bluuebunny/crossref_metadata_2025_split huggingface dataset:
Understanding the Family Planning Needs of Female Participants in a Syringe Exchange Program: A Needs Assessment and Pilot Project
Authors: Tschann Mary , Wright Tricia , Lusk Heather , Giorgio Willa , Colon Anaeliz , Kaneshiro Bliss 
Published: February 2019

Objectives:
To describe the reproductive health needs of women who inject drugs (WWID) and are participants in a syringe exchange program (SEP) in Hawaii. Our secondary objective was to develop and pilot services in response to those needs.

Methods:
We conducted a reproductive health needs-assessment of women participating in the SEP. We also documented the perspectives and recommendations of key informants who work closely with women in this program. This needs-assessment informed a pilot contraceptive project at the SEP.

Results:
We received surveys from 50 syringe exchange participants and hosted 1 focus group with 6 participants. We completed 8 key informant interviews. The majority of survey respondents indicated that they did not want to become pregnant in the next year, but most were not using a reliable method of contraception. Additionally, for most respondents, prevention of pregnancy was a lower priority than other health and wellness needs. Focus group participants and key informants emphasized the importance of developing a network of accessible providers to address reproductive health needs, and also the importance of using the principles of trauma-informed care when developing a service. We developed a pilot program to offer contraceptive injections at the syringe exchange program. In the first 6 months of offering the service, 1 participant elected to use the injection.

Conclusions:
WWID participating in this SEP may not prioritize their family planning needs when other health and safety needs are unmet. A pilot program to offer contraceptive injections at SEP had almost zero uptake.
Bundled Care for Hip Fractures: A Machine-Learning Approach to an Untenable Patient-Specific Payment Model
Authors: Karnuta Jaret M. , Navarro Sergio M. , Haeberle Heather S. , Billow Damien G. , Krebs Viktor E. , Ramkumar Prem N. 
Published: February 2019

Objectives:
With the transition to a value-based model of care delivery, bundled payment models have been implemented with demonstrated success in elective lower extremity joint arthroplasty. Yet, hip fracture outcomes are dependent on patient-level factors that may not be optimized preoperatively due to acuity of care. The objectives of this study are to (1) develop a supervised naive Bayes machine-learning algorithm using preoperative patient data to predict length of stay and cost after hip fracture and (2) propose a patient-specific payment model to project reimbursements based on patient comorbidities.

Methods:
Using the New York Statewide Planning and Research Cooperative System database, we studied 98,562 Medicare patients who underwent operative management for hip fracture from 2009 to 2016. A naive Bayes machine-learning model was built using age, sex, ethnicity, race, type of admission, risk of mortality, and severity of illness as predictive inputs.

Results:
Accuracy was demonstrated at 76.5% and 79.0% for length of stay and cost, respectively. Performance was 88% for length of stay and 89% for cost. Model error analysis showed increasing model error with increasing risk of mortality, which thus increased the risk-adjusted payment for each risk of mortality.

Conclusions:
Our naive Bayes machine-learning algorithm provided excellent accuracy and responsiveness in the prediction of length of stay and cost of an episode of care for hip fracture using preoperative variables. This model demonstrates that the cost of delivery of hip fracture care is dependent on largely nonmodifiable patient-specific factors, likely making bundled care an implausible payment model for hip fractures.
New Five-Factor Modified Frailty Index Predicts Morbidity and Mortality in Geriatric Hip Fractures
Authors: Traven Sophia A. , Reeves Russell A. , Althoff Alyssa D. , Slone Harris S. , Walton Zeke J. 
Published: February 2019

Introduction:
Although the 11-factor modified frailty index (mFI-11) has been shown to predict adverse outcomes in elderly patients undergoing surgery for hip fractures, the newer 5-factor index has not been evaluated in this population. The goal of this study is to evaluate the mFI-5 as a predictor of morbidity and mortality in elderly patients undergoing surgical management for hip fractures.

Methods:
The NSQIP database was queried for patients 60 years of age and older who underwent surgical management for hip fractures between 2005 and 2016. The 5-factor score, which comprised diabetic status, history of COPD or current pneumonia, congestive heart failure, hypertension requiring medication, and nonindependent functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and 30-day postoperative complications.

Results:
A total of 58,603 patients were identified. After adjusting for comorbidities, the mFI-5 was a strong predictor for total complications, serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), surgical site infections, readmission, extended hospital length of stay, and mortality (P ≤ 0.008). For each point increase, the risk for any complication increased by 29.8%, serious medical complications 35.4%, surgical site infections 14.7%, readmission 24.6%, and mortality 33.7%.

Conclusions:
The mFI-5 is an independent predictor of postoperative morbidity and mortality in elderly patients undergoing surgery for hip fractures. This clinical tool can be used by hospitals and surgeons to identify high-risk patients, accurately council patients and families with transparency, and guide perioperative care to optimize patient outcomes.

Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Targeting CD39 Toward Activated Platelets Reduces Systemic Inflammation and Improves Survival in Sepsis: A Preclinical Pilot Study*
Authors: Granja Tiago , Körner Andreas , Glück Christian , Hohmann Jan David , Wang Xiaowei , Köhler David , Streißenberger Ariane , Nandurkar Harshal H. , Mirakaj Valbona , Rosenberger Peter , Peter Karlheinz , Straub Andreas 
Published: February 2019

Objectives:Sepsis is associated with a systemic inflammatory reaction, which can result in a life-endangering organ dysfunction. Pro-inflammatory responses during sepsis are characterized by increased activation of leukocytes and platelets, formation of platelet-neutrophil aggregates, and cytokine production. Sequestration of platelet-neutrophil aggregates in the microvasculature contributes to tissue damage during sepsis. At present no effective therapeutic strategy to ameliorate these events is available. In this preclinical pilot study, a novel anti-inflammatory approach was evaluated, which targets nucleoside triphosphate hydrolase activity toward activated platelets via a recombinant fusion protein combining a single-chain antibody against activated glycoprotein IIb/IIIa and the extracellular domain of CD39 (targ-CD39).Design:Experimental animal study and cell culture study.Setting:University-based experimental laboratory.Subjects:Human dermal microvascular endothelial cells 1, human platelets and neutrophils, and C57BL/6NCrl mice.Interventions:Platelet-leukocyte-endothelium interactions were evaluated under inflammatory conditions in vitro and in a murine lipopolysaccharide-induced sepsis model in vivo. The outcome of polymicrobial sepsis was evaluated in a murine cecal ligation and puncture model. To evaluate the anti-inflammatory potential of activated platelet targeted nucleoside triphosphate hydrolase activity, we employed a potato apyrase in vitro and in vivo, as well as targ-CD39 and as a control, nontarg-CD39 in vivo.Measurements and Main Results:Under conditions of sepsis, agents with nucleoside triphosphate hydrolase activity decreased platelet-leukocyte-endothelium interaction, transcription of pro-inflammatory cytokines, microvascular platelet-neutrophil aggregate sequestration, activation marker expression on platelets and neutrophils contained in these aggregates, leukocyte extravasation, and organ damage. Targ-CD39 had the strongest effect on these variables and retained hemostasis in contrast to nontarg-CD39 and potato apyrase. Most importantly, targ-CD39 improved survival in the cecal ligation and puncture model to a stronger extent then nontarg-CD39 and potato apyrase.Conclusions:Targeting nucleoside triphosphate hydrolase activity (CD39) toward activated platelets is a promising new treatment concept to decrease systemic inflammation and mortality of sepsis. This innovative therapeutic approach warrants further development toward clinical application.
Central Venous Access Capability and Critical Care Telemedicine Decreases Inter-Hospital Transfer Among Severe Sepsis Patients: A Mixed Methods Design
Authors: Ilko Steven A. , Vakkalanka J. Priyanka , Ahmed Azeemuddin , Harland Karisa K. , Mohr Nicholas M. 
Published: February 2019

Objectives:
Severe sepsis is a complex, resource intensive, and potentially lethal condition and rural patients have worse outcomes than urban patients. Early identification and treatment are important to improving outcomes. The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer.

Design:
Mixed method study integrating data from a telephone survey and retrospective cohort study of state administrative claims.

Setting and Subjects:
Survey of Iowa emergency department administrators between May 2017 and June 2017 and cohort of adults seen in Iowa emergency departments for severe sepsis and septic shock between January 2005 and December 2013.

Interventions:
None.

Measurements and Main Results:
Multivariable logistic regression was used to identify independent predictors of inter-hospital transfer. We included 114 institutions that provided data (response rate = 99%), and responses were linked to a total of 150,845 visits for severe sepsis/septic shock. In our adjusted model, having the capability to place central venous catheters or having a subscription to a tele-ICU service was independently associated with lower odds of inter-hospital transfer (adjusted odds ratio, 0.69; 95% CI, 0.54–0.86 and adjusted odds ratio, 0.69; 95% CI, 0.54–0.88, respectively). A facility’s participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer (adjusted odds ratio, 1.62; 95% CI, 1.10–2.39).

Conclusions:
The insertion of central venous catheters and access to a critical care physician during sepsis treatment are important capabilities in hospitals that transfer fewer sepsis patients. In the future, hospital-specific capabilities may be used to identify institutions as regional sepsis centers.
Reflective Practice for Patient Benefit: An Analysis of Doctors' Appraisal Portfolios in Scotland
Authors: Wakeling Judy , Holmes Sarah , Boyd Alan , Tredinnick-Rowe John , Cameron Niall , Marshall Martin , Bryce Marie , Archer Julian 
Published: February 2019

Introduction:
Reflective practice has become the cornerstone of continuing professional development for doctors, with the expectation that it helps to develop and sustain the workforce for patient benefit. Annual appraisal is mandatory for all practicing doctors in the United Kingdom as part of medical revalidation. Doctors submit a portfolio of supporting information forming the basis of their appraisal discussion where reflection on the information is mandated and evaluated by a colleague, acting as an appraiser.

Methods:
Using an in-depth case study approach, 18 online portfolios in Scotland were examined with a template developed to record the types of supporting information submitted and how far these showed reflection and/or changes to practice. Data from semistructured interviews with the doctors (n = 17) and their appraisers (n = 9) were used to contextualize and broaden our understanding of the portfolios.

Results:
Portfolios generally showed little written reflection, and most doctors were unenthusiastic about documenting reflective practice. Appraisals provided a forum for verbal reflection, which was often detailed in the appraisal summary. Portfolio examples showed that reflecting on continued professional development, audits, significant events, and colleague multisource feedback were sometimes considered to be useful. Reflecting on patient feedback was seen as less valuable because feedback tended to be uncritical.

Discussion:
The written reflection element of educational portfolios needs to be carefully considered because it is clear that many doctors do not find it a helpful exercise. Instead, using the portfolio to record topics covered by a reflective discussion with a facilitator would not only prove more amenable to many doctors but would also allay fears of documentary evidence being used in litigation.
Parent-Child Interaction Therapy for Children with Developmental Delay: The Role of Sleep Problems
Authors: Acosta Juliana , Garcia Dainelys , Bagner Daniel M. 
Published: February 2019

ABSTRACT:

Objective:
Sleep problems are common and associated with externalizing behavior problems in young children, particularly among young children with developmental delay (DD). The aims of the current study, which was a secondary data analysis of 2 previously conducted randomized controlled trials, were to assess whether parent-child interaction therapy (PCIT) led to decreases in child sleep problems and whether initial sleep problems moderated the effect of PCIT on child behavior.

Methods:
The study participants were 44 children (M = 49.19 months, SD = 13.1) with DD or borderline DD and with co-occurring clinically significant levels of externalizing behavior problems and their mothers (M = 35.9 years, SD = 7.3). These participants were randomly assigned to either an immediate treatment group or a waitlist control group.

Results:
Findings revealed a significant direct effect of PCIT on decreases in sleep problems. Additionally, moderation analyses revealed that lower levels of child sleep problems at pretreatment were associated with greater improvements in observed child compliance compared with higher levels of child sleep problems at pretreatment.

Conclusion:
This study extends previous findings by providing support for the preliminary efficacy of PCIT in reducing sleep problems in children with DD and borderline DD and highlighting the role of sleep problems as a factor associated with differential treatment effects in behavioral parenting intervention research.
Is the Pathologic Response of T3 Rectal Cancer to High-Dose-Rate Endorectal Brachytherapy Comparable to External Beam Radiotherapy?
Authors: Garfinkle Richard , Lachance Sebastian , Vuong Te , Mikhail Alexandre , Pelsser Vincent , Gologan Adrian , Morin Nancy A. , Vasilevsky Carol-Ann , Boutros Marylise 
Published: February 2019

BACKGROUND:
Endorectal brachytherapy is an attractive option in the neoadjuvant setting for locally advanced rectal cancer, but it is not considered standard of care.

OBJECTIVE:
This study aimed to compare pathologic outcomes of patients with clinical T3 rectal cancer who underwent high-dose-rate endorectal brachytherapy with those who underwent conventional external beam radiotherapy.

DESIGN:
This study is a retrospective chart review.

SETTINGS:
This study was conducted in a single large tertiary academic colorectal surgery practice in Canada.

PATIENTS:
Adult patients with MRI-staged T3 rectal adenocarcinoma treated with neoadjuvant radiotherapy followed by total mesorectal excision from 2007 to 2016 were included.

INTERVENTIONS:
Neoadjuvant radiotherapy was delivered by high-dose-rate endorectal brachytherapy or conventional external beam radiotherapy.

MAIN OUTCOME MEASURES:
Primary outcome was pathologic complete response, defined as ypT0N0. Secondary outcomes included tumor (T stage) and lymph node (N stage) downstaging and tumor regression grade.

RESULTS:
Ninety-nine patients were identified as having clinical T3 rectal cancer based on blinded pretreatment MRI review. Mean age was 66.2 years (± 6.2) and 59 patients (59.6%) were male. Thirty-three patients were clinically node negative (33.3%), 45 had c-N1 disease (45.5%), and 21 had c-N2 disease (21.2%). Sixty-four patients (64.6%) underwent high-dose-rate endorectal brachytherapy and 35 (35.4%) underwent external beam radiotherapy. The high-dose-rate endorectal brachytherapy group had a lower median mesorectal depth of invasion (4 mm vs 5 mm, p = 0.010); all other preoperative tumor characteristics were similar in both groups. Eighteen patients (18.2%) achieved pathologic complete response: 12 in the high-dose-rate endorectal brachytherapy group and 6 in the conventional external beam radiotherapy group (18.8% vs 17.1%, p = 0.84). High-dose-rate endorectal brachytherapy was superior to conventional radiotherapy for tumor (T stage) downstaging (59.4% vs 28.6%, p = 0.0030) but not for lymph node (N stage) downstaging (35.9% vs 51.4%, p = 0.14).

LIMITATIONS:
This study was limited by its retrospective nature and modest sample size.

CONCLUSIONS:
Neoadjuvant treatment of T3 rectal cancer with high-dose-rate endorectal brachytherapy appears to achieve equivalent rates of pathologic complete response and superior T-stage downstaging compared with conventional external beam radiotherapy. See Video Abstract at http://links.lww.com/DCR/A905.
Laparoscopic Mesorectal Excision in Obesity: Novel Insights and Technical Strategies
Authors: Ng Jia Lin , Kajohnwongsatit Krittin , Sahakitrungruang Chucheep 
Published: February 2019

INTRODUCTION:
Obesity is a burgeoning problem worldwide. Although beneficial in obese patients, conventional laparoscopic mesorectal excision for rectal cancer is technically challenging, with a higher conversion rate to open compared with nonobese patients. We describe novel strategies to circumvent these difficulties.

TECHNIQUE:
The key steps are 1) lateral-to-medial colonic mobilization and left-sided mesorectal excision with the surgeon on the patient’s right; 2) switching to the patient’s left for right-sided mesorectal excision; 3) further rectal retraction with cotton tape and preperitoneal fat sling; and 4) caudal-to-cephalad mobilization of colon after distal transection, which facilitates extrapelvic mesenteric dissection and vessel ligation.

RESULTS:
These techniques optimize gravity to negate the lack of exposure due to visceral obesity. Triangulation is improved by changing the surgeon’s position during mesorectal dissection. This allows accurate identification of anatomical planes and avoids excessive pneumoperitoneum pressures and Trendelenburg tilt.

CONCLUSIONS:
Adopting these strategies can facilitate laparoscopic mesorectal excision in the obese patient and may reduce conversion to open.
A Diagnostic Challenge: Changes in Histopathologic Tumor Diagnosis of Atypical Squamous Proliferations After Surgical Removal
Authors: Rubin Ashley G. , Brian Jiang Shang I. 
Published: February 2019

BACKGROUND
Biopsy-proven “atypical squamous proliferations” (ASPs) may prove difficult to diagnose histologically because of partial sampling, lack of complete criteria for definitive diagnosis, or overlap of histopathological features with other neoplasms. There are no guidelines concerning the management of ASPs.

OBJECTIVE
To retrospectively clarify the diagnosis of biopsy-proven ASPs after surgical removal, specifically, to ascertain what fraction represent malignant tumors.

METHODS
Medical records of patients who underwent surgical removal of biopsy-proven ASPs in an academic dermatologic surgical unit from June 2008 to July 2013 were examined. The resultant histopathologic diagnosis of these lesions after surgical removal, along with other demographic data, was obtained.

RESULTS
Of the 71 biopsy-proven ASPs that were treated by surgical removal in the study period, 54.9% exhibited resultant pathologic diagnosis of nonmelanoma skin cancer (NMSC).

CONCLUSION
Biopsy-proven ASPs present a therapeutic challenge. The authors' data illustrate the importance of subsequent tissue sampling, as these lesions often represent NMSCs.
Assessment of Skin Physiology Change and Safety After Intradermal Injections With Botulinum Toxin: A Randomized, Double-Blind, Placebo-Controlled, Split-Face Pilot Study in Rosacea Patients With Facial Erythema
Authors: Kim Min Jung , Kim Jin Hee , Cheon Hye In , Hur Min Seok , Han Song Hee , Lee Yang Won , Choe Yong Beom , Ahn Kyu Joong 
Published: February 2019

BACKGROUND
Botulinum toxin (BTX) has been used cosmetically with good clinical efficacy and tolerable safety.

OBJECTIVE
This randomized, double-blind, split-face clinical study aimed to investigate the efficacy and safety of intradermal BTX in patients with rosacea.

MATERIALS AND METHODS
Twenty-four participants were enrolled and randomly given intradermal injections of BTX and normal saline in both cheeks. Clinician Erythema Assessment (CEA) score, Global Aesthetic Improvement Scale (GAIS) score, skin hydration, transepidermal water loss (TEWL), melanin content, erythema index, elasticity, and sebum secretions were evaluated at baseline and 2, 4, 8, and 12 weeks.

RESULTS
On the BTX-treated side, the CEA score significantly decreased and the GAIS score significantly increased. The erythema index decreased at Weeks 4 and 8. Skin elasticity was improved at Weeks 2 and 4 and skin hydration, at Weeks 2, 4, and 8. However, TEWL and sebum secretion did not show significant differences.

CONCLUSION
Intradermal BTX injections reduced erythema and rejuvenated the skin effectively and safely in patients with rosacea.
TOXIC POSTERIOR SEGMENT SYNDROME AFTER DROPLESS CATARACT SURGERY WITH COMPOUNDED TRIAMCINOLONE-MOXIFLOXACIN
Authors: Patel Sagar B. , Reddy Nikitha K. , He Yu-Guang 
Published: February 2019

Purpose:To report toxic posterior segment syndrome after dropless cataract surgery using locally compounded triamcinolone-moxifloxacin.Methods:A retrospective case review of 7 patients presenting with a decrease in visual acuity after dropless cataract surgery.Results:All patients experienced significant reductions in best-corrected visual acuity of the postoperative eye ranging from 20/40 to count finger at 4 feet (average best-corrected visual acuity 20/220) immediately after surgery. The presenting symptoms included flashes, floaters, photophobia, glare, halos, visual distortions, and problems assessing colors. In three cases, foveal retinal pigment epithelium changes were noted on dilated fundus exam (DFE). Ellipsoid zone loss was noted on ocular coherence tomography in five of the seven affected eyes. Electrophysiology testing in five of the seven affected eyes demonstrated large decreases in full-field electroretinogram amplitude, oscillatory potentials, multifocal electroretinogram, and visual evoked potential, along with a negative electroretinogram. One patient was treated with a dexamethasone implant, but no improvement in visual acuity was noted.Conclusion:This is the first case series of toxic posterior segment syndrome occurring secondary to intracameral compounded triamcinolone-moxifloxacin in dropless cataract surgery. The FDA has attributed the toxicity to abnormally high levels of the binding agent poloxamer 407 in the compounded medication. Clinicians should be aware of this phenomenon and exhibit caution when using compounded medications.