bluuebunny/crossref_metadata_2025_split huggingface dataset:
High-performing primary care clinics across high-need, high-cost Medicare populations
Authors: Beckman Adam L , Tietschert Maike , Old Andrew , Orav E John , Singer Sara J , Figueroa Jose F 
Published: July 2023

BackgroundTo reduce spending and improve quality, some primary care clinics in the USA have focused on high-need, high-cost (HNHC) Medicare beneficiaries, which include clinically distinct subpopulations: older adults with frailty, adults under 65 years with disability and beneficiaries with major complex chronic conditions. Nationally, the extent to which primary care clinics are high-performing ‘Bright Spots’—clinics that achieve favourable outcomes at lower costs across HNHC beneficiary subpopulations—is not known.ObjectiveTo determine the prevalence of primary care clinics that perform highly on commonly used cost or quality measures for HNHC subpopulations.Design and participantsCross-sectional study using Medicare claims data from 2014 to 2015.Main measuresAnnual spending, avoidable hospitalisations for ambulatory care-sensitive conditions, treat-and-release emergency department visits, all-cause 30-day unplanned hospital readmission rates and healthy days at home. Clinics were high performing when they ranked in the top quartile of performance for ≥4 measures for an HNHC subpopulation. ‘Bright Spot’ clinics were in the top quartile of performance for ≥4 measures across all the HNHC subpopulations.Key resultsA total of 2770 primary care clinics cared for at least 10 beneficiaries from each of the three HNHC subpopulations (adults under 65 with disability, older adults with frailty and beneficiaries with major complex chronic conditions). Less than 4% of clinics were high performing for each HNHC subpopulation; <0.5% of clinics were in the top quartile for all five measures for a given subpopulation. No clinics met the definition of a primary care ‘Bright Spot’.ConclusionsHigh-performing primary care clinics that achieved favourable health outcomes or lower costs across subpopulations of HNHC beneficiaries in the Medicare programme in 2015 were rare. Efforts are needed to support primary care clinics in providing optimal care to HNHC subpopulations.
Using an electronic safety netting tool designed to improve safety with respect to cancer referral in primary care: a qualitative service evaluation using rapid appraisal methods
Authors: Black Georgia B , Machen Samantha , Parker-Deeks Saira , Cronin Andrea , Chung Donna 
Published: July 2023

BackgroundThis evaluation assesses the impact of an electronic safety netting software (E-SN) package, C the Signs, in primary care services across five boroughs in North East London (NEL).AimThis study evaluates the use of E-SN software in primary care, examining its benefits and barriers, safety implications, and overall impact on individual and practice usage.Design and settingThe study is based on semi-structured interviews with 21 clinical and non-clinical members of staff from all primary care services using the software in NEL.MethodSemi-structured interviews were conducted to gather data on individual use of the software, safety implications and practice use of features such as the monitoring dashboard. Data were analysed using a rapid qualitative methodology.ResultsTwo approaches to E-SN software adoption were reported: whole practice adoption and self-directed use. Practices benefitted from shared responsibility for safety netting and using software to track patients’ progress in secondary care. Adoption was affected by information technology and administrative resources. Decision-support tools were used infrequently due to a lack of appreciation for their benefits. Selective adoption of different E-SN functions restricted its potential impact on early diagnosis.ConclusionThe use of E-SN software in primary care services in NEL varied among participants. While some found it to be beneficial, others were sceptical of its impact on clinical decision-making. Nonetheless, the software was found to be effective in managing referral processes and tracking patients’ progress in other points of care.
Medics as influencers: a historical analysis of British Army military medical exercises in Kenya over two decades
Authors: Falconer Hall Patricia , Falconer Hall T , Bailey Z , Horne S T 
Published: July 2023

IntroductionAnnual British Army medical training exercises have run in Kenya since the early 1990s, initially with a dual purpose—to deliver the Kenyan Extended Programme of Immunisation (in remote locations) and to undertake austere training. This provided a specific response to a capability gap request from the partner nation, but as this gap closed, the exercise changed in various ways. This study aimed to qualitatively explore the impact of these exercises on the Kenyan healthcare system and the influence and relationships between the nations.MethodsSemistructured interviews were conducted for 10 former senior commanders and medical officers who had deployed in key command and clinical positions from 1993 to 2019. Three researchers conducted thematic content analysis on the key-informant interviews.ResultsFive domains with 18 subdomains formed the study’s analysis framework. 16 recurring themes were identified and placed into four categories that denote if they were of benefit to the engagement, enabled success, had the potential to cause harm or were a barrier to successful engagement. Three distinct phases of the exercise were identified: supporting Kenyan vaccinations, direct clinical care, training and education.ConclusionsThis is the first qualitative analysis of the impact of a British Defence Engagement (Health) on the partner nation and UK influence gained through it. It has identified factors which may improve outcomes, namely, ensuring sustainability and continuity between iterations; maintaining enduring stakeholder relationships; responding to a capability gap request; intelligence-led planning with incorporated assessment, monitoring and evaluation; adapting to changes in needs or contextual settings; while ensuring mutual benefit in objective setting. These may be used as the basis for a conceptual framework supporting the planning and execution of high-quality, mutually beneficial Defence Engagement (Health) activities in future. This framework and future research would also benefit from gaining perspectives from the partner nation.
Enhanced detection of severe aortic stenosis via artificial intelligence: a clinical cohort study
Authors: Strange Geoff , Stewart Simon , Watts Andrew , Playford David 
Published: July 2023

ObjectiveWe developed an artificial intelligence decision support algorithm (AI-DSA) that uses routine echocardiographic measurements to identify severe aortic stenosis (AS) phenotypes associated with high mortality.Methods631 824 individuals with 1.08 million echocardiograms were randomly spilt into two groups. Data from 442 276 individuals (70%) entered a Mixture Density Network (MDN) model to train an AI-DSA to predict an aortic valve area <1 cm2, excluding all left ventricular outflow tract velocity or dimension measurements and then using the remainder of echocardiographic measurement data. The optimal probability threshold for severe AS detection was identified at the f1 score probability of 0.235. An automated feature also ensured detection of guideline-defined severe AS. The AI-DSA’s performance was independently evaluated in 184 301 (30%) individuals.ResultsThe area under receiver operating characteristic curve for the AI-DSA to detect severe AS was 0.986 (95% CI 0.985 to 0.987) with 4622/88 199 (5.2%) individuals (79.0±11.9 years, 52.4% women) categorised as ‘high-probability’ severe AS. Of these, 3566 (77.2%) met guideline-defined severe AS. Compared with the AI-derived low-probability AS group (19.2% mortality), the age-adjusted and sex-adjusted OR for actual 5-year mortality was 2.41 (95% CI 2.13 to 2.73) in the high probability AS group (67.9% mortality)—5-year mortality being slightly higher in those with guideline-defined severe AS (69.1% vs 64.4%; age-adjusted and sex-adjusted OR 1.26 (95% CI 1.04 to 1.53), p=0.021).ConclusionsAn AI-DSA can identify the echocardiographic measurement characteristics of AS associated with poor survival (with not all cases guideline defined). Deployment of this tool in routine clinical practice could improve expedited identification of severe AS cases and more timely referral for therapy.
Psychological factors and prognostic communication preferences in advanced cancer: multicentre study
Authors: Ramchandani Avinash , Mihic-Góngora Luka , Hernández Raquel , Zafra-Poves Marta , Muñoz María M , Ferreira Estrella , Cruz-Castellanos Patricia , Fernández-Montes Ana , Pacheco-Barcia Vilma , Jiménez-Fonseca Paula , Calderon Caterina 
Published: July 2023

ObjectivesCommunication regarding prognosis to patients with advanced cancer is fundamental for informed medical decision making. Our objective was to analyse (1) the proportion of subjects with advanced cancer who prefer to know their prognosis, (2) the characteristics associated with patients’ preference for prognostic information, (3) the psychological factors that impact the preference to know prognosis and 4) the concordance between preference for prognostic information perceived among physicians and patients.MethodsA prospective, cross-sectional design was adopted. Data were collected from 748 participants with advanced cancer at 15 tertiary hospitals in Spain. Participants completed the following questionnaires: Mental Adjustment to Cancer; Trust in the Physician; Uncertainty in Illness Scale Patient’s Prognostic Preferences.ResultsFifty-two per cent of advanced cancer sufferers preferred to know the prognosis of their disease. Compared with participants who preferred not to know, those who did reported more uncertainty, greater satisfaction with their physician and higher scores on positive attitude (all p=0.001). Thirty-seven per cent of the physicians believed that patients want to know their prognosis, indicating that they underestimate the number of such patients. No significant differences were found regarding preference to know prognosis as a function of sociodemographic and clinical variables.ConclusionsA substantial proportion of individuals with advanced cancer prefer to know the prognosis of their disease. It appears that knowing their prognosis was mainly motivated by a need to maintain a positive attitude, lessen uncertainty and by satisfaction with the physician. It is important to explore patients’ preferences for information to offer more personalised communication.
Effective nonlinear Ehrenfest hybrid quantum-classical dynamics
Authors: Alonso José Luis , Bouthelier-Madre Carlos , Clemente-Gallardo Jesús , Martínez-Crespo David , Pomar Javier 
Published: July 2023

AbstractThe definition of a consistent evolution equation for statistical hybrid quantum-classical systems is still an open problem. In this paper, we analyze the case of Ehrenfest dynamics on systems defined by a probability density and identify the relations of the nonlinearity of the dynamics with the obstructions to define a consistent dynamics for the first quantum moment of the distribution. This first quantum moment represents the physical states as a family of classically-parametrized density matrices $${\hat{\rho }}(\xi )$$

ρ
^

(
ξ
)

, for $$\xi$$
ξ
a classical point; and it is the most common representation of hybrid systems in the literature. Due to this obstruction, we consider higher order quantum moments, and argue that only a finite number of them are physically measurable. Because of this, we propose an effective solution for the hybrid dynamics problem based on approximating the distribution by those moments and representing the states by them.
Age at Menopause, Leukocyte Telomere Length, and Coronary Artery Disease in Postmenopausal Women
Authors: Schuermans Art , Nakao Tetsushi , Uddin Md Mesbah , Hornsby Whitney , Ganesh Shriie , Shadyab Aladdin H. , Liu Simin , Haring Bernhard , Shufelt Chrisandra L. , Taub Margaret A. , Mathias Rasika A. , Kooperberg Charles , Reiner Alexander P. , Bick Alexander G. , Manson JoAnn E. , Natarajan Pradeep , Honigberg Michael C. 
Published: July 2023

BACKGROUND:
Premature menopause is a risk factor for accelerated cardiovascular aging, but underlying mechanisms remain incompletely understood. This study investigated the role of leukocyte telomere length (LTL), a marker of cellular aging and genomic instability, in the association of premature menopause with cardiovascular disease.

METHODS:
Participants from the UK Biobank and Women’s Health Initiative with complete reproductive history and LTL measurements were included. Primary analyses tested the association between age at menopause and LTL using multivariable-adjusted linear regression. Secondary analyses stratified women by history of gynecologic surgery. Mendelian randomization was used to infer causal relationships between LTL and age at natural menopause. Multivariable-adjusted Cox regression and mediation analyses tested the joint associations of premature menopause and LTL with incident coronary artery disease.

RESULTS:

This study included 130 254 postmenopausal women (UK Biobank: n=122 224; Women’s Health Initiative: n=8030), of whom 4809 (3.7%) had experienced menopause before age 40. Earlier menopause was associated with shorter LTL (meta-analyzed ß=−0.02 SD/5 years of earlier menopause [95% CI, −0.02 to −0.01];
P
=7.2×10
-12
). This association was stronger and significant in both cohorts for women with natural/spontaneous menopause (meta-analyzed ß=−0.04 SD/5 years of earlier menopause [95% CI, −0.04 to −0.03];
P
<2.2×10
-16
) and was independent of hormone therapy use. Mendelian randomization supported a causal association of shorter genetically predicted LTL with earlier age at natural menopause. LTL and age at menopause were independently associated with incident coronary artery disease, and mediation analyses indicated small but significant mediation effects of LTL in the association of menopausal age with coronary artery disease.

CONCLUSIONS:
Earlier age at menopause is associated with shorter LTL, especially among women with natural menopause. Accelerated telomere shortening may contribute to the heightened cardiovascular risk associated with premature menopause.
Temporal Trends in Infarct Severity Outcomes in ST‐Segment–Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study
Authors: Lechner Ivan , Reindl Martin , Tiller Christina , Holzknecht Magdalena , Fink Priscilla , Troger Felix , Angerer Georg , Angerer Simon , Henninger Benjamin , Mayr Agnes , Klug Gert , Bauer Axel , Metzler Bernhard , Reinstadler Sebastian J. 
Published: July 2023

Background
Severity of myocardial tissue injury is a main determinant of morbidity and death related to ST‐segment–elevation myocardial infarction (STEMI). Temporal trends of infarct characteristics at the myocardial tissue level have not been described. This study sought to assess temporal trends in infarct characteristics through a comprehensive assessment by cardiac magnetic resonance imaging at a standardized time point early after STEMI.

Methods and Results

We analyzed patients with STEMI treated with percutaneous coronary intervention at the University Hospital of Innsbruck who underwent cardiac magnetic resonance imaging between 2005 and 2021. The study period was divided into terciles. Myocardial damage characteristics were assessed using a multiparametric cardiac magnetic resonance imaging protocol within the first week after STEMI and compared between groups. A total of 843 patients with STEMI (17% women) with a median age of 57 (interquartile range, 51–66) years were analyzed. While age, sex, and the clinical risk profile expressed as thrombolysis in myocardial infarction risk score were comparable across the study period, there were differences in guideline‐recommended therapies. At the same time, there was no significant change in infarct size (
P
=0.25), microvascular obstruction (
P
=0.50), and intramyocardial hemorrhage (
P
=0.34). Left ventricular remodeling indices and left ventricular ejection fraction remained virtually unchanged (all
P
>0.05). Major adverse cardiovascular events at 4 (interquartile range, 4–5) months were similar between groups (
P
=0.36).

Conclusions
In this magnetic resonance imaging study investigating patients with STEMI treated with primary percutaneous coronary intervention over the past 15 years, no change in infarct severity at the myocardial level has been observed. Clinical research on novel therapeutic approaches to reduce myocardial tissue injury should be a priority.
Robotic Left Hepatectomy for Hemorrhagic Hepatocellular Adenoma: The Role of Robotic Surgery in a Semi-Acute Setting
Authors: Sucandy Iswanto , Ross Sharona , Lim-Dy Allyson , Younos Ahmed , Rosemurgy Alexander 
Published: July 2023

Hepatocellular adenomas are benign liver tumors, more frequently seen in young women with a history of long-standing use of estrogenic hormonal contraception. An acute rupture of these adenomas can be the first sign of symptoms; however, they can be life-threatening. The definitive management of hepatic adenoma is liver resection for those larger than 4 cm as this cutoff size is known to be associated with an exponential risk of harboring malignancy and an increased risk for intratumor bleeding. Once intratumor hemorrhage occurs however, the management of hepatic adenoma becomes much more timely critical. In this study, we describe the use of robotic liver resection for the management of hemorrhagic hepatocellular adenoma in a semi-acute setting. We also include a series of robotic hepatic adenoma resection completed in our hepatobiliary program since 2016, which demonstrated the safety, feasibility, and reproducibility of robotic technique in treating hepatic adenoma.
Risk Factors for Acute Renal Failure After Endovascular Aneurysm Repair
Authors: Zambetti Benjamin R. , Zickler William P. , Byerly Saskya , Garrett H. Edward , Magnotti Louis J. 
Published: July 2023

Background Acute kidney injury (AKI) after endovascular aortic aneurysm repair (EVAR) is uncommon though carries significant morbidity. Procedural risk factors are not well established for acute renal failure (ARF) that requires initiation of dialysis. The goal of this study was to examine the impact of ARF on patients undergoing EVAR and identify risk factors for ARF using a large, national dataset. Methods Patients undergoing EVAR were identified from the National Surgical Quality Improvement Program (NSQIP) database over 9 years, ending in 2019. Demographics, indication for repair, comorbidities, procedural details, complications, hospital and ICU LOS, and mortality were recorded. Patients were stratified by presence of ARF and compared. Patients were further stratified by indication for EVAR and presence of ARF. Multivariable logistic regression (MLR) analysis was performed to determine the independent predictors of ARF. Results 18 347 patients were identified. Of these 234 (1.3%) developed ARF requiring dialysis. Mortality (40 vs 1.8%, P < .0001), ICU LOS (5 vs 0 days, P < .0001), and hospital LOS (11 vs 2 days, P < .0001) were all significantly increased in patients with ARF. Multivariable logistic regression identified increasing diameter, creatinine, operative time, preoperative transfusions, ASA class, emergent repair, female gender, and juxtarenal/suprarenal proximal landing zone as predictors of ARF. Conclusions ARF after EVAR causes significant morbidity, prolongs hospitalizations, and increases mortality rates. Those patients at risk of ARF after EVAR should be closely monitored to reduce both morbidity and mortality.
Influence of Prognostic Nutritional Index on the Surveillance After Surgery-Based Systematic Therapy for Breast Cancer
Authors: Zhang Xiaoyu , Liu Yue , Mu Dali 
Published: July 2023

Objective Prognostic nutritional index (PNI) is a comprehensive reflection of the nutritional and immune status of the patient, which is closely related to the ability of the organism to clear tumor cells and reduce local recurrence. Several findings suggested that PNI was a prognostic indicator for breast cancer, but the conclusions were conflicting. We aimed to comprehensively elucidate the prognostic value of PNI in breast cancer patients. Methods Relevant studies in PubMed, Embase, Cochrane Library, and Web of Science databases were searched through March 2023. Data extraction and literature quality assessment of the screened studies were performed. The associations between PNI and overall survival (OS), disease-free survival (DFS), and progression-free survival (PFS) in breast cancer patients who received clinical treatment were assessed by hazard ratios ( HR) and 95% confidence intervals ( CIs). Results A total of 7 studies involving 2212 patients met the inclusion criteria. High PNI was a favorable independent predictor of prolonged OS and PFS after clinical treatment in breast cancer patients compared to low PNI (for OS: HR = .38, 95% CIs .31 ∼ .46, P < .001; for DFS: HR = .32, 95% CIs .19 ∼ .51, P < .001). In subgroup analysis, high PNI was a prognostic factor for extended DFS in the context of a study sample size ≥300 ( HR = .39, 95% CIs .28 ∼ .54, P < .001) and patients not receiving neoadjuvant chemotherapy ( HR = .51, 95% CIs .37 ∼ .70, P < .001). Conclusion The PNI has a significant correlation with the prognosis of breast cancer patients. We suggest that individualized targeted treatment and long-term surveillance should be implemented for patients with different levels of PNI.
Incentives as a Driving Force for Scholarly Activity in General Surgery Training: Survey of Program Directors and our Institution’s Experience
Authors: Katuwal Binit , Flynn Jeffrey C. , Mittal Vijay K. 
Published: July 2023

Introduction Scholarly activity in a few of the domains is required for both residents and faculty per Accreditation Council for Graduate Medical Education’s Common Program Requirements. Increased burden in clinical activities and economic changes in the health care environment have created new challenges, which have negatively affected faculty and residents to participate in scholarly activity. Various avenues are being sought which might help in improving the scholarly activity in an institution by providing dedicated time, salaried positions, grants, paid conferences, and financial incentives. Methods A survey was sent to program directors of surgery residency programs in 2020 to evaluate the impact of financial incentives on scholarly activity. Data was analyzed on SPSS 20, and descriptive statistics using frequencies and percentages were done. Results Out of 230 surveys sent, 80 (35%) program directors responded (35%). 52 (65%) of respondents were from university hospitals and 28 (35%) were from community hospitals. Both the faculty and residents were required to publish in 56 (70%) of the institutions surveyed. 59 (73.7%) considered a PubMed publication as a scholarly activity. Only 9 (11%) programs were supportive of residents being involved in research activities that had a designated rotation. 48 (60%) respondents stated that residents and faculty would be more likely to pursue research endeavors if they were provided some form of financial incentive, but only 9 (11%) had some sort of incentive program in place. Conclusion Given the results of the survey, there is a need to seek uniform, acceptable, and sustainable alternative incentive programs to help promote and increase the scholarly activity of residents and faculty.