N. , Hawley Carol , Charlton Judith L. , Marshall Shawn , Gillespie Ian , Koppel Sjaan , Vrkljan Brenda , Ayotte Debbie , Rapoport Mark J. 
Published: July 2018

Objective:
To synthesize knowledge of the risk of motor vehicle collision (MVC) following a traumatic brain injury (TBI) and the associated risk of driving impairment, as measured by on-road tests, computerized simulators, and self-reported or state-recorded driving records.

Methods:
Our international team searched 7 databases for studies published between 1990 and 2015 of people with TBI, controls, and data concerning either MVC or driving impairment. The included articles examined the risk of MVC among people with TBI; we excluded studies that examined the risk of having a TBI associated with being involved in an MVC.

Results:
From 13 578 search results, we included 8 studies involving 1663 participants with TBI and 4796 controls. We found no significant difference in the risk of MVC (odds ratio = 1.24, 95% confidence interval = 0.80-1.91, P = .34). When we restricted the analysis to self-report, the risk of MVC was higher for those without a TBI (odds ratio = 1.63, 95% confidence interval = 1.21-2.22, P = .002). In contrast, participants with TBI consistently performed worse during on-road assessments and had more problems with vehicular control.

Conclusion:
Limitations of reviewed studies included small sample sizes, failure to specify TBI severity or time postinjury, and absence of objective measures of risk. Findings concerning the relationship between TBIs from non-MVC causes and crash risk are, therefore, inconclusive and do not provide evidence for major changes to existing clinical guidelines for driving with TBI.
Effect of Sex on Recovery From Persistent Postconcussion Symptoms in Children and Adolescents Participating in an Active Rehabilitation Intervention
Authors: Gauvin-Lepage Jérôme , Friedman Debbie , Grilli Lisa , Gagnon Isabelle 
Published: July 2018

Objective:To estimate the extent to which biologic sex contributes to the severity of postconcussion symptoms (PCSs) in concussed youth, who are slow to recover and who receive an active rehabilitation intervention (ARI) as part of their standard care.Setting:The concussion clinic of a pediatric trauma center in Canada.Participants:A total of 355 youth with persistent PCS (188 girls and 167 boys) as per the following criteria: (1) diagnosed with a concussion (or mild traumatic brain injury) as per the 2004 World Health Organization definition; (2) aged 8 to 17 years (mean = 14.34, standard deviation [SD] = 2.22 years); (3) presenting with at least 1 PCS interfering with daily activities (mean total PCS score at initial assessment = 24.50, SD = 18.88); and (4) on ARI 4 weeks postinjury (mean = 30.46, SD = 3.74 days).Design:A retrospective analysis of a prospective cohort.Main Measures:PCS severity, measured by the PCS Scale (PCSS) included in the Sports Concussion Assessment Tool-3, was the dependent variable. PCSs were assessed 3 times over a 4-week period.Results:Boys presented with significantly fewer symptoms than girls 4 weeks postinjury, at initiation of the ARI (PCSS total score mean: ♂ = 19.9, ♀ = 28.5,P< .001, confidence interval = −14.8 to −6.4), at 2 and 4 weeks of follow-up, but the rate of recovery was slightly faster for girls over the follow-up period.Conclusion:Despite differences between the PCSS score reduction after 4 weeks of intervention, our results favored to a slightly faster recovery for girls over the follow-up period. Although our findings are not strong enough to suggest distinct sex-specific intervention, both boys and girls benefit from participating in an ARI.
VASCULARIZED SARCOID GRANULOMA COMPLICATED BY PLACOID DISEASE IN A PEDIATRIC PATIENT
Authors: Pichi Francesco 
Published: July 2018

Purpose:
To report a case of pediatric vascularized sarcoid choroidal granuloma complicated by placoid-like inflammation.

Methods:
Case report.

Results:
A 10-year-old girl presented with blurry vision in her right eye and a yellowish macular lesion that had been diagnosed as fibrotic choroidal neovascular membrane and observed for several months. On referral to our clinic, optical coherence tomography revealed a homogeneous hyperreflective lesion obliterating the choroidal vasculature and protruding under the retina with associated subretinal and intraretinal fluid. Optical coherence tomography angiography revealed vascularization of this granulomatous lesion, and the girl underwent six intravitreal injections of anti–vascular endothelial growth factor, with reabsorption of the fluid and consolidation of the lesion. A sudden, abrupt decrease in the visual acuity of the right eye 3 months after the last injection was accompanied on optical coherence tomography by hyperreflective inflammatory lesions breaking from the retinal pigment epithelium and involving the outer nuclear layer, all around the fibrotic granulomatous lesion. The girl was treated with oral steroids, and an extensive systemic evaluation revealed hilar adenopathy, thus posing the diagnosis of pediatric sarcoidosis complicated by placoid chorioretinopathy.

Conclusion:
Atypical presentations of typical uveitic diseases are quite common in children. The presence of a foveal vascularized granuloma complicated by a placoid disorder should prompt the exclusion of infectious etiologies such as tuberculosis, to establish a therapy to preserve the child's vision.
ATL
Authors: Zhu Xinxin , Zhao Ling , Lang Jinghe 
Published: July 2018

ObjectiveThis study aimed to assess the relationship between BRCA1 gene methylation, PD-L1 protein expression, and the clinicopathologic features of sporadic ovarian cancer (OC).MethodsBisulfite pyrosequencing and immunohistochemistry were used to detect BRCA1 gene methylation and PD-L1 protein expression, respectively, in tumor tissues from 112 patients with sporadic OC. Their levels were analyzed against clinicopathologic characteristics and prognosis using standard statistical methods.ResultsTwenty percent (22/112) of the OC cases exhibited BRCA1 gene hypermethylation. The frequency of BRCA1 hypermethylation was significantly higher in serous OC (25%) than in nonserous OC (8%; P < 0.05). No significant correlations were discovered between BRCA1 hypermethylation and age, menstrual status, tumor location, stage, lymph node metastasis, and prognosis (P > 0.05). Among the 112 OC cases, 59% (66/112) cases were positive for PD-L1 protein expression. No significant difference existed between PD-L1 expression and age, menstrual status, histological type, tumor location, stage, lymph node metastasis, and prognosis (P > 0.05). Moreover, no correlation existed between BRCA1 methylation and PD-L1 expression (P > 0.05, r = 0.002).ConclusionsThis is the first study linking BRCA1 hypermethylation variability to PD-L1 protein expression and the clinicopathologic features of OC. The data demonstrated that an epigenetic alteration of BRCA1 was closely associated with serous OC. The expression of PD-L1 was unrelated to the clinicopathologic features or BRCA1 hypermethylation in sporadic OC.