bluuebunny/crossref_metadata_2025_split huggingface dataset:
High Kynurenine:Tryptophan Ratio Is Associated With Liver Fibrosis in HIV-Monoinfected and HIV/Hepatitis C Virus–Coinfected Women
Authors: Kardashian Ani , Ma Yifei , Yin Michael T , Scherzer Rebecca , Nolan Olivia , Aweeka Francesca , Tien Phyllis C , Price Jennifer C 
Published: June 2019

Abstract

Background
Tryptophan catabolism, measured by the kynurenine:tryptophan (kyn/trp) ratio, is associated with gut microbiota alterations in people with HIV (PWH). We examined the association of the kyn/trp ratio with liver fibrosis in women with/without HIV infection.

Methods
The plasma kyn/trp ratio was measured in 137 HIV-monoinfected, HIV/hepatitis C virus (HCV)–coinfected, and uninfected women in the Women’s Interagency HIV Study. Fibrosis was estimated using FIB-4 in all participants and vibration-controlled transient elastography liver stiffness measurement (LSM) in a subset (n = 83). We used multivariable linear regression to evaluate the associations of infection status and kyn/trp ratio with relative differences in fibrosis estimates.

Results
The median kyn/trp ratio (interquartile range) was 0.056 (0.045–0.066) in HIV/HCV-coinfected, 0.038 (0.032–0.046) in HIV-monoinfected, and 0.031 (0.025–0.034) in uninfected women (P &lt; .001). After adjustment for sociodemographic, lifestyle, and metabolic factors, HIV monoinfection and HIV/HCV coinfection were associated with 37% (95% confidence interval [CI], 9% to 73%) and 164% (95% CI, 100% to 250%) greater FIB-4, respectively. When kyn/trp ratio was included, higher kyn/trp ratio was associated with greater FIB-4 (27% per kyn/trp doubling; 95% CI, 5% to 53%), and the associations of HIV monoinfection (29% per kyn/trp doubling; 95% CI, 2% to 63%) and HIV/HCV coinfection (123% per kyn/trp doubling; 95% CI, 63% to 203%) with greater FIB-4 were attenuated. Among those with LSM, higher kyn/trp ratio was associated with greater LSM (43% per kyn/trp doubling; 95% CI, 15% to 79%) in multivariable analysis.

Conclusions
The kyn/trp ratio is elevated in PWH and is associated with greater liver fibrosis. Tryptophan catabolism may modify the relationships between HIV, HCV, and fibrosis.
The predictors of and reasons for non-adherence in an observational cohort of patients with rheumatoid arthritis commencing methotrexate
Authors: Hope Holly F , Hyrich Kimme L , Anderson James , Bluett James , Sergeant Jamie C , Barton Anne , Cordingley Lis , Verstappen Suzanne M M ,   RAMS co-investigators, Adebajo Ade , Ahmed Khalid , Al-Ansari Atheer , Amarasena Roshan , Bukhari Marwan , Callan Margaret , Chelliah Easwaradhas G , Chinoy Hector , Cooper Annie , Dasgupta Bhaskar , Davis Martin , Galloway James , Gough Andrew , Green Michael , Gullick Nicola , Hamilton Jennifer , Hassan Waji , Hider Samantha , Hyrich Kimme , Kamath Sanjeet , Knight Susan , Lane Suzanne , Lee Martin , Levy Sarah , Macphie Lizzy , Marguerie Christopher , Marshall Tarnya , Mathews Catherine , McKenna Frank , Naz Sophia , Perry Mark , Pollard Louise , Quilty Brian , Robertson Lindsay , Roy Dipak , Sanders Paul , Saravanan Vadivelu , Scott David , Smith Gillian , Smith Richard , Symmons Deborah , Teh Lee-Suan , Viner Nick 
Published: June 2019

Abstract

Objective
In order to develop interventions to optimize MTX use for the treatment of RA we evaluated the rate of, reasons for and predictors of MTX non-adherence during the first 6 months of therapy.

Methods
The Rheumatoid Arthritis Medication Study (RAMS) is a prospective multicentre cohort study of incident MTX users in the UK. Prior to MTX commencement demographic, clinical and psychological data were collected. A weekly patient-completed diary recorded MTX dose, possible side effects and adherence over 26 weeks. The number of non-adherent weeks was calculated. Potential baseline predictors of ever non-adherence (⩾1 week non-adherent) during the first 6 months of MTX therapy were identified using logistic regression analyses.

Results
606 patients with RA were included; 69% female, mean (s.d.) age 60 (13) years and DAS28 score 4.2 (1.2). Over the first 6 months following MTX initiation, 158 (26%) patients were ever non-adherent (71% intentional, 19% non-intentional, 10% unexplained) and mean (s.d.) number of non-adherent weeks was 2.5 (2.1). Multivariable predictors of ever non-adherence included DAS28 [odds ratios (OR) 1.1, 95% CI 1.0, 1.4], fatigue (OR 1.1, 95% CI 1.0, 1.2 per cm), ⩾2 comorbidities vs no comorbidities (OR 1.9, 95% CI 1.1, 3.5) and high medication concerns despite perceived need (OR 1.1, 95% CI 1.0, 1.1 per unit decrease in need/concern differential).

Conclusion
This is the largest study evaluating early intentional and non-intentional non-adherence to MTX, which has identified that patient beliefs and multi-morbidity strongly link with non-adherence. These findings can direct the design of and provide potential targets for interventions to improve patient adherence.
Drug provocation testing: risk stratification is key
Authors: Garvey Lene H. , Savic Louise C. 
Published: June 2019

Purpose of review
This review aims to describe current best practice and recent advances in the use of risk stratification as a tool for drug provocation testing (DPT). In particular, we focus on the testing of unsubstantiated penicillin allergy labels.

Recent findings
The inherent risks of DPT are mitigated through careful selection of patients. A detailed history will elicit features of a potentially severe index reaction, as well as significant patient comorbidities which may increase the risks associated with DPT. Such patients require skin testing and/or in vitro testing prior to consideration for a DPT. However, there is increasing evidence that patients without these features may be able to proceed directly to DPT. This has been demonstrated extensively with unsubstantiated penicillin allergy labels, and a variety of risk stratification models have been employed to identify the ‘low-risk’ patient. Improved outcomes and reduced cost have been demonstrated with such models without compromising patient safety.

Summary
Risk stratification tools may enable well-tolerated and effective ‘delabelling’ of low-risk patients, with less demand on already scarce resources.
The roles of omega-3 fatty acids and resolvins in allergic conjunctivitis
Authors: Hirakata Toshiaki , Yokomizo Takehiko , Matsuda Akira 
Published: June 2019

Purpose of reviewLipids are one of the most important constituents in our body. Advances of lipidomics are elucidating the new roles of various lipid molecules in allergic diseases. For example, some reports showed anti-inflammatory effects of omega-3 fatty acids (FAs), such as docosahexaenoic acid, eicosapentaenoic acid, and their metabolites, on allergic diseases. Here, we introduce the role of lipid mediators in allergic conjunctivitis mouse model.Recent findingsLipidomics using liquid chromatography–tandem mass spectrometry can profile numerous lipid molecules from small tissue samples such as conjunctival specimens. Lipidomics analysis showed that various inflammatory lipid mediators are produced in the conjunctival tissue of allergic conjunctivitis mouse model. Dietary omega-3 FAs reduced these inflammatory lipid mediators in the conjunctiva and alleviated allergic conjunctivitis symptoms in mouse models. In addition, the roles of specialized proresolving lipid mediators (SPMs) have been reported for allergic inflammation.SummaryLipid mediators have important roles for the pathophysiology of the allergic diseases including allergic conjunctivitis. Omega-3 FAs and SPMs are expected as new treatment tools for allergic conjunctivitis.
Comparing Postoperative Analgesic Effect of Dexmedetomidine or Dexamethasone Added to Lidocaine Through Infraclavicular Block in Forearm Surgery
Authors: Yaghoobi Siamak , Shahamat Hoda , Alizadeh Ali , Khezri Marzieh Beigom 
Published: June 2019

Objective:
The objective of this study was to compare the analgesic efficacy of dexamethasone versus dexmedetomidine added to lidocaine using infraclavicular block in patients undergoing forearm fracture surgery.

Method:
Seventy-five patients aged 20 to 60 years were recruited for a prospective, double-blinded, randomized clinical trial. Ultrasound-guided infraclavicular brachial plexus block was performed in 3 groups by injecting 28 mL lidocaine plus 2 mL distilled water (Lido), 28 mL lidocaine plus 2 mL (8 mg) dexamethasone (Dexa), and 28 mL lidocaine plus 2 mL (1 µg/kg) dexmedetomidine (Dexm). Sensory and motor block onset time and the duration, hemodynamic variables, the time for the first analgesic request, and the total analgesic agents consumed within 6 hours after infraclavicular block were assessed.

Results:
Sensory block duration in the Dexm group was significantly greater than in the Lido (P=0.019) and Dexa (P=0.046) groups. The mean motor block duration in the Dexm group showed to be significantly longer than that in the Lido group (P=0.009). Pain intensity within 4 hours after block significantly increased in the Lido group compared with that in the Dexa and Dexm groups (P=0.001). Analgesic consumption during 6 hours after the procedure was higher in the Lido group when compared with the other 2 groups (P=0.001). The Dexm group showed the highest reduction in the mean arterial pressure (P=0.006) and heart rate (P=0.001) among the 3 groups.

Conclusions:
There was no significant difference in postoperative pain intensity between the Dexa and Dexm groups, although DEXm demonstrated a longer sensory block duration in comparison with dexamethasone as a lidocaine adjuvant in infraclavicular block.
Evaluation of Opioid Use With Split Doses of Oral Opioids in a Postcesarean Delivery Analgesia Order Set
Authors: Nanji Jalal A. , Guo Nan , Riley Edward T. , Faulkner Bethan , Do Christina , Carvalho Brendan 
Published: June 2019

OBJECTIVE:
To evaluate whether an order set change that halved the initial dose of oxycodone and allowed the remainder to be given 1 hour later, if requested, was associated with reduced opioid use and side effects after cesarean delivery.

METHODS:
This retrospective, clinical practice study reviewed electronic medical records after implementation of a new order set for cesarean delivery. Oxycodone orders changed from 5 mg (for verbal pain score of 4/10 or lower) and 10 mg (for 5–10/10) to 2.5 mg (for verbal pain score 1–4/10) or 5 mg (for 5–10/10), and the patient requesting pain relief, with a nurse check within 1 hour to administer another 2.5 or 5 mg, respectively, if needed. The primary outcome was opioid use (in intravenous morphine equivalents) in the first 48 hours. Secondary outcomes included incidence and treatment of nausea or vomiting and pruritis, average and peak verbal pain scores within 48 hours, and satisfaction.

RESULTS:
The records of 1,050 women were examined (542 before and 508 after the change). Opioid use in the first 48 hours was lower after the practice change (median [interquartile range] 10.0 [1.3–25.0] mg before vs 4.4 [0–12.5] mg after; P<.001). A small increase in average verbal pain score occurred (mean [SD] 1.8 [1.0] before vs 2.0 [1.3] after; difference −0.2; 95% CI −0.3 to −0.04). Peak verbal pain score (5.9 [2.0] before vs 6.0 [2.1] after; difference −0.1; 95% CI −0.4 to 0.1) and mean (SD) satisfaction score (97.7 [7.2] before vs 97.1 [7.5] after; difference 0.6, 95% CI −0.5 to 1.6) did not change. Fewer patients reported postoperative nausea or vomiting (30.9% before vs 19.3% after; odds ratio 0.5; 95% CI 0.4 to 0.7).

CONCLUSION:
Split doses of oxycodone were associated with 56% reduction in 48 hours opioid use after cesarean delivery.
Increased Rwandan Access to Obstetrician–Gynecologists Through a U.S.–Rwanda Academic Training Partnership
Authors: Small Maria , Magriples Urania , Ghebre Rahel , Bazzett-Matabele Lisa , Ntirushwa David , Kitessa Doee , Ntasumbumuyange Diomede , Lantos Paul , Ngabonziza Eugene , Hill Washington , Ruzindana Kenneth , Rukundo Jean Damascene , Moscovitz Alexandra N. , Bagambe Patrick , Brown Haywood , Rulisa Stephen 
Published: June 2019

OBJECTIVE:
To evaluate the first 5 years of the Human Resources for Health Rwanda program from the program onset in the July 2012–2016 academic years, and its effects on access to care through examination of: 1) the number of trained obstetrician–gynecologists (ob-gyns) who graduated from the University of Rwanda and the University of Rwanda-Human Resources for Health program and 2) a geospatial analysis of pregnant women's access to Rwandan public hospitals with trained ob-gyns.

METHODS:
We used GPS coordinates in this cross-sectional study to identify public (government) hospitals with ob-gyns in 2011 (before initiation of the program) compared with 2016 (year 5 of the program). We compared access to care for the years 2011 and 2016 through geocoding the proportion of pregnant women within 10 and 25 km from these hospitals and compared the travel time to these hospitals in the two time periods. We used a World Pop dataset of Rwandan pregnancies from 2015, ArcGIS for spatial operations, R for statistical analysis, zonal statistics for circular distances, and friction surface for travel time analysis.

RESULTS:
The number of ob-gyns in public hospitals increased from 14 to 49 nationally. Before the program, 18 residents graduated over a 7-year period (two residents per year); 33 graduated by year 5 (six residents per year). Rwandan faculty increased by 45%. In 2011, most providers were in the capital city. Between 2011 and 2016, the proportion of pregnant women living 10 km from an ob-gyn-staffed public hospital increased from 13.0% to 31.6%; within 25 km increased from 28.4% to 82.9%. Travel time analysis from 2011 to 2016 showed 49.1% of Rwandan women within 1 hour of a hospital and 85.6% within 2 hours. In 2016, this coverage increased to 87.5% and 98.3%, respectively.

CONCLUSION:
In 5 years, the Human Resources for Health Rwanda program improved the number of residency graduates in obstetrics and gynecology and nationwide access to these providers. The program reduced rural–urban disparities in access to ob-gyns.
Implementation of the Safe Reduction of Primary Cesarean Births Safety Bundle During the First Year of a Statewide Collaborative in Maryland
Authors: Callaghan-Koru Jennifer A. , Creanga Andreea A. , DiPietro Bonnie , Mark Katrina , Sowe Ardy , Aboumatar Nour , Burke Ann B. , Curran Geoffrey 
Published: June 2019

OBJECTIVE:
To describe the status of implementation of the Alliance for Innovation in Maternal Health's primary cesarean birth patient safety bundle in Maryland after 1 year (2016–2017), and assess whether hospital characteristics and implementation strategies employed are associated with bundle implementation.

METHODS:
The Alliance for Innovation in Maternal Health's bundle to decrease primary cesarean births includes 26 evidence-based practices that hospitals can adopt based on specific needs. One year after the start of a statewide implementation collaborative at 31 of 32 birthing hospitals in Maryland, we sent a computer-based survey to hospital collaborative leaders to assess progress. Respondents reported on hospital characteristics, adoption of bundle practices, and use of 15 selected implementation strategies. We conducted descriptive and bivariate analyses of their responses.

RESULTS:
Among 26 hospitals with complete reporting, 23 fully implemented at least one bundle practice (range 1–7) during the collaborative's first year. Of 26 bundle practices, on average, hospitals had fully implemented a third (mean 8.6; SD 5.5; range 0–17) before the collaborative, and 3 new practices (SD 2.4; range 0–8) during the collaborative. Hospitals' use of six implementation strategies, all highly dependent on strong clinician involvement, was significantly associated with their fully implementing more practices during the collaborative's first year.

CONCLUSION:
Our assessment has promising results, with a majority of hospitals having implemented new cesarean birth bundle practices during the collaborative's first year. However, there are lessons from the wide variability in the number and type of practices adopted. Clinicians should be aware of this variability and become more involved in the implementation of cesarean birth bundle practices. We identified six strategies associated with full implementation of more bundle practices for which clinicians' support and commitment to practice changes are critical. Clinicians' understanding of available and effective implementation strategies can better assist with the implementation of this and other Alliance for Innovation in Maternal Health patient safety bundles.
A Predictive Score for Determining Risk of Surgical Site Infection After Orthopaedic Trauma Surgery
Authors: Wise Brent T. , Connelly Daniel , Rocca Michael , Mascarenhas Daniel , Huang Yanjie , Maceroli Michael A. , Gage Mark J. , Joshi Manjari , Castillo Renan C. , O'Toole Robert V. 
Published: June 2019

Objectives:
To determine factors predictive of postoperative surgical site infection (SSI) after fracture fixation and create a prediction score for risk of infection at time of initial treatment.

Design:
Retrospective cohort study.

Setting:
Level I trauma center.

Patients/Participants:
Study group, 311 patients with deep SSI; control group, 608 patients.

Intervention:
We evaluated 27 factors theorized to be associated with postoperative infection. Bivariate and multiple logistic regression analyses were used to build a prediction model. A composite score reflecting risk of SSI was then created.

Main Outcome Measures:
Risk of postoperative infection.

Results:
The final model consisted of 8 independent predictors: (1) male sex, (2) obesity (body mass index ≥ 30) (3) diabetes, (4) alcohol abuse, (5) fracture region, (6) Gustilo–Anderson type III open fracture, (7) methicillin-resistant Staphylococcus aureus nasal swab testing (not tested or positive result), and (8) American Society of Anesthesiologists classification. Risk strata were well correlated with observed proportion of SSI and resulted in a percent risk of infection of 1% for ≤3 points, 6% for 4–5 points, 11% for 6 to 8–9 points, and 41% for ≥10 points.

Conclusion:
The proposed postoperative infection prediction model might be able to determine which patients have fractures at higher risk of infection and provides an estimate of the percent risk of infection before fixation.

Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?
Authors: Al-Hourani Khalid , Fowler Tim , Whitehouse Michael R. , Khan Umraz , Kelly Michael 
Published: June 2019

Objective:
To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo–Anderson type IIIB open tibial diaphyseal fractures.

Design:
Retrospective comparative cohort study over a 2-year period.

Setting:
Level 1 trauma center.

Patients/Participants:
A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis.

Intervention:
Time to initial debridement and definitive management.

Main Outcome Measurement:
Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant.

Results:
Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion.

Conclusions:
Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Pretibial Pruritic Papular Dermatitis: A Comprehensive Clinical and Pathologic Review of Cases at a Single Institution
Authors: Flores Shadai , Wada David A. , Florell Scott R. , Bowen Anneli R. 
Published: June 2019

Background:
Studies characterizing clinical and pathologic details of pretibial pruritic papular dermatitis (PPPD) are scarce. Several cases of PPPD at our institution have displayed lymphocyte atypia and CD30 positivity, resembling lymphomatoid papulosis (LyP). We explore the clinical and histological spectrum of PPPD, with emphasis on lymphocyte atypia.

Methods:
Retrospective observational study of 40 archived pathological specimens (hematoxylin/eosin, CD3, CD20, and CD30 immunohistochemistry) from 38 PPPD patients in an academic center. Clinical photographs were available in 22 cases.

Results:
Microscopic epidermal changes were focal, but common (spongiosis 75%, parakeratosis 90%, interface changes 43%, Langerhans cell microgranulomas 25%, multinucleated keratinocytes 55%, Civatte bodies 55%, erosion 20%, and more than focal irregular psoriasiform hyperplasia 37%) and certain dermal changes were universal (papillary dermal fibrosis 100%, stellate fibroblasts 100%, and multinucleated fibroblasts 93%). At least focal lymphocyte atypia was present in all cases. Lymphocytes were almost exclusively CD3+ T cells with rare CD20+ B cells. Up to 30% of lymphocytes exhibited weak CD30 staining. Clinically, all cases exhibited discrete papules, but plaques and erosions were not uncommon.

Limitations:
As a retrospective series, clinical images were not available for all cases.

Conclusion:
This study suggests a broader histological and clinical spectrum of PPPD than previously described. Epidermal changes are common in PPPD, as are atypical lymphocytes and focal CD30 positivity. Although the papular clinical appearance, lymphocyte atypia, and focal CD30 positivity may resemble LyP, the relatively low number of atypical lymphocytes, low intensity of CD30 staining, and absence of spontaneous resolution help to distinguish PPPD from LyP.
Surgical Volume of Dermatologists Who Do Not Perform Mohs Micrographic Dermatologic Surgery: A Cross-Sectional Individual-Level Analysis Using Medicare Data
Authors: Kantor Jonathan 
Published: June 2019

BACKGROUND
Dermatologists overall perform a large number of procedures billed to Medicare, though the proportion of surgical procedures attributable to general dermatologists who do not perform Mohs micrographic dermatologic surgery (MDS) is unknown.

OBJECTIVE
To determine the surgical volume of dermatologists who do not perform MDS and compare it to the surgical volume of MDS-performing dermatologists and all non-dermatologists.

METHODS
A cross-sectional analytical study was performed using the Medicare public use file for 2014. Data were divided by physician specialty (dermatologists vs all non-dermatologists), and dermatologists were then dichotomized by MDS performance.

RESULTS
Non-MDS dermatologists performed 42.19% of the benign excisions, 57.18% of the malignant excisions, and 46.00% of the intermediate repairs billed to Medicare in 2014. Micrographic dermatologic surgery–performing dermatologists were responsible for most of the complex repairs (67.56%), flaps (52.85%), and grafts (59.65%) billed to Medicare.

CONCLUSION
Dermatologists who do not perform MDS represent the single largest group billing Medicare for benign excisions, malignant excisions, and intermediate repairs. They also bill for more complex repairs than all non-dermatologists combined. Micrographic dermatologic surgery–performing dermatologists performed most of the complex repairs, flaps, and grafts billed to Medicare.