bluuebunny/crossref_metadata_2025_split huggingface dataset:
Perceptual and Structural Facilitators and Barriers to Becoming a Surgeon: A Qualitative Study of African American and Latino Surgeons
Authors: Ulloa Jesus G. , Viramontes Omar , Ryan Gery , Wells Kenneth , Maggard-Gibbons Melinda , Moreno Gerardo 
Published: May 2018

Purpose
As racial and ethnic heterogeneity in the United States increases, it is important that the health care workforce, including surgery, mirror that diversity. Structural and perceptual barriers may contribute to an underrepresentation of African American and Latino surgeons. Understanding these barriers may translate into interventions and, in turn, improved diversification of the U.S. surgery workforce.

Method
In 2016, the authors conducted in-depth semistructured interviews, exploring structural and perceptual barriers that African American and Latino surgeons face. The authors used conventional qualitative techniques to analyze data and identify themes.

Results
The authors interviewed 23 participants and observed three major themes characterizing the path to becoming a surgeon: creating a path to medicine, surgical culture, and mentorship. Subthemes provided further nuance. For creating a path to medicine, the subthemes were personal attributes, family support, community assets/barriers, and minority experience. For surgical culture, the subthemes comprised quality of life, surgeon–patient relationship, and restoring health. For mentorship, the subthemes were aspirational figures, formal programs/peer support, and professional opportunities. Experiences described by African Americans and Latinos were similar, but the experiences of participants of different self-identified childhood socioeconomic status were dissimilar.

Conclusions
The path to a surgical career as experienced by African American and Latino surgeons is heavily influenced by mentors mediating their integration into surgical culture and engendering a feeling of belonging. Future surgeons from groups underrepresented in medicine would benefit from identifying aspirational figures early, a structured introduction into the rigors of the profession, and a deconstruction of negative surgical norms.
Gaps in the Substance Use Disorder Treatment Referral Process: Provider Perceptions
Authors: Blevins Claire E. , Rawat Nishi , Stein Michael D. 
Published: May 2018

Objectives:
The demand for substance use disorder treatment is increasing, fueled by the opioid epidemic and the Affordable Care Act mandate to treat substance use disorders. The increased demand for treatment, however, is not being met by a corresponding increase in access to or availability of treatment. This report focuses specifically on the treatment referral process, which we have identified as 1 of the key barriers to timely and effective treatment. Difficulties in referral to substance use disorder treatment are examined through the lens of providers who make referrals (ie, referral source) and individuals who work in substance use disorder facilities (ie, referral recipient).

Methods:
Administrative officials, emergency department physicians, addiction physicians, government officials, providers, insurance officials, and mental health advocates (n = 59) were interviewed on the referral process protocol, challenges for providers and others making referrals, and issues with substance use treatment facility intake procedures.

Results:
Several main themes were identified as barriers in the process: difficulties in determining patient eligibility, lack of transparency regarding treatment capacity, referral source knowledge/understanding of options, and issues with communication between referral source and recipient. We then proposed several solutions to address specific barriers.

Conclusions:
Current gaps in the referral process cause delays to care. Improving systems would involve addressing these themes and expanding the use of appropriate treatments for the many patients in need.
Evaluation of Two Circumaural Earphones for Audiometry
Authors: Smull Clae C. , Madsen Brandon , Margolis Robert H. 
Published: May 2018

Objective:
The Sennheiser HDA 200 earphone, a standard circumaural earphone used in audiometry for many years, is out of production and is replaced by the RadioEar DD450. The Sennheiser HD 280 Pro earphone is a consumer product that has characteristics that may be suitable for audiometry and may be a low-cost alternative to the DD450. The DD450 and HD 280 Pro earphones were compared with the HDA 200 for use in audiometry.

Design:
RadioEar DD450 and Sennheiser HD 280 Pro earphones were evaluated for reference equivalent threshold sound pressure levels (RETSPLs), ambient-noise attenuation, and occlusion effects. Audiometric thresholds measured on a group of normal-hearing adults were used to determine RETSPLs. Ambient-noise attenuation was determined by measuring the sound pressure in the ear canal produced by a broadband signal from a loudspeaker with and without occlusion by the earphone. Acoustic occlusion effects were determined by measuring the ear-canal sound pressure produced by a bone-conducted source with and without occlusion by the earphone. The results were compared with measurements obtained from the HDA 200 earphone.

Results:
Audiometric thresholds obtained using the DD450 earphone did not differ from those obtained with the HDA 200 earphones, indicating that the HDA 200 RETSPLs provided in the audiometer standards (ANSI S3.6-2010; ISO 389-8-2004) are transferable to the DD450. New RETSPLs for the HD 280 Pro earphone were determined from the threshold measurements. Ambient-noise attenuation provided by the DD450 was equivalent to the attenuation provided by the HDA 200. The HD 280 Pro provided less ambient-noise attenuation than the other circumaural earphones, but more than the supra-aural earphones commonly used in audiometry. The DD450 produced an occlusion effect 5 dB larger than that of the HDA 200 at 0.25 and 0.5 kHz; both earphones produced negligible occlusion effects at higher frequencies. The HD 280 Pro produced larger occlusion effects in the low frequencies than the other two earphones, with negligible occlusion effects at 1.0 kHz and above.

Conclusions:
The HDA 200 RETSPLs are transferable to the DD450. Ambient-noise attenuation and occlusion effects are similar for these two earphones. RETSPLs for the HD 280 Pro are provided. The HD 280 Pro has less ambient-noise attenuation and larger occlusion effects than the DD450 but is a viable low-cost alternative.
A Novel Indirect Reduction Technique in Ankle Syndesmotic Injuries: A Cadaveric Study
Authors: Cosgrove Christopher T. , Spraggs-Hughes Amanda G. , Putnam Sara M. , Ricci William M. , Miller Anna N. , McAndrew Christopher M. , Gardner Michael J. 
Published: May 2018

Objective:
To describe a novel technique using preoperative computed tomography (CT) to plan clamp tine placement along the trans-syndesmotic axis (TSA). We hypothesized that preoperative CT imaging provides a reliable template on which to plan optimal clamp tine positioning along the TSA, reducing malreduction rates compared with other described techniques.

Methods:
CT images of 48 cadaveric through-knee specimens were obtained, and the TSA was measured as well as the optimal position of the medial clamp tine. The syndesmosis was then fully destabilized. Indirect clamp reductions were performed with the medial clamp tine placed at positions 10 degrees anterior to the TSA, along the TSA, and at both 10 and 20 degrees posterior to the TSA. The specimens were then separately reduced using manual digital pressure and palpation alone. CT was performed after each clamp and manual reduction.

Results:
On average, reduction clamp tines were within 3 ± 2 degrees of the desired angle and within 5% ± 4% of the templated location along the tibial line for all clamp reduction attempts. Palpation and direct visualization produced the overall lowest malreduction rates in all measurements: 4.9% and 3.0%, respectively. Off-axis clamping 10 degrees anterior or 20 degrees posterior to the patient-specific TSA demonstrated an increased overall malreduction rate: 15.8% and 11.3%, respectively. Significantly more over-compression occurred when a reduction clamp was used versus manual digital reduction alone (8.6% vs. 0%).

Conclusions:
Reduction clamp placement directly along an optimal clamping vector can be facilitated by preoperative CT measurements of the uninjured ankle. However, even in this setting, the use of reduction clamps increases the risk for syndesmotic malreduction and over-compression compared with manual digital reduction or direct visualization.
Hypovitaminosis D in Orthopaedic Trauma: Which Guidelines Should Be Followed?
Authors: Schiffman Brett , Summers Hobie , Bernstein Mitchell , DiSilvio Frank , Foyil Sarah , Lack William 
Published: May 2018

Objective:
To evaluate the risk factors for hypovitaminosis D and to determine the baseline vitamin D supplementation associated with normal vitamin D levels at presentation.

Design:
Prospective observational study.

Setting:
Level I trauma center.

Patients:
This study included 259 adult patients undergoing operative treatment for orthopaedic trauma (OTA 11–15, 21–23, 31–34, 41–44, 61–62, 70C, 81–82, 87) between January 1, 2014, and December 31, 2014.

Intervention:
Prospective, observational study.

Main Outcomes:
Association of hypovitaminosis D with patient characteristics, injury factors, and vitamin D supplementation.

Results:
Univariate predictors of hypovitaminosis D included a lack of preinjury supplementation, non-white race, younger age, female sex, non-Medicare insurance, smoking, obesity, Charlson Comorbidity Index <2, and high-energy mechanism. On multivariate analysis, preinjury supplementation was associated with a lower risk (odds ratio: 0.31, 95% confidence interval: 0.15–0.63, P = 0.001) and non-white race was associated with a higher risk (odds ratio: 3.63, 95% confidence interval: 1.58–8.37, P = 0.001) of hypovitaminosis D. Logistic regression analysis found a dose-dependent relationship between vitamin D supplementation and hypovitaminosis D. Each 100-IU increase in vitamin D supplementation was associated with an 8% decrease in the risk of hypovitaminosis D.

Conclusions:
A lack of preinjury supplementation and non-white race were independently associated with hypovitaminosis D. Baseline supplementation consistent with Endocrine Society guidelines (2000 IU daily) was more effective than that consistent with Institute of Medicine guidelines (400 IU daily) in maintaining 25-hydroxyvitamin D above 30 ng/mL in this population.

Level of Evidence:
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Using a Validated Middle-Age and Geriatric Risk Tool to Identify Early (<48 Hours) Hospital Mortality and Associated Cost of Care
Authors: Lott Ariana , Haglin Jack , Saleh Hesham , Hall Jordan , Egol Kenneth A. , Konda Sanjit R. 
Published: May 2018

Objectives:
(1) To demonstrate that a validated trauma triage score for middle-aged and geriatric patients could identify those at high risk of mortality within the first 2 days of hospitalization and (2) determine the cost of care for this cohort of patients.

Design:
Prospective cohort study.

Setting:
Single level 1 trauma center.

Patients:
Patients 55 years of age and older who were evaluated in the emergency department setting by orthopaedics or who met the American College of Surgeons Tier 1–3 criteria.

Intervention:
Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle-aged patients, using patient's demographic, injury severity, and functional status; main outcome measurements: length of stay, inpatient mortality, time between presentation and time of death, and direct variable costs of hospitalization.

Results:
A total of 1470 consecutive patients (mean age of 72.2 ± 11.9 years) were enrolled in this study, 17 of whom died within 48 hours of presentation to the emergency department. These patients had a significantly higher trauma triage score than the rest of the cohort with a score of 50.9% ± 37.2% versus 3.3% ± 9.5%, P < 0.001 indicating that they had a mean risk of inpatient mortality of over 50%. Mean total cost per day was much higher in the cohort of patients who died within 48 hours of admission compared with all other trauma patients [$49,367 ± $79,057 vs. $3966 ± $2897 (P = 0.031)].

Conclusions:
To achieve value-based care in this high-risk cohort, targeted cost savings while improving patient outcomes and/or expediting goals-of-care and end-of-life goals is necessary and the STTGMA score allows for stratification of these patients in both mortality risk and cost profile.
Locking Plate Fixation in a Series of Bicondylar Tibial Plateau Fractures Raises Treatment Costs Without Clinical Benefit
Authors: Cavallero Matthew , Rosales Richard , Caballero Jesse , Virkus Walter W. , Kempton Laurence B. , Gaski Greg E. 
Published: May 2018

Objectives:
To compare outcomes and costs between locking and nonlocking (NL) constructs in the treatment of bicondylar tibial plateau (BTP) fractures.

Design:
Retrospective cohort study.

Setting:
Level 1 academic trauma center.

Patients:
All patients who presented with complete articular, BTP fractures OTA/AO 41-C and Schatzker VI between 2013 and 2015 were screened (n = 112). Patients treated with a mode of fixation other than plate-and-screw were excluded. Fifty-six patients with a minimum follow-up of 12 months were included in the analysis.

Intervention:
Operative fixation of BTP fractures with locking (n = 29) or NL (n = 27) implants.

Main outcome measurements:
Implant cost, patient-reported outcomes (PROMIS physical function and pain interference), clinical, and radiographic outcomes.

Results:
There were no differences between the 2 groups with respect to demographics, injury characteristics, radiographic outcomes (change in alignment), or clinical outcomes (PROMIS, reoperation, nonunion, and infection). Implant costs were significantly greater in the locking group compared with the NL group (mean L, $4453; mean NL, $2569; P < 0.01).

Conclusions:
This study demonstrated improved value of treatment (less cost with no difference in clinical outcome) with NL implants for BTP fractures when dual-plate fixation strategies are performed.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Exploratory Application of Neuropharmacometabolomics in Severe Childhood Traumatic Brain Injury*
Authors: Hagos Fanuel T. , Empey Philip E. , Wang Pengcheng , Ma Xiaochao , Poloyac Samuel M. , Bayir Hülya , Kochanek Patrick M. , Bell Michael J. , Clark Robert S. B. 
Published: May 2018

Objectives:
To employ metabolomics-based pathway and network analyses to evaluate the cerebrospinal fluid metabolome after severe traumatic brain injury in children and the capacity of combination therapy with probenecid and N-acetylcysteine to impact glutathione-related and other pathways and networks, relative to placebo treatment.

Design:
Analysis of cerebrospinal fluid obtained from children enrolled in an Institutional Review Board–approved, randomized, placebo-controlled trial of a combination of probenecid and N-acetylcysteine after severe traumatic brain injury (Trial Registration NCT01322009).

Setting:
Thirty-six–bed PICU in a university-affiliated children’s hospital.

Patients and Subjects:
Twelve children 2–18 years old after severe traumatic brain injury and five age-matched control subjects.

Intervention:
Probenecid (25 mg/kg) and N-acetylcysteine (140 mg/kg) or placebo administered via naso/orogastric tube.

Measurements and Main Results:
The cerebrospinal fluid metabolome was analyzed in samples from traumatic brain injury patients 24 hours after the first dose of drugs or placebo and control subjects. Feature detection, retention time, alignment, annotation, and principal component analysis and statistical analysis were conducted using XCMS-online. The software “mummichog” was used for pathway and network analyses. A two-component principal component analysis revealed clustering of each of the groups, with distinct metabolomics signatures. Several novel pathways with plausible mechanistic involvement in traumatic brain injury were identified. A combination of metabolomics and pathway/network analyses showed that seven glutathione-centered pathways and two networks were enriched in the cerebrospinal fluid of traumatic brain injury patients treated with probenecid and N-acetylcysteine versus placebo-treated patients. Several additional pathways/networks consisting of components that are known substrates of probenecid-inhibitable transporters were also identified, providing additional mechanistic validation.

Conclusions:
This proof-of-concept neuropharmacometabolomics assessment reveals alterations in known and previously unidentified metabolic pathways and supports therapeutic target engagement of the combination of probenecid and N-acetylcysteine treatment after severe traumatic brain injury in children.
Biologics and Cardiovascular Disease
Authors: Van Taunay John S. , Albelda M. Teresa , Frias Juan Carlos , Lipinski Michael J. 
Published: May 2018

Abstract:
The advent of biologic therapy has enhanced our ability to augment disease in an increasingly targeted manner. The use of biologics in cardiovascular disease (CVD) has steadily increased over the past several decades. Much of the early data on biologics and CVD were derived from their use in rheumatologic populations. Atherosclerosis, myocardial infarction, and heart failure have been closely linked to the inflammatory response. Accordingly, cytokines such as tumor necrosis factor (TNF)-alpha and interleukin (IL)-1 have been targeted. Noninflammatory mediators, such as proprotein convertase subtilisin kexin type 9 (PCSK9), have been selected for therapeutic intervention as well. Furthermore, RNA interference (RNAi) therapy has emerged and may serve as another targeted therapeutic mechanism. Herein, we will review the history, obstacles, and advances in using biologic therapy for CVD.
Is ovarian reserve associated with body mass index and obesity in reproductive aged women? A meta-analysis
Authors: Moslehi Nazanin , Shab-Bidar Sakineh , Ramezani Tehrani Fahimeh , Mirmiran Parvin , Azizi Fereidoun 
Published: May 2018

Abstract

Objective:
The associations of body mass index (BMI) and obesity with ovarian reserve are controversial. This systematic review and meta-analysis was conducted to investigate the associations in reproductive-aged women.

Methods:
PubMed and Scopus were searched up to December, 2016. Original studies on the association of BMI with ovarian reserve markers, anti-Mullerian hormone (AMH), follicle-stimulating hormone (FSH), inhibin β, and antral follicle count (AFC), either according to BMI categories or a continuous variable, were selected. Analyses were stratified into three groups based on polycystic ovary syndrome (PCOS) and fertility status of women.

Results:
Of 4,055 records identified, 45 studies were eligible for inclusion. Comparing the obese with nonobese, the pooled mean differences (MDs) and 95% confidence intervals (CIs) were −1.08 (95% CIs −1.52, −0.63) ng/mL for AMH, −0.22 (95% CIs −0.39, −0.06) mIU/mL for FSH, −0.09 (95% CIs −0.60, 0.42) for AFC, and −21.06 (95% CIs −41.18, −0.85) pg/mL for inhibin β in overall populations. The MDs were significant for AMH in fertile non-PCOS and PCOS women, and for FSH only in PCOS women. Fisher's Z showed significant correlations of BMI with AMH in the overall populations (−0.15 [95% CIs −0.20, −0.11]) and in all subgroups, and with FSH in the fertile non-PCOS women (−0.16 [95% CIs −0.28, −0.04]).

Conclusion:
Ovarian reserve markers of AMH and FSH are significantly lower in obese than in nonobese women, and BMI is negatively correlated with AMH in all study populations, and with FSH in fertile non-PCOS subgroups. PCOS and fertility status do not appear to affect the associations.
Anxiety levels predict fracture risk in postmenopausal women assessed for osteoporosis
Authors: Catalano Antonino , Martino Gabriella , Bellone Federica , Gaudio Agostino , Lasco Carmen , Langher Viviana , Lasco Antonino , Morabito Nunziata 
Published: May 2018

Abstract

Objective:
There has been increasing interest in the association of psychiatric disorders with fracture risk. This study aimed at investigating the role of severity of anxiety in bone health.

Methods:
Multiple clinical risk factors for fractures, the Fracture Risk Assessment Tool score, the bone mineral density (BMD) at the lumbar spine and femoral neck, Hamilton Anxiety Rating Scale (HAMA) scores, Beck Depression Inventory scores, and the 36-Item Short Form Health Survey (SF-36) scores for evaluation of the quality of life were determined, and x-ray vertebral morphometry was carried out in postmenopausal women referred for osteoporosis.

Results:
Of the 192 women recruited (mean age 67.5 ± 9.5 years), participants allocated to the tertile of the lowest HAMA scores (HAMA-1) showed a lower probability of fracture than did participants with the highest scores (HAMA-3) (20.44 ± 9.3 vs 24.94 ± 13%, respectively; P = 0.01), and the same trend was observed when comparing the HAMA-2 and HAMA-3 tertiles. Women in the HAMA-3 group exhibited lower lumbar T-score vales in the lumbar spine than did women in the HAMA-1 group (−2.84 ± 1.4 vs −2.06 ± 1.2 SD, respectively; P < 0.001) and a lower T-score value in the femoral neck (−2.21 ± 0.9 vs −1.93 ± 0.6 SD, respectively; P < 0.05). Lower T-score values were observed in HAMA-3 than in HAMA-2. A higher prevalence rate of vertebral fractures was observed in HAMA-3 than in HAMA-1, but the difference was not significant. Anxiety levels were significantly related to age, menopausal age, years since menopause, and depressive symptoms, and a multiple regression analysis was predictive of reduced BMD in the lumbar spine (β = −0.00672, SE = 0.001, P = 0.0002).

Conclusion:
In postmenopausal women, anxiety levels were associated with BMD in the lumbar spine and femoral neck.