bluuebunny/crossref_metadata_2025_split huggingface dataset:
Artificial Intelligence in the U.S. Military Health System: Forging a New Frontier for Clinical Care and Efficiency
Authors: Adirim Terry , Madsen Cathaleen 
Published: September 2024

ABSTRACT
The Military Health System (MHS) has historically been at the forefront of innovation in medicine and science, but it has also historically struggled to implement battlefield innovations or civilian technologies for wider domestic use. Artificial intelligence (AI) has emerged as a transformative force in health care with civilian health systems and institutions at the forefront of these innovations. While these tools have the potential to support resolution of military health’s most pressing issues, the MHS is behind its civilian counterparts in advancing AI. Adoption of AI could benefit the MHS in such areas as service member and beneficiary access to care; more precise allocation of medical personnel and resources; improved operations of military treatment facilities; early detection of emerging threats to health; and force multiplication of existing telehealth capabilities. This evolving and highly visible technology also presents challenges in the military context above those in the civilian context, such as additional levels of privacy and security, integration with purpose-built secure systems, and additional regulatory obligations. To address these, the MHS should engage in three lines of effort to advance AI: establishing governance, education and training of medical personnel, and engaging in research, development, testing, and piloting of AI applications. This will require dedicated personnel and resources for a substantial initial outlay to be recouped later through more effective administration and care. By leveraging lessons learned from civilian systems, the MHS can design, adopt, and implement AI solutions to improve care for service members in both domestic and operational contexts, and for their beneficiaries.
Evaluation of a Novel Needle Decompression Device Against Standard of Care: A Cadaveric Model
Authors: Myers John C , Achay Jennifer , Limon David , Gerhardus Christian , Eastridge Brian , Gelfond Jonathan , Willis Ross , Nicholson Susannah , Bynum Jim 
Published: September 2024

ABSTRACT

Introduction
Pneumothorax (PTX) incidence in patients arriving to a trauma center can be as high as 20%. The severity of PTX can range from insignificant to life-threatening. Five percent of combat casualties sustaining thoracic trauma have tension PTX (tPTX) at the time of death. Rapid diagnosis and decompression, traditionally with a needle decompression in the prehospital setting, is essential. However, high iatrogenic injury rates reveal a need for a device with the potential to decrease injury rate without compromising decompression success. The Donaldson Decompression Needle (DDN) is a 10-gauge × 3.25 inch needle with a locking mechanism designed to prevent over-insertion. During insertion, a spring-loaded blunt tip retracts, releasing the lock. After penetration of the parietal pleura, the blunt tip projects forward, which in turn locks the device in place on the chest. The device also contains an integrated 1-way valve (OWV) to prevent causing iatrogenic PTX, if placed into a healthy lung cavity.

Materials and Methods
We compared the DDN against a standard-of-care (SOC) needle (E-ARS 10 gauge × 3.25”) in a cadaveric randomized crossover design study. Tension pneumothorax was created by inserting a needle adjacent to the sternum and insufflating to 15 mmHg. Data collected included participant demographics/experience, cadaver measurements, and procedure data such as intrathoracic pressures and decompression time. Participants also completed a postprocedure survey. A secondary objective was evaluation of decompression rate with the OWV on vs. off.

Results
Twenty participants were enrolled in the study. Five participants required exclusion. While there were no differences in set-up times for the 2 procedures (DDN vs. SOC, 33 seconds vs. 28 seconds, P = .63), the decompression times were significantly different between the 2 groups (DDN vs. SOC, 2:06 vs. 1:06, P = .019). Evaluation of the secondary outcome resulted in 18 repetitions. The average decompression time for the OWV on group (n = 9) vs. OWV off group (n = 9) was 44 seconds vs. 10 seconds (P=&lt;.05).

Conclusions
Despite the similar length and gauge of the DDN compared to the standard of care (SOC), the success rate of thoracic decompression was lower for the DDN when compared to the SOC (46% vs. 87%, P = .077) although statistical noninferiority was not established. Additionally, intradevice comparisons indicated decompression with the OWV on significantly prolonged decompression time when compared to when it was removed. It could be appropriate to consider removing the OWV after placement to decrease the decompression time, followed by reattachment for transport. Further research into the ability of the DDN to decrease iatrogenic injury will follow validation of decompression capabilities.
The Potential Utility of Retinal Biomarkers to Index Central Nervous System Effects of Repetitive Blast Exposure in Military Personnel
Authors: Silverstein Steven M 
Published: September 2024

ABSTRACT
Military personnel exposed to blasts receive repeated subconcussive head impacts. Although these events typically do not cause immediate symptoms and do not lead to medical evaluation, the cumulative effects of subconcussive impacts can be significant and can include postconcussive symptoms, changes in brain structure and function, long-term cognitive dysfunction, depression, and chronic traumatic encephalopathy. Retinal measures such as thickness of retinal neural layers, density of retinal microvasculature, and strength of retinal neuronal firing are associated with cognitive function and brain structure and function in healthy populations and in neurodegenerative disease cohorts, and changes over time in retinal indices predict cognitive decline and brain atrophy in longitudinal studies in a range of medical populations. This commentary highlights the potential benefits of using retinal biomarkers in the routine screening and monitoring of brain health in warfighters and veterans. Retinal measures can be rapidly acquired (often in a matter of seconds) using methods that are inexpensive and noninvasive, and they can be collected with movable and often portable equipment that uses automated scoring routines that can be used for prediction and decision-making at the individual level. To date, however, retinal biomarkers have not been included in studies of blast overpressure exposures in military personnel. Despite this, preclinical and human evidence suggests that they could be among the most effective methods for tracking central nervous system damage in people exposed to repeated blasts. Retinal biomarkers could also contribute to brief test batteries to determine who is most at risk for long-term negative effects of future exposures. In addition, the sensitivity of retinal indices to blast exposure and mild traumatic brain injury suggests that they should be incorporated into research on strategies to minimize or prevent blast-related short- and long-term central nervous system changes in blast-exposed military personnel.
Investigating the impact of COVID-19 lockdowns on fragility fracture risk and bone mineral density in a large observational cohort: a cross-sectional study
Authors: Amin Hamzah , Khan Muhammed Aqib , Bukhari Marwan 
Published: September 2024

Abstract

Objectives
Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2 or COVID-19) led to lockdowns predisposing people to sedentary lifestyles and unhealthy behaviours which may have affected bone mineral density (BMD) and fragility fracture risk. However, limited studies describe such an association. We aimed to investigate how COVID-19 lockdowns has affected BMD and fragility fractures in a large cohort.

Methods
Patients were referred to our DXA scanner from 2004 to 2024 and were subsequently categorized as pre- or post-March 23, 2020 (pre- and post-COVID-19) to allow analysis between the groups. Demographic, BMD and compositional data were compared between the two populations. A multivariate logistic regression modelled the odds of reporting a fracture including hip and non-hip fracture. A multiple linear regression was used to model how the lockdown has affected bone density. All analyses were adjusted for confounders.

Results
Of 43 799 referrals, 6564 were post-COVID-19. Post-COVID-19 patients had higher non-hip fracture rates (42.0% vs 39.8%), were 3 kg heavier, and had lower left femoral T-scores. Patients referred post-COVID-19 had a statistically significant reduction of −0.23 to their T-score after adjusting for confounders as well as increased risk of getting diagnosed with osteoporosis [odds ratio (OR) 1.49, 95% CI 1.40–1.59]. Patients referred after the pandemic had a reduced odds of any fracture (OR 0.83, 95% CI 0.77–0.88), hip (OR 0.74, 95% CI 0.62–0.88) and non-hip fracture (OR 0.78, 95% CI 0.73–0.83).

Conclusion
COVID-19 lockdowns may have negatively affected bone; however, this has not translated to an increased fracture risk in our study. Further research is needed with prospective cohorts to corroborate this risk.
The Implementation of Enhanced Recovery After Spine Surgery in High and Low/Middle-income Countries: A Systematic Review and Meta-Analysis
Authors: Lele Abhijit V. , Moreton Elizabeth O. , Mejia-Mantilla Jorge , Blacker Samuel N. 
Published: September 2024

In this review article, we explore the implementation and outcomes of enhanced recovery after spine surgery (spine ERAS) across different World Bank country-income levels. A systematic literature search was conducted through PubMed, Embase, Scopus, and CINAHL databases for articles on the implementation of spine ERAS in both adult and pediatric populations. Study characteristics, ERAS elements, and outcomes were analyzed and meta-analyses were performed for length of stay (LOS) and cost outcomes. The number of spine ERAS studies from low-middle-income countries (LMICs) increased since 2017, when the first spine ERAS implementation study was published. LMICs were more likely than high-income countries (HICs) to conduct studies on patients aged ≥18 years (odds ratio [OR], 6.00; 95% CI, 1.58-42.80), with sample sizes 51 to 100 (OR, 4.50; 95% CI, 1.21-22.90), and randomized controlled trials (OR, 7.25; 95% CI, 1.77-53.50). Preoperative optimization was more frequently implemented in LMICs than in HICs (OR, 2.14; 95% CI, 1.06-4.41), and operation time was more often studied in LMICs (OR 3.78; 95% CI, 1.77-8.35). Implementation of spine ERAS resulted in reductions in LOS in both LMIC (−2.06; 95% CI, −2.47 to −1.64 d) and HIC (−0.99; 95% CI, −1.28 to −0.70 d) hospitals. However, spine ERAS implementation did result in a significant reduction in costs. This review highlights the global landscape of ERAS implementation in spine surgery, demonstrating its effectiveness in reducing LOS across diverse settings. Further research with standardized reporting of ERAS elements and outcomes is warranted to explore the impact of spine ERAS on cost-effectiveness and other patient-centered outcomes.
Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials*
Authors: McDougall Garrett G. , Flindall Holden , Forestell Ben , Lakhanpal Devan , Spence Jessica , Cordovani Daniel , Sharif Sameer , Rochwerg Bram 
Published: September 2024

OBJECTIVES:
Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients.

DATA SOURCES:
We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024.

STUDY SELECTION:
We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation.

DATA EXTRACTION:
Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945).

DATA SYNTHESIS:
We included 20 RCTs (n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06–1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27–0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51–1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19–1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88–1.07; low certainty) compared with DL.

CONCLUSIONS:
In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality.
Association Between Restricting Symptoms and Disability After Critical Illness Among Older Adults
Authors: Jain Snigdha , Han Ling , Gahbauer Evelyne A. , Leo-Summers Linda , Feder Shelli L. , Ferrante Lauren E. , Gill Thomas M. 
Published: September 2024

OBJECTIVES:
Older adults who survive critical illness are at risk for increased disability, limiting their independence and quality of life. We sought to evaluate whether the occurrence of symptoms that restrict activity, that is, restricting symptoms, is associated with increased disability following an ICU hospitalization.

DESIGN:
Prospective longitudinal study of community-living adults 70 years old or older who were interviewed monthly between 1998 and 2018.

SETTING:
South Central Connecticut, United States.

PATIENTS:
Two hundred fifty-one ICU admissions from 202 participants who were discharged alive from the hospital.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
Occurrence of 15 restricting symptoms (operationalized as number of symptoms and presence of ≥ 2 symptoms) and disability in activities of daily living, instrumental activities of daily living, and mobility was ascertained during monthly interviews throughout the study period. We constructed multivariable Poisson regression models to evaluate the association between post-ICU restricting symptoms and subsequent disability over the 6 months following ICU hospitalization, adjusting for known risk factors for post-ICU disability including pre-ICU disability, frailty, cognitive impairment, mechanical ventilation, and ICU length of stay. The mean age of participants was 83.5 years (sd, 5.6 yr); 57% were female. Over the 6 months following ICU hospitalization, each unit increase in the number of restricting symptoms was associated with a 5% increase in the number of disabilities (adjusted rate ratio, 1.05; 95% CI, 1.04–1.06). The presence of greater than or equal to 2 restricting symptoms was associated with a 29% greater number of disabilities over the 6 months following ICU hospitalization as compared with less than 2 symptoms (adjusted rate ratio, 1.29; 95% CI, 1.22–1.36).

CONCLUSIONS:
In this longitudinal cohort of community-living older adults, symptoms restricting activity were independently associated with increased disability after ICU hospitalization. These findings suggest that management of restricting symptoms may enhance functional recovery among older ICU survivors.
Steroid-refractory immune checkpoint inhibitor (ICI) hepatitis and ICI rechallenge: A systematic review and meta-analysis
Authors: Hwang Soo Young , Hsieh Pinghsin , Zhang Wei 
Published: September 2024

Background:
In recent years, the use of immune checkpoint inhibitors (ICIs) has become a cornerstone in cancer treatment. However, this has also resulted in the emergence of immune-related adverse events, notably ICI hepatitis, posing a significant clinical challenge. While steroids are the primary treatment, there are increasing cases of steroid-refractory ICI hepatitis. Our objective is to investigate the management of ICI hepatitis and its response to steroid treatment.

Methods:
PubMed/MEDLINE, EMBASE, and CENTRAL databases were searched in July 2023 based on keywords including ICIs (anti–Programmed cell death protein 1/Programmed Death-Ligand 1, anti–CTLA–4, and anti-LAG3) and hepatitis.

Results:
A total of 4358 studies were screened, and 44 studies were included in this systematic review. One thousand eight hundred fifty-six patients with ICI hepatitis were included (grade 1-2: 31.7%, grade 3-4: 56.0%, and unknown: 12.3%) with 1184 patients who received corticosteroid treatment. The duration of treatment and dosage varied considerably across the studies. Mycophenolate mofetil was the predominant agent used in 68 out of 82 cases (82.9%), followed by infliximab and azathioprine. A summary estimate of the proportion of steroid-refractory hepatitis in a random effects model was 16% (95% CI: 11%–23%). An estimated 40% (95% CI: 30%–51%) of patients of all patients with ICI hepatitis were rechallenged with an ICI, and of those rechallenged, there was an estimated 22% (95% CI: 15%–30%) recurrence.

Conclusions:
Corticosteroids are the primary treatment for ICI hepatitis, with mycophenolate mofetil used as a secondary option for steroids-refractory cases. Current practices mostly rely on expert consensus, highlighting the need for further research to validate and optimize these treatments, particularly for steroid-resistant cases.
Prevalence of SARS-CoV-2 in Children Identified by Preprocedural Testing at 5 US Children’s Hospital Systems
Authors: Wang-Erickson Anna F. , Zhang Xueyan , Dauer Klancie , Zerr Danielle M. , Adler Amanda , Englund Janet A. , Lee Brian , Schuster Jennifer E. , Selvarangan Rangaraj , Rohlfs Chelsea , Staat Mary A. , Sahni Leila C. , Boom Julie A. , Balasubramani G. K. , Williams John V. , Michaels Marian G. 
Published: September 2024

Background:
The burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in asymptomatic children was initially presumed to be high, which influenced hospital, school and childcare policies. Before vaccines were widely available, some hospitals implemented universal preprocedural SARS-CoV-2 polymerase chain reaction testing on asymptomatic patients. Understanding SARS-CoV-2 prevalence in asymptomatic children is needed to illuminate the diversity of viral characteristics and inform policies implemented during future pandemics.

Methods:
Data were extracted from patient records of outpatient children who were preprocedurally tested for SARS-CoV-2 from 5 US hospital systems between March 1, 2020, and February 28, 2021. Prevalence was determined from positive test results. Adjusted odds ratios (AORs) were calculated using mixed logistic regression with the site as a random effect.

Results:
This study analyzed 93,760 preprocedural SARS-CoV-2 test results from 74,382 patients and found 2693 infections (3.6%) from 2889 positive tests (3.1%). Site-specific prevalence varied across sites. Factors modestly associated with infection included being uninsured [AOR, 1.76 (95% confidence interval [CI], 1.45–2.13)], publicly insured [AOR, 1.17 (95% CI, 1.05–1.30)], Hispanic [AOR, 1.78 (95% CI, 1.59–1.99)], Black [AOR, 1.22 (95% CI, 1.06–1.39)], elementary school age [5–11 years; AOR, 1.15 (95% CI, 1.03–1.28)], or adolescent [12–17 years; AOR, 1.26 (95% CI, 1.13–1.41)].

Conclusions:
SARS-CoV-2 prevalence was low in outpatient children undergoing preprocedural testing, a population that was predominantly asymptomatic at the time of testing. This study contributes evidence that suggests that undetected infection in children likely did not play a predominant role in SARS-CoV-2 transmission during the early prevaccine pandemic period when the general population was naive to the virus.
Relationship between postablation fever and prognosis in initial hepatocellular carcinoma: a 15-year multicenter, retrospective cohort study
Authors: Cai Qian , Pang Chuan , Wang Zhen , Li Jianming , Dai Yuqing , Fan Fang-ying , Wang Zhong-qi , Hu Xin , Li Lijuan , Chen Xu-wei , Ji Ran , Mei Qian , Zhang Chao , Liang Ping , Yu Xiaoling , Liu Fang-yi , Cheng Zhigang , Yu Jie 
Published: September 2024

Background:
Fever is a common side effect following thermal ablation in patients with hepatocellular carcinoma (HCC), yet its impact on prognosis remains unclear.

Materials and Methods:
This retrospective study included initial HCC patients who underwent US-guided percutaneous microwave ablation at 13 hospitals between January 2006 and February 2021. All patients were categorized into afebrile, transient low-grade fever (TLF), and prolonged or high-grade fever (PHF) groups. Primary outcomes included very early recurrence (VER) and early recurrence (ER), secondary outcomes were disease-free survival (DFS) and overall survival (OS). Fever cut-offs for VER/ER were established using restrictive cubic splines and an adjusted Cox model. Survival analyses used the Kaplan–Meier method.

Results:
A total of 1458 initial HCC patients (mean age, 59±11[SD]; 1146 men). Compared to afebrile individuals, patients with TLF (temperatures ranging 37.0–38.8°C for 1–2 days), showed independent protective effects against VER (HR, 0.73; 95% CI: 0.57–0.95; P=0.02) and ER (HR, 0.66; 95% CI: 0.54–0.81; P<0.001), however, PHF showed no differences in VER (HR, 0.99; 95% CI: 0.76–1.30; P=0.96) and ER (HR, 0.86; 95% CI: 0.69–1.07; P=0.17). With a median follow-up of 47 months (IQR: 26–79), the median DFS for TLF patients was 40 months, superior to afebrile (30 months, P=0.019) and PHF patients (33 months, P=0.049). The 5-year OS rate for TLF patients was 73.2%, higher than afebrile (69.3%, P=0.02) and PHF patients (66.7%, P=0.03). No significant difference was found in DFS and OS between afebrile and PHF patients (P=0.90 and 0.71). Notably, TLF patients exhibited the highest lymphocyte counts increasing median 7 days after ablation (P<0.001 vs. afebrile and P=0.01 vs. PHF).

Conclusion:
Transient low-grade fever following percutaneous microwave ablation in hepatocellular carcinoma patients demonstrated protection against early recurrence, possibly attributed to the short-term activation of lymphocytes.