bluuebunny/crossref_metadata_2025_split huggingface dataset:
Assessment of Quality Improvement and Patient Safety Resources, including Event Reporting Systems, in Graduate Medical Education Training Programs - An Institutional National Survey
Authors: Atkins Megan , Akrawe Silvy , Flynn Jeffrey C , Sankari Abdulghani , Mittal Vijay K 
Published: August 2024

Background Quality improvement (QI) and patient safety (PS) education were requirements implemented in 2017 by the Accreditation Council for Graduate Medical Education (ACGME) for residents and fellows. Trainees must receive training and experience in QI processes, including an understanding of healthcare disparities, but how training and experience occur remains largely unknown. Our study aimed to determine how institutions have integrated these requirements into medical education. Methods A Google Forms survey was emailed to the Designated Institutional Officials (DIOs) of 650 United States’ institutions with ACGME accredited programs in September 2021. The survey consisted of 34 multiple choice questions related to QI and PS parameters and the event reporting system (ERS); a Likert scale was used. Results More than half (n=392) of the emails were undeliverable, leaving only 258 possible responders; 51 responses were received, and all but one met the inclusion criteria of having at least one training program, which translated to a response rate of 19% (=50/257). The survey found that while 90% of institutions had an institutional QI/PS Committee, only 30% of these institutions also had a Graduate Medical Education-specific QI/PS Committee as well. Most institutions provided QI (88%) or PS training (94%), but only 71% and 83%, respectively, had mandatory training. Most institutions utilized an ERS (96%). While one of the less common methods was education on the ERS, approximately two-thirds of responding DIOs believed that by providing education on the ERS, resident/fellow participation in event reporting would improve, as well as contribute to their total education. Conclusions Further ERS education is warranted to encourage resident/fellow participation to develop various protocols related to QI and PS parameters.
Radiologist Accuracy in Predicting Pathology in Breast Imaging
Authors: Dhingra Kirti , Lin Jeffrey , Brannan Grace , Gari Nedi , Singh Evita 
Published: August 2024

Introduction: Breast cancer, the most prevalent cancer in women and second only to lung cancer in female mortality, has seen rising incidence, especially during the 1980s and 1990s due to increased mammography screening. Screening’s primary goal is early tumor detection, reducing mortality by over 40%. Yet, it has downsides, including false-positive cases of benign biopsies and potential increased patient anxiety and stress. The average recall rate from screening mammograms is 5-10%. Among women requiring biopsy, the anticipated rate of malignant findings range between 30-50%. With the evolution of image-guided breast biopsy techniques, concerns have risen regarding the escalating frequency of breast biopsies. The possible causes are overlapping imaging characteristics of benign and malignant pathologies, patients’ anxiety, litigation risk and radiologist years of experience. A radiologists’ ability to predict breast histology from imaging findings remains an understudied domain. This study’s core purpose is to comprehensively analyze the ability of a radiologist to predict benign versus malignant results to provide guidance in reducing the number of benign biopsies. Methods: This prospective study involved radiologists completing survey sheets when recommending biopsies and when performing the biopsy, predicting benign vs malignant, specific pathology, with confidence interval. Predictions were compared to the final biopsy results to determine accuracy. All patients who underwent biopsy at our institutions were included in the data. Data was categorized as either concordant or discordant when comparing predicted pathology results to actual. Results: The accuracy of radiologist prediction from initial diagnostic imaging when compared to actual pathology results in the study population is 71% (95% CI,61.8%-79.37%) with a sensitivity of 75 % (95% CI, 60.4%-86.36%). The accuracy of radiologist prediction at biopsy when compared to actual pathology results is 80.79% (95% CI, 75.89%-85.08%) with sensitivity of 79.77% (95% CI, 73%-85.49%). The accuracy of less to moderately experienced radiologists to highly experienced radiologists is similar, 78.2% vs 81.0%. Further analysis of specific pathology prediction reveals that fibroadenoma is the most common benign pathology encountered, the prediction of which by imaging alone/at biopsy is 65%/68%. In the malignant category, invasive ductal carcinoma is the most common pathology encountered where the prediction is 68%/85%. Conclusions: This data will potentially help radiologists gain confidence in watching likely benign lesions based on imaging features (assigned as BIRADS 3) to reduce benign biopsies.
Diagnostic Performance of Cardiac Stress Testing Following Exclusion of Acute Myocardial Infarction with a 0/1-Hour, High-Sensitivity Cardiac Troponin Protocol
Authors: Nassereddine Hashem , Miller Joseph , Cook Bernard , Klausner Howard , Gunaga Satheesh , Morton Thayer , Tuttle Jacob , Mohammed Husna , Husain Arqam , McCord James 
Published: August 2024

Background: Rapid exclusion of acute myocardial infarction (AMI) is critical for patients presenting to emergency departments (EDs) with chest pain or other anginal equivalents. High-sensitivity cardiac troponin (hs-cTn) protocols have been widely adopted in the United States for this purpose. These protocols allow for early identification and exclusion of patients with AMI using a 0 and 1-hour hs-cTn measurement. However, little is known about the use of cardiac stress testing in patients who ruled-out for AMI within 1 hour with very low hs-cTn values. This study analyzed the diagnostic performance of cardiac stress tests in this population. Methods: We performed a secondary analysis of the RACE-IT trial, a stepped-wedge cluster randomized trial performed across 9 EDs in a large metropolitan health system from July 2020 through March 2021. The eligibility criteria for the trial mirrored the real-world use of hs-cTn testing, including both patients complaining of chest pain and/or other anginal equivalents. All adults with a hs-cTnI and electrocardiogram (ECG) completed in the ED were enrolled, while patients with ST- segment elevation AMI, trauma, or pregnancy were excluded. In the interventional arm of the trial, AMI was excluded if hs-cTnI was <4 ng/L at presentation or =4 ng/L at presentation with a 1-hour value < 8 ng/L. The trial followed all patients through 30 days to assess for AMI or death and captured all cardiac testing. We compared stress testing results to invasive coronary imaging with or without revascularization. Results: 10,444 study patients (43.61%) ruled out for AMI in the ED within 1 hour and were included in this analysis. There were 320 (3.0%) patients who had a stress test within 30 days, with few ischemic findings (25, 0.24%) or revascularization procedures (5, 0.05%). The positive predictive value of stress testing in this population to identify the need for revascularization was 10.1% (95% CI 2.8% - 29.4%). Table 1 displays the proportion of ischemic stress tests and overall test performance in this population. The rate of 30-day death or AMI was low (17, 0.20%) among those discharged from the ED or placed in observation (n=8,553). Conclusions: Our study highlights the infrequent use and low diagnostic yield of stress testing in patients who have been ruled out for AMI within 1 hour using an accelerated hs-cTn protocol in the ED.
Assessing the Efficacy of Farnesoid X Receptor Agonists in the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease: A Systematic Review and Meta-Analysis
Authors: Kumar Jai , Hasan Misha , Mohsin Sana , Nagar Tripti , Tegeltija Vesna , Kumar Sarwan 
Published: August 2024

Background: Several randomized clinical trials have been conducted assessing the potential efficacy of X receptor (FXR) agonists in patients with metabolic dysfunction-associated liver disease (MASLD). A comprehensive review and analysis were needed to evaluate the findings of these trials. Hence, this systematic review and meta-analysis aim to study the association between FXR agonists and hepatic outcomes in patients with MASLD. Introduction: Metabolic dysfunction-associated liver disease (MASLD) involves abnormal lipid accumulation in the liver, potentially progressing to metabolic dysfunction-associated steatohepatitis (MASH) with severe outcomes. X receptors (FXR), activated by bile acids, regulate liver metabolism and inflammation, offering a promising therapeutic target. Clinical trials with FXR agonists like obeticholic acid and tropifexor show potential in improving MASH histology. However, a comprehensive analysis of FXR modulation’s impact on liver pathology and metabolism in MASLD and MASH is lacking. This systematic review aims to address this gap, informing future therapeutic approaches. Methods: Systematic review and meta-analysis evaluating the efficacy of FXR agonists in 1,227 patients assigned to the FXR intervention group compared to 650 patients in the placebo group. Changes in liver enzymes and hepatic steatosis assessed by MRI-PDFF were evaluated. Results: FXR agonist use was associated with a significant reduction in levels of AST, (WMD= -4.51, 95% CI=[-8.39,-0.63], P=0.02); ALT (WMD= -13.02, 95% CI=[-17.85,-8.19], P<0.00001); GGT (WMD= -32.20, 95% CI=[-38.63,-25.98], P<0.00001); MRI-PDFF, (SMD= -1.14, 95% CI=[-1.92,-0.35], P=0.005). FXR agonists did not significantly affect ALP levels, (WMD= 25.04, 95% CI= [19.22,30.87], P<0.00001}. Conclusions: Results show promising evidence supporting the efficacy of FXR agonists in reducing hepatic steatosis and biomarkers of hepatic injury such as ALT, AST, and GGT.
The Effects of the STREAMLINE™ Surgical System versus Endoscopic Cyclophotocoagulation in Primary and Secondary Glaucoma
Authors: Beckman Jamie 
Published: August 2024

Introduction: Glaucoma is an optic neuropathy that is the second most common cause of blindness worldwide and affects over three million Americans. Currently, the only known modifiable risk factor to prevent glaucomatous damage is to decrease the intraocular pressure (IOP). The STREAMLINE™ Surgical System (SSS) is a microinvasive glaucoma (MIGs) device that can create a goniotomy and dilates the drainage system of the eye to reduce IOP. Question & Significance: This study aims to compare the effects on intraocular pressure of patients that had cataract surgery combined the SSS, endoscopic cyclophotocoagulation (ECP), or ECP with SSS in patients with primary and secondary glaucoma’s for 6 months post operatively. Methods: This is a retrospective chart review of patients that had cataract surgery with either ECP, SSS, or SSS + ECP from April 1st, 2022 through April 1st, 2023. Primary endpoints were mean IOP reductions and medication reliance at 6 months compared to baseline. Secondary outcomes were best corrected visual acuity (BCVA), number of patients with  20% decrease in IOP, number of patients with a decrease in IOP lower medications, and significant complications after treatment. Results: Comparing 6-month post-operative mean IOPs in these treatment groups, a significant reduction was noted only in the ECP group at the 6-month visit (p<0.003). No statistically significant reduction was found in either the SSS (p=0.333) or SSS+ECP (p=0.134) groups. The percent of patients having a  20% decrease in IOP from baseline were 52%, 10%, and 38% for ECP, SSS, and SSS+ECP groups, respectively. Conclusions: In the SSS only group, we found a significantly smaller proportion of patients able to achieve the  20% IOP reduction at only 10% of patients compared to other previous studies. This difference is likely due no medication washout in our study. This study did find similar decrease in IOP lowering medications.
Implementation of a Standardized Feeding Protocol in a Level III Neonatal Intensive Care Unit
Authors: Rahimo Maryam , Miliara Evgenia , Piatek Monika , Pappas Athina 
Published: August 2024

Introduction: The nutritional management of preterm infants in the Neonatal Intensive Care Unit (NICU) can be challenging and can often lead to extrauterine growth restriction (EUGR). A new feeding protocol was recently established and implemented at Ascension St. John’s NICU. Objectives: 1.) To determine the association of a standardized feeding protocol in the NICU and feeding intolerance, as well as growth outcomes and the number of days on parenteral nutrition; and 2.) To determine the association of a standardized feeding protocol and the development of necrotizing enterocolitis and central line associated infections. Methods: This study was a historical cohort study done by retrospective chart review. The pre-feeding protocol period included infants <32 weeks gestation and <1500g who were in the NICU between 1/1/2018 to 12/31/2020. The post-feeding protocol period was from 1/1/2021 to 11/15/2023. Data were recorded on demographics; and measurements at birth, 34 weeks postmenstrual age, and at discharge. Nutritional milestones and clinical outcomes were collected. Statistical analysis was done using Student’s t-test, the chi-squared test, the Mann-Whitney U test and repeated measures analysis of variance. Results: A total of 243 infants were included: 158 pre-implementation and 85 post-implementation of protocol. The mean gestational age was 27.7 ± 2.3 weeks, 61.7% of infants were black and 53.5% were female; there were no significant differences by time period. Results show no statistically significant difference in growth outcomes, days when infants received nothing by mouth; necrotizing enterocolitis, or sepsis. There was a delay in fortification and reaching full feeds, longer parental nutrition and central line days, and higher number of central line associated infections in the post-implementation period. Rates of intraventricular hemorrhage, retinopathy of prematurity and pulmonary outcomes were improving. Conclusions: The data suggest that implementation of a standardized feeding protocol can improve short term morbidities in high-risk neonates. Future studies are needed to optimize feeding protocols with the goal of improving growth, nutrition, and neurodevelopmental outcomes of this high-risk population.
Radiological Evaluation and Comparative Analysis of First Metatarsal-Cuneiform Fusion Constructs: Assessing Outcomes and Stability Across Varied Fusion Techniques
Authors: Lyons Katherine , Adelman Ronald , Nguyen Hoang , Cleypool Katelyn 
Published: August 2024

Background: The Lapidus procedure has become a cornerstone in the surgical management of hallux valgus, especially in cases with associated tarsometatarsal instability. This study investigates and compares the radiographic outcomes following three distinct Lapidus constructs, aiming to provide valuable insights into the optimal fusion configurations for achieving long-term stability improvement and maintaining intermetatarsal angle post operatively. Methods: In this retrospective study, the objective is to assess and compare the outcomes of three different fusion constructs employed in the Lapidus procedure: Group 1: Transverse screw fixation, Group 2: Metatarsal cuneiform screw fixation, and Group 3: Combined transverse and metatarsal cuneiform screw fixation. The study encompasses a total of 32: 11 feet in group 1, 8 feet in group 2, and 13 feet in group 3. The primary focus is to evaluate postoperative stability through radiographic imaging, complemented by clinical assessments and an examination of complications. Statistical analyses were used to compare outcomes across the three fixation groups at immediate post-op, 3 months, 6 months, and 1-year post-op. Results: The study found that TMT fusion using these 3 constructs was effective in correcting the hallux valgus deformity and restoring medial midfoot stability to the tarsometatarsal joint. Radiographic assessments demonstrated successful fusion, and patients reported improvements in pain, function, and overall satisfaction with the procedure. Complication rates were within an acceptable range. The intermetatarsal angle (IMA) in all three groups exhibited a significant reduction postoperatively compared to preoperative measurements. Group 3, characterized by combined transverse and metatarsal cuneiform screw fixation, demonstrated a notably stronger initial reduction in the intermetatarsal angle compared to Groups 1 and 2. This difference became evident by the 3-month mark and persisted, maintaining significant distinctions among the three techniques at the final follow-up. Radiological assessments indicated that Group 3 maintained stable IMA values and exhibited a lower recurrence rate compared to the other two groups. Conclusions: The findings of this study endorse the utilization of TMT fusion with these 3 constructs, particularly with combined transverse and metatarsal cuneiform screw fixation, as a dependable and efficacious surgical approach in addressing hallux valgus with concomitant tarsometatarsal instability.
Lactate Expression, Mortality, and Length of Stay in Emergency Department Patients with Sepsis and Intubation
Authors: Ahdi Heaveen , Berger David , Talia Nadine , Zhao Lili , Otero Ronny 
Published: August 2024

Introduction: Patients in septic shock with a lactate <2 have a mortality of 20-46%. Our prior work reported that emergency department (ED) patients with a second lactate ≥2 (lac) have a two-fold increase in 30-day mortality when compared to patients with a second lactate <2 (alac). On secondary analysis, we found that intubated patients with a second lactate ≤2 have a longer hospital length of stay (LOS). Our objective is to further scrutinize this 30-day mortality and LOS. Methods: This is a retrospective cohort study of an eight-hospital health system using data from the electronic medical record. Inclusion criteria consisted of patients ≥18 years of age who presented to the ED from 1/1/2017 to 11/30/2022 with ≥2 lactate levels measured in the ED, were diagnosed with sepsis, and admitted to the intensive care unit within 24 hours. Patients were classified based on their lactate values. Multivariable regression analysis was performed for 30-day mortality and LOS, adjusting for vitals, BMI, DNR status, and intubation timing. Results: 1285 patients met inclusion criteria, were intubated, and categorized based on their lactate expression: alac-> alac (reference; 111/1285, 8.9%), alac-> lac (28/1285, 2.2%), lac-> alac (259/1285, 20.2%), and lac-> lac (887/1285, 69.0%). Lac-> lac had a significantly higher 30-day mortality (OR = 2.058, 95% CI = [1.353, 3.154]) compared to alac-> alac. Lac-> alac had a significantly increased LOS (OR = 1.133 (95% CI = [1.003, 1.280]) compared to alac-> alac. Conclusions: Patients in the lac-> lac group had a two-fold increase in 30-day mortality when compared to alac-> alac. The lac-> alac group consistently had a greater LOS compared to alac-> alac. However, no further associations existed between the lactate expression category and LOS. Our prior work did not adjust for DNR and intubation timing, which may have spuriously augmented the LOS differences.
Trainee Preparedness to Enter Physiatry Residency: Early Findings from a National Cross-Sectional Survey Study
Authors: Jung Jungyoon , Roskos P Tyler 
Published: August 2024

Introduction: This national survey study investigates the transition of PM&R residents from as they transition into residency, aiming to identify associated factors influencing their preparedness. The transition to residency can be stressful, and insufficient preparedness is associated with a higher risk of burnout. While existing research has examined this transition in large specialties like internal medicine and surgery, there is a gap in understanding preparedness for PM&R residency in PGY-2. PM&R residency offers diverse routes, and not all medical schools have PM&R departments, leading to varied exposure and experience among incoming residents. Methods: To address this gap, a voluntary national survey study was conducted, collecting data from 55 residents across the USA from PGY-2 to PGY-4. Results: Participants reported their overall preparedness, with 51% feeling prepared and 49% feeling unprepared for clinical care at the start of residency. The prepared group demonstrated higher emotional and clinical preparedness, particularly in performing neuro/musculoskeletal physical examinations, managing rehabilitation issues, and interpreting imaging. Experience as an intern emerged as the most critical factor influencing preparedness. There were no significant differences between the prepared and unprepared groups in terms of age, gender, medical degree, timing of PM&R exposure, participation in PM&R interest group, type of internship pursued (transitional, medicine, surgery, or categorical), or academic versus community hospital during intern year. Conclusions: Incoming residents who self-identified as unprepared may specifically benefit from early check-ins with residents about wellbeing and early focused education on the neuro/musculoskeletal physical examination, management of common rehabilitation related issues, and interpretation of neuromusculoskeletal imaging, given the differences in responses we observed between prepared and unprepared groups in these domains. Residents trended toward feeling unprepared in handling rapid responses, pediatric rehabilitation patients, and therapy prescriptions and precautions at the start of PM&R residency.