bluuebunny/crossref_metadata_2025_split huggingface dataset:
Triple-low Alerts Do Not Reduce Mortality
Authors: Sessler Daniel I. , Turan Alparslan , Stapelfeldt Wolf H. , Mascha Edward J. , Yang Dongsheng , Farag Ehab , Cywinski Jacek , Vlah Claudene , Kopyeva Tatyana , Keebler Allen L. , Perilla Mauricio , Ramachandran Mangakalaraip , Drahuschak Sean , Kaple Kristina , Kurz Andrea 
Published: October 2018

Abstract

EDITOR’S PERSPECTIVE

What We Already Know about This Topic
Intraoperative triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction of anesthetic less than 0.8) have been found to be associated with increased risk of mortality

What This Article Tells Us That Is New
A randomized electronic alert of triple-low events to treating clinicians did not reduce 90-day mortality
The alerts minimally influenced clinician responses, assessed as vasopressor administration or reduction in end-tidal volatile anesthetic partial pressure, and there was no association between response to alerts and mortality
Triple-low events predict mortality but do not appear to be causally related

Background
Triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction less than 0.8) are associated with mortality but may not be causal. This study tested the hypothesis that providing triple-low alerts to clinicians reduces 90-day mortality.

Methods
Adults having noncardiac surgery with volatile anesthesia and Bispectral Index monitoring were electronically screened for triple-low events. Patients having triple-low events were randomized in real time, with clinicians either receiving an alert, “consider hemodynamic support,” or not. Patients were blinded to treatment. Helpful responses to triple-low events were defined by administration of a vasopressor within 5 min or a 20% reduction in end-tidal volatile anesthetic concentration within 15 min.

Results
Of the qualifying patients, 7,569 of 36,670 (20%) had triple-low events and were randomized. All 7,569 were included in the primary analysis. Ninety-day mortality was 8.3% in the alert group and 7.3% in the nonalert group. The hazard ratio (95% CI) for alert versus nonalert was 1.14 (0.96, 1.35); P = 0.12, crossing a prespecified futility boundary. Clinical responses were helpful in about half the patients in each group, with 51% of alert patients and 47% of nonalert patients receiving vasopressors or having anesthetics lowered after start of triple low (P < 0.001). There was no relationship between the response to triple-low events and adjusted 90-day mortality.

Conclusions
Real-time alerts to triple-low events did not lead to a reduction in 90-day mortality, and there were fewer responses to alerts than expected. However, similar mortality with and without responses suggests that there is no strong relationship between responses to triple-low events and mortality.
A Cost-utility Analysis of Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Lumbar Disc Herniation
Authors: Wang Dongdong , Xie Wangcheng , Cao Wenxin , He Shisheng , Fan Guoxin , Zhang Hailong 
Published: October 2018

Study Design.
A cost-utility analysis (CUA).

Objective.
The aim of this study was to evaluate the cost-effectiveness of percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) techniques for the treatment of L5-S1 lumbar disc herniation (LDH).

Summary of Background Data.
The annual cost of treatment for lumbar disc herniation is staggering. As the two major approaches of percutaneous endoscopic lumbar discectomy (PELD): percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) have gained recognition for the treatment of L5-S1 lumbar disc herniation (LDH) and showed similar clinical outcome. ost-utility analysis (CUA) can help clinicians make appropriate decisions about optimal health care for L5-S1 LDH.

Methods.
Fifty and 25 patients were included in the PETD and PEID groups of the study. Patients’ basic characteristics, health care costs, and clinical outcome of PETD and PEID group were collected and analyzed. Quality-adjusted life-years (QALYs) were calculated and validated by EuroQol five-dimensional (EQ-5D) questionnaire. Cost-effectiveness was determined by the incremental cost per QALY gained.

Results.
The mean total cost of the PETD group was $5275.58 ± 292.98 and the PEID group was $5494.45 ± 749.24. No significant differences were observed in hospitalization expenses, laboratory and radiographic evaluations expenses, surgical expenses, and drug costs. Surgical equipment and materials costs, and anesthesia expense in the PEID group were significantly higher than in the PETD group (P < 0.001). Clinical outcomes, including Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores, and Japanese Orthopaedic Association (JOA), also showed no significant differences between the two groups. The cost-effectiveness ratio of PETD and PEID were $6816.05 ± 717.90/QALY and $7073.30 ± 1081.44/QALY, respectively. The incremental cost-effectiveness ratios (ICERs) of PEID over PETD was $21887.00/QALY.

Conclusion.
Observed costs per QALY gained for L5-S1 LDH with PETD or PEID were similar for patients, demonstrating that the two different approaches of PELD are equally cost-effective and valuable interventions.

Level of Evidence: 5
Group and Individual-level Change on Health-related Quality of Life in Chiropractic Patients With Chronic Low Back or Neck Pain
Authors: Hays Ron D. , Spritzer Karen L. , Sherbourne Cathy D. , Ryan Gery W. , Coulter Ian D. 
Published: October 2018

Study Design.
A prospective observational study.

Objective.
The aim of this study was to evaluate group-level and individual-level change in health-related quality of life among persons with chronic low back pain or neck pain receiving chiropractic care in the United States.

Summary of Background Data.
Chiropractors treat chronic low back and neck pain, but there is limited evidence of the effectiveness of their treatment

Methods.
A 3-month longitudinal study of 2024 patients with chronic low back pain or neck pain receiving care from 125 chiropractic clinics at six locations throughout the United States was conducted. Ninety-one percent of the sample completed the baseline and 3-month follow-up survey (n = 1835). Average age was 49, 74% females, and most of the sample had a college degree, were non-Hispanic White, worked full-time, and had an annual income of $60,000 or more. Group-level (within-group t tests) and individual-level (coefficient of repeatability) changes on the Patient-Reported Outcomes Measurement Information System (PROMIS-29) v2.0 profile measure was evaluated: six multi-item scales (physical functioning, pain, fatigue, sleep disturbance, social health, emotional distress) and physical and mental health summary scores.

Results.
Within-group t tests indicated significant group-level change (P < 0.05) for all scores except for emotional distress, and these changes represented small improvements in health (absolute value of effect sizes ranged from 0.08 for physical functioning to 0.20 for pain). From 13% (physical functioning) to 30% (PROMIS-29 v2.0 Mental Health Summary Score) got better from baseline to 3 months later according to the coefficient of repeatability.

Conclusion.
Chiropractic care was associated with significant group-level improvement in health-related quality of life over time, especially in pain. But only a minority of the individuals in the sample got significantly better (“responders”). This study suggests some benefits of chiropractic on functioning and well-being of patients with low back pain or neck pain.

Level of Evidence: 3
Economic Evaluation of Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome*
Authors: Barrett Kali A. , Hawkins Neil , Fan Eddy 
Published: October 2018

Objectives:
Venovenous extracorporeal membrane oxygenation is increasingly being used to support patients with severe acute respiratory distress syndrome, but its cost-effectiveness is unknown. We assessed the cost-utility of venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome in adults compared with standard lung protective ventilation from the perspective of the healthcare system.

Design:
We conducted a cost-utility analysis with a cohort state transition decision model using a lifetime time horizon, 1.5% discount rate, and outcomes reported as cost per quality-adjusted life year. Literature reviews were conducted to inform the model variables. Deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty in the model.

Setting:
Canadian publicly funded healthcare system.

Patients:
Hypothetical cohort of adults with severe acute respiratory distress syndrome.

Interventions:
Venovenous extracorporeal membrane oxygenation or standard lung protective ventilation.

Measurements and Main Results:
In our model, the use of venovenous extracorporeal membrane oxygenation compared with lung protective ventilation resulted in a gain of 5.2 life years and 4.05 quality-adjusted life years, at an additional lifetime cost of $145,697 Canadian dollars. The incremental cost-effectiveness ratio was $36,001/quality-adjusted life year. Sensitivity analyses show that the incremental cost-effectiveness ratio is sensitive to the efficacy of extracorporeal membrane oxygenation therapy and costs.

Conclusions:
Based on current data, venovenous extracorporeal membrane oxygenation is cost-effective for patients with severe acute respiratory distress syndrome. Additional evidence on the efficacy of venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome and in different subgroups of patients will allow for greater certainty in its cost-effectiveness.
Predictors of Metastases in Rectal Neuroendocrine Tumors: Results of a National Cohort Study
Authors: Concors Seth J. , Sinnamon Andrew J. , Folkert Ian W. , Mahmoud Najjia N. , Fraker Douglas L. , Paulson E. Carter , Roses Robert E. 
Published: October 2018

BACKGROUND:
Rectal neuroendocrine tumors are often found incidentally. Local excision alone has been advocated for lesions ≤2 cm; however, the evidence base for this approach is limited.

OBJECTIVE:
Associations among tumor size, degree of differentiation, and presence of distant metastatic disease were examined.

DESIGN:
This was a retrospective cohort study.

SETTINGS:
This study was conducted using a nationwide cohort.

PATIENTS:
A total of 4893 patients with rectal neuroendocrine tumors were identified in the National Cancer Database (2006–2015).

MAIN OUTCOME MEASURES:
Logistic regression analyses were used to evaluate associations among tumor size, degree of differentiation, and presence of regional and distant metastatic disease. Cut point analysis was performed to identify an optimal size threshold predictive of distant metastatic disease.

RESULTS:
Of patients included for analysis, 3880 (79.3%) had well-differentiated tumors, 540 (11.0%) had moderately differentiated tumors, and 473 (9.7%) had poorly differentiated tumors. On logistic regression, increasing size was associated with a higher likelihood of pathologically confirmed lymph node involvement (among patients undergoing proctectomy), and both size and degree of differentiation were independently associated with a higher likelihood of distant metastatic disease. The association between tumor size and distant metastatic disease was stronger for well-differentiated and moderately differentiated tumors (OR = 1.4; p < 0.001 for both) than for poorly differentiated tumors (OR = 1.1; p = 0.010). For well-differentiated tumors, the optimal cut point for the presence of distant metastatic disease was 1.15 cm (area under the curve = 0.88; 88% sensitive and 88% specific). Tumors ≥1.15 cm in diameter were associated with a substantially increased incidence of distant metastatic disease (72/449 (13.8%)). For moderately differentiated tumors, the optimal cut point was also 1.15 cm (area under the curve = 0.87, 100% sensitive and 75% specific).

LIMITATIONS:
This study was limited by its retrospective design.

CONCLUSIONS:
Tumor size and degree of differentiation are predictive of regional and distant metastatic disease in rectal neuroendocrine tumors. Patients with tumors >1.15 cm are at substantial risk of distant metastasis and should be staged and managed accordingly. See Video Abstract at http://links.lww.com/DCR/A778.
PARS PLANA VITRECTOMY FOR THE TREATMENT OF TRACTIONAL AND DEGENERATIVE LAMELLAR MACULAR HOLES
Authors: Figueroa Marta S. , Govetto Andrea , Steel David H. , Sebag J. , Virgili Gianni , Hubschman Jean Pierre 
Published: October 2018

Purpose:
Functional and anatomical outcomes of vitrectomy with membrane peeling were compared in tractional lamellar macular holes (LMH)/macular pseudoholes (MPH) versus degenerative LMH.

Methods:
This multicenter retrospective study enrolled patients with a minimum follow-up of 6 months. The association of spectral domain optical coherence tomography parameters with preoperative and postoperative best-corrected visual acuity was analyzed.

Results:
Seventy-seven (74.8%) tractional LMH/MPH and 26 (25.2%) degenerative LMH were included. Preoperative best-corrected visual acuity was better in tractional LMH/MPH (0.39 ± 0.2 logarithm of the minimal angle of resolution, 20/50 Snellen equivalent) than degenerative LMH (0.56 ± 0.2 logarithm of the minimal angle of resolution, 20/66 Snellen equivalent; P < 0.001). Premacular membranes were found in all tractional LMH/MPH, whereas LMH-associated epiretinal proliferation (LHEP) was present in all degenerative LMH. Primary anatomical success was achieved in 97/103 eyes (94.2%), with foveal restoration occurring earlier in degenerative LMH (1.6 ± 2.3 vs. 3.3 ± 3.6 months; P = 0.025). Best-corrected visual acuity improved in both tractional LMH/MPH and degenerative LMH (P < 0.001 and P = 0.012, respectively) but was better in tractional LMH/MPH (P = 0.001).

Conclusion:
The presence of premacular membranes and absence of LMH-associated epiretinal proliferation in all tractional LMH/MPH further distinguishes this from degenerative LMH. Best-corrected visual acuity improved in both subgroups but more so in tractional LMH/MPH. Complete anatomical restoration of foveal microanatomy was rare in degenerative LMH, reflecting significant morphological and pathophysiological differences between the two lesions.
INTRAVITREAL ANTI–VASCULAR ENDOTHELIAL GROWTH FACTOR FOR THE MANAGEMENT OF NEOVASCULARIZATION IN RETINOBLASTOMA AFTER INTRAVENOUS AND/OR INTRAARTERIAL CHEMOTHERAPY
Authors: Stathopoulos Christina , Gaillard Marie-Claire , Moulin Alexandre , Puccinelli Francesco , Beck-Popovic Maja , Munier Francis L. 
Published: October 2018

Purpose:
To report the use of anti–vascular endothelial growth factor in the management of retinoblastoma.

Methods:
Retrospective review of 35 eyes (33 patients) treated with at least one intravitreal anti–vascular endothelial growth factor (ranibizumab and/or aflibercept) for new iris (n = 26) and/or retinal neovascularization (n = 21) after intravenous chemotherapy and/or intraarterial chemotherapy.

Results:
Most eyes (n = 31/35, 89%) were Group D or E. Previous treatments were salvage intraarterial chemotherapy after intravenous chemotherapy (n = 21/35, 60%), first-line intraarterial chemotherapy (n = 7/35, 20%), and first-line intravenous chemotherapy (n = 7/35, 20%). Associated clinical features were retinal ischemia (94%), retinal detachment (51%), active tumor (34%), intravitreal hemorrhage (43%), and/or glaucoma (17%). Mean 1.6 anti–vascular endothelial growth factor injections/eye were given; 28 eyes received ranibizumab, 2 aflibercept, and 5 both agents. Eight eyes underwent complementary treatments of ischemic retina. Resolution of neovascularization was observed in 28 eyes (n = 28/35, 80%). Globe salvage was achieved in 51% (n = 18/35), including 25% of those with active tumor (n = 3/12). One eye became phthisic. Sixteen eyes were enucleated, nine for tumor relapse/progression. Five eyes had high-risk histopathologic risk factors and received adjuvant intravenous chemotherapy. All patients are alive with no extraocular extension nor metastases (mean follow-up 3.7 years, range 1.1–7.6).

Conclusion:
Intravitreal anti–vascular endothelial growth factor contributed to a globe salvage rate of 51% by providing conditions to continue conservative treatment.
Predicting Engagement With Online Walking Promotion Among Metropolitan and Rural Cancer Survivors
Authors: Frensham Lauren J. , Parfitt Gaynor , Dollman James 
Published: October 2018

Background
Physical activity has numerous associated benefits for cancer survivors. Compared with their urban counterparts, rural Australians experience a health disadvantage, including poorer survival rate after diagnosis of cancer.

Objective
The aims of this study were to test the effectiveness of an online 12-week walking intervention designed for cancer survivors and explore region-specific psychological predictors of behavior change.

Methods
This was a quasi-randomized controlled trial of an online resource designed according to Social Cognitive Theory and Self-determination Theory, based on individualized goal setting. Measures of habitual walking, motivation, and self-efficacy were taken at baseline, postintervention, and 3-month follow-up in an intervention group (n = 46) and active control group (n = 45). The control group was provided a pedometer but did not have access to the online program.

Results
An increase in steps/day at 12 weeks was observed in both groups, with a larger increase in the intervention group; these increases were not sustained at the 3-month follow-up. Psychological predictors of maintained change in steps per day (motivation, barrier self-efficacy, and relapse self-efficacy) did not differ between metropolitan and rural participants. Changes in steps per day among intervention participants were predicted by changes in relapse self-efficacy and barrier self-efficacy.

Conclusions
The intervention was successful in increasing physical activity postintervention; however, changes were not maintained at follow-up. There were no region-specific predictors of engagement in the intervention.

Implications for Practice
Nurses are seamlessly positioned to promote health interventions like walking. Nurses should reframe physical activity with patients so that relapse is seen as common and possibly inevitable when adopting a regular physical activity habit.
A Patient Decision Aid for Men With Localized Prostate Cancer
Authors: Stacey Dawn , Taljaard Monica , Breau Rodney H. , Baba Nicole , Blackmore Terry , Boland Laura , Carley Meg , Wu Robert Chi , Smylie Jennifer , Légaré France 
Published: October 2018

Background
There are multiple options for men diagnosed with localized prostate cancer. Patient decision aids (PtDAs) help empower individuals and reduce unwarranted practice variation, but few are used in clinical practice.

Objective
We compared 2 programs implementing PtDAs for men with localized prostate cancer.

Methods
This was a comparative case study. Case 1 was a hospital prostate pathway and case 2 was a provincial prostate pathway with 2 locations (2a, 2b). Nurses provided the men with PtDAs and answered questions. Data sources were as follows: (a) 2 years administrative data for men with localized prostate cancer, (b) clinicians survey and interviews, and (c) patients/spouses interviews. Analysis was within and across cases.

Results
The PtDA was used with 23% of men in case 1 (95% confidence interval, 19.8%–26.1%) and 98% of men in case 2a (95% confidence interval, 96.5%–99.8%). The pathway was not implemented in case 2b. Men given the PtDA had positive experiences. Many clinicians supported the use of PtDAs, some adapted their discussions with patients, and others did not support the use of PtDAs. To increase use in case 1, participants identified needing a Canadian PtDA available electronically and endorsed by all clinicians. In case 2b, the provincial prostate pathway needed to be implemented.

Conclusions
There was variable uptake of the PtDAs between the cases. Men who received the PtDA had positive outcomes. Several strategies were identified to increase or sustain PtDA use.

Implications for Practice
Nurses have a key role in supporting men making decisions about prostate cancer treatment by providing PtDAs, answering questions, and advocating for men's preferences.
Opioid Agonist Treatment and Improved Outcomes at Each Stage of the HIV Treatment Cascade in People Who Inject Drugs in Ukraine
Authors: Mazhnaya Alyona , Marcus Ruthanne , Bojko Martha J. , Zelenev Alexei , Makarenko Iuliia , Pykalo Iryna , Filippovych Sergii , Dvoriak Sergii , Altice Frederick L. 
Published: October 2018

Background:
The HIV treatment cascade is a crucial tool to guide HIV prevention and treatment strategies. The extent to which opioid agonist treatments (OATs) such as methadone and buprenorphine influence this cascade was examined in a nationwide study of people who inject drugs (PWID) in Ukraine.

Setting:
Cross-sectional stratified survey of PWID followed by HIV and hepatitis C virus testing in 5 Ukrainian cities.

Methods:
Opioid-dependent PWID (N = 1613) were sampled from January 2014 to March 2015. Analysis was confined to 520 participants with HIV, with 184 (35.4%) prescribed OAT. Weighted logistic regression models were used to assess independent factors associated with the 5 steps in the HIV treatment cascade.

Results:
Compared with PWID not on OAT (N = 336), participants who prescribed OAT (N = 184) were significantly more likely to be diagnosed (91% vs. 71%), linked (81% vs. 52%), and retained (69% vs. 35%) in HIV care, and prescribed (56% vs. 31%) and optimally (>95% of doses) adherent to antiretroviral therapy (41% vs. 22%). Receiving OAT contributed most as an independent factor with every step of the cascade. Other steps in the HIV treatment cascade were influenced by age, depression, and geographical variability.

Conclusions:
OAT remains an essential and effective strategy to not only treat patients with opioid use disorder, but also a crucial strategy to engage PWID in care to meet UNAIDS 90-90-90 targets. Geographical differences suggest local structural impediments. With low OAT coverage prescribed for 2.9% of the estimated 347,000 PWID in Ukraine, OAT expansion requires strategic interventions that target the individual, clinical care settings, policies, and funding.