bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Operating Room Black Box: Understanding Adherence to Surgical Checklists
Authors: Al Abbas Amr I. , Sankaranarayanan Ganesh , Polanco Patricio M. , Cadeddu Jeffrey A. , Daniel William , Palter Vanessa , Grantcharov Teodor , Bartolome Sonja , Dandekar Priya , Evans Kim , Zeh Herbert J. 
Published: September 2022

Objective:We report for the first time the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality.Background:Implementation of operative checklists is associated with improved outcomes. Compliance is difficult to monitor. Most studies report either no assessment of checklist compliance or deployed in-person short-term assessment. The ORBB a novel artificially intelligence-driven data analytic platform affords the opportunity to assess checklist compliance without disrupting surgical workflow.Methods:This was a retrospective review of prospectively collected ORBB data. Operative cases included elective surgery at a quaternary referral center. Cases were analyzed as prepolicy change (first 9 months) or as a postpolicy change (last 9 months). Measures of checklist compliance, engagement, and quality were assessed.Results:There were 3879 cases that were performed and monitored for checklist compliance between August 15, 2020, and February 20, 2022. The overall scores for compliance, engagement, and quality were 81%, 84%, and 67% respectively. When broken down by phase, the scores for time-out were compliance 100%, engagement 98%, and quality 61%. Scores for the debrief phase were 81% for compliance, 98% for engagement, and 66% for quality. After a hospital policy change, the debrief scores improved significantly (85%;P<0.001 for compliance, 88%;P<0.001 for engagement and 71%;P<0.001 for quality).Conclusions:ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. Utilization of this technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.
Recognizing life-threatening bleeding in pediatric trauma: A standard for when to activate massive transfusion protocol
Authors: Morgan Katrina M. , Gaines Barbara A. , Richardson Ward M. , Strotmeyer Stephen , Leeper Christine M. 
Published: September 2022

BACKGROUND
Traumatic hemorrhage is the most common cause of preventable death in civilian and military trauma. Early identification of pediatric life-threatening hemorrhage is challenging. There is no accepted clinical critical administration threshold (CAT) in children for activating massive transfusion protocols.

METHODS
Children 0 to 17 years old who received any transfusion in the first 24 hours after injury between 2010 and 2019 were included. The type, volume, and time of administration for each product were recorded. The greatest volume of weight-adjusted products transfused within 1 hour was calculated. The cut point for the number of products that maximized sensitivity and specificity to predict in-hospital mortality, need for urgent surgery, and second life-threatening bleeding episode was determined using Youden's index. A binary variable (CAT+) was generated using this threshold for inclusion in a multivariable logistic regression model.

RESULTS
In total, 287 patients were included. The median (interquartile range) age was 6 (2–14) years, 60% were males, 83% sustained blunt trauma, and the median (interquartile range) Injury Severity Score was 26 (17–35). The optimal cutoff to define CAT+ was >20 mL/kg of product; this optimized test characteristics for mortality (sensitivity, 70%; specificity, 77%), need for urgent hemorrhage control procedure (sensitivity, 65%; specificity, 74%). and second bleeding episode (sensitivity, 77%; specificity, 74%). There were 93 children (32%) who were CAT+. On multivariate regression, being CAT+ was associated with 3.4 increased odds of mortality (95% confidence interval, 1.67–6.89; p = 0.001) after controlling for age, hypotension, Injury Severity Score, and Glasgow Coma Scale. For every unit of product administered, there was a 10% increased risk of mortality (odds ratio, 1.1; p < 0.001).

CONCLUSION
Transfusion of more than 20 mL/kg of any blood product within an hour should be used as a threshold for activating massive transfusion protocols in children. Children who meet this CAT are at high risk of mortality and need for interventions; this population may benefit from targeted, timely, and aggressive hemostatic resuscitation.

LEVEL OF EVIDENCE
Therapeutic/Care Management; Level III.
Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe?
Authors: Van Wijck Suzanne F.M. , Pieracci Fredric M. , Smith Elizabeth F. , Madden Kelley , Moore Ernest E. , Wijffels Mathieu M.E. , Werner Nicole L. 
Published: September 2022

BACKGROUND
Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions.

METHODS
This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses.

RESULTS
A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries (p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted β, −2.511 [95% confidence interval, −4.87 to −0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted β, −5.19 [95% confidence interval, −10.2 to −0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management.

CONCLUSION
In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions.

LEVEL OF EVIDENCE
Therapeutic/Care Management; Level IV.
DeepBackRib: Deep learning to understand factors associated with readmissions after rib fractures
Authors: Choi Jeff , Alawa Jude , Tennakoon Lakshika , Forrester Joseph D. 
Published: September 2022

BACKGROUND
Deep neural networks yield high predictive performance, yet obscure interpretability limits clinical applicability. We aimed to build an explainable deep neural network that elucidates factors associated with readmissions after rib fractures among nonelderly adults, termed DeepBackRib. We hypothesized that DeepBackRib could accurately predict readmissions and a game theoretic approach to elucidate how predictions are made would facilitate model explainability.

METHODS
We queried the 2017 National Readmissions Database for index hospitalization encounters of adults aged 18 to 64 years hospitalized with multiple rib fractures. The primary outcome was 3-month readmission(s). Study cohort was split 60-20-20 into training-validation-test sets. Model input features included demographic/injury/index hospitalization characteristics and index hospitalization International Classification of Diseases, Tenth Revision, diagnosis codes. The seven-layer DeepBackRib comprised multipronged strategies to mitigate overfitting and was trained to optimize recall. Shapley additive explanation analysis identified the marginal contribution of each input feature for predicting readmissions.

RESULTS
A total of 20,260 patients met the inclusion criteria, among whom 11% (n = 2,185) experienced 3-month readmissions. Feature selection narrowed 3,164 candidate input features to 61, and DeepBackRib yielded 91%, 85%, and 82% recall on the training, validation, and test sets, respectively. Shapley additive explanation analysis quantified the marginal contribution of each input feature in determining DeepBackRib's predictions: underlying chronic obstructive pulmonary disease and long index hospitalization length of stay had positive associations with 3-month readmissions, while private primary payer and diagnosis of pneumothorax during index admission had negative associations.

CONCLUSION
We developed and internally validated a high-performing deep learning algorithm that elucidates factors associated with readmissions after rib fractures. Despite promising predictive performance, standalone deep learning algorithms are insufficient for clinical prediction tasks: a concerted effort is needed to ensure that clinical prediction algorithms remain explainable.

LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level III.
Serum levels of copeptin predict adverse outcomes and improve risk prediction of TRISS and MGAP scores in patients with multiple trauma: A single-center prospective cohort study
Authors: Hsein Yenh-Chen , Wu I-Ju , Tan Jasmine , Huang Sih-Shiang , Lu Kuan-Ting , Su Chin-Hua , Hsu Wan-Ting , Chen Shyr-Chyr , Lee Chien-Chang 
Published: September 2022

BACKGROUND
Multiple trauma deserves early prognostication and stratification. Copeptin, a precursor of vasopressin, is produced in response to stress. We examined the association between serum levels of copeptin and mortality risk in patients with multiple trauma. We aimed to also enhance the previously established Trauma-Related Injury Severity Score (TRISS) and Mechanism, GCS, Age, and Arterial Pressure (MGAP) score with the additional consideration of copeptin levels.

METHODS
This single-center prospective cohort study enrolled patients who presented to the emergency department with potential major injuries. The serum levels of copeptin were measured, and the correlation to clinical severity in terms of 30-day mortality and requirement of intensive care management was analyzed. By combining copeptin levels with TRISS or MGAP, comparison between performance of the original models with the copeptin-enhanced models was performed via discrimination, calibration, and reclassification analyses.

RESULTS
There was a significant increase in copeptin levels in patients who died within 30 days (median 644.4 pg/L, interquartile range [472.5, 785.9]) or were admitted to intensive care units (233.8 pg/L, [105.7, 366.4]), compared with those who survived (37.49 pg/L, [17.88, 77.68]). Adding the natural log of copeptin levels to the established TRISS and MGAP models improved the AUC of TRISS from 0.89 to 0.96, and that of MGAP from 0.82 to 0.95. Both calibrations as measured by Brier’s scores and reclassification as measured by net reclassification improvement or integrated discrimination improvement demonstrated significant improvements. A Web-based calculator was built to generate predicted mortality rates of various models for convenient clinical use.

CONCLUSION
Admission serum copeptin levels were correlated with clinical severity in multiple trauma. Coupling copeptin with preexisting trauma severity scores improved prediction accuracy. Copeptin shows promise as a novel biomarker for the prediction of trauma outcome.

LEVEL OF EVIDENCE
Prognostic and Epidemiologic; Level III.
The Evolution of a Chest Wall Injury and Reconstruction Clinic During a Pandemic
Authors: Eriksson Evert A. , Waite Amanda M. , Shivers Shaune D. 
Published: September 2022

Background
In 2019, we sought to develop a Chest Wall Injury and Reconstruction Clinic(CWIRC) to treat patients with chest wall pain and rib fractures. This initiative was fueled by the recognition of an unmet need as well as evolving research demonstrating improved patient care and experience. We will describe the evolution of this clinic program from an Acute Care Surgery/General Surgery(ACS/GS) clinic to a CWIRC.

Methods
We identified outpatient encounters generated from a general surgery clinic staffed by a physician and nurse practitioner team. A retrospective cohort review was performed to identify all outpatient encounters and surgeries associated with these encounters from 1/1/2017–11/30/2021. Outpatient and operative wRVU production as well as payer mix was compared as the primary outcome.

Results
Over this time period, the number of clinic interactions decreased (2017-284 vs. 2021-229). Clinic productivity increased however from 181 wRVU in 2017 to 295 wRVU in 2021. The CWIRC patient visits increased from 4% to 70%. Additionally, telehealth visits increased from 0% to 23% of encounters. The operative wRVU productivity attributable to outpatient clinic visits increased (2017–253 vs. 2021–591). Combined, the CWIRC resulted in an overall growth of 104% in total wRVU. The payer mixes for patients with rib diagnosis have a higher number of Blue Cross Blue Shield, Medicare, and Managed Care compared to ACS/GS. The most common diagnosis was rib fracture initial evaluation (37%), rib fracture subsequent encounter (25%), rib pain (24%), and flail chest initial evaluation (4%).

Conclusions
The initiation of a CWIRC increased wRVU production despite a decrease in clinical encounters. These clinics may produce more wRVU per encounter than ACS/GS clinics. An underserved population has been identified of chest wall pathology patients presenting for initial evaluation as outpatients. Further investigation into this concept is warranted to serve this population.

Level of Evidence
IV Therapeutic / care management
The Molecular Diagnosis Might Be Clinically Useful in Discrepant Kidney Allograft Biopsy Findings: An Analysis of Clinical Outcomes
Authors: Schachtner Thomas , von Moos Seraina , Kokkonen Sanna M. , Helmchen Birgit , Gaspert Ariana , Mackova Martina , Halloran Philip F. , Mueller Thomas F. 
Published: September 2022

Background.
The Molecular Microscope Diagnostic System (MMDx) may overcome histology shortcomings. Previous studies have simply examined discrepant findings but have not attempted to determine clinical endpoints. To measure performance, clinical outcomes are strongly required.

Methods.
This single-center cohort study described discrepancies between MMDx and histology from 51 kidney transplant recipients (KTRs) and analyzed 72 indication biopsies, including 21 follow-up biopsies. Clinical performance was assessed by a combined endpoint of graft failure, rejection on follow-up biopsy, de novo donor-specific antibody, and improvement of kidney allograft function upon antirejection treatment.

Results.
MMDx agreed in 33 (65%) and differed in 18 (35%) of 51 KTRs. Most discrepancies occurred in biopsies called no rejection by MMDx and rejection by histology (15/24, 63%). In contrast, in biopsies called rejection by MMDx, 3 were classified as no rejection by histology (3/27, 11%). Discrepant findings between MMDx and histology occurred following delayed graft function and MMDx from biopsies with a low percentage of cortex. Among 15 biopsies classified as no rejection by MMDx but rejection by histology, the clinical course suggested no rejection in 9 cases. Six KTRs reached the endpoint, showing predominant t ≥ 2 lesions.

Conclusions.
The most often occurring discrepancy is rejection by histology but no rejection by MMDx. As more KTRs do not meet the combined endpoint for rejection, MMDx might be clinically useful in these discrepant cases. Although strong histological findings have priority in indicating the treatment, clinical implementation of MMDx could strengthen treatment strategies.
Nodular Regenerative Hyperplasia Is Not a Rare Condition After Liver Transplantation: Incidence, Predictive Factors, and Impact on Survival
Authors: Kounis Ilias , Sebagh Mylène , Evain Manon , Cailliez Valérie , Roche Bruno , De Martin Eleonora , Sobesky Rodolphe , Guettier Catherine , Allard Marc Antoine , Golse Nicolas , Azoulay Daniel , Vibert Eric , Duclos Vallee Jean Charles , Feray Cyrille , Samuel Didier , Coilly Audrey 
Published: September 2022

Background.
The objectives of this study were to evaluate incidence and to identify the risk factors of occurrence and the predictive factors of symptomatic forms of nodular regenerative hyperplasia (NRH) after liver transplantation (LT).

Methods.
To identify risk factors of NRH following LT, we included 1648 patients transplanted from 2004 to 2018 and compared the patients developing NRH after LT to those who did not. To identify predictive factors of symptomatic NRH, we selected 115 biopsies displaying NRH and compared symptomatic to asymptomatic forms. Symptomatic NRH was defined as the presence of ascites, esophageal varices, hepatic encephalopathy, portal thrombosis, retransplantation, or death related to NRH.

Results.
The incidence of NRH following LT was 5.1%. In multivariate analysis, the independent factor of developing NRH after LT was the donor’s age (odds ratio [OR] = 1.02; confidence interval, 1.01-1.03; P = 0.02). Symptomatic forms occurred in 29 (25.2%) patients: 19 (16.5%) patients presented with ascites, 13 (11.3%) with esophageal varices, 4 (3.5%) with hepatic encephalopathy, and 8 (7%) with portal thrombosis. The median period before the onset of symptoms was 8.4 (1.5–11.3) y after LT. The spleen size at diagnosis/before LT ratio (OR = 12.5; 114.17-1.37; P = 0.0252) and thrombectomy during transplantation (OR = 11.17; 1.48-84.11; P = 0.0192) were associated with symptomatic NRH in multivariate analysis.

Conclusions.
NRH following LT is frequent (5.1%) and leads to symptomatic portal hypertension in 25.2% of patients. Using older grafts increases the risk of developing NRH after LT. Clinicians should screen for signs of portal hypertension, particularly in measuring spleen size.
Accounting for assay performance when estimating the temporal dynamics in SARS-CoV-2 seroprevalence in the U.S
Authors: García-Carreras Bernardo , Hitchings Matt D. T. , Johansson Michael A. , Biggerstaff Matthew , Slayton Rachel B. , Healy Jessica M. , Lessler Justin , Quandelacy Talia , Salje Henrik , Huang Angkana T. , Cummings Derek A. T. 
Published: September 2022

AbstractEstimating the incidence of SARS-CoV-2 infection is central to understanding the state of the pandemic. Seroprevalence studies are often used to assess cumulative infections as they can identify asymptomatic infection. Since July 2020, commercial laboratories have conducted nationwide serosurveys for the U.S. CDC. They employed three assays, with different sensitivities and specificities, potentially introducing biases in seroprevalence estimates. Using mechanistic models, we show that accounting for assays explains some of the observed state-to-state variation in seroprevalence, and when integrating case and death surveillance data, we show that when using the Abbott assay, estimates of proportions infected can differ substantially from seroprevalence estimates. We also found that states with higher proportions infected (before or after vaccination) had lower vaccination coverages, a pattern corroborated using a separate dataset. Finally, to understand vaccination rates relative to the increase in cases, we estimated the proportions of the population that received a vaccine prior to infection.
Quotidian Profile of Vergence Angle in Ambulatory Subjects Monitored with Wearable Eye Tracking Glasses
Authors: Dilbeck Mikayla D. , Gentry Thomas N. , Economides John R. , Horton Jonathan C. 
Published: September 2022

ABSTRACTPURPOSEWearable tracking glasses record eye movements and fixations as ambulatory subjects navigate their environment. We tested the performance of eye tracking glasses under laboratory and real world conditions, to characterize the vergence behavior of normal individuals engaged in their customary daily pursuits.METHODSTo define the accuracy and variability of the eye tracking glasses, 4 subjects fixated with the head stabilized at a series of distances corresponding to vergence demands of: 0.25, 0.50, 1, 2, 4, 8, 16, and 32°. Then, 10 subjects wore the eye tracking glasses for prolonged periods while carrying out their normal activities. Vergence profiles were compiled for each subject and compared with interpupillary distance.RESULTSIn the laboratory the eye tracking glasses were comparable in accuracy to remote video eye trackers, outputting a mean vergence value within 1° of demand at all angles except 32°. In ambulatory subjects the glasses were less accurate, due to tracking interruptions and measurement errors, only partly mitigated by application of data filters. Nonetheless, a useful record of vergence behavior was obtained in every subject. Vergence angle often had a bimodal distribution, reflecting a preponderance of activities at near (mobile phone, computer) or far (driving, walking). Vergence angle was highly correlated with interpupillary distance.CONCLUSIONSWearable eye tracking glasses provide a history of vergence angle and the corresponding scene witnessed by ambulatory subjects. They offer insight into the diversity of human ocular motor behavior and may become useful for diagnosis of disorders that affect vergence, such as convergence insufficiency, Parkinson disease, and strabismus.
SARS-CoV-2 mRNA vaccination elicits broad and potent Fc effector functions to VOCs in vulnerable populations
Authors: Hederman Andrew P. , Natarajan Harini , Wiener Joshua A. , Wright Peter F. , Bloch Evan M. , Tobian Aaron A.R. , Redd Andrew D. , Blankson Joel N. , Rottenstreich Amihai , Zarbiv Gila , Wolf Dana , Goetghebuer Tessa , Marchant Arnaud , Ackerman Margaret E. 
Published: September 2022

AbstractSARS-CoV-2 variants have continuously emerged even as highly effective vaccines have been widely deployed. Reduced neutralization observed against variants of concern (VOC) raises the question as to whether other antiviral antibody activities are similarly compromised, or if they might compensate for lost neutralization activity. In this study, the breadth and potency of antibody recognition and effector function was surveyed in both healthy individuals as well as immunologically vulnerable subjects following either natural infection or receipt of an mRNA vaccine. Considering pregnant women as a model cohort with higher risk of severe illness and death, we observed similar binding and functional breadth for healthy and immunologically vulnerable populations. In contrast, considerably greater functional antibody breadth and potency across VOC was associated with vaccination than prior infection. However, greater antibody functional activity targeting the endemic coronavirus OC43 was noted among convalescent individuals, illustrating a dichotomy in recognition between close and distant human coronavirus strains that was associated with exposure history. Probing the full-length spike and receptor binding domain (RBD) revealed that antibody-mediated Fc effector functions were better maintained against full-length spike as compared to RBD. This analysis of antibody functions in healthy and vulnerable populations across a panel of SARS-CoV-2 VOC and extending through endemic alphacoronavirus strains suggests the differential potential for antibody effector functions to contribute to protecting vaccinated and convalescent subjects as the pandemic progresses and novel variants continue to evolve.One Sentence SummaryAs compared to natural infection with SARS-CoV-2, vaccination drives superior functional antibody breadth raising hopes for candidate universal CoV vaccines.