bluuebunny/crossref_metadata_2025_split huggingface dataset:
Systems-Oriented Workplace Learning Experiences for Early Learners: Three Models
Authors: O’Brien Bridget C. , Bachhuber Melissa R. , Teherani Arianne , Iker Theresa M. , Batt Joanne , O’Sullivan Patricia S. 
Published: June 2016

Purpose
Early workplace learning experiences may be effective for learning systems-based practice. This study explores systems-oriented workplace learning experiences (SOWLEs) for early learners to suggest a framework for their development.

Method
The authors used a two-phase qualitative case study design. In Phase 1 (spring 2014), they prepared case write-ups based on transcribed interviews from 10 SOWLE leaders at the authors’ institution and, through comparative analysis of cases, identified three SOWLE models. In Phase 2 (summer 2014), studying seven 8-week SOWLE pilots, the authors used interview and observational data collected from the seven participating medical students, two pharmacy students, and site leaders to construct case write-ups of each pilot and to verify and elaborate the models.

Results
In Model 1, students performed specific patient care activities that addressed a system gap. Some site leaders helped students connect the activities to larger systems problems and potential improvements. In Model 2, students participated in predetermined systems improvement (SI) projects, gaining experience in the improvement process. Site leaders had experience in SI and often had significant roles in the projects. In Model 3, students worked with key stakeholders to develop a project and conduct a small test of change. They experienced most elements of an improvement cycle. Site leaders often had experience with SI and knew how to guide and support students’ learning.

Conclusions
Each model could offer systems-oriented learning opportunities provided that key elements are in place including site leaders facile in SI concepts and able to guide students in SOWLE activities.
The Predictive Validity of the National Board of Osteopathic Medical Examiners’ COMLEX-USA Examinations With Regard to Outcomes on American Board of Family Medicine Examinations
Authors: O’Neill Thomas R. , Peabody Michael R. , Song Hao 
Published: June 2016

Purpose
To examine the predictive validity of the National Board of Osteopathic Medical Examiners’ Comprehensive Osteopathic Medical Licensing Examination of the United States of America (COMLEX-USA) series with regard to the American Board of Family Medicine’s (ABFM’s) In-Training Examination (ITE) and Maintenance of Certification for Family Physicians (MC-FP) Examination.

Method
A repeated-measures design was employed, using test scores across seven levels of training for 1,023 DOs who took the MC-FP for the first time between April 2012 and November 2014 and for whom the ABFM had ITE scores for each of their residency years. Pearson and disattenuated correlations were calculated; Fisher r to z transformation was performed; and sensitivity, specificity, and positive and negative predictive values for the COMLEX-USA Level 2–Cognitive Evaluation (CE) with regard to the MC-FP were computed.

Results
The Pearson and disattenuated correlations ranged from 0.55 to 0.69 and from 0.61 to 0.80, respectively. For MC-FP scores, only the correlation increase from the COMLEX-USA Level 2-CE to Level 3 was statistically significant (for Pearson correlations: z = 2.41, P = .008; for disattenuated correlations: z = 3.16, P < .001). The sensitivity, specificity, and positive and negative predictive values of the COMLEX-USA Level 2-CE with the MC-FP were 0.90, 0.39, 0.96, and 0.19, respectively.

Conclusions
Evidence was found that the COMLEX-USA can assist family medicine residency program directors in predicting later resident performance on the ABFM’s ITE and MC-FP, which is becoming increasingly important as graduate medical education accreditation moves toward a single aligned model.
Epidural Against Systemic Analgesia
Authors: Roeb Mauritz M. , Wolf Alexander , Gräber Stefan S. , Meißner Winfried , Volk Thomas 
Published: June 2016

Background:
The PAIN OUT registry collected data from >30,000 patients on pain on the first postoperative day in hospitals worldwide. Utilizing the database, we compared systemic and epidural analgesia (EA) on postoperative pain and related side-effects in patients after abdominal surgeries (ASs).

Methods:
ASs were identified through the ICD9-Code and subgrouped into laparoscopic surgery and open surgery. After identifying patients in this subset with and without EA, propensity-score matching was performed on the basis of demographics and comorbidities. Primary outcomes were different qualities of pain, and secondary outcomes were pain-related sensations and treatment-related side effects measured with the numeric rating scale. They were calculated as the risk ratio (RR) using the median as the divisor.

Results:
The database contained 29,108 cases, with 5365 AS, and 646 cases remained after matching. A risk analysis revealed that for the AS group, EA posed a significantly lower risk for the perception of worst pain (RR, 0.75; confidence interval [CI], 0.64-0.87), least pain (RR, 0.61; CI, 0.5-0.75), time in severe pain (RR, 0.61; CI, 0.5-0.75), in-bed activity interference of pain (RR, 0.71; CI, 0.59-0.85), pain interference with coughing (RR, 0.68; CI, 0.57-0.82) or sleeping (RR, 0.73; CI, 0.61-0.87), and a higher chance of pain relief (RR, 1.5; CI, 1.23-1.83). The risk for itchiness (RR, 2.23; CI, 1.62-3.07) appeared to be higher, as did the probability of satisfaction (RR, 1.25; CI, 1.03-1.51). The risk for feeling helpless (RR, 0.83; CI, 0.7-0.99) and drowsiness (RR, 0.74; CI, 0.63-0.88) was reduced. Both subgroups showed similar tendencies.

Discussion:
Regarding the pain intensity, satisfaction, and relatable side-effects, EA seems to be superior compared with systemic analgesia after AS.
Prospective Evaluation of Posttraumatic Stress Disorder in Injured Patients With and Without Orthopaedic Injury
Authors: Warren Ann Marie , Jones Alan L. , Bennett Monica , Solis Jaicus K. , Reynolds Megan , Rainey Evan E. , Viere Grace , Foreman Michael L. 
Published: June 2016

Objectives:
The study purposes were to prospectively evaluate occurrence of posttraumatic stress (PTS) symptoms at hospital admission and 6 months later in patients with orthopaedic injury; to explore differences in PTS symptoms in those with and without orthopaedic injury; and to determine whether PTS symptoms are influenced by orthopaedic injury type.

Design:
Prospective, longitudinal observational study.

Setting:
Level 1 Trauma Center.

Patients/Participants:
Two hundred fifty-nine participants admitted for at least 24 hours.

Main Outcome Measurements:
The Primary Care Posttraumatic Stress Disorder (PTSD) Screen (PC-PTSD) measured PTSD symptoms during hospitalization. The PTSD Checklist–Civilian Version (PCL-C) measured PTS symptoms at 6 months.

Results:
In orthopaedic patients, 28% had PTS at 6 months, compared with 34% of nonorthopaedic patients. Odds ratios (ORs) were calculated to determine the influence of pain, physical and mental function, depression, and work status. At 6 months, if the pain score was 5 or higher, the odds of PTS symptoms increased to 8.38 (3.55, 19.8) (P < 0.0001). Those scoring below average in physical function were significantly more likely to have PTS symptoms [OR = 7.60 (2.99, 19.32), P < 0.0001]. The same held true for mental functioning and PTS [OR = 11.4 (4.16, 30.9), P < 0.0001]. Participants who screened positive for depression had a 38.9 (14.5, 104) greater odds (P < 0.0001). Participants who did not return to work after injury at 6 months were significantly more likely to have PTS [OR = 16.5 (1.87, 146), P = 0.012].

Conclusions:
PTSD is common in patients after injury, including those with orthopaedic trauma. At 6 months, pain of 5 or greater, poor physical and mental function, depression, and/or not returning to work seem to be predictive of PTSD. Orthopaedic surgeons should identify and refer for PTSD treatment given the high incidence postinjury.

Level of Evidence:
Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Therapeutic Drug Monitoring, Electronic Health Records, and Pharmacokinetic Modeling to Evaluate Sirolimus Drug Exposure–Response Relationships in Renal Transplant Patients
Authors: Zimmerman Kanecia O. , Wu Huali , Greenberg Rachel , Guptill Jeffrey T. , Hill Kevin , Patel Uptal D. , Ku Lawrence , Gonzalez Daniel , Hornik Christoph , Jiang Wenlei , Zheng Nan , Melloni Chiara , Cohen-Wolkowiez Michael 
Published: June 2016

Background:Sirolimus, an immunosuppressive agent used in renal transplantation, can prevent allograft rejection. Identification of the therapeutic index (the ratio of minimum toxic concentration to minimum therapeutic concentration) for immunosuppresants is necessary to optimize the care of patients and set standards for bioequivalence evaluation of sirolimus products. However, the therapeutic index for sirolimus has been inconsistently defined, potentially because of inconsistencies in sirolimus exposure–response relationships.Methods:The authors used retrospective therapeutic drug monitoring data from the electronic health records of patients treated in a tertiary health care system from 2008 to 2014 to (1) develop a population pharmacokinetic (PK) model, (2) use the model to simulate sirolimus concentrations, and (3) characterize the exposure–response relationship. Using Wilcoxon rank-sum and Fisher exact tests, the authors determined relationships between sirolimus exposure and adverse events (AEs) (anemia, leukopenia, thrombocytopenia, hyperlipidemia, and decline in renal function) and the composite efficacy end point of graft loss or rejection.Results:The developed 2-compartment population PK model showed appropriate goodness of fit. In a late-phase (>12 months), postrenal transplant population of 27 inpatients, the authors identified statistically significant relationships between 83 simulated peak and trough sirolimus concentrations and outcomes: graft loss or rejection (P= 0.018) and decline in renal function (P= 0.006), respectively.Conclusions:Use of therapeutic drug monitoring results and PK modeling permitted correlation of sirolimus concentrations with graft loss or rejection and decline in renal function. However, the method was limited in its assessment of other AEs. To better evaluate sirolimus exposure–response relationships, the method should be applied to a larger sample of newly transplanted patients with a higher propensity toward AEs or efficacy failure.
Updates in uterine fibroid tissue extraction
Authors: Cohen Sarah L. , Hariton Eduardo , Afshar Yalda , Siedhoff Matthew T. 
Published: June 2016

Purpose of review
Safety concerns regarding morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in surgical technique.

Recent findings
The prevalence of occult leiomyosarcoma is debated; however, estimates from a robust meta-analysis suggest it may be in the range of 1 case per 1960–8300 fibroid surgeries. Advancing age is an important clinical risk factor for occult malignancy. The impact of tumor morcellation may vary by mode of tissue removal, though tissue fragmentation is consistently associated with poorer outcomes. Decision and cost analyses continue to support laparoscopic hysterectomy as a low-morbidity and cost-effective approach. The increased scrutiny on fibroid procedures in the past few years may lead to changes in surgical approach; however, alternative tissue extraction options are evolving, including incorporation of contained morcellation.

Summary
Although the incidence of occult leiomyosarcoma is low, outcomes are poor and may be worsened by morcellation. By addressing risk factors for malignancy and incorporating evolving surgical techniques into practice, gynecologists can continue to offer patients a minimally invasive approach for fibroid management.
MESECTODERMAL LEIOMYOMA OF THE CILIARY BODY PRESENTING AS ANTERIOR STAPHYOMA
Authors: Lavric Alenka , Tsimpida Maria , Hungerford John L. , M. L. Cohen Victoria 
Published: June 2016

Purpose:
To report two cases of mesectodermal leiomyoma of the ciliary body presenting as anterior staphyloma.

Methods:
Two case reports with cytopathologic correlation.

Results:
First patient (15-year-old boy) presented with a nodular lesion in the sclera. Second patient (31-year-old woman) was found to have a brown ciliary body mass. Growth of the lesion and extrascleral extension was noticed after several years of follow-up. Ultrasonography, light microscopy, and immunohistochemistry of both cases are described confirming mesectodermal leiomyoma of the ciliary body.

Conclusion:
Mesectodermal leiomyoma, despite its rarity, should be considered in the differential diagnosis of uveal tract tumors. Clinically, the diagnosis is difficult and histopathological and immunohistochemical assesment is necessary to avoid inappropriate diagnosis and erroneous treatment.
BARTONELLA QUINTANA–ASSOCIATED NEURORETINITIS: LONGITUDINAL SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHIC FINDINGS
Authors: Mello Luiz Guilherme M. , Lima Luiz H. , Cabral Thiago , Rodrigues Mariana Z. , Peçanha Paulo M. , Belfort Rubens 
Published: June 2016

Purpose:
To report an unusual case of neuroretinitis caused by Bartonella quintana and its spectral-domain optical coherence tomographic (SD-OCT) features.

Methods:
A 12-year-old girl presented with unilateral neuroretinitis with stellate maculopathy. Bartonellosis was confirmed after serologic testing for antibodies to B. quintana.

Results:
Color photograph of the right eye revealed papillitis and stellate macular exudation. spectral-domain optical coherence tomography of the right eye revealed hyperreflective dots in the outer nuclear and outer plexiform layers, as well as disruption and loss of the external limiting membrane, ellipsoid zone, and interdigitation zone in the foveal area.

Conclusion:
The authors report an unusual case of neuroretinitis by B. quintana and its spectral-domain optical coherence tomographic findings.
Glaucoma Mini-Shunt Implantation After Keratoplasty
Authors: Ledesma-Gil Jasbeth , García-Rodríguez María de los Ángeles , Gurria Lulu U. , Graue-Hernández Enrique O. , Navas Alejandro 
Published: June 2016

Purpose:
To report the outcomes of patients who underwent miniature glaucoma shunt implantation after secondary glaucoma due to keratoplasty.

Materials and Methods:
Prospective study of consecutive clinical cases who underwent mini-glaucoma shunt implantation following keratoplasty. In brief, a fornix-based conjunctival flap was performed, approximately 50% thickness scleral flap. Mitomycin C 0.025% placed under Tenon’s capsule. A 25-G needle created entry for mini-shunt. Ex-PRESS model P-50 was inserted. Scleral flap and conjunctiva were closed with 10-0 Nylon. STATA 8.0 and SPSS software were used for statistical analysis.

Results:
Seventeen eyes of 17 patients with a mean age of 39.70 years (SD=18.33, range: 18 to 76). A total of 64.70% were male and 35.30% female. Eleven cases after penetrating keratoplasty, 3 cases after triple procedure, 2 after deep anterior lamellar keratoplasty, and 1 following endothelial keratoplasty. Most of the indications for keratoplasty were keratoconus in 9 cases (52.94%), 4 due to endothelial failure (23.52%), 3 cases of herpetic keratitis (17.64%), and 1 case of post-LASIK ectasia (5.88%). Mean preoperative intraocular pressure was 35.94 mm Hg with maximal medical therapy (SD=9.65, range: 18 to 55). Decreasing intraocular pressure to 12.76 mm Hg postoperatively (SD=2.51, range 10 to 18) (P=0.001). Mean follow-up after mini-glaucoma shunt implantation was 23.76 months (SD=8.73, range: 10 to 35 mo). Preoperative mean uncorrected distance visual acuity (UDVA) was 1.31±0.63 (20/408 Snellen) and postoperative mean UDVA was 0.85±0.40 (20/141 Snellen) (P=0.001). Preoperative mean corrected distance visual acuity (CDVA) was 0.83±0.76 (20/135 Snellen) and postoperative mean CDVA was 0.56±0.44 (20/72 Snellen) (P=0.032).

Conclusions:
Ex-PRESS miniature glaucoma shunt could be an alternative treatment in postkeratoplasty glaucoma resistant to medical treatment. This technique may be helpful, in trying to avoid corneal damage produced by conventional glaucoma procedures.
Features of Hepatitis in Hepatitis‐associated Aplastic Anemia
Authors: Patel Kalyani R. , Bertuch Alison , Sasa Ghadir S. , Himes Ryan W. , Wu Hao 
Published: June 2016

ABSTRACTObjectives:Hepatitis‐associated aplastic anemia (HAA) is a rare variant of aplastic anemia in which patients present with severe pancytopenia after an episode of acute hepatitis. The marrow failure is often rapid, severe, and usually fatal if untreated. The preceding hepatitis is largely under‐studied.Methods:Retrospective study of the clinical and histopathologic features of hepatitis in pediatric patients who subsequently developed aplastic anemia and comparison with consecutive cases of acute liver failure and random cases of autoimmune hepatitis during the same time frame.Results:All 7 patients of HAA had significant elevations in aminotransferases and conjugated hyperbilirubinemia at initial presentation. Echoing liver function indices, cholestatic hepatitis with sinusoidal obstruction‐type endothelial injury was seen histomorphologically. Autoimmune hepatitis serology such as anti‐F‐actin, anti‐liver/kidney microsome, and hypergammaglobulinemia was negative in all patients. Five of 7 patients (71.4%) had, however, elevated antinuclear antibody, all with a speckled pattern. Hepatitis virus serology was negative in all patients. By immunohistochemical staining, the lobular CD8/CD4 lymphocyte ratio was markedly elevated in all of the initial samples with significant reduction in this ratio (P = 0.03) in 3 patients post treatment (ursodiol, antibiotics, and/or immunosuppressive therapy).Conclusions:Hepatitis preceding HAA is characterized by marked elevation of aminotransferases, conjugated hyperbilirubinemia, elevated antinuclear antibody with a speckled pattern, cholestatic hepatitis with sinusoidal obstruction morphology, and CD8+ dominant lobular infiltrates. The present study suggests HAA may result from cytotoxic T–cell‐mediated sinusoidal endothelial and hepatocytic injury.
Human Milk Oligosaccharides Influence Intestinal Epithelial Cell Maturation In Vitro
Authors: Holscher Hannah D. , Bode Lars , Tappenden Kelly A. 
Published: June 2016

ABSTRACTObjectives:Human milk oligosaccharides (HMOs) are reported to promote epithelial cell differentiation in vitro. The aim of the present study was to assess induction of epithelial cell differentiation by individual and combined administration of 3 HMOs.Methods:An in vitro epithelial model of the crypt‐villus axis consisting of preconfluent HT‐29, preconfluent Caco‐2Bbe, and postconfluent Caco‐2Bbe cells was used. Cultures were randomized to 17 treatments for 72 hours of incubation: low‐ and high‐dose HMOs (3′sialyllactose [3′SL] at 0.2 and 1.0 g/L, 6′siallylactose [6′SL] at 0.4 and 1.0 g/L, and 2′fucosyllactose at 0.2 and 2.0 g/L), HMO combinations at both low and high doses, and controls (culture medium, 4 g/L pooled HMO, and lipopolysaccharide).Results:High doses of individual HMOs (P < 0.05), combined HMOs (P < 0.05), and pooled HMO decreased (P < 0.001) proliferation in preconfluent HT‐29 cultures. Pooled means of individual low and high treatments with 3′SL and 6′SL, combinations of 2 or 3 high‐dose HMOs, and total HMO significantly reduced (P < 0.05) proliferation in preconfluent Caco‐2Bbe cells. HMOs increased differentiation in preconfluent HT‐29 and Caco‐2Bbe cells. 3′SL and 6′SL increased alkaline phosphatase activity but did not affect disaccharidase activity in postconfluent Caco‐2Bbe cells. Apoptosis and necrosis were both decreased (P < 0.001) in postconfluent Caco‐2Bbe cells treated with pooled HMO.Conclusions:HMO treatments inhibited proliferation with some associated enhancement of epithelial differentiation. Effects of HMOs were additive but no specific combinations of HMOs were especially potent. These results suggest that commercially viable individual HMOs and specific combinations may promote intestinal epithelial cell maturation.
Trauma Arrest and Spinal Injury in a 3-Year-Old Girl
Authors: High Kevin , Walsh Michele , Kidd Rebecca 
Published: June 2016

Abstract
Management of an acutely injured pediatric patient with multiple traumas is a common challenge facing clinicians in pediatric emergency care. Blunt trauma is more common in the pediatric population with motor vehicle accidents being the most common cause of injury. Spinal injury, especially in young children, is only seen in 1% to 2% of cases and can be lethal. It is incumbent upon clinicians to be able to meet the challenges of patient management including airway management, providing hemodynamic support, and addressing potentially reversible causes of arrest while recognizing presenting symptoms of spinal injury. This case presents a child in trauma arrest after a motor vehicle crash requiring advanced interventions, diagnostics, and support. Her clinical course is described and reveals a complete distraction of the cervical and thoracic spine. This case illustrates pathology and management along with the importance of proper management and interventions by pediatric emergency clinicians to manage the patient and attempt to maximize the patient's outcome.
Mechanism of Hyponatremia in Community-Acquired Pneumonia
Authors: Hausman-Kedem Moran , Reif Shimon , Danino Dana , Limor Rona , Grinspan Zachary M. , Yerushalmi-Feler Anat , Ben-Tov Amir , Birger Amir 
Published: June 2016

ObjectiveHyponatremia is a well-known sequela of community-acquired pneumonia (CAP). B-type natriuretic peptide (BNP) has a natriuretic effect and was found to be elevated in patients with CAP. We investigated whether BNP has a role in the pathophysiology of hyponatremia in pediatric CAP.MethodsSerum and urine electrolytes and osmolality, as well as NT-pro-BNP (N-BNP), were obtained in 49 hospitalized pediatric patients with CAP (29 with hyponatremia, 20 with normal sodium levels.ResultsUrine sodium levels were lower in the hyponatremic group compared with the normonatremic group (24.3 meq/L vs 66.7 meq/L,P= 0.006). No difference in N-BNP levels was found between groups (median, 103.8 vs 100.1;P= 0.06; interquartile range, 63.7–263.3 pg/mL vs 47.4–146.4 pg/mL). N-BNP was not associated with serum or urinary sodium levels.ConclusionsThese results indicate that BNP is unlikely to play a causative role in the mechanism of hyponatremia in CAP.
Altered Mental Status in a Child With an Unwitnessed Fall
Authors: Fleurat Michelle R. , Zaia Brita E. 
Published: June 2016

Abstract
We report a case of altered mental status in a 5-year-old boy who presented to the emergency department after presumed head trauma. A computed tomography head was conducted and its findings were normal, and the boy was discharged home. He returned the next day with persistent altered mental status and was found to have an abnormal MR brain suggestive of embolic strokes. An echocardiogram revealed a large atrial mass that was later confirmed by pathology to be an atrial myxoma. This is a unique and, to our knowledge, unreported presentation of a known but rare disease process in a pediatric patient.