title: Sleep-disordered breathing, impaired cardiac adrenergic innervation and prognosis in heart failure.

text: OBJECTIVE Unfavourable effects of sleep-disordered breathing (SDB) in heart failure (HF) are mainly mediated by impaired sympathetic activity. Few data are available on SDB and cardiac adrenergic impairment evaluated at myocardial level. The aim of the study was to assess the relationship between SDB, cardiac sympathetic innervation assessed by 123I-metaiodobenzylguanidine (123I-MIBG) imaging and prognosis in HF. METHODS Observational, prospective study enrolling patients with HF and reduced systolic function. Patients underwent nocturnal cardiorespiratory monitoring to assess SDB presence by apnoea/hypopnoea index (AHI), and 123I-MIBG imaging to calculate heart-to-mediastinum (H/M) ratios and washout rate. Patients were prospectively followed for 29±18 months for the combined endpoint of cardiovascular death and HF hospitalisation. RESULTS Ninety-four patients (66.1±9.8 years; left ventricular ejection fraction 32±7%) were enrolled; 72 (77%) showed SDB and, compared with non-SDB, significantly reduced early (1.67±0.22 vs 1.77±0.13; p=0.019) and late H/M ratios (1.50±0.22 vs 1.61±0.23; p=0.038). Dividing patients into two groups according to SDB severity, patients with a moderate-severe disturbance (AHI >15; n=43) showed significantly worse survival for the composite study outcome (log-rank test, p=0.001) with respect to patients with mild or no disorder (AHI ≤15; n=51). Adding SDB variables to the already known prognostic role of 123I-MIBG imaging, we observed a worse survival in patients with both SDB and H/M impairment. CONCLUSIONS Patients with systolic HF and SDB show more impaired cardiac adrenergic innervation assessed by 123I-MIBG imaging, and more adverse prognosis compared with HF patients without SDB.


title: Reliable Intraoperative Repair Nuances of Cerebrospinal Fluid Leak in Anterior Cervical Spine Surgery and Review of the Literature.

text: BACKGROUND Cerebrospinal fluid (CSF) leak during anterior cervical spine surgery can lead to complications, including wound breakdown, meningitis, headaches, need for lumbar drain, or additional surgery. These leaks can be difficult to manage given the limited field of view and lack of deep access. Herein, we describe 8 consecutive patients who underwent intraoperative repair of CSF leak, with no postoperative evidence of wound dehiscence or drainage. METHODS A retrospective review was performed on 8 cases where CSF leak was encountered during an anterior cervical spine surgery. Patients had ossification of the posterior longitudinal ligament, intradural disk herniation, or dural ectasia. Intraoperative repair was as follows. First, CSF was drained to low pressure, and durotomy was covered by dural substitute and sealant agent. Then the interbody graft used was manually undersized in the anteroposterior dimension to allow for expansion of the agents used. Anterior instrumentation was then performed. Finally, a wound drain was anchored to a biologic bag for shoulder level passive drainage. RESULTS In all 8 cases, there were no cases of wound dehiscence or CSF leak using this strategy. Likewise, there was no evidence of cord compression or neurologic deficits. No meningitis or persistent headaches were reported, and there was no need for lumbar drain placement at any time postoperatively. CONCLUSIONS Once durotomy is encountered during anterior spine surgery, draining the CSF to a low pressure followed by dural substitute with a sealing agent, followed by a smaller anteroposterior size graft is an effective strategy of preventing complications in an inescapable problem.


Vaccination Compliance and the US Measles Epidemic--Reply.


title: Tissue Expanders in Skin Deficient Ventral Hernias Utilizing Component Separation.

text: Skin deficient complex ventral hernias are complicated surgical cases that have multimodal approaches. There is no current consensus on the management of those patients who also have concomitant stomas or enterocutaneous fistula. We present 2 cases in which the senior authors were able to apply tissue expanders above and between the abdominal wall in patients with an enterocutaneous fistula or stoma. After expansion and final closure, the patients did not experience recurrent hernias.


title: Esmolol reduces anesthetic requirements thereby facilitating early extubation; a prospective controlled study in patients undergoing intracranial surgery.

text: BACKGROUND Adequate cerebral perfusion pressure with quick and smooth emergence from anesthesia is a major concern of the neuroanesthesiologist. Anesthesia techniques that minimize anesthetic requirements and their effects may be beneficial. Esmolol, a short acting hyperselective β-adrenergic blocker is effective in blunting adrenergic response to several perioperative stimuli and so it might interfere in the effect of the anesthetic drugs on the brain. This study was designed to investigate the effect of esmolol on the consumption of propofol and sevoflurane in patients undergoing craniotomy. METHOD Forty-two patients that underwent craniotomy for aneurysm clipping or tumour dissection were randomly divided in two groups (four subgroups). Anesthesia was induced with propofol, fentanyl and a single dose of cis-atracurium, followed by continuous infusion of remifentanil and either propofol or sevoflurane. Patients in the esmolol group received 500 mcg/kg of esmolol bolus 10 min before induction of anesthesia, followed by additional 200 mcg/kg/min of esmolol. Monitoring of the depth of anesthesia was also performed using the Bispectral Index-BIS and cardiac output. The inspired concentration of sevoflurane and the infusion rate of propofol were adjusted in order to maintain a BIS value between 40-50. Intraoperative emergence was detected by the elevation of BIS value, HR or MAP. RESULTS The initial and the intraoperative doses of propofol and sevoflurane were 18-50 mcg/kg/min and 0.2-0.5 MAC respectively in the esmolol group, whereas in the control group they where 100-150 mcg/kg/ and 0.9-2.0 MAC respectively (p = 0.000 for both groups). All procedures were anesthesiologically uneventful with no episodes of intraoperative emerge. CONCLUSIONS Esmolol is effective not only in attenuating intraoperative hemodynamic changes related to sympathetic overdrive but also in minimizing significant propofol and sevoflurane requirements without compromising the hemodynamic status. ClinicalTrials.gov Identifier: NCT02455440 . Registered 26 May 2015.


Prehabilitation could save lives in a pandemic.


title: Effectiveness of a new tunneled catheter in preventing catheter malfunction: a comparative study.

text: PURPOSE To compare infection and malfunction rates of two different types of antimicrobial-eluting tunneled cuffed catheters (TCCs) for hemodialysis. MATERIALS AND METHODS The HemoSplit TCC with BioBloc (silver sulfadiazine) coating (n = 100, control group) and the Tal Palindrome Ruby TCC, which has a novel silver antimicrobial sleeve and a spiral-z tip design (n = 100, study group), were compared in this case-controlled study. The main endpoints were TCC infection and malfunction. RESULTS Primary-assisted TCC patency was significantly reduced with the BioBloc TCC (71% and 61% at 90 and 180 days, respectively) compared with the Palindrome Ruby TCC (94% at 90 and 180 days, P < .0001). Multivariate analysis identified only the BioBloc TCC and common femoral access site as independent predictors of worse patency. The unadjusted relative risk (95% confidence interval) for TCC dysfunction with the BioBloc compared with the Palindrome Ruby was 6.0 (2.33-15.53, P < .001), and the relative risk adjusted for access site was 3.2 (1.71-11.96, P = .002). The infection-free rates of the two TCC types were similar (P = .36). The reintervention-free rate for infection or malfunction was significantly better with the Palindrome Ruby TCC (76% and 58% at 90 and 180 days, respectively) than with the BioBloc TCC (60% and 45% at 90 and 180 days, respectively; P = .03). CONCLUSIONS The results support the use of the Palindrome Ruby TCC on the basis of the significantly lower thrombosis and reintervention rate; randomized trials are justified to confirm this finding and to evaluate its role in the prevention of TCC infection.


Safeguarding children: a call to action.


title: Blood-Based Protein Biomarkers for the Management of Traumatic Brain Injuries in Adults Presenting to Emergency Departments with Mild Brain Injury: A Living Systematic Review and Meta-Analysis.

text: Accurate diagnosis of traumatic brain injury (TBI) is critical to effective management and intervention, but can be challenging in patients with mild TBI. A substantial number of studies have reported the use of circulating biomarkers as signatures for TBI, capable of improving diagnostic accuracy and clinical decision making beyond current practice standards. We performed a systematic review and meta-analysis to comprehensively and critically evaluate the existing body of evidence for the use of blood protein biomarkers (S100 calcium binding protein B [S100B], glial fibrillary acidic protein [GFAP], neuron specific enolase [NSE], ubiquitin C-terminal hydrolase-L1 [UCH-L1]. tau, and neurofilament proteins) for diagnosis of intracranial lesions on CT following mild TBI. Effects of potential confounding factors and differential diagnostic performance of the included markers were explored. Further, appropriateness of study design, analysis, quality, and demonstration of clinical utility were assessed. Studies published up to October 2016 were identified through a MEDLINE®, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) search. Following screening of the identified articles, 26 were selected as relevant. We found that measurement of S100B can help informed decision making in the emergency department, possibly reducing resource use; however, there is insufficient evidence that any of the other markers is ready for clinical application. Our work pointed out serious problems in the design, analysis, and reporting of many of the studies, and identified substantial heterogeneity and research gaps. These findings emphasize the importance of methodologically rigorous studies focused on a biomarker's intended use, and defining standardized, validated, and reproducible approaches. The living nature of this systematic review, which will summarize key updated information as it becomes available, can inform and guide future implementation of biomarkers in the clinical arena.


N-Acetylcysteine Protection in COPD: An Alternative Mechanism of Action.


title: Flexitarian Diets and Health: A Review of the Evidence-Based Literature.

text: A flexitarian or semi-vegetarian diet (SVD) is one that is primarily vegetarian with the occasional inclusion of meat or fish. Of late, there appears to be an increasing movement toward this practice. There has not been a recent update on these diets from a health perspective. Using the National Centre for Biotechnology Information PubMed database, a search was made for all studies published between 2000 and 2016 that met defined inclusion criteria. A total of 25 studies were located with 12 focusing on body weight and diet quality. There was emerging evidence suggestive of benefits for body weight, improved markers of metabolic health, blood pressure, and reduced risk of type 2 diabetes. SVD may also have a role to play in the treatment of inflammatory bowel diseases, such as Crohn's disease. Given that there is a higher tendency for females to be flexitarian yet males are more likely to overconsume meat, there is a clear need to communicate the potential health benefits of these diets to males.


Personal Experiences With Coronavirus Disease 2019 and Diabetes: The Time for Telemedicine is Now.


title: A Comprehensive Approach for the Ergonomic Evaluation of 13 Emergency and Transport Ventilators.

text: BACKGROUND Mechanical ventilation is an important part of emergency medicine and is frequently used for transportation. Human errors during ventilator settings are frequent and may be associated with high morbidity/mortality. The aim of the study was to provide a complete ergonomic evaluation of emergency and transport ventilators, taking into account objective and subjective human-machine interface assessments and individual mental work load. METHODS We performed a prospective bench ergonomic evaluation of 13 emergency and transport ventilators, using standardized conditions and a global methodological approach. The study was performed in an evaluation laboratory dedicated to respiratory care, and 12 emergency physicians unfamiliar with the tested devices were included in the evaluation. The ventilators were classified into 3 categories (simple, sophisticated, and ICU-like). Objective chronometric evaluations were conducted considering 9 tasks, and subjective evaluations were performed (ease of use, willingness to use, and user-friendliness of monitoring) using Likert scales. Mental work load evaluation was performed using the NASA Task Load Index scale. RESULTS Overall task failure rate represented 4% of all attempts. Setting modifications, ventilation mode changes, and powering down durations were different between simple and other emergency and transport ventilator categories (P < .005). There was no difference between ventilator categories for the ease of use and user-friendliness of the monitoring. In contrast, the willingness to use was lower for simple devices, compared with sophisticated and ICU-like emergency and transport ventilators (2.9 ± 1.4 vs 3.9 ± 1.2, P = .002 and 4.3 ± 1, P < .001). No differences were observed between devices regarding the mental work load, except for several specific devices in the sophisticated category. CONCLUSIONS A comprehensive ergonomic evaluation provides valuable information while investigating operational friendliness in emergency and transport ventilators. The choice of a device not only depends on its technical characteristics but should take into account its clinical operational setting and ergonomics in order to decrease mental work load. Sophisticated emergency and transport ventilators should only be used by clinicians who demonstrate expertise in mechanical ventilation.


Postmortem Examination of Patients With COVID-19.


title: Turnover of hydrogen isotopes in lake sturgeon blood: implications for tracking movements of wild populations.

text: Naturally occurring deuterium ((2)H) in biota can be used to trace movement, migration and geographic origin of a range of organisms. However, to evaluate movements of animals using δ(2)H measurements of tissues, it is necessary to establish the turnover time of (2)H in the tissues and the extent of isotopic discrimination from different environmental (2)H sources to those tissues. We investigated the turnover of (2)H in lake sturgeon (Acipenser fulvescens) blood by manipulating both environmental water δ(2)H and diet δ(2)H over a four-month period. The half-life of deuterium in lake sturgeon blood was 37.9 days after an increase in the environmental water δ(2)H of +714 ‰. However, no clear turnover in blood (2)H occurred over the same period in a separate trial following a change of -63.8 ‰ or +94.2 ‰ in diet. These findings suggest that environmental water (2)H exchanges much faster with blood than diets and that blood δ(2)H values can be used to trace movements of sturgeon and other fish moving among isotopically distinct waters.


title: Single-incision right hemicolectomy for malignancy: a feasible technique with standard laparoscopic instrumentation.

text: AIM Single-incision laparoscopy is a rapidly evolving technique in the spectrum 'standard laparoscopy-natural orifice transluminal endoscopic surgery (NOTES)'. From a commercial perspective, purchase of articulating instruments is advised. However, here we present our early experience with single-incision laparoscopy for right hemicolectomy with standard laparoscopic instrumentation. METHOD Between June 2010 and December 2011, 25 patients presenting with malignant disease underwent single-incision laparoscopy for right hemicolectomy. Four different ports (SILS™ port, Covidien; SSL(®) Access system, Ethicon; X-Cone/S-Portal(®) , Storz; and OCTO™ port, AFS Medical) were used. Patients were recruited prospectively and all data were processed retrospectively. RESULTS Twenty-five patients were included in our study (and their characteristics, described later in this paragraph, are expressed as median (range)). Four conversions to standard laparoscopy were performed. The age of patients was 69 (36-89) years, and they had a body mass index (BMI) of 24.5 (19.1-34.2). The duration of surgery was 110 (70-148) min with a healed skin incision length of 35 (20-60) mm. Hospital stay was 5 (2-15) days. In four patients discharge was delayed because of comorbidity. One patient suffered an overwhelming pneumonia. CONCLUSION Single-incision laparoscopy using standard laparoscopic instruments appears to be a safe and feasible technique for malignant disease requiring right hemicolectomy. Randomized, prospective trials are ongoing to prove the benefits of this technique and to compare its oncological outcome measures with those of conventional laparoscopy. In our experience, a low-profile port with a wide intra-abdominal range of motion is most preferable.


title: Prognostic power of proadrenomedullin in community-acquired pneumonia is independent of aetiology.

text: Biomarkers are useful in community-acquired pneumonia (CAP). Recently, midregional (MR) proadrenomedullin (proADM) has been shown to be of potential prognostic use. We sought to determine whether this prognostic role depends on the cause of CAP. We conducted a prospective cohort study of immunocompetent patients with CAP. Pneumonia Severity Index (PSI) and CURB-65 score (confusion (abbreviated mental test score of ≤ 8), urea ≥ 7 mol · L(-1), respiratory rate ≥ 30 breaths · min(-1), blood pressure <90 mmHg systolic or <60 mmHg diastolic, and age ≥ 65 yrs), blood C-reactive protein, procalcitonin, MR-proADM, and microbiological studies were systematically performed. Patients were grouped as bacterial, viral/atypical and mixed CAP, and were followed up at 30, 90 and 180 days, and 1 yr. We recruited 228 CAP patients. Identification of at least one pathogen was achieved in 155 (68%) patients. MR-proADM levels closely correlated with increasing severity scores, and showed an important predictive power for complications and short- and long-term mortality (1 yr). Its addition to PSI and CURB-65 significantly improved their prognostic accuracy. A MR-proADM cut-off of 0.646 nmol · L(-1) identified 92% of patients scored as PSI classes IV and V as high risk. MR-proADM outcome prediction power was not affected by different aetiologies. MR-proADM has high short- and long-term prognostic accuracy, and increases the accuracy of clinical scores. The prognostic value of MR-proADM is not modified by different possible CAP aetiologies.


title: Novel technique of robotic extralevator abdominoperineal resection with gracilis flap closure.

text: BACKGROUND The purpose of this paper is to introduce a robotic assisted approach to extralevator abdominoperineal excision in the modified Lloyd-Davis position with reconstruction of the perineum using pedicled gracilis flaps, and to discuss outcomes in a cohort of six patients. METHODS Data was collected by chart review on six patients who underwent extralevator excision with gracilis flap reconstruction from 10/2013 to 06/2015. Technical details, operative data, oncologic outcomes, and wound healing complications were evaluated. RESULTS There were no instances of intraoperative perforation or positive circumferential resection margin, and one case of locoregional recurrence. Two patients experienced flap venous congestion and one patient developed a perineal abscess. All patients went on to complete healing. CONCLUSIONS The combination of a minimally invasive robotic assisted extralevator abdominoperineal excision performed in the modified Lloyd-Davis position with reconstruction of the perineum with pedicled gracilis flaps has excellent oncologic outcomes and acceptable wound healing complications. Copyright © 2016 John Wiley & Sons, Ltd. StartCopTextCopyright © 2016 John Wiley & Sons, Ltd.


title: Prevalence of alcohol use disorders before and after bariatric surgery.

text: CONTEXT Anecdotal reports suggest bariatric surgery may increase the risk of alcohol use disorder (AUD), but prospective data are lacking. OBJECTIVE To determine the prevalence of preoperative and postoperative AUD, and independent predictors of postoperative AUD. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study (Longitudinal Assessment of Bariatric Surgery-2) of adults who underwent bariatric surgery at 10 US hospitals. Of 2458 participants, 1945 (78.8% female; 87.0% white; median age, 47 years; median body mass index, 45.8) completed preoperative and postoperative (at 1 year and/or 2 years) assessments between 2006 and 2011. MAIN OUTCOME MEASURE Past year AUD symptoms determined with the Alcohol Use Disorders Identification Test (indication of alcohol-related harm, alcohol dependence symptoms, or score ≥8). RESULTS The prevalence of AUD symptoms did not significantly differ from 1 year before to 1 year after bariatric surgery (7.6% vs 7.3%; P = .98), but was significantly higher in the second postoperative year (9.6%; P = .01). The following preoperative variables were independently related to an increased odds of AUD after bariatric surgery: male sex (adjusted odds ratio [AOR], 2.14 [95% CI, 1.51-3.01]; P < .001), younger age (age per 10 years younger with preoperative AUD: AOR, 1.31 [95% CI, 1.03-1.68], P = .03; age per 10 years younger without preoperative AUD: AOR, 1.95 [95% CI, 1.65-2.30], P < .001), smoking (AOR, 2.58 [95% CI, 1.19-5.58]; P = .02), regular alcohol consumption (≥ 2 drinks/week: AOR, 6.37 [95% CI, 4.17-9.72]; P < .001), AUD (eg, at age 45, AOR, 11.14 [95% CI, 7.71-16.10]; P < .001), recreational drug use (AOR, 2.38 [95% CI, 1.37-4.14]; P = .01), lower sense of belonging (12-item Interpersonal Support Evaluation List score per 1 point lower: AOR, 1.09 [95% CI, 1.04-1.15]; P = .01), and undergoing a Roux-en-Y gastric bypass procedure (AOR, 2.07 [95% CI, 1.40-3.08]; P < .001; reference category: laparoscopic adjustable gastric band procedure). CONCLUSION In this cohort, the prevalence of AUD was greater in the second postoperative year than the year prior to surgery or in the first postoperative year and was associated with male sex and younger age, numerous preoperative variables (smoking, regular alcohol consumption, AUD, recreational drug use, and lower interpersonal support) and undergoing a Roux-en-Y gastric bypass procedure.


title: Pericardial flap: an effective method of surgical repair of late post-pneumonectomy fistula.

text: BACKGROUND We report our experience with the surgical closure of late post-pneumonectomy bronchopleural fistula (PBF) using our own method of coverage of the bronchial stump: Pedicled pericardial flap in combination with fibrin glue. METHODS We reviewed the surgical results of 33 patients who underwent surgical closure of PBF by thoracotomy access using three methods: Myoplasty (MYO)-12, omentoplasty (OMT)-10, and pedicled pericardial flap (PPF) with fibrin glue-11. Post-operative follow up was six months. RESULTS The patients' demography was comparable among the groups. The diameter of the fistulas ranged from 5 mm to total dehiscence. The mean time of the fistula manifestation (in weeks) was 21.5 in the MYO group, 19.50 in the OMT, and 20.1 in the PPF group. The shortest period of hospital drainage of the pleural space was noted in the PPF group. Healing of the fistula was obtained in 66.67% in the MYO group, 80% in the OMT, and 100% in the PPF group. The number of complications was similar in all groups. The hospitalization time was significantly shorter in the PPF group (13.00 d) versus the MYO group (19.58 d) and the OMT (20.01 d). Overall mortality rate was 18.18%; 33.33% of the patients in the MYO group and 20% in the OMT group died. There were no hospital deaths in the PPF group. CONCLUSION Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of postpneumonectomy PBF in selected patients. Compared with other methods of bronchial stump coverage (omentopasty and myoplasty), this one showed a higher percentage of healing of the fistulas and shorter duration of hospital drainage and hospitalization.


title: Hydroxychloroquine in Patients with Rheumatic Disease Complicated by COVID-19: Clarifying Target Exposures and the Need for Clinical Trials.

text: OBJECTIVE To characterize hydroxychloroquine exposure in patients with rheumatic disease receiving long-term hydroxychloroquine compared to target concentrations with reported antiviral activity against the 2019 coronavirus SARS-CoV-2. METHODS We evaluated total hydroxychloroquine concentrations in serum and plasma from published literature values, frozen serum samples from a pediatric lupus trial, and simulated concentrations using a published pharmacokinetic model during pregnancy. For each source, we compared observed or predicted hydroxychloroquine concentrations to target concentrations with reported antiviral activity against SARS-CoV-2. RESULTS The average total serum/plasma hydroxychloroquine concentrations were below the lowest SARS-CoV-2 target of 0.48 mg/L in all studies. Assuming the highest antiviral target exposure (total plasma concentration of 4.1 mg/L), all studies had approximately one-tenth the necessary concentration for in-vitro viral inhibition. Pharmacokinetic model simulations confirmed that pregnant adults receiving common dosing for rheumatic diseases did not achieve target exposures; however, the models predict that a dosage of 600 mg once a day during pregnancy would obtain the lowest median target exposure for most patients after the first dose. CONCLUSION We found that the average patient receiving treatment with hydroxychloroquine for rheumatic diseases, including children and non-pregnant/pregnant adults, are unlikely to achieve total serum or plasma concentrations shown to inhibit SARS-CoV-2 in-vitro. Nevertheless, patients receiving hydroxychloroquine long-term may have tissue concentrations far exceeding that of serum/plasma. Because the therapeutic window for hydroxychloroquine in the setting of SARS-CoV-2 is unknown, well-designed clinical trials that include patients with rheumatic disease are urgently needed to characterize the efficacy, safety, and target exposures for hydroxychloroquine.


title: Weight loss after laparoscopic adjustable gastric band and resolution of the metabolic syndrome and its components.

text: BACKGROUND Substantial weight loss in the setting of obesity has considerable metabolic benefits. Yet some studies have shown improvements in obesity-related metabolic comorbidities with more modest weight loss. By closely monitoring patients undergoing bariatric surgery, we aimed to determine the effects of weight loss on the metabolic syndrome and its components and determine the weight loss required for their resolution. METHODS We performed a prospective observational study of obese participants with metabolic syndrome (Adult Treatment Panel III criteria) who underwent laparoscopic adjustable gastric banding. Participants were assessed for all criteria of the metabolic syndrome monthly for the first 9 months, then 3-monthly until 24 months. RESULTS There were 89 participants with adequate longitudinal data. Baseline body mass index was 42.4±6.2 kg m-2 with an average age was 48.2±10.7 years. There were 56 (63%) women. Resolution of the metabolic syndrome occurred in 60 of the 89 participants (67%) at 12 months and 60 of the 75 participants (80%) at 24 months. The mean weight loss when metabolic syndrome resolved was 10.9±7.7% total body weight loss (TBWL). The median weight loss at which prevalence of disease halved was 7.0% TBWL (17.5% excess weight loss (EWL)) for hypertriglyceridaemia; 11% TBWL (26.1-28% EWL) for high-density lipoprotein cholesterol and hyperglycaemia; 20% TBWL (59.5% EWL) for hypertension and 29% TBWL (73.3% EWL) for waist circumference. The odds ratio for resolution of the metabolic syndrome with 10-12.5% TBWL was 2.09 (P=0.025), with increasing probability of resolution with more substantial weight loss. CONCLUSIONS In obese participants with metabolic syndrome, a weight loss target of 10-12.5% TBWL (25-30% EWL) is a reasonable initial goal associated with significant odds of having metabolic benefits. If minimal improvements are seen with this initial target, additional weight loss substantially increases the probability of resolution.


title: The prevalence of type 2 diabetes in people with psychiatric disorders: an umbrella review protocol.

text: BACKGROUND Many epidemiological studies have investigated the prevalence of type 2 diabetes in individuals with a psychiatric disorder. In an umbrella review, we aim to systematically summarize existing systematic reviews examining the prevalence of type 2 diabetes in people with a psychiatric disorder. When information is available in the identified systematic reviews, comparisons with control groups without a psychiatric disorder will be made. Furthermore, we aim to assess the quality of the included systematic reviews. METHODS The umbrella review will be based on a comprehensive systematic search of systematic reviews of observational (cross-sectional or longitudinal) studies investigating the prevalence of type 2 diabetes in people with a psychiatric disorder. Four electronic databases (Embase, PsycINFO, PubMed, and the Cochrane Database of Systematic Reviews) will be searched. Retrieved papers will be screened for eligibility by two independent reviewers. Furthermore, the reference lists of all included publications will be screened. Data will be extracted by using an a priori developed data extraction form and two independent reviewers will assess the risk of bias in the included systematic reviews using with the Risk of Bias in Systematic Reviews (ROBIS) tool. A narrative data-synthesis and a subsequent meta-analysis based on the primary studies will be made. DISCUSSION For each psychiatric disorder, the data regarding the prevalence of type 2 diabetes will be summarized and discussed. When possible, comparisons with control groups will be reported and discussed. Finally, future implications and recommendations for clinical care will be presented. SYSTEMATIC REVIEW REGISTRATION This protocol was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) on December 9, 2019 (registration number: pending).


title: Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency.

text: OBJECTIVE Pressure ulcers (PUs) involve the destruction of skin and underlying tissue due to prolonged pressure and shear forces. These ulcers are painful and significantly reduce a person's quality of life. PUs are also expensive to manage and impact negatively on the achievement of cost-effective, efficient care delivery. METHOD Prone positioning is a postural therapy that aims to enhance respiratory function through increasing oxygenation levels. In contemporary clinical practice, ventilation in the prone position is indicated for patients with severe acute respiratory distress syndrome. However, despite its advantages in terms of respiratory function, several studies have examined complications of prone position ventilation and have identified PUs (facial PUs as well as PUs on other weight-bearing areas of the body) as a frequent complication in patients who are already in a precarious medical situation. International data suggest that up to 57% of patients nursed in the prone position develop a PU. The aim of this clinical review is to identify and review evidence-based recommendations developed to facilitate the selection and application of preventive interventions aimed at reducing PU development in patients ventilated in the prone position. Given the current COVID-19 crisis, this review is timely as intensive care unit (ICU) patients with COVID-19 require ventilation in the prone position at a level that is disproportionate to the general intensive care population. Up to 28% of patients admitted to the ICU with confirmed infection due to severe COVID-19 are cared for in the prone position. The scope of this review is limited to adult individuals only. RESULTS The skin assessment should be undertaken before proning and following positioning the patient back into the supine position. Although it is essential to keep the skin clean and moisturised, using pH-balanced cleansers, there is inconsistency in terms of the evidence to support the type of moisturiser. Use of positioning devices in addition to repositioning is recommended to offload pressure points on the face and body. Further, using dressings such as hydrocolloids, transparent film and silicone may be of benefit in decreasing facial skin breakdown. CONCLUSION Given the importance of PU prevention in this cohort of patients, adopting a focused prevention strategy, including skin assessment and care, offloading and pressure redistribution, and dressings for prevention may contribute to a reduction in the incidence and prevalence of these largely preventable wounds.


title: Volume comparison of radiofrequency ablation at 3- and 5-cm target volumes for four different radiofrequency generators: MR volumetry in an open 1-T MRI system versus macroscopic measurement.

text: INTRODUCTION In a patient, it is usually not macroscopically possible to estimate the non-viable volume induced by radiofrequency ablation (RFA) after the procedure. The purpose of this study was to use an ex vivo bovine liver model to perform magnetic resonance (MR) volumetry of the visible tissue signal change induced by RFA and to correlate the MR measurement with the actual macroscopic volume measured in the dissected specimens. MATERIALS AND METHODS Sixty-four liver specimens cut from 16 bovine livers were ablated under constant simulated, close physiological conditions with target volumes set to 14.14 ml (3-cm lesion) and 65.45 ml (5-cm lesion). Four commercially available radiofrequency (RF) systems were tested (n=16 for each system; n=8 for 3 cm and n=8 for 5 cm). A T1-weighted turbo spin echo (TSE) sequence with inversion recovery and a proton-density (PD)-weighted TSE sequence were acquired in a 1.0-T open magnetic resonance imaging (MRI) system. After manual dissection, actual macroscopic ablation diameters were measured and volumes calculated. MR volumetry was performed using a semiautomatic software tool. To validate the correctness and feasibility of the volume formula in macroscopic measurements, MR multiplanar reformation diameter measurements with subsequent volume calculation and semiautomatic MR volumes were correlated. RESULTS Semiautomatic MR volumetry yielded smaller volumes than manual measurement after dissection, irrespective of RF system used, target lesion size, and MR sequence. For the 3-cm lesion, only 43.3% (T1) and 41.5% (PD) of the entire necrosis are detectable. For the 5-cm lesion, only 40.8% (T1) and 37.2% (PD) are visualized in MRI directly after intervention. The correlation between semiautomatic MR volumes and calculated MR volumes was 0.888 for the T1-weighted sequence and 0.875 for the PD sequence. CONCLUSION After correlation of semiautomatic MR volumes and calculated MR volumes, it seems reasonable to use the respective volume formula for macroscopic volume calculation. Hyperacute MRI after ex vivo intervention may result in the underestimation of the real expansion of the produced necrosis zone. This must be kept in mind when using MRI for validating ablation success directly after RFA. One reason for the discrepancy between macroscopic and MRI appearance immediately after RFA may be that the transitional zone shows no or only partially visible MR signal change.


title: Emerging Infectious Diseases in Pregnancy.

text: It has been recognized for centuries that pregnant women have unique susceptibilities to many infectious diseases that predispose them to untoward outcomes compared with the general adult population. It is thought a combination of adaptive alterations in immunity to allow for the fetal allograft combined with changes in anatomy and physiology accompanying pregnancy underlie these susceptibilities. Emerging infectious diseases are defined as those whose incidence in humans has increased in the past two decades or threaten to increase in the near future. The past decade alone has witnessed many such outbreaks, each with its own unique implications for pregnant women and their unborn fetuses as well as lessons for the health care community regarding response and mitigation. Examples of such outbreaks include, but are not limited to, severe acute respiratory syndrome, the 2009 H1N1 pandemic influenza, Ebola virus, and, most recently, the Zika virus. Although each emerging pathogen has unique features requiring specific considerations, there are many underlying principles that are shared in the recognition, communication, and mitigation of such infectious outbreaks. Some of these key principles include disease-specific delineation of transmission dynamics, understanding of pathogen-specific effects on both mothers and fetuses, and advance planning and contemporaneous management that prioritize communication among public health experts, clinicians, and patients. The productive and effective working collaboration among the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine has been a key partnership in the successful communication and management of such outbreaks for women's health care providers and patients alike. Going forward, the knowledge gained over the past decade will undoubtedly continue to inform future responses and will serve to optimize the education and care given to pregnant women in the face of current and future emerging infectious disease outbreaks.


title: Does lopinavir measure up in the treatment of Covid-19?

text: INTRODUCTION Lopinavir in combination with ritonavir is approved for the treatment of HIV and has recently been subject to a clinical trial in severe Covid-19. AREAS COVERED This evaluation is of LOTUS China (the Lopinavir Trial for Suppression of SARS-Cov-2 in China), which was a randomised trial in hospitalised subjects with Covid-9 in a respiratory sample and pneumonia. As, in severe Covid-19, lopinavir/ritonavir had no beneficial effects but increased gastrointestinal adverse effects, this combination should not be used at this stage of Covid-19. EXPERT OPINION In my opinion, the rationale for undertaking a trial of lopinavir/ritonavir in Covid-19 was poor. The analysis of a modified intention to treat group analysis in LOTUS China may have introduced bias. After LOTUS China, there is probably no future for lopinavir in the treatment of severe Covid-19, but some clinical trials for prevention or in various stages of Covid-19 have recently started or are ongoing. The major limitation to these trials is that, as lopinavir does not inhibit Covid-19, it is unlikely to prevent infection, reduce viral load, or reduce severity. However, these trials may be worthwhile in finally determining whether lopinavir has any role in preventing or treating Covid-19.


title: Comparative evaluation of the cadaveric, radiographic and computed tomographic anatomy of the heads of green iguana (Iguana iguana), common tegu (Tupinambis merianae) and bearded dragon (Pogona vitticeps).

text: BACKGROUND Radiology and computed tomography are the most commonly available diagnostic tools for the diagnosis of pathologies affecting the head and skull in veterinary practice. Nevertheless, accurate interpretation of radiographic and CT studies requires a thorough knowledge of the gross and the cross-sectional anatomy. Despite the increasing success of reptiles as pets, only a few reports over their normal imaging features are currently available. The aim of this study is to describe the normal cadaveric, radiographic and computed tomographic features of the heads of the green iguana, tegu and bearded dragon. RESULTS 6 adult green iguanas, 4 tegus, 3 bearded dragons, and, the adult cadavers of: 4 green iguana, 4 tegu, 4 bearded dragon were included in the study. 2 cadavers were dissected following a stratigraphic approach and 2 cadavers were cross-sectioned for each species. These latter specimens were stored in a freezer (-20°C) until completely frozen. Transversal sections at 5 mm intervals were obtained by means of an electric band-saw. Each section was cleaned and photographed on both sides. Radiographs of the head of each subject were obtained. Pre- and post- contrast computed tomographic studies of the head were performed on all the live animals. CT images were displayed in both bone and soft tissue windows. Individual anatomic structures were first recognised and labelled on the anatomic images and then matched on radiographs and CT images. Radiographic and CT images of the skull provided good detail of the bony structures in all species. In CT contrast medium injection enabled good detail of the soft tissues to be obtained in the iguana whereas only the eye was clearly distinguishable from the remaining soft tissues in both the tegu and the bearded dragon. CONCLUSIONS The results provide an atlas of the normal anatomical and in vivo radiographic and computed tomographic features of the heads of lizards, and this may be useful in interpreting any imaging modality involving these species.


title: Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment.

text: Intracranial DAVFs are pathologic dural-based shunts and account for 10%-15% of all intracranial arteriovenous malformations. These malformations derive their arterial supply primarily from meningeal vessels, and the venous drainage is either via dural venous sinuses or through the cortical veins. DAVFs have a reported association with dural sinus thrombosis, venous hypertension, previous craniotomy, and trauma, though many lesions are idiopathic. The diagnosis is dependent on a high level of clinical suspicion and high-resolution imaging. Cross-sectional imaging techniques by using CT and MR imaging aid in the diagnosis, but conventional angiography remains the most accurate method for complete characterization and classification of DAVFs. The pattern of venous drainage observed on dynamic vascular imaging determines the type of DAVF and correlates with the severity of symptoms and the risk of hemorrhage.


title: Ablative therapy for esophageal dysplasia and early malignancy: focus on RFA.

text: Ablative therapies have been utilized with increasing frequency for the treatment of Barrett's esophagus with and without dysplasia. Multiple modalities are available for topical ablation of the esophagus, but radiofrequency ablation (RFA) remains the most commonly used. There have been significant advances in technique since the introduction of RFA. The aim of this paper is to review the indications, techniques, outcomes, and most common complications following esophageal ablation with RFA.


title: Laparoscopic total pelvic exenteration using transanal minimal invasive surgery technique with en bloc bilateral lymph node dissection for advanced rectal cancer.

text: A 59-year-old man presenting with fecal occult blood visited our hospital. He was diagnosed with advanced lower rectal cancer, which was contiguous with the prostate and the left seminal vesicle. There were no metastatic lesions with lymph nodes or other organs. We performed laparoscopic total pelvic exenteration (LTPE) using transanal minimal invasive surgery technique with bilateral en bloc lateral lymph node dissection for advanced primary rectal cancer after neoadjuvant chemoradiotherapy. The total operative time was 760 min, and the estimated blood loss was 200 ml. LTPE is not well established technically, but it has many advantages including good visibility of the surgical field, less blood loss, and smaller wounds. A laparoscopic approach may be an appropriate choice for treating locally advanced lower rectal cancer, which requires TPE.


title: Hybrid transvaginal incisional hernia repair.

text: AIM Natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) is a new approach that allows surgical manipulations and specimen extractions through the natural orifices such as the vagina. There have been limited numbers of cases about the adaptation of NOTES for ventral hernia repairs. Here, we aimed to present two more cases and highlight our technical differences compared with the previously reported instances. PATIENTS AND METHODS Two patients (43 and 46 years old; body mass index of 29 and 30 kg/m(2), respectively) were treated with hybrid transvaginal incisional hernia repairs. Two 5-mm abdominal trocars were used to monitor transvaginal access, adhesiolysis, dissection of the hernia, and tuckering of the mesh. A 15-mm transvaginal trocar was used for scope and mesh introduction into the abdomen. Defects were 3-5 cm in diameter. RESULTS A rigid 5-mm laparoscope was used. The composite synthetic meshes were, respectively, 11 and 13 cm in diameter. These were passed through the vagina without any protection such as a bag or sheath. No conversion or additional port was required. Respective operative times were 120 and 180 minutes, and the patients were discharged uneventfully on the second day. One patient had seroma, which was managed conservatively (aspiration of 20 mL on Day 7). There were no recurrences after 7 and 13 months, respectively. CONCLUSIONS Conventional laparoscopic equipment can be used for hybrid transvaginal incisional hernia repair. An anti-adhesive synthetic mesh can be inserted through the vaginal trocar without protective devices. The main advantage of this technique is to avoid 10-15-mm abdominal trocars, which increase the risk of trocar-site hernias themselves.


title: Assessing the Surrogate Susceptibility of Oxacillin and Cefoxitin for Commonly Utilized Parenteral Agents against Methicillin-Susceptible Staphylococcus aureus: Focus on Ceftriaxone Discordance between Predictive Susceptibility and in Vivo Exposures.

text: Susceptibility testing with the use of surrogate agents is common among clinical microbiology laboratories. One such example is oxacillin and cefoxitin for β-lactams against methicillin-susceptible Staphylococcus aureus (MSSA). This study aimed to assess the surrogate predictive value (SPV) of oxacillin and cefoxitin for the susceptibility of commonly utilized parenteral β-lactams against MSSA as well as to evaluate the concordance between predictive susceptibility testing and the in vivo exposures for ceftriaxone. Broth microdilution MICs were determined for cefazolin, cefoxitin, ceftaroline, ceftriaxone, nafcillin, and oxacillin against a national collection of 1238 MSSA from US hospitals. Pharmacodynamic profiling was utilized to establish a clinical breakpoint for commonly utilized doses of ceftriaxone. Oxacillin had good SPVs for all the β-lactams tested, whereas cefoxitin produced unacceptable major errors for all four agents and thus appears to be an unacceptable susceptibility surrogate. While oxacillin is an adequate surrogate based on the currently defined laboratory criteria, our data also suggest that caution should be exercised when incorporating this testing approach in the clinical setting in view of the fact that the MIC distribution of MSSA coupled with the commonly utilized low doses of ceftriaxone may result in inadequate in vivo exposures against this pathogen.


title: Dynamics and predisposition of respiratory viral co-infections in children and adults.

text: OBJECTIVES The epidemiology of respiratory co-infection pairings is poorly understood. Here we assess the dynamics of respiratory viral co-infections in children and adults and determine predisposition for or against specific viral pairings. METHODS Over 5 respiratory seasons from November 30, 2013 through June 6, 2018, mono- and co-infection prevalence of 13 viral pathogens were tabulated at The Cleveland Clinic. Employing a model to proportionally distribute viral pairs utilizing individual virus' co-infection rate with prevalence patterns of concurrent co-circulating viruses, we compared predicted-to-observed occurrences of 132 viral pairing permutations using binomial analysis. RESULTS Of 30,535 respiratory samples, 9,843 (32.2%) were positive for ≥1 virus of which 1,018 (10.8%) were co-infected. Co-infected samples predominantly originated from children. Co-infection rate in pediatric population was 35.0% (2068/5906), compared to only 5.8% (270/4591) in adults. Adenovirus C (ADVC) had the highest co-infection rate (426/623, 68.3%) while influenza B had the lowest (55/546, 10.0%). ADVC-rhinovirus (HRV), RSVA-HRV, and RSVB-HRV pairings occurred at significantly higher frequencies than predicted by the proportional distribution model (p<0.05). Additionally, several viral pairings had fewer co-infections than predicted by our model: notably metapneumovirus (hMPV)-PIV3, hMPV-RSVA, and RSVA-RSVB. CONCLUSIONS This is one of the largest studies on respiratory viral co-infections in children and adults. Co-infections are substantially more common in children, especially under 5 years of age and the most frequent pairings occurred at a higher frequency than would be expected by random. Specific pairings occur at altered rates than those predicted by proportional distribution suggesting either direct or indirect interactions result between specific viral pathogens.


title: Does Surgical Approach Affect Patient-reported Function After Primary THA?

text: BACKGROUND Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach. QUESTIONS/PURPOSES We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA? METHODS Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon's direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques. RESULTS After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, -9; 95% CI, -13 to -5; standard error, 2), compared with the posterior approach (3-month score change, -9; 95% CI, -14 to -3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2-10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79-160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3-10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events. CONCLUSIONS With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively. LEVEL OF EVIDENCE Level III, therapeutic study.


title: Feline gastrointestinal eosinophilic sclerosing fibroplasia: 13 cases and review of an emerging clinical entity.

text: OBJECTIVE Feline gastrointestinal eosinophilic sclerosing fibroplasia (FGESF) is a recently described inflammatory disease of cats affecting stomach or intestines and draining regional lymph nodes. This study presents clinical and laboratory data on 13 newly described cases from Australia (11) and the UK (two). OBSERVATIONS The disease was most often observed in middle-aged cats (median 7 years of age; interquartile range 5-9 years). Ragdolls (7/13) and males (9/13) were overrepresented. Cats generally had a long history of vomiting and/or diarrhoea. Lesions were typically large, hard, non-painful, easily palpable and most commonly situated near the pylorus or ileocaecocolic junction. Lesions were heterogeneous ultrasonographically and on sectioning at celiotomy or necropsy. Masses were hard and 'gritty' on fine-needle aspiration due to internal trabeculae made up of mature collagen bundles. Bacteria were commonly detected within masses (9/13 cases) using either culture or conventional light microscopy and a panel of special stains, and/or fluorescence in situ hybridisation (FISH), although detection often required a diligent search of multiple tissue sections. A consistent bacterial morphology could not be appreciated among the different cases. OUTCOME Patients were treated with a variable combination of cytoreduction (debulking and biopsy, to complete surgical resection), immunosuppressive therapy and antimicrobial agents. Many cats had a poor outcome, which was attributable to late diagnosis combined with suboptimal management. It is hoped that suggestions outlined in the discussion may improve clinical outcomes and long-term survival in future cases.


title: How to perform the endoscopically assisted components separation technique (ECST) for large ventral hernia repair.

text: BACKGROUND The components separation technique (CST) is frequently used for reconstructing large ventral hernias. Unfortunately, it is associated with a high wound complication rate up to 50 %, caused by large wound surface and inherent trauma to abdominal skin vascularization. An endoscopically assisted modification of the original technique (ECST) spares skin vascularization and reduces wound surface, supposedly reducing wound complications. This study accurately describes ECST step by step with detailed illustrations and report the results of a 27 patient cohort. METHODS Since September 2012 patients with midline hernias without previous subcutaneous dissection and a maximum diameter of approximately 10-15 cm underwent ECST in an expert centre for abdominal wall reconstructions. Prospective data was gathered during inpatient care and 3-6 monthly follow-up. RESULTS Twenty-seven patients (17 male/10 female) with median age of 60 years (range 35-77), average BMI 27 (SD ±2) kg/m(2) and median ASA classification 2 (range 1-3) underwent ECST. Two patients were excluded due to bilateral conversion to conventional CST and finding of peritoneal metastases. Median defect size was 116 ± 48 cm(2). Median length of stay was 5 days (range 3-15). Wound complication rate was 11 %. Recurrence rate was 29 % after a median follow-up of 13 months. CONCLUSIONS Endoscopically assisted modification of the original technique can be used for reconstructing large and complex ventral hernias up to 15 cm in diameter. The results of this small sized cohort study showed that ECST is feasible in patients with a uro-, or enterostomy and suggest that ECST reduces wound complication rate when compared to CST.


title: Single incision laparoscopic right hemicolectomy for colon cancer: less is more?

text: Single incision laparoscopic colectomy has been reported to be safe and feasible using several techniques and devices. The authors' report their experience with a single incision laparoscopic colectomy performed in a lateral to medical fashion using a commercially developed access device with standard laparoscopic instruments.


title: The impact of patient navigation: a scoping review protocol.

text: REVIEW OBJECTIVE/QUESTION The objective of this review is to synthesize the evidence on the impact of patient navigation for all populations across all settings. The question of this review is: What is the existing evidence on the impact of patient navigation?


title: Reconstruction of a long defect of the median nerve with a free nerve conduit flap.

text: Upper limb nerve damage is a common condition, and evidence suggests that functional recovery may be limited following peripheral nerve repair in cases of delayed reconstruction or reconstruction of long nerve defects. A 26-year-old man presented with traumatic injury from a wide, blunt wound of the right forearm caused by broken glass, with soft tissue loss, complete transection of the radial and ulnar arteries, and a large median nerve gap. The patient underwent debridement and subsequent surgery with a microsurgical free radial fasciocutaneous flap to provide a direct blood supply to the hand; the cephalic vein within the flap was employed as a venous vascularized chamber to wrap the sural nerve graft and to repair the wide gap (14 cm) in the median nerve. During the postoperative period, the patient followed an intensive rehabilitation program and was monitored for functional performance over 5 years of follow-up. Our assessment demonstrated skin tropism and sufficient muscle power to act against strong resistance (M5) in the muscles previously affected by paralysis, as well as a good localization of stimuli in the median nerve region and an imperfect recovery of two-point discrimination (S3+). We propose a novel and efficient procedure to repair >10-cm peripheral nerve gap injuries related to upper limb trauma.


Scientists fear coronavirus spread in countries least able to contain it.


title: Oral administration of porcine epidemic diarrhea virus spike protein expressing in silkworm pupae failed to elicit immune responses in pigs.

text: The silkworm (Bombyx mori) and its pupae have been used for decades as nutritional additives and applied on the production of high-quality recombinant proteins via the baculovirus expression vector (BEV) system. The bio-capsule, the fat-rich body, and some body components of the silkworm pupae, which deliver antigens passing through the harsh environment of digestive tract and reaching the intestine, have been used as a vehicle for oral vaccines. In the present study, to develop a novel oral vaccine against porcine epidemic diarrhea virus (PEDV), the PEDV spike (S) protein was expressed in silkworm pupae and BmN cells using the BEV system. After three doses of oral administrations with 2-week intervals in pigs, neither PEDV S protein-specific humoral nor mucosal immune responses can be detected. The failure of eliciting the PEDV-specific immune response suggested that the BEV system using BmN cells or silkworm pupae as oral immunogen-expression vehicles was not able to overcome the immunological unresponsiveness, which was possibly due to gastrointestinal specific barriers and oral tolerance. Better strategies to enhance the delivery and immunogenicity of oral vaccines should be further investigated. Nevertheless, the PEDV S protein generated in the BmN cells and silkworm pupae herein provides an efficient tool to produce the recombinant antigen for future applications.


title: Patterns and Clinical Impact of Angiographically Visible Distal Emboli During Thrombectomy With Solitaire for Acute Ischemic Stroke.

text: BACKGROUND Revascularization rates with stent retrievers after acute ischemic stroke are 69% to 86%, but favorable clinical outcomes occur in just 43% to 58% of cases. New distal emboli may negatively impact clinical outcomes. OBJECTIVE To determine the prevalence and angiographic pattern of distal emboli associated with mechanical thrombectomy using the Solitaire Flow Restoration device and evaluate their correlation with clinical outcome. METHODS We retrospectively reviewed the cerebral angiography of all patients with acute ischemic stroke who underwent mechanical thrombectomy with the use of the Solitaire FR device from 2012 to 2013. Angiographic microcatheter runs prior to Solitaire deployment and after thrombectomy were compared to identify new distal filling defects. Clinical outcome was assessed at discharge and after 90 days. RESULTS Successful revascularization using the Solitaire device occurred in 36 of 39 patients (92%). Three distinct patterns were identified: new distal emboli in the same vascular territory (n = 3), new distal emboli in a new vascular territory (n = 3), and distal emboli that resolved after proximal revascularization (n = 7). Thirteen patients had distal emboli before and after Solitaire runs, and 13 showed no evidence of distal emboli. Favorable outcome (modified Rankin scores 0-2) was seen in 54% of all patients and 83% of patients with new distal emboli; thus, there was no correlation between new emboli and unfavorable clinical outcome (P = .67). CONCLUSION We report an incidence rate of at least 15% of new emboli associated with use of the Solitaire device during thrombectomy in our series. Filling defects after Solitaire use were not associated with poor outcomes at discharge or 90-day follow-up.


title: Effect of Continuous versus Intermittent Subglottic Suctioning on Tracheal Mucosa by the Mallinckrodt TaperGuard Evac Oral Tracheal Tube in Intensive Care Unit Ventilated Patients: A Prospective Randomized Study.

text: Background and Aims A risk of tracheal mucosa injury induced by subglottic suctioning has been raised. Therefore, this prospective randomized study aims to compare the effect of continuous suctioning of subglottic secretions versus intermittent suctioning of subglottic secretions (CSSS vs. ISSS) secretions on tracheal mucosa in front of the suctioning port of the endotracheal tube. Patients and Methods Patients requiring intubation or reintubation in Intensive Care Unit with an expected ventilation duration > 24 h were eligible. Participants received CSSS at -20 mmHg or ISSS at -100 mmHg during 15 s and no suction during 8 s. The effect on tracheal mucosa in front of the suction port was assessed after intubation (T0) and before extubation (T1) using bronchoscopy. Tracheal mucosa damages were graded into five categories (no injury, erythema, edema, ulceration, or necrosis). The occurrence (no injury observed at T0 but present at T1) or the worsening (injury observed at T0 exacerbating at T1) was studied. Results Seventy-three patients were included and 53 patients (CSSS, n = 26 and ISSS, n = 27) were evaluable on the primary endpoint. The occurrence or worsening of tracheal mucosal damages did not differ between the two groups (CSSS, n = 7 [27%] vs. ISSS, n = 5 [17%], P = 0.465). Daily average volume of suctioned secretion was higher with ISSS (74 ± 100 ml vs. 20 ± 25 ml, P < 0.001). Impossibility to aspirate was higher with CSSS (0.14 ± 0.16 per day vs. 0.03 ± 0.07 per day, P < 0.001). Conclusions Our results suggest that tracheal mucosal damages did not differ between CSSS and ISSS. The aspirated volume was higher and impossibility to aspirate was lower with ISSS. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT01555229.


title: Improving palliative and end-of-life care with machine learning and routine data: a rapid review.

text: Introduction: Improving end-of-life (EOL) care is a priority worldwide as this population experiences poor outcomes and accounts disproportionately for costs. In clinical practice, physician judgement is the core method of identifying EOL care needs but has important limitations. Machine learning (ML) is a subset of artificial intelligence advancing capacity to identify patterns and make predictions using large datasets. ML approaches have the potential to improve clinical decision-making and policy design, but there has been no systematic assembly of current evidence. Methods: We conducted a rapid review, searching systematically seven databases from inception to December 31st, 2018: EMBASE, MEDLINE, Cochrane Library, PsycINFO, WOS, SCOPUS and ECONLIT. We included peer-reviewed studies that used ML approaches on routine data to improve palliative and EOL care for adults. Our specified outcomes were survival, quality of life (QoL), place of death, costs, and receipt of high-intensity treatment near end of life. We did not search grey literature and excluded material that was not a peer-reviewed article. Results: The database search identified 426 citations. We discarded 162 duplicates and screened 264 unique title/abstracts, of which 22 were forwarded for full text review. Three papers were included, 18 papers were excluded and one full text was sought but unobtainable. One paper predicted six-month mortality, one paper predicted 12-month mortality and one paper cross-referenced predicted 12-month mortality with healthcare spending. ML-informed models outperformed logistic regression in predicting mortality but poor prognosis is a weak driver of costs. Models using only routine administrative data had limited benefit from ML methods. Conclusion: While ML can in principle help to identify those at risk of adverse outcomes and inappropriate treatment near EOL, applications to policy and practice are formative. Future research must not only expand scope to other outcomes and longer timeframes, but also engage with individual preferences and ethical challenges.


title: Advances in laboratory assays for detecting human metapneumovirus.

text: Human metapneumovirus (HMPV) is one of the major causes of acute respiratory tract infection (ARI) and shows high morbidity and mortality, particularly in children and immunocompromised patients. Various methods for detecting HMPV have been developed and applied in clinical laboratories. When reviewing the literature, we found that polymerase chain reaction (PCR)-based assays have been most frequently and consistently used to detect HMPV. The most commonly used method was multiplex reverse transcriptase-PCR (RT-PCR; 57.4%), followed by real-time RT-PCR (38.3%). Multiplex RT-PCR became the more popular method in 2011-2019 (69.7%), in contrast to 2001-2009 (28.6%). The advent of multiplex PCR in detecting broader viral pathogens in one run and coinfected viruses influenced the change in user preference. Further, newly developed microarray technologies and ionization mass spectrometry were introduced in 2011-2019. Viral culture (including shell vial assays) and fluorescent immunoassays (with or without culture) were once the mainstays. However, the percentage of studies employing culture and fluorescent immunoassays decreased from 21.4% in 2001-2010 to 15.2% in 2011-2019. Meanwhile, the use of PCR-based methods of HMPV detection increased from 78.6% in 2001-2010 to 84.8% in 2011-2019. The increase in PCR-based methods might have occurred because PCR methods demonstrated better diagnostic performance, shorter hands-on and run times, less hazards to laboratory personnel, and more reliable results than traditional methods. When using these assays, it is important to acquire a comprehensive understanding of the principles, advantages, disadvantages, and precautions for data interpretation. In the future, the combination of nanotechnology and advanced genetic platforms such as next-generation sequencing will benefit patients with HMPV infection by facilitating efficient therapeutic intervention. Analytical and clinical validation are required before using new techniques in clinical laboratories.


title: Could a Feeding Jejunostomy be Integrated into a Standardized Preoperative Management of Oeso-gastric Junction Adenocarcinoma?

text: PURPOSE To evaluate the impact of a feeding jejunostomy (FJ) on the preoperative management of patients with an oesogastric adenocarcinoma (OGA). METHODS From January 2007 to December 2014, patients with potentially resectable OGA were enrolled in a perioperative chemotherapy protocol. FJ was performed before starting perioperative treatments in patients presenting with dysphagia or with a nutritional risk index (NRI) <97.5. The patients who did not require a FJ served as a control group. RESULTS Among the 114 patients with OGA consecutively admitted in our surgical department, 88 (77.2%) were enrolled for neoadjuvant treatment. A FJ was placed in 50 patients (56.8%) before the neoadjuvant treatment (FJ group), whereas 38 patients (43.2%) started neoadjuvant treatments without FJ (control group). Ninety-six percent of patients (n = 48) in the FJ group successfully completed the neoadjuvant treatment but only 81.6% of patients without FJ (n = 31; p = 0.004). The FJ group was divided between responders: 37 patients with a weight response (74%), and nonresponders: 13 patients without weight response (26%). In the FJ group, the nutritional response during preoperative chemotherapy was a significant predictive factor for the achievement of second stage oesogastric resection (p = 0.002). CONCLUSIONS FJ with enteral nutritional support during the preoperative management of OGA is a safe and effective support for the completion of the preoperative chemotherapy. The weight response to the enteral support is a predictor factor for a completion of the preoperative chemotherapy and could identify a group of patients who would have a better chance of reaching radical surgery.


title: Laparoscopic Appendectomy versus Mini-Incision Appendectomy in Patients with Lower Body Mass Index and Noncomplicated Appendicitis.

text: Laparoscopic appendectomy has become favored over open surgical methods for its association with decreased postoperative pain, more rapid return to daily activities, and improved cosmetic results. Mini-incision appendectomy was being performed in our clinic for a long time especially in patients with noncomplicated appendicitis and in patients with appropriate body mass index. Although laparoscopy presents obvious advantages especially for obese patients and young women, with respect to the results of our study, mini-incision appendectomy seems to be an alternative for selected patient groups.


Meniscal repair with the newest fixators: which are best?


title: Issues in the diagnosis and management of the papilledema shunt.

text: BACKGROUND Dural arteriovenous fistulas (DAVFs) that shunt blood into the transverse or superior sagittal venous sinuses cause papilledema by raising intracranial pressure ("the papilledema shunt"). Such fistulas pose unique diagnostic and therapeutic challenges. METHODS Case report and literature review. RESULTS In a patient presenting with papilledema, non-invasive brain vascular imaging disclosed subtle signs of a DAVF. Digital angiography delineated the DAVF and revealed cortical venous reflux. After three transarterial embolizations with ethylene vinyl alcohol, the DAVF was closed and papilledema resolved. CONCLUSIONS The imaging features of a DAVF that cause papilledema may be subtle on non-invasive vascular imaging. If overlooked, and lumbar puncture is performed, there is a substantial risk of brain herniation. Cortical venous reflux, which may be relatively common in these DAVFs, impels the need for endovascular closure. The transvenous route, often employed for closing cavernous sinus DAVFs, should be avoided because of the dangers of dural venous sinus thrombosis.


title: Role of C-arm VasoCT in the use of endovascular WEB flow disruption in intracranial aneurysm treatment.

text: BACKGROUND AND PURPOSE The WEB aneurysm embolization system is still under evaluation but seems to be a promising technique to treat wide-neck bifurcation aneurysms. However, this device is barely visible using conventional DSA; thus, high-resolution contrast-enhanced flat panel detector CT (VasoCT) may be useful before detachment to assess the sizing and positioning of the WEB. The purpose of this study was to evaluate the interest of VasoCT during WEB procedures. MATERIALS AND METHODS From March 2012 to July 2013, twelve patients (10 women and 2 men; age range, 44-55 years) were treated for 13 intracranial aneurysms with the WEB device. DSA and VasoCT were used and compared to depict any protrusion of the device in parent arteries before detachment. Two neuroradiologists reviewed each VasoCT scan, and the quality was graded on a subjective quality scale. RESULTS The mesh of the WEB was very well-depicted in all cases, allowing a very good assessment of its deployment. Device protrusion was clearly detected with VasoCT in 5 cases, leading to WEB repositioning or size substitution. During follow-up, VasoCT also allows good assessment of eventual residual blood flow inside the aneurysm or the WEB device. CONCLUSIONS Unlike DSA, VasoCT is an excellent tool to assess WEB deployment and positioning. In our experience, it allowed a precise evaluation of the WEB sizing and its relation to the parent vessel. Such information very likely enhances the ability to safely use this device, avoiding potential thromboembolic events in cases of protrusion in the parent arteries.


Making Decisions in a COVID-19 World.


Expansion of the Priority Review Voucher Program Under the 21st Century Cures Act: Implications for Innovation and Public Health.


title: Comparison of surgical plume among laparoscopic ultrasonic dissectors using a real-time digital quantitative technology.

text: BACKGROUND This study aimed to analyze the effect of surgical plume generation from various ultrasonic dissectors on laparoscopic visibility, including the first cordless ultrasonic dissector, using a novel real-time digital quantification technique. METHODS The Covidien Cordless Sonicision, the Harmonic ACE, and the Olympus SonoSurg were applied to bovine liver with industry-specified settings. Consecutive activations were digitally captured from a laparoscope positioned to replicate the clinical setting. Plume was recognized by ImageJ software, and the percentage of pixels containing plume in each video frame was calculated. Analysis of variance statistical multi-analysis and Welch's t test were computed for all p values. RESULTS The average maximum plume produced by the Sonicision, ACE, and SonoSurg with the maximum setting were respectively 8.76% (range, 4.32-17.41%), 18.04% (range, 9.07-55.12%), and 9.46% (range, 5.68-22.12%) (p = 0.026). The deviations between the ACE and the other devices were significant (p < 0.05). The average maximum plumes produced with the coagulation setting were 4.80% (range, 0.24-19.83%) for the Sonicision, 26.63% (range, 8.12-73.50%) for the ACE, and 0.21% (range, 0.06-1.05%) for the SonoSurg (p < 0.001). The differences between all the instruments in the coagulation setting were significant. CONCLUSION To the authors' knowledge, this is the first report on a real-time digital analysis of surgical plume generation using ImageJ software. In the coagulation setting, the SonoSurg generated minimal plume. The Sonicision obstructed approximately 4%, whereas the ACE generated plume that obstructed 25% of the laparoscopic field. In the cutting setting, the SonoSurg and Sonicision generated the least obstruction, whereas the ACE caused the most obstruction.


title: SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY: TECHNICAL ASPECTS AND RESULTS.

text: BACKGROUND The search for less traumatic surgical procedures without compromising efficacy and safety, together with the technological advances and greater experience of the teams, led to the development of operative techniques with increasingly smaller incisions, the so-called "minimally invasive surgeries". AIM To evaluate the technical aspects and results of single port cholecystectomy. METHOD Were analyzed 170 patients between 18-74 years submitted to videolaparoscopic cholecystectomies by single port, regardless of elective or urgent indication, without restriction of patient selection. RESULTS Among the 170 operations, 158 were exclusively performed by single port, and the conversion rate was 7% (inclusion of other accessory trocars or conversion to multiportal). Conversion to open surgery occurred in three cases (1.76%). The mean surgical time was 67.97 min, showing a marked decrease when was reached close to 50 cases and a stabilization after 100 surgeries. The overall complication rate was 10%, with minor complications such as: incisional pain, hematomas, granulomas, port access hernias (9.41%). CONCLUSION Single port cholecystectomy can, after standardization and surgical team training, be a safe surgical procedure associated with a recognized aesthetic advantage.


title: PAP therapy increases the risk of transmission of COVID-19.

text: Positive airway pressure (PAP) therapy is an open system that can generate contact, droplet, and airborne COVID-19 thereby increasing the risk of transmission of COVID-19 like other procedures such as tracheal intubation, noninvasive ventilation, and cardiopulmonary resuscitation. Medically prudent recommendations have been established for home use of PAP therapy in asymptomatic patients and patients with suspected or confirmed COVID-19. Recommendations for sleep clinics and sleep laboratory activities are also discussed as well as the emergency use of PAP devices as a substitute for ventilation.


title: A systematic review and meta-analysis assessing the effectiveness of alternative listening devices to conventional hearing aids in adults with hearing loss.

text: Recent technological advances have led to a rapid increase in alternative listening devices to conventional hearing aids. The aim was to systematically review the existing evidence to assess the effectiveness of alternative listening devices in adults with mild and moderate hearing loss. A systematic search strategy of the scientific literature was employed, reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) checklist. Eleven studies met eligibility for inclusion: two studies evaluated personal sound amplification products, and nine studies assessed remote microphone systems (frequency modulation, Bluetooth, wireless). The evidence in this review suggests that alternative listening devices improve behavioural measures of speech intelligibility relative to unaided and/or aided conditions. Evidence for whether alternative listening devices improve self-reported outcomes is inconsistent. The evidence was judged to be of poor to good quality and subject to bias due to limitations in study design. Our overall recommendation is that high-quality evidence (i.e. randomised controlled trials) is required to demonstrate the effectiveness of alternative listening devices. Such evidence is not currently available and is necessary to guide healthcare commissioners and policymakers when considering new service delivery models for adults with hearing loss. Review registration: Prospective Register of Systematic Reviews (PROSPERO), CRD42015029582.


title: Radiation to the Gastric Fundus Increases the Risk of Anastomotic Leakage After Esophagectomy.

text: BACKGROUND Concerns have been raised regarding the toxicity of neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer that could contribute to an increased risk of postoperative complications. The aim of this study was to determine the influence of the radiation dose to the gastric fundus on the risk of postoperative anastomotic leakage in patients undergoing nCRT followed by transthoracic esophagectomy. METHODS Between January 2012 and July 2015, 97 consecutive patients who underwent nCRT followed by transthoracic esophagectomy were included in this single-center cohort study. The gastric fundus was contoured on the pretreatment planning computed tomography. Within this contour, dose-volume histogram variables were calculated, and logistic regression analysis was used to determine their influence on the risk of anastomotic leakage. RESULTS In 25 of 97 patients (26%) anastomotic leakage occurred. The mean radiation dose to the gastric fundus was significantly higher in patients with than without leakage (median 35.6 Gy versus 24.9 Gy, respectively, p = 0.047). A mean dose more than versus less than 31.4 Gy was associated with leakage rates of 43% versus 15%, respectively. Adjusted for tumor location, clinical T stage, and radiation method, the mean radiation dose to the gastric fundus remained significantly and independently associated with an increased risk of anastomotic leakage (adjusted odds ratio 1.05 per 1-Gy increase, 95% confidence interval: 1.002 to 1.10, p = 0.043). CONCLUSIONS Efforts should be made to minimize the radiation dose to the gastric fundus when planning nCRT for esophageal cancer, because higher dose levels to the gastric fundus are associated with an increased risk of anastomotic leakage after subsequent transthoracic esophagectomy and cervical anastomosis.


Tri-axial Biopsy Needle Cauterization During Splenic Biopsy.


title: Lopinavir/ritonavir combination therapy amongst symptomatic coronavirus disease 2019 patients in India: Protocol for restricted public health emergency use

text: As of February 29, 2020, more than 85,000 cases of coronavirus disease 2019 (COVID-19) have been reported from China and 53 other countries with 2,924 deaths. On January 30, 2020, the first laboratory-confirmed case of COVID was reported from Kerala, India. In view of the earlier evidence about effectiveness of repurposed lopinavir/ritonavir against severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronavirus (CoV), as well as preliminary docking studies conducted by the ICMR-National Institute of Virology, Pune, the Central Drugs Standard Control Organization approved the restricted public health use of lopinavir/ritonavir combination amongst symptomatic COVID-19 patients detected in the country. Hospitalized adult patients with laboratory-confirmed SARS-CoV-2 infection with any one of the following criteria will be eligible to receive lopinavir/ritonavir for 14 days after obtaining written informed consent: (i) respiratory distress with respiratory rate ≥22/min or SpO(2) of <94 per cent; (ii) lung parenchymal infiltrates on chest X-ray; (iii) hypotension defined as systolic blood pressure <90 mmHg or need for vasopressor/inotropic medication; (iv) new-onset organ dysfunction; and (v) high-risk groups - age >60 yr, diabetes mellitus, renal failure, chronic lung disease and immunocompromised persons. Patients will be monitored to document clinical (hospital length of stay and mortality at 14, 28 and 90 days), laboratory (presence of viral RNA in serial throat swab samples) and safety (adverse events and serious adverse events) outcomes. Treatment outcomes amongst initial cases would be useful in providing guidance about the clinical management of patients with COVID-19. If found useful in managing initial SARS-CoV-2-infected patients, further evaluation using a randomized control trial design is warranted to guide future therapeutic use of this combination.


Rapid Development of Resident-Led Procedural Response Teams to Support Patient Care During the Coronavirus Disease 2019 Epidemic: A Surgical Workforce Activation Team.


title: Robotic-assisted total mesorectal excision with the aid of a single-port device.

text: UNLABELLED INTRODUCTION AND INDICATIONS: Robotic surgery has numerous advantages in rectal cancer surgery. Studies have reported the advantages associated with single-port approaches, such as eliminating the need for additional incisions, as well as the difficulties inherent in this technique. The authors present a hybrid technique that they performed using a robotic total mesorectal excision with the aid of a single port-device. Materials and methods. The authors performed the technique on 2 patients using a single-port device through an umbilical incision and 3 accessory ports for the robotic arms. There was no need to place ports for the assistant's equipment or for an assistant incision. RESULTS AND COMPLICATIONS The operation time was 177.5 minutes, and there were no intraoperative or postoperative complications. Both patients were discharged 7 days after the operation. CONCLUSIONS This technical variation is an additional step forward for oncological surgery with minimal damage to the abdominal wall.


title: Phosphatidylinositol 3-kinase-, actin-, and microtubule-dependent transport of Semliki Forest Virus replication complexes from the plasma membrane to modified lysosomes.

text: Like other positive-strand RNA viruses, alphaviruses replicate their genomes in association with modified intracellular membranes. Alphavirus replication sites consist of numerous bulb-shaped membrane invaginations (spherules), which contain the double-stranded replication intermediates. Time course studies with Semliki Forest virus (SFV)-infected cells were combined with live-cell imaging and electron microscopy to reveal that the replication complex spherules of SFV undergo an unprecedented large-scale movement between cellular compartments. The spherules first accumulated at the plasma membrane and were then internalized using an endocytic process that required a functional actin-myosin network, as shown by blebbistatin treatment. Wortmannin and other inhibitors indicated that the internalization of spherules also required the activity of phosphatidylinositol 3-kinase. The spherules therefore represent an unusual type of endocytic cargo. After endocytosis, spherule-containing vesicles were highly dynamic and had a neutral pH. These primary carriers fused with acidic endosomes and moved long distances on microtubules, in a manner prevented by nocodazole. The result of the large-scale migration was the formation of a very stable compartment, where the spherules were accumulated on the outer surfaces of unusually large and static acidic vacuoles localized in the pericentriolar region. Our work highlights both fundamental similarities and important differences in the processes that lead to the modified membrane compartments in cells infected by distinct groups of positive-sense RNA viruses.


title: Endovascular thrombectomy for stroke: current best practice and future goals.

text: Endovascular thrombectomy for large vessel ischaemic stroke substantially reduces disability, with recent positive randomised trials leading to guideline changes worldwide. This review discusses in detail the evidence provided by recent randomised trials and meta-analyses, the remaining areas of uncertainty and the future directions for research. The data from existing trials have demonstrated the robust benefit of endovascular thrombectomy for internal carotid and proximal middle cerebral artery occlusions. Uncertainty remains for more distal occlusions where the efficacy of alteplase is greater, less tissue is at risk and the safety of endovascular procedures is less established. Basilar artery occlusion was excluded from the trials, but with a dire natural history and proof of principle that rapid reperfusion is effective, it seems reasonable to continue treating these patients pending ongoing trial results. There has been no evidence of heterogeneity in treatment effect in clinically defined subgroups by age, indeed, those aged >80 years have at least as great an overall reduction in disability and reduced mortality. Similarly there was no heterogeneity across the range of baseline stroke severities included in the trials. Evidence that routine use of general anaesthesia reduces the benefit of endovascular thrombectomy is increasing and conscious sedation is generally preferred unless severe agitation or airway compromise is present. The impact of time delays has become clearer with description of onset to imaging and imaging to reperfusion epochs. Delays in the onset to imaging reduce the proportion of patients with salvageable brain tissue. However, in the presence of favourable imaging, rapid treatment appears beneficial regardless of the onset to imaging time elapsed. Imaging to reperfusion delays lead to decay in the clinical benefit achieved, particularly in those with less robust collateral flow. The brain imaging options to assess prognosis have various advantages and disadvantages, but whatever strategy is employed must be fast. Ongoing trials are investigating extended time windows, using advanced brain imaging selection. There is also a need for further technical advances to maximise rates of complete reperfusion in the minimum time.


title: Antithrombotic therapy use in patients with atrial fibrillation before the era of non-vitamin K antagonist oral anticoagulants: the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) Phase I cohort.

text: AIMS The introduction of non-VKA oral anticoagulants (NOACs), which differ from the earlier vitamin K antagonist (VKA) treatments, has changed the approach to stroke prevention in atrial fibrillation (AF). GLORIA-AF is a prospective, global registry programme describing the selection of antithrombotic treatment in newly diagnosed AF patients at risk of stroke. It comprises three phases: Phase I, before the introduction of NOACs; Phase II, during the time of the introduction of dabigatran, the first NOAC; and Phase III, once NOACs have been established in clinical practice. METHODS AND RESULTS In Phase I, 1063 patients were eligible from the 1100 enrolled (54.3% male; median age 70 years); patients were from China (67.1%), Europe (EU; 27.4%), and the Middle East (ME; 5.6%). The majority of patients using VKAs had high stroke risk (CHA2DS2-VASc ≥ 2; 86.5%); 13.5% had moderate risk (CHA2DS2-VASc = 1). Vitamin K antagonist use was higher for persistent/permanent AF (47.7%) than that for paroxysmal (23.9%). Most patients in China were treated with antiplatelet agents (53.7%) vs. 27.1% in EU and 28.8% in ME. In China, 25.9% of patients had no antithrombotic therapy, vs. 8.6% in EU and 8.5% in ME. CONCLUSION Phase I of GLORIA-AF shows that VKAs were mostly used in patients with persistent/permanent (vs. paroxysmal) AF and in those with high stroke risk. Furthermore, there were meaningful geographical differences in the use of VKA therapy in the era before the availability of NOACs, including a much lower use of VKAs in China, where most patients either received antiplatelet agents or no antithrombotic treatment.


title: A review on human influenza A H5N1 infections in Hong Kong.

text: Avian influenza A H5N1 remains the most threatening virus that may cause another devastating pandemic in the foreseeable future. In 1997, Hong Kong was the first place to detect human infections due to this virus originated from birds. The experience and lessons learnt provide important information for controlling further outbreaks caused by avian influenza viruses.


Adrenal Vascular Changes in COVID-19 Autopsies.


title: Etiology and seasonality of viral respiratory infections in rural Honduran children.

text: BACKGROUND Limited data are available in Honduras that describe the etiology and seasonality of respiratory infections, especially in rural outpatient settings. Better data may lead to improved therapeutic and preventive strategies. The goal of our study was to determine the viral etiology and seasonality of acute respiratory infections in a rural Honduran population of children. METHODS Prospective clinic surveillance was conducted to identify children < 5 years of age presenting with respiratory symptoms of < 5 days duration. We obtained data on age, sex, medical history, breastfeeding history, symptoms, risk factors, household setting, temperature, respiratory rate and chest examination findings. To assess the association between specific viruses and weather, regional meteorological data were collected. Nasopharyngeal samples were tested for 16 respiratory viruses using a multiplex polymerase chain reaction panel. RESULTS From February 2010 through June 2011, 345 children < 5 years of age were enrolled; 17%, 23%, 30% and 31% were <6, 6-11, 12-23 and 24-60 months old, respectively. Including all clinics in the region, 44.5% of patients < 5 years of age with documented respiratory diagnoses were enrolled. At least 1 virus was identified in 75.4% children, of which 7.5% were coinfections; 13.3% were positive for parainfluenza, 11.9% for influenza, 8.1% for human metapneumovirus and 7.5% for respiratory syncytial virus. Rainfall correlated with parainfluenza (P < 0.0001), influenza (P < 0.0001), human metapneumovirus (P = 0.0182) and respiratory syncytial virus (P < 0.0001). CONCLUSIONS These results suggest that the spectrum of viruses in ill, rural, Honduran children is similar to that in North and Central America, although the seasonality is typical of some tropical regions.


Policy opportunities to enhance sharing for pandemic research.


title: Phage-derived fully human antibody scFv fragment directed against human vascular endothelial growth factor receptor 2 blocked its interaction with VEGF.

text: Vascular endothelial growth factor receptor 2 (VEGFR-2) plays a critical role in tumor angiogenesis. None therapeutic antibodies targeting VEGFR-2 are available in clinical use. Herein, we describe the screening of a new single-chain antibody fragment (scFv) targeting extracellular domain 3 of human VEGFR-2 (kinase insert domain-containing receptor [KDR]3) from Griffin phage display scFv library. A comprehensive sequence analysis was performed to assign the framework and complementary-determining regions. The scFv exerted particular binding sites to KDR3 on molecular docking, and the binding affinity was further convinced by binding analysis both in quantitative ELISA and real-time kinetic determination by biosensors (K(D) = 40 nM). Finally, the scFv was revealed to inhibit VEGF-stimulated proliferation of human umbilical vein endothelial cells (HUVECs; IC(50) = 5 nM) and to inhibit HUVEC migration significantly at 17 nM. Taken together, our results indicate that we have successfully isolated a scFv which differentially recognizes KDR3 and has potential clinical applications in the treatment of angiogenesis related diseases.


title: Transcriptomic correlates of organ failure extent in sepsis.

text: OBJECTIVES Sepsis is characterised by the frequent presence of organ failure and marked immunologic alterations. We studied the association between the extent of organ failure and the transcriptomic response of septic patients. METHODS Gene expression profiles in the blood of 74 surgical patients with sepsis were compared with those of 30 surgical patients with no sepsis. Differentially expressed genes were assessed for their correlation with the sequential organ failure (SOFA) score. RESULTS The expression levels of a group of genes participating in the cell cycle (HIST1H1C, CKS2, CCNA2, CDK1, CCNB2, CIT, CCNB1, AURKA, RAD51), neutrophil protease activity (ELANE, ADORA3, MPO, MMP8, CTSG), IL-1R and IL-18R response correlated directly with SOFA and mortality. Genes involved in T cell (LCK, CD3G, CD3D, ZAP70, ICOS, CD3E, CD28, IL2RB, CD8B, CD8A, CD40LG, IL23A, CCL5, SH2D1A, ITK, CD247, TBX21, GATA3, CCR7, LEF1, STAT4) and NK cell immunity (CD244, KLRK1, KLRD1) were inversely associated with SOFA and mortality. CONCLUSIONS The extent of organ failure in sepsis correlates directly with the existence of imbalanced innate and adaptive responses at the transcriptomic level. Quantification of the expression levels of the genes identified here could contribute to the simultaneous assessment of disease severity and immunological alterations in sepsis.