bluuebunny/crossref_metadata_2025_split huggingface dataset:
In Search of Black Swans: Identifying Students at Risk of Failing Licensing Examinations
Authors: Barber Cassandra , Hammond Robert , Gula Lorne , Tithecott Gary , Chahine Saad 
Published: September 2017

Purpose
To determine which admissions variables and curricular outcomes are predictive of being at risk of failing the Medical Council of Canada Qualifying Examination Part 1 (MCCQE1), how quickly student risk of failure can be predicted, and to what extent predictive modeling is possible and accurate in estimating future student risk.

Method
Data from five graduating cohorts (2011–2015), Schulich School of Medicine & Dentistry, Western University, were collected and analyzed using hierarchical generalized linear models (HGLMs). Area under the receiver operating characteristic curve (AUC) was used to evaluate the accuracy of predictive models and determine whether they could be used to predict future risk, using the 2016 graduating cohort. Four predictive models were developed to predict student risk of failure at admissions, year 1, year 2, and pre-MCCQE1.

Results
The HGLM analyses identified gender, MCAT verbal reasoning score, two preclerkship course mean grades, and the year 4 summative objective structured clinical examination score as significant predictors of student risk. The predictive accuracy of the models varied. The pre-MCCQE1 model was the most accurate at predicting a student’s risk of failing (AUC 0.66–0.93), while the admissions model was not predictive (AUC 0.25–0.47).

Conclusions
Key variables predictive of students at risk were found. The predictive models developed suggest, while it is not possible to identify student risk at admission, we can begin to identify and monitor students within the first year. Using such models, programs may be able to identify and monitor students at risk quantitatively and develop tailored intervention strategies.
Medical Students’ Empathy for Vulnerable Groups: Results From a Survey and Reflective Writing Assignment
Authors: Wellbery Caroline , Saunders Pamela A. , Kureshi Sarah , Visconti Adam 
Published: September 2017

Purpose
As medical education curricula increasingly acknowledge the contributions of the social determinants of health to individual health, new methods of engaging students in the care of vulnerable groups are needed. Empathy is one way to connect students with patients, but little is known about how to nurture students’ empathy on behalf of populations. This study examined the relationship between individual and social empathy as groundwork for cultivating students’ empathy for vulnerable groups.

Method
In 2014–2015, first-year medical students completed the Social Empathy Index at the start and end of a two-semester population health course, and they completed a reflective writing assignment exploring the challenges of caring for vulnerable patients. Pre- and posttest mean survey scores were compared, and reflective writing assignments were analyzed for themes concerning social empathy.

Results
Data from 130 students were analyzed. Scores for the contextual understanding of systemic barriers domain increased significantly. There was a trend toward increased cumulative social empathy scores that did not reach statistical significance. Students’ essays revealed three themes relating to individual empathy as the foundation for social empathy; civic and moral obligations; and the role of institutional practices in caring for vulnerable groups.

Conclusions
This study extends understanding of empathy beyond care for the individual to include care for vulnerable groups. Thus, social empathy may function as a valuable concept in developing curricula to support students’ commitment to care for the underserved. Educators first need to address the many barriers students cited that impede both individual and social empathy.
Concurrent Use of Opioids and Benzodiazepines: Evaluation of Prescription Drug Monitoring by a United States Laboratory
Authors: McClure Fred Leland , Niles Justin K. , Kaufman Harvey W. , Gudin Jeffrey 
Published: September 2017

Objectives:
Recently, more than 63% of the 52,404 drug overdose deaths in the United States involved heroin and opioid pain medications. More than 30% of opioid-related deaths also involved benzodiazepines. Previous studies examining the extent of concurrent opioid and benzodiazepine use have relied on prescription data. To gain fuller insight into the extent of the concurrent use problem, we analyzed opioid and benzodiazepine prescription patterns in the context of drug testing results.

Methods:
All specimens from patients that were prescribed at least 1 drug and were tested for both opioids and benzodiazepines by a national reference laboratory were included. This resulted in an analytical set of 231,228 sets of test results from 144,535 patients with diverse demographic factors being tested in a variety of health care settings.

Results:
Laboratory test results indicated concurrent use of opioids and benzodiazepines in over 25% of patients. In 52% of test results with evidence of concurrent use, 1 drug class was prescribed and the other was non-prescribed. Nearly 1 in 5 specimens (19%) testing positive for prescribed opioids also tested positive for non-prescribed benzodiazepines. Over 15% of specimens with prescribed benzodiazepines also demonstrated non-prescribed opioid use.

Conclusions:
The extent of concurrent use of benzodiazepines and opioids, particularly non-prescribed use, suggests the need for more effective clinician assessment and intervention. The results support the Centers for Disease Control and Prevention opioid prescribing guidelines that drug testing occur before and periodically throughout opioid use and suggest that this testing should be extended to patients prescribed benzodiazepines as well.
Cardiac complications of systemic sclerosis and management: recent progress
Authors: Rangarajan Vibhav , Matiasz Richard , Freed Benjamin H. 
Published: September 2017

Purpose of review
Cardiac complications in systemic sclerosis (SSc) continue to be a leading cause of death in this patient population. Early recognition and treatment of the cardiac diseases commonly associated with SSc is essential.

Recent findings
Recent studies have confirmed the significant increase in mortality in SSc patients with cardiac involvement. Electrocardiography and echocardiography (2DE) continue to play a major role in screening and diagnosing cardiac manifestations such as arrhythmias or biventricular dysfunction, respectively. Novel techniques such as myocardial strain imaging on 2DE and T1 mapping on cardiovascular magnetic resonance are useful for detecting subclinical cardiac abnormalities, but the clinical relevance of these findings is still not known. An expert consensus was recently published to help establish best practice guidelines on management of cardiac complications in SSc, but data supporting these recommendations remain limited.

Summary
Recent studies continue to enhance our understanding of SSc cardiac disease. Although the results of these studies help lessen the ambiguity of managing and treating these patients, there is still much more research to be done.
Postoperative Resolution of Magnetic Resonance Imaging Signal Intensity Changes and the Associated Impact on Outcomes in Degenerative Cervical Myelopathy
Authors: Kato So , Nouri Aria , Reihani-Kermani Hamed , Oshima Yasushi , Cheng Joseph , Fehlings Michael G. 
Published: September 2017

Study Design.
Subanalysis of the prospective AOSpine CSM North America and International studies.

Objective.
To describe the postoperative changes in magnetic resonance imaging (MRI) spinal cord signal intensity in degenerative cervical myelopathy (DCM) patients and to investigate the impact of its postoperative resolution on clinical outcomes.

Summary of Background Data.
When examining the spinal cord, hyperintensity found in MRI T2-weighted images and hypointensity in T1-weighted images are known to correlate with preoperative severity of DCM and to predict postoperative neurological recovery. However, the clinical importance of these signal intensity changes in postoperative images has not been established.

Methods.
Among 757 surgical DCM patients enrolled in two prospective multicenter studies, postoperative MRI images obtained between 6 and 24 months after the operation were examined with a focus on T2 hyper- and T1 hypointensity in the spinal cord. The 2-year postoperative Nurick grade, modified Japanese Orthopaedic Association score and modified Japanese Orthopaedic Association recovery rate (RR) were analyzed between patients with or without resolution of signal intensity changes.

Results.
A total of 167 patients with preoperative T2 hyperintensity were included with complete postoperative MRI images. Of these patients, 11% showed resolution of signal intensity changes, 70% retained T2 hyperintensity only, and 19% showed both T2 hyper- and T1 hypointensity postoperatively. There was a stepwise trend toward worse postoperative outcomes, with the no signal intensity change group showing the best outcome and the T1 hypointensity group showing the worst (mean RR: 72% vs. 51% vs. 36%, P = 0.02). Patients who exhibited resolution of T2 hyperintensity showed better outcomes than those who retained it (RR: 72% vs. 47%, P = 0.04), but the resolution of T1 hypointensity was not associated with improved outcomes (RR: 38% vs. 26%, P = 0.36).

Conclusion.
Postoperative resolution of T2 hyperintensity in patients with DCM was associated with the best clinical outcomes, whereas those with T1 hypointensity showed the worst.

Level of Evidence: 3
Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary Critical Care Physicians for Right Ventricle Assessment in Patients With Acute Pulmonary Embolism*
Authors: Filopei Jason , Acquah Samuel O. , Bondarsky Eric E. , Steiger David J. , Ramesh Navitha , Ehrlich Madeline , Patrawalla Paru 
Published: September 2017

Objectives:
Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow’s performance of goal-directed echocardiograms and intensivists’ interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism.

Design:
Prospective observational study and retrospective chart review.

Setting:
Four hundred fifty bed urban teaching hospital.

Patients:
Adult in/outpatients diagnosed with acute pulmonary embolism.

Interventions:
Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date.

Measurements and Main Results:
Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow’s area under the curve for size and function was 0.83 (95% CI, 0.75–0.90) and 0.83 (95% CI, 0.75–0.90), respectively. Intensivists’ 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82–0.94), (1) 0.87 (95% CI, 0.80–0.93) and (2) 0.88 (95% CI, 0.82–0.95), (2) 0.88 (95% CI, 0.82–0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes.

Conclusions:
This is the first study to evaluate pulmonary critical care fellows’ and intensivists’ use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.
Calcium Hydroxylapatite Combined with Microneedling and Ascorbic Acid is Effective for Treating Stretch Marks
Authors: Casabona Gabriela , Marchese Paula 
Published: September 2017

Background:
Stretch marks can have a negative psychological impact on some individuals. Methods are available for treating stretch marks, but high-quality evidence supporting their use is limited. We treat stretch marks using injections of diluted calcium hydroxylapatite (CaHA, Radiesse) filler combined with microneedling and topical ascorbic acid. This retrospective study evaluated the effectiveness of this combined therapy.

Methods:
Subjects presented with red (n = 25) or white (n = 10) striae on their buttocks, thighs, knees, abdomen, and breasts. CaHA filler was diluted 1:1 with lidocaine 2% without epinephrine. A maximum of 3.0 mL of filler was injected per patient at all skin depths using a 23G needle. This was immediately followed by microneedling and topical application of 20% ascorbic acid. Microneedling with ascorbic acid was repeated after 1 and 2 months. Skin biopsies were obtained from a patient who later underwent abdominoplasty.

Results:
The mean (±SD) pretreatment Manchester Scar Scale scores were 12.0 (±0.8), decreasing to 7.1 (±1.4) 1 month after the final treatment, indicating improvement in stretch mark appearance (P < 0.001). Subjects were very satisfied (n = 22; 62.9%), satisfied (n = 8; 22.9%), neither satisfied nor dissatisfied (n = 4; 11.4%), or unsatisfied (n = 1; 2.8%) with their treatment results. Analysis revealed a significant correlation between Scar Scale scores and Patient Satisfaction scores (r = 0.483; P = 0.003). Skin biopsies showed increased quantity and quality of collagen and elastin fibers in areas treated with combination therapy. Procedures were well tolerated.

Conclusion:
Combining 1:1 diluted CaHA with microneedling and topical ascorbic is safe and effective for treating stretch marks.
Cosmetic Surgery Training in Plastic Surgery Residency Programs
Authors: McNichols Colton H. L. , Diaconu Silviu , Alfadil Sara , Woodall Jhade , Grant Michael , Lifchez Scott , Nam Arthur , Rasko Yvonne 
Published: September 2017

Background:
Over the past decade, plastic surgery programs have continued to evolve with the addition of 1 year of training, increase in the minimum number of required aesthetic cases, and the gradual replacement of independent positions with integrated ones. To evaluate the impact of these changes on aesthetic training, a survey was sent to residents and program directors.

Methods:
A 37 question survey was sent to plastic surgery residents at all Accreditation Council for Graduate Medical Education–approved plastic surgery training programs in the United States. A 13 question survey was sent to the program directors at the same institutions. Both surveys were analyzed to determine the duration of training and comfort level with cosmetic procedures.

Results:
Eighty-three residents (10%) and 11 program directors (11%) completed the survey. Ninety-four percentage of residents had a dedicated cosmetic surgery rotation (an increase from 68% in 2015) in addition to a resident cosmetic clinic. Twenty percentage of senior residents felt they would need an aesthetic surgery fellowship to practice cosmetic surgery compared with 31% in 2015. Integrated chief residents were more comfortable performing cosmetic surgery cases compared with independent chief residents. Senior residents continue to have poor confidence with facial aesthetic and body contouring procedures.

Conclusions:
There is an increase in dedicated cosmetic surgery rotations and fewer residents believe they need a fellowship to practice cosmetic surgery. However, the comfort level of performing facial aesthetic and body contouring procedures remains low particularly among independent residents.
New Internal Fixation Technique for Transconjunctival Fat Repositioning
Authors: Chang Cheol Ho , Cha Myung Kyu 
Published: September 2017

Summary:
To treat tear trough deformities in young patients, transconjunctival orbital fat repositioning has been widely used. Although internal fixation of transposed fat enables more secure and stable fixation than the externalized percutaneous suture method, the latter is used more commonly because of the narrow operation field and consequent technical difficulty of the internal fixation method. We describe a novel technique using a newly devised needle (Chang's needle) that facilitates internal fixation of transposed fat pedicles.
The Impact of Scleral Contact Lens Vault on Visual Acuity and Comfort
Authors: Otchere Heinz , Jones Lyndon , Sorbara Luigina 
Published: September 2017

Purpose:
To assess how varying degrees of corneal clearance of scleral contact lenses (ScCL) impact visual acuity (VA) and comfort in patients with corneal ectasia.

Method:
Three ScCL were fitted to 20 subjects with previous diagnosis of either keratoconus (n=18) or pellucid marginal degeneration (n=2). Fitting of ScCL was based on corneal sagittal height (CSH) measured with Visante OCT at a 15-mm chord on the horizontal meridian. To select the ScCL from the diagnostic lens set, values of 325, 375, and 425 μm were randomly added in sequence to CSH. Subjects wore ScCL for 1 hr. Central corneal clearance (CCC) and topographic corneal clearance (TCC) along the vertical meridian were assessed using an ultralong optical coherence tomographer. High-contrast VA (HCVA) and low-contrast VA (LCVA) were measured using a logarithm of the minimum angle of resolution VA chart, and comfort ratings were obtained with a standard comfort scale (0–100).

Results:
Mean CSH in the horizontal meridian was 3.78±0.53 (range: 3.33–4.17) mm at a 15-mm chord. Mean CCC was 190±100 μm (TCC: 160±94 μm at +3 mm and 180±94 μm at −3 mm), 360±120 μm (TCC: 260±100 μm at +3 mm and 330±110 μm at −3 mm), and 450±170 μm (TCC: 320±120 μm at +3 mm and 400±120 μm at −3 mm) for each lens (P=0.001). Mean HCVA for lenses 1, 2, and 3 were 0.05±0.12, 0.07±0.11, and 0.11±0.08 respectively, which were significantly different (P=0.02). Tukey post hoc analysis showed that this difference was only significant between lenses 1 and 3 (P=0.01). Similar findings were found for LCVA. Comfort ratings for lenses 1, 2, and 3 were 74.9±9.2, 79.7±11.6, and 78.6±10.8, respectively (P=0.24).

Conclusion:
The CSH is an effective method of determining the appropriate lens/cornea relationship. Lens 2 (+375 μm) gave the best combination of acuity and comfort ratings. Evaluation of the fluorescein pattern must be balanced with VA and comfort ratings for successful fitting in a clinical setting.
Descemet Membrane Endothelial Keratoplasty in Eyes With Previous Laser Refractive Surgery: Outcomes and Complications
Authors: Zeidenweber Dorian A. , Mayko Zachary M. , Straiko Michael D. , Terry Mark A. 
Published: September 2017

Purpose:
To evaluate the refractive predictability and efficacy of Descemet membrane endothelial keratoplasty (DMEK) for patients with previous laser refractive surgery.

Methods:
We retrospectively reviewed our cohort of endothelial keratoplasty surgical cases. We identified 21 eyes that underwent laser-assisted in situ keratomileusis (n = 17) or photorefractive keratectomy (n = 4) and were treated with DMEK for endothelial failure. Patients were analyzed preoperatively and at 6 months postoperatively for changes in visual acuity, refraction, and corneal topography.

Results:
Six months after surgery, eyes significantly improved to a mean best-corrected visual acuity of 20/23 (P < 0.001). Mean astigmatism amplitude changed from 1.13 ± 0.96 preoperatively to 0.92 ± 0.51 diopters postoperatively (P = 0.28). However, shifts in the axis of corneal astigmatism ranged from 1 to 70 degrees, with 6 eyes (30%) showing an axis shift of more than 30 degrees. Spherical equivalents in nontriple procedures remained unchanged (n = 16; P = 0.69) at 6 months.

Conclusions:
DMEK and DMEK triple procedures are predictable in patients with previous refractive surgery achieving good visual results. However, refraction after the use of toric intraocular lenses may be unpredictable because of the variability in changes of the magnitude and axis of corneal astigmatism; we recommend extreme caution in the use of the toric intraocular lens in this group of patients and proper counseling for possible individual postoperative residual astigmatism.
Prospective Randomized Trial Evaluating Ketamine for Adult Bronchoscopy
Authors: Fruchter Oren , Manevich Yair , Carmi Uri , Rozengarten Dror , Kramer Mordechai R. 
Published: September 2017

Background and Objectives:
Ketamine has been used in pediatric flexible fiberoptic bronchoscopy (FFB). Its efficacy and safety for sedation of adults undergoing FFB has not been thoroughly investigated, and, consequently, it is not used by most interventional bronchoscopists. We aimed to evaluate the safety and efficacy of sedation for FFB under ketamine-propofol-midazolam (KPM) compared with the fentanyl-propofol-midazolam (FPM) regimen.

Materials and Methods:
This was a prospective randomized trial of adult patients (n=80) undergoing FFB, randomized to receive sedation with either KPM (n=39) or FPM (n=41). Vital signs including transcutaneous carbon dioxide tension (TcPCO2) were continuously monitored. Sedation-related complications and interventions to maintain respiratory and hemodynamic stability were compared. Both operator and patient were blinded to the sedation regimen used. The operator’s and patient’s satisfaction from sedation were assessed following recovery.

Results:
Maximal intraprocedural TcPCO2 values and minimal oxygen saturation did not differ significantly between the KPM and FPM groups (63.2±11.4 mm Hg vs. 61.1±7.2 mm Hg) and (77.1%±12.5% vs. 81.8%±12.0%), respectively. No significant differences were noted between the KPM and FPM groups with respect to sedation-related respiratory or hemodynamic complications. The operator’s and patient’s satisfaction from sedation was similar between the groups.

Conclusions:
Ketamine is as safe and effective as fentanyl for adult analgesia and sedation during FFB. In light of this observation and the fact that ketamine does not cause hemodynamic suppression, like most sedative agents, and is a potent bronchodilator, should encourage its more widespread use for adult sedation during FFB.