Endovascular treatment for stroke: when does the window for good outcome close?


title: Nano-sensitive optical coherence tomography.

text: Depth resolved label-free detection of structural changes with nanoscale sensitivity is an outstanding problem in the biological and physical sciences and has significant applications in both the fundamental research and healthcare diagnostics arenas. Here we experimentally demonstrate a novel label-free depth resolved sensing technique based on optical coherence tomography (OCT) to detect structural changes at the nanoscale. Structural components of the 3D object, spectrally encoded in the remitted light, are transformed from the Fourier domain into each voxel of the 3D OCT image without compromising sensitivity. Spatial distribution of the nanoscale structural changes in the depth direction is visualized in just a single OCT scan. This label free approach provides new possibilities for depth resolved study of pathogenic and physiologically relevant molecules in the body with high sensitivity and specificity. It offers a powerful opportunity for early diagnosis and treatment of diseases. Experimental results show the ability of the approach to differentiate structural changes of 30 nm in nanosphere aggregates, located at different depths, from a single OCT scan, and structural changes less than 30 nm in time from two OCT scans. Application for visualization of the structure of human skin in vivo is also demonstrated.


title: HIV-related data among key populations to inform evidence-based responses: protocol of a systematic review.

text: BACKGROUND Key populations who bear a disproportionate burden of HIV, including female sex workers, men who have sex with men, people who use drugs, transgender people, and incarcerated populations, have been understudied, especially in the context of broadly generalized HIV epidemics. Program and investment planning documents often do not take into account the data that do exist. Prior systematic reviews have been comprehensive, but lack sustainability and relevance over time. This review aims to synthesize all available data for key populations and present the data through an accessible, updatable user-friendly graphic interface. The outputs of this systematic review will serve as a resource for decision-makers, providing government stakeholders and donors with the tools to make evidence-based decisions for national planning. METHODS We will conduct a systematic review of data published or made available between January 1, 2006, and January 1, 2019, that captures the burden of HIV, both prevalence and incidence estimates, HIV prevention and treatment cascades, key population size estimates, experienced violence, consistent condom use, and engagement with healthcare systems for female sex workers, men who have sex with men, people who use drugs, transgender people, and incarcerated populations. A team of reviewers will use Covidence to conduct two independent reviews of both title/abstract and full text for each article. REDCap will be used for data abstraction and storage. DISCUSSION Findings from this systematic review and the development of the enhanced graphical interface to display data, along with ongoing efforts to build capacity among key stakeholders to better use and interpret available data, will help ensure that available epidemiologic data related to key populations can be appropriately used to guide large-scale HIV funding and programmatic responses. SYSTEMATIC REVIEW REGISTRATION PROPSERO CRD42016047259 .


title: Ciliary muscle dimensions measured by swept-source optical coherence tomography in eyes with primary open-angle glaucoma and healthy eyes.

text: PURPOSE To compare in vivo swept-source optical coherence tomography (SS-OCT) measurements of the ciliary muscle (CM) in patients with primary open-angle glaucoma (POAG) and healthy subjects, and examine correlations between CM dimensions and several covariates. METHODS This was a cross-sectional study of the right eyes of 181 subjects: 89 POAG patients and 92 healthy subjects. Using the Triton SS-OCT device (Topcon, Tokyo, Japan), CM length (CML), area (CMA) and thickness measured 1000 µm (CMT1), 2000 µm (CMT2) and 3000 µm (CMT3) from the scleral spur were determined in the temporal and nasal quadrants. POAG patients were subjected to visual field (VF) and peripapillary retinal nerve fiber layer (RNFL) assessment. CM dimensions were then assessed for correlation with VF mean defect (MD), mean RNFL thickness and intraocular pressure (IOP). RESULTS Mean CMLs were 4325 ± 340 µm and 4195 ± 843 µm for the healthy subjects and POAG patients, respectively (p = 0.17). Mean CM thicknesses were CMT1 = 546 ± 56 µm, CMT2 = 326 ± 44 µm and CMT3 = 174 ± 16 µm in the healthy eyes versus CMT1 = 534 ± 108, CMT2 = 332 ± 99 and CMT3 = 183 ± 74 in the POAG eyes, with no significant differences detected (all p ≥ 0.25). In the temporal quadrant, mean CMA was 1.12 ± 0.29 mm2 and 1.15 ± 0.24 mm2 for the healthy and POAG subjects, respectively (p = 0.45). No correlations were observed between CM measurements and RNFL thickness (p ≥ 0.15), IOP or VF MD (p ≥ 0.14) in POAG subjects irrespective of glaucoma severity (p ≥ 0.19). CONCLUSIONS While SS-OCT proved useful to measure CM dimensions in vivo, these dimensions did not differ between healthy individuals and POAG subjects. In the patients with POAG, no correlations were detected between CM dimensions and VF, RNFL or IOP.


title: In Vitro Evaluation of Eslicarbazepine Delivery via Enteral Feeding Tubes.

text: Purpose: The feasibility of preparing an eslicarbazepine acetate suspension using Aptiom tablets for administration via enteral feeding tubes was evaluated. Methods: Eslicarbazepine acetate suspension (40 mg/mL) was prepared using Aptiom tablets after optimizing the tablet crushing methods and the vehicle composition. A stability-indicating high-performance liquid chromatography (HPLC) method was developed to monitor the eslicarbazepine stability in the prepared suspension. Three enteric feeding tubes of various composition and dimensions were evaluated for the delivery of the suspensions. The suspension was evaluated for the physical and chemical stability for 48 hours. Results: The reproducibility and consistency of particle size reduction was found to be best with standard mortar/pestle. The viscosity analysis and physical stability studies showed that ORA-Plus:water (50:50 v/v) was optimal for suspending ability and flowability of suspension through the tubes. The developed HPLC method was found to be stability indicating and suitable for the assay of eslicarbazepine acetate in the prepared suspension. The eslicarbazepine concentrations in separately prepared suspensions were within acceptable range (±3%), indicating accuracy and reproducibility of the procedure. The eslicarbazepine concentrations in suspensions before and after delivery through the enteric feeding tubes were within acceptable range (±4%), indicating absence of any physical/chemical interactions of eslicarbazepine with the tubes and a successful delivery of eslicarbazepine dosage via enteric feeding tubes. The stability study results showed that eslicarbazepine concentration in the suspension remained unchanged when stored at room temperature for 48 hours. Conclusion: The study presents a convenient procedure for the preparation of a stable suspension of eslicarbazepine acetate (40 mg/mL) using Aptiom tablets, for administration via enteral feeding tubes.


title: Respiratory Support during Bronchiolitis Due to One Virus versus More Than One Virus: An Observational Study.

text: Bronchiolitis is common during infancy and frequently leads to pediatric intensive care unit (PICU) admission. This study aimed to determine if there is a difference in the duration of respiratory support when bronchiolitis is due to one virus or more than one virus. This is a retrospective, observational study of cases admitted to PICU with confirmed bronchiolitis. There were 306 cases analyzed, 70% (215/306) were infected by a single virus and 30% (91/306) were infected with more than one virus. Both groups had similar duration of respiratory support and PICU length of stay (LOS). Hospital LOS was longer for the group with more than one virus.


title: Detecting the priority areas for health workforce allocation with LISA functions: an empirical analysis for China.

text: BACKGROUND Health workforce misdistribution leads to severe inequity and low-efficiency in health services in the developing countries. Targeting at China, this research aims to reveal, visualize and compare the geographical distribution patterns of different subtypes of urban and rural health workforce and identify the priority regions for health workforce planning and allocation policies designing. METHODS The health workforce density (workforce-to-population ratio) is adopted to represent the accessibility to health workforce in each geographical unit. Besides a descriptive geography of health workforce as a whole, the local indicators of spatial association (LISA) are used to explore the spatial clusters of different subtypes of health workforce, which are visualized by geographical tools. RESULTS Results reveal that regional disparities and spatial clusters exist in China's health workforce distribution, with different types of workforce exhibiting relatively different spatial distribution characteristics. Besides, huge urban-rural disparities are found in the distribution of health workforce in China. Unexpectedly but intriguingly, most of the high-high and high-low cluster area of urban health workforce are concentrated in the western China (Xinjiang, Xizang etc.), indicating the relative abundant stock of urban health workforce in these units, while the low-low and low-high cluster area of different types of urban health workforce are mainly distributed in middle China. Regarding the rural health workforce, there is an obvious and similar low-low and low-high clustering pattern in western provinces (Sichuan, Yunnan) for the licensed doctors, pharmacists, technologists, which play a critical role in health services delivery. CONCLUSIONS Different types of health workforce displayed distinct spatial distribution patterns, while the misdistribution of rural health workforce imposed more challenges to the Chinese health sector due to its poorer stock and more disadvantaged positions of backward regions (i.e., low-low and low-high cluster area). Subtype-specific and region-oriented health workforce planning and allocation policies are suggested to be made, aiming at the urban and rural health workforce respectively, by prioritizing the identified low-low and low-high cluster areas.


title: Placement of a caudal vena cava stent for treatment of Budd-Chiari-like syndrome in a 4-month-old Ragdoll cat.

text: CASE DESCRIPTION A 16-week-old 1.5-kg (3.3-lb) sexually intact male Ragdoll kitten that had a 9-week history of marked modified transudate ascites was evaluated. A membranous obstruction of the caudal vena cava at the cranial aspect of the liver was identified via CT angiography. CLINICAL FINDINGS Physical examination findings included a markedly distended abdomen and panting. Testing for circulating FIV antibody and FeLV antigen, a PCR assay for feline coronavirus performed on a sample of peritoneal fluid, and fecal flotation yielded negative results. A diagnosis of Budd-Chiari-like syndrome secondary to a membranous obstruction of the caudal vena cava was made. TREATMENT AND OUTCOME The cat was anesthetized, and the subhepatic portion of the caudal vena cava was identified and accessed via median celiotomy and direct venipuncture. A 6F 8 × 24-mm balloon-expandable nitinol biliary stent was placed across the stenotic area under fluoroscopic guidance. The patient remained free of clinical signs at the last follow-up 13 months following the procedure. CLINICAL RELEVANCE Budd-Chiari-like syndrome is a rare phenomenon in veterinary medicine, and congenital malformations should be considered in young feline patients with ascites. Computed tomography angiography proved to be a helpful adjunctive imaging technique to establish a diagnosis in this case. To the authors' knowledge, this is the first report of successful treatment of a congenital caudal vena cava obstruction by means of stent placement in a juvenile cat.


Chinese medical staff request international medical assistance in fighting against COVID-19.


title: The impact of capnography monitoring among children and adolescents in the postanesthesia care unit: a randomized controlled trial.

text: BACKGROUND Pulse oximetry does not reliably recognize respiratory depression, particularly in the presence of supplemental oxygen. Capnography frequently detects hypoventilation and apnea among children recovering from anesthesia. Although children are routinely monitored with capnography during anesthesia, reducing the rate of adverse events, it is not routinely used in the postanesthesia care unit (PACU), where patients remain at risk for respiratory depression. AIM We hypothesized that children monitored with capnography would have more frequent staff interventions and fewer adverse events than children monitored with pulse oximetry alone. METHODS Otherwise healthy children of age 1-20 years undergoing general anesthesia for elective surgery were eligible for enrollment upon entering the pediatric PACU. Subjects were randomized as to whether PACU staff could view the capnography monitor (intervention group) or not (control group). All children received standard monitoring with pulse oximetry. Vital signs and patient interventions were recorded every 30 s by a portable monitor or a research associate. RESULTS Data from 201 children were analyzed. The rates of hypopneic hypoventilation [5% (95% CI: 2-8%) per minute vs 1% (95% CI: -1% to 3%) per minute, difference 4% (95% CI: 0.2-8%) per minute; P = 0.04] and apnea [11% (95% CI: 8-14%) per minute vs 1.5% (95% CI: -2% to 5%) per minute, difference 9% (5-14%) per minute; P < 0.001] decreased significantly faster in our intervention group as compared to the control group. The rates of bradypnea decreased faster in our control group [5% (95% CI: 2-8%) per minute vs 1% (95% CI: 0-4%) per minute, difference 4% per minute, 95% CI: 0-9%; P = 0.05]. Rates of respiratory events over time between groups were affected by the presence or absence of interventions. There were no differences in rates of hypoxemia between groups over time. CONCLUSIONS Children monitored with capnography have different rates of adverse respiratory events over time than children monitored solely with pulse oximetry. The addition of capnography improved the efficacy of staff interventions, however did not impact rates of oxygen desaturation.


title: Number of COVID-19 cases in Chile at 120 days with data at 21/03/2020 and threshold of daily effort to flatten the epi-curve.

text: We present a straightforward projection with data up to 21/03/2020 of the evolution of the number of COVID-19 cases per day in Chile using data from the Ministry of Health. Assuming an arithmetical growth in the second variation of the data, we present a cubic adjustment model in which we estimate over 100 000 cases at 120 days consistent with the data recorded to date. Furthermore, we use an exponential total case model to represent (using a parameter) the daily effort to reduce a high initial daily growth rate. We simulate this model with different numerical scenarios of feasibility and desired future prevalence.


title: What Is a Host? Attributes of Individual Susceptibility.

text: In every epidemic some individuals become sick and some may die, whereas others recover from illness and still others show no signs or symptoms of disease. These differences highlight a fundamental question of microbial pathogenesis: why are some individuals susceptible to infectious diseases while others who acquire the same microbe remain well? For most of human history, the answer assumed the hand of providence. With the advent of the germ theory of disease, the focus on disease causality became the microbe, but this did not explain how there can be different outcomes of infection in different individuals with the same microbe. Here we examine the attributes of susceptibility in the context of the "damage-response framework" of microbial pathogenesis. We identify 11 attributes that, although not independent, are sufficiently distinct to be considered separately: microbiome, inoculum, sex, temperature, environment, age, chance, history, immunity, nutrition, and genetics. We use the first letter of each to create the mnemonic MISTEACHING, underscoring the need for caution in accepting dogma and attributing disease causality to any single factor. For both populations and individuals, variations in the attributes that assemble into MISTEACHING can create an enormity of combinations that can in turn translate into different outcomes of host-microbe encounters. Combinatorial diversity among the 11 attributes makes identifying "signatures" of susceptibility possible. However, with their inevitable uncertainties and propensity to change, there may still be a low likelihood for prediction with regard to individual host-microbe interactions, although probabilistic prediction may be possible.


title: THE EPITHELIUM AS A TARGET IN SEPSIS.

text: Organ dysfunction induced by sepsis has been consistently associated with worse outcome and death. Regardless of the organ compromised, epithelial dysfunction is present throughout the body, affecting those organs that contain epithelia like the skin, lungs, liver, gut, and kidneys. Despite their obvious differences, sepsis seems to alter common features of all epithelia, such as barrier function and vectorial ion transport. Such alterations in the lung, the gut, and the kidney have direct implications that may explain the profound organ functional impairments in the absence of overt cell death. Epithelial injury in this context is not only an explanatory real pathophysiologic event, but also represents a source of biomarkers that have been explored to identify organ compromise earlier, predict outcome, and even to test novel therapeutic interventions such as blood purification. However, this remains largely experimental, and despite promising results, work is still required to better understand the response of the epithelial cells to sepsis, to define their role in adaptation to insults, to comprehend the interorgan cross-talk that occurs in these circumstances, and to exploit these aspects in pursuit of targeted therapies like blood purification, which may improve outcome for these patients in the future.


News Feature: Avoiding pitfalls in the pursuit of a COVID-19 vaccine.


Tracheostomy in the COVID-19 Era: The Apneic Approach.


title: A novel method of endoscopic-assisted esophageal clearance in advanced achalasia.

text: Background and study aims In order to perform peroral endoscopic myotomy (POEM) safely, retained liquid and food debris must be removed before the procedure is started. We developed a novel technique using a super-slim gastroscope, and a gastric tube to remove retained food debris in achalasia patients. In this study, the safety and efficacy of this novel technique were investigated. Patients and methods Eleven patients with achalasia were enrolled in this study and underwent this novel method for esophageal clearance. Results All patients had complete clearance of the retained food debris using this method. The median procedure time (range) was 13 (6 - 30) minutes. There were no serious adverse events (AEs) and one minor AE of mucosal erythema due to mucosal suctioning. Conclusion This novel method for esophageal clearance is safe and effective in achalasia patients with large amounts of retained food debris.


title: Impact of ASPECTS on computed tomography angiography source images on outcome after thrombolysis or endovascular therapy in large vessel occlusions.

text: BACKGROUND AND PURPOSE Endovascular therapy (ET) is superior to intravenous thrombolysis (IVT) in selected patients with anterior circulation large vessel occlusions. However, it is unclear if this positive effect also applies to patients with extensive early ischaemic changes. The aim of this study was to analyze the impact of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on the CT angiography source images (SI) on outcome after ET or IVT. METHODS Using our prospectively obtained stroke database and the admission SI-ASPECTS divided into three groups (0-5, 6-7 and 8-10), primarily the rates of good outcome [modified Rankin Scale (mRS) ≤2 at discharge] after either ET (n = 255) or IVT (n = 479) were compared. RESULTS A favorable SI-ASPECTS (8-10) was present in 501 patients, 132 patients had a moderately favorable SI-ASPECTS (6-7) and 101 patients had an unfavorable SI-ASPECTS (0-5). Irrespective of the treatment modality, no patient with an unfavorable SI-ASPECTS had a good outcome and 38% died during hospital stay. Whilst significantly more patients with a favorable SI-ASPECTS had a good outcome after ET than after IVT (51% vs. 35%, P < 0.01), there was only a non-significant trend towards a good outcome after ET than after IVT in patients with a moderately favorable ASPECTS (25% vs. 14%, P = 0.1). CONCLUSION Patients with extensive early ischaemic changes on CT scans (SI- ASPECTS ≤5) might not profit from ET. The impact of ET on outcome in patients with moderately favorable SI-ASPECTS should be addressed in further trials.


Platelets and Immunity: Going Viral.


title: Effectiveness of Cloth Masks for Protection Against Severe Acute Respiratory Syndrome Coronavirus 2.

text: Cloth masks have been used in healthcare and community settings to protect the wearer from respiratory infections. The use of cloth masks during the coronavirus disease (COVID-19) pandemic is under debate. The filtration effectiveness of cloth masks is generally lower than that of medical masks and respirators; however, cloth masks may provide some protection if well designed and used correctly. Multilayer cloth masks, designed to fit around the face and made of water-resistant fabric with a high number of threads and finer weave, may provide reasonable protection. Until a cloth mask design is proven to be equally effective as a medical or N95 mask, wearing cloth masks should not be mandated for healthcare workers. In community settings, however, cloth masks may be used to prevent community spread of infections by sick or asymptomatically infected persons, and the public should be educated about their correct use.


title: Comparison of the performance of battery-operated fluid warmers.

text: OBJECTIVES Warming intravenous fluids is essential to prevent hypothermia in patients with trauma, especially when large volumes are administered. Prehospital and transport settings require fluid warmers to be small, energy efficient and independent of external power supply. We compared the warming properties and resistance to flow of currently available battery-operated fluid warmers. METHODS Fluid warming was evaluated at 50, 100 and 200 mL/min at a constant input temperature of 20°C and 10°C using a cardiopulmonary bypass roller pump and cooler. Output temperature was continuously recorded. RESULTS Performance of fluid warmers varied with flows and input temperatures. At an input temperature of 20°C and flow of 50 mL/min, the Buddy Lite, enFlow, Thermal Angel and Warrior warmed 3.4, 2.4, 1 and 3.6 L to over 35°C, respectively. However, at an input temperature of 10°C and flow of 200 mL/min, the Buddy Lite failed to warm, the enFlow warmed 3.3 L to 25.7°C, the Thermal Angel warmed 1.5 L to 20.9°C and the Warrior warmed 3.4 L to 34.4°C (p<0.0001). CONCLUSION We found significant differences between the fluid warmers: the use of the Buddy Lite should be limited to moderate input temperature and low flow rates. The use of the Thermal Angel is limited to low volumes due to battery capacity and low output temperature at extreme conditions. The Warrior provides the best warming performance at high infusion rates, as well as low input temperatures, and was able to warm the largest volumes in these conditions.


title: Genomic and epidemiological characteristics provide new insights into the phylogeographical and spatiotemporal spread of porcine epidemic diarrhea virus in Asia.

text: Porcine epidemic diarrhea has become pandemic in the Asian pig-breeding industry, causing significant economic loss. In the present study, 11 complete genomes of porcine epidemic diarrhea virus (PEDV) field isolates from China were determined and analyzed. Frequently occurring mutations were observed, which suggested that full understanding of the genomic and epidemiological characteristics is critical in the fight against PEDV epidemics. Comparative analysis of 49 available genomes clustered the PEDV strains into pandemic (PX) and classical (CX) groups and identified four hypervariable regions (V1 to V4). Further study indicated key roles for the spike (S) gene and the V2 region in distinguishing between the PX and CX groups and for studying genetic evolution. Genotyping and phylogeny-based geographical dissection based on 219 S genes revealed the complexity and severity of PEDV epidemics in Asia. Many subgroups have formed, with a wide array of mutations in different countries, leading to the outbreak of PEDV in Asia. Spatiotemporal reconstruction based on the analysis suggested that the pandemic group strains originated from South Korea and then extended into Japan, Thailand, and China. However, the novel pandemic strains in South Korea that appeared after 2013 may have originated from a Chinese variant. Thus, the serious PED epidemics in China and South Korea in recent years were caused by the complex subgroups of PEDV. The data in this study have important implications for understanding the ongoing PEDV outbreaks in Asia and will guide future efforts to effectively prevent and control PEDV.


title: Preferred Terms and Icons for Labels on Electrosurgical Units: Survey of VA Nurses.

text: Electrosurgical units (ESUs) developed by different manufacturers use varying terminology and icons to label the same components, which can result in confusion among users and the potential for erroneous ESU configuration. The objective of the current study was to identify nurse-preferred terms and icons for labeling ESU components. A total of 165 operating room (OR) nurses from Veterans Health Administration facilities across the United States were surveyed regarding terms and icons found on 25 ESU models. The results showed that 81% of OR nurses preferred ESUs that included both a term and an icon for labeling each component. In addition, greater consensus existed among OR nurses regarding preferred terms, rather than preferred icons, for representing each component. These findings on OR nurses' preferred terms and icons can be leveraged to improve ESU labeling practices and inform the development of a standardized, user-centered set of labels for ESU components.


Should infection control teams enforce an antimicrobial stewardship program for all clinicians?


title: Blocking eIF4E-eIF4G interaction as a strategy to impair coronavirus replication.

text: Coronaviruses are a family of enveloped single-stranded positive-sense RNA viruses causing respiratory, enteric, and neurologic diseases in mammals and fowl. Human coronaviruses are recognized to cause up to a third of common colds and are suspected to be involved in enteric and neurologic diseases. Coronavirus replication involves the generation of nested subgenomic mRNAs (sgmRNAs) with a common capped 5' leader sequence. The translation of most of the sgmRNAs is thought to be cap dependent and displays a requirement for eukaryotic initiation factor 4F (eIF4F), a heterotrimeric complex needed for the recruitment of 40S ribosomes. We recently reported on an ultrahigh-throughput screen to discover compounds that inhibit eIF4F activity by blocking the interaction of two of its subunits (R. Cencic et al., Proc. Natl. Acad. Sci. U. S. A. 108:1046-1051, 2011). Herein we describe a molecule from this screen that prevents the interaction between eIF4E (the cap-binding protein) and eIF4G (a large scaffolding protein), inhibiting cap-dependent translation. This inhibitor significantly decreased human coronavirus 229E (HCoV-229E) replication, reducing the percentage of infected cells and intra- and extracellular infectious virus titers. Our results support the strategy of targeting the eIF4F complex to block coronavirus infection.


title: Materials and methods for delivery of biological drugs.

text: Biological drugs generated via recombinant techniques are uniquely positioned due to their high potency and high selectivity of action. The major drawback of this class of therapeutics, however, is their poor stability upon oral administration and during subsequent circulation. As a result, biological drugs have very low bioavailability and short therapeutic half-lives. Fortunately, tools of chemistry and biotechnology have been developed into an elaborate arsenal, which can be applied to improve the pharmacokinetics of biological drugs. Depot-type release systems are available to achieve sustained release of drugs over time. Conjugation to synthetic or biological polymers affords long circulating formulations. Administration of biological drugs through non-parenteral routes shows excellent performance and the first products have reached the market. This Review presents the main accomplishments in this field and illustrates the materials and methods behind existing and upcoming successful formulations and delivery strategies for biological drugs.


title: A case of delayed distal coil migration after coil embolization of an unruptured distal azygos anterior cerebral artery aneurysm: A case report and literature review.

text: Intraprocedural coil migration during endovascular treatment for an aneurysm that might carry serious ischemic complications is well known. On the other hand, delayed coil migration after endovascular treatment for an aneurysm is very rare. A 77-year-old woman was incidentally diagnosed with unruptured aneurysm associated with distal azygos anterior cerebral artery (ACA). The aneurysm was located at the distal bifurcation of the azygos ACA and was wide necked (approximately 7 mm in diameter). Endovascular coil embolization was selected and the aneurysm was occluded successfully, but 29 days after endovascular therapy, follow-up computed tomography (CT) and magnetic resonance (MR) angiography revealed distal coil migration in the peripheral portion of the ACA. In addition, CT on day 57 after therapy revealed the migrated coil had moved more distally. Fortunately, in the course of these events, the patient remained asymptomatic. To the best of our knowledge, this represents the first case of delayed distal coil migration associated with relatively rare azygos ACA aneurysm, and also the first report confirming more distal coil movement over time. In the future, a large number of patients could develop this complication as more aneurysms are aggressively treated with endovascular treatment. Knowledge regarding the possibility of delayed coil migration is thus important.


title: Predicting immunogenic tumour mutations by combining mass spectrometry and exome sequencing.

text: Human tumours typically harbour a remarkable number of somatic mutations. If presented on major histocompatibility complex class I molecules (MHCI), peptides containing these mutations could potentially be immunogenic as they should be recognized as 'non-self' neo-antigens by the adaptive immune system. Recent work has confirmed that mutant peptides can serve as T-cell epitopes. However, few mutant epitopes have been described because their discovery required the laborious screening of patient tumour-infiltrating lymphocytes for their ability to recognize antigen libraries constructed following tumour exome sequencing. We sought to simplify the discovery of immunogenic mutant peptides by characterizing their general properties. We developed an approach that combines whole-exome and transcriptome sequencing analysis with mass spectrometry to identify neo-epitopes in two widely used murine tumour models. Of the >1,300 amino acid changes identified, ∼13% were predicted to bind MHCI, a small fraction of which were confirmed by mass spectrometry. The peptides were then structurally modelled bound to MHCI. Mutations that were solvent-exposed and therefore accessible to T-cell antigen receptors were predicted to be immunogenic. Vaccination of mice confirmed the approach, with each predicted immunogenic peptide yielding therapeutically active T-cell responses. The predictions also enabled the generation of peptide-MHCI dextramers that could be used to monitor the kinetics and distribution of the anti-tumour T-cell response before and after vaccination. These findings indicate that a suitable prediction algorithm may provide an approach for the pharmacodynamic monitoring of T-cell responses as well as for the development of personalized vaccines in cancer patients.


title: Robot-Assisted Versus Laparoscopic Sleeve Gastrectomy: Learning Curve, Perioperative, and Short-Term Outcomes.

text: BACKGROUND Currently, sleeve gastrectomy is most commonly performed laparoscopically. However, robot-assisted approach for sleeve gastrectomy is increasing in number among bariatric surgeons. The aim of our study is to compare perioperative outcomes of robot-assisted (RA-LSG) and laparoscopic sleeve gastrectomy (LSG). METHODS Between June 2008 and December 2014, 647 patients underwent LSG and RA-LSG at our institution. A retrospective review was performed for 379 LSG and 268 R-LSG patients, noting the outcomes and complications of the procedure. RESULTS The first 100 LSG and RA-LSG cases were separated to reflect the influence of learning curve. Mean length of hospital stay (LOS) was longer in RA-LSG patients at 1.3 ± 0.6 days (range, 1-4), while it was 1.1 ± 0.3 days (range, 1-2) in LSG patients. Thirty-day readmission rate was similar in both groups, 5.0 % in LSG and 6.0 % in RA-LSG group. One mortality (1.0 %) occurred in the RA-LSG group. In patients after 100 cases, mean LOS was still longer in RA-LSG patients at 1.7 ± 1.8 days (range, 1-21), while it was 1.2 ± 0.5 days (range, 1-5) LSG patients. Thirty-day readmission rate and 30-day reoperation rate did not show a significant difference between the two groups. Overall leak rate was 3.2 % (n = 9) in LSG group, and 1.9 % (n = 5) in RA-LSG group, and the difference was not statistically significant. CONCLUSIONS Our study showed similar 30-day readmission and reoperation rate between LSG and RA-LSG during the learning curve and after the proficiency has been achieved.


title: Wide-Band Tympanometry Results during an Acute Episode of Ménière's Disease.

text: BACKGROUND Wide-band tympanometry (WBT) was introduced as a beneficial diagnostic test for Ménière's disease (MD) almost 15 years ago. However, an acute episode of MD has not been evaluated by using WBT yet. OBJECTIVE To investigate WBT findings in patients with MD during acute attacks. METHOD Thirty definite MD patients with unilateral acute low-tone sensorineural hearing loss and aural fullness, and thirty age- and sex-matched control subjects were enrolled prospectively in a tertiary referral center. Ears were divided into three groups as follows: (1) affected ears of MD patients, (2) contralateral ears of MD patients, (3) control ears. Individuals underwent WBT. The resonance frequency (RF), mean absorbance value, mean low- and high-frequency absorbance values (LF-A and HF-A), and double peak width at 2 kHz of conductance tympanometry (2-kHz PW) were assessed. RESULTS Seventy percent in group 1, 66.7% in group 2, and 78.3% in group 3 demonstrated double peaks at 2 kHz. The mean 2-kHz PW values were 157.52 ± 79.19, 177.40 ± 79.14, and 139.64 ± 87.501 daPa for groups 1, 2, and 3, respectively. There were no significant differences between groups with respect to 2-kHz PW, RF, absorbance, LF-A, and HF-A. CONCLUSION This was the first study that evaluated the effects of acute Ménière attacks on WBT findings. An acute Ménière attack was found to have no significant effect on the 2-kHz PW and other variables measured using WBT.


title: Albuminuria, cognitive functioning, and white matter hyperintensities in homebound elders.

text: BACKGROUND Albuminuria, a kidney marker of microvascular disease, may herald microvascular disease elsewhere, including in the brain. STUDY DESIGN Cross sectional. SETTING & PARTICIPANTS Boston, MA, elders receiving home health services to maintain independent living who consented to brain magnetic resonance imaging. PREDICTOR Urine albumin-creatinine ratio (ACR). OUTCOME Performance on a cognitive battery assessing executive function and memory by using principal components analysis and white matter hyperintensity volume on brain imaging, evaluated in logistic and linear regression models. RESULTS In 335 participants, mean age was 73.4 +/- 8.1 years and 123 participants had microalbuminuria or macroalbuminuria. Each doubling of ACR was associated with worse executive function (beta = -0.05; P = 0.005 in univariate and beta = -0.07; P = 0.004 in multivariable analyses controlling for age, sex, race, education, diabetes, cardiovascular disease, hypertension, medications, and estimated glomerular filtration rate [eGFR]), but not with worse memory or working memory. Individuals with microalbuminuria or macroalbuminuria were more likely to be in the lower versus the highest tertile of executive functioning (odds ratio, 1.18; 95% confidence interval, 1.06 to 1.32; odds ratio, 1.19; 95% confidence interval, 1.05 to 1.35 per doubling of ACR in univariate and multivariable analyses, respectively). Albuminuria was associated with qualitative white matter hyperintensity grade (odds ratio, 1.13; 95% confidence interval, 1.02 to 1.25; odds ratio, 1.15; 95% confidence interval, 1.02 to 1.29 per doubling of ACR) in univariate and multivariable analyses and with quantitative white matter hyperintensity volume (beta = 0.11; P = 0.007; beta = 0.10; P = 0.01) in univariate and multivariable analyses of log-transformed data. Results were similar when excluding individuals with macroalbuminuria. LIMITATIONS Single measurement of ACR, indirect creatinine calibration, and reliance on participant recall for elements of medical history. CONCLUSIONS Albuminuria is associated with worse cognitive performance, particularly in executive functioning, as well as increased white matter hyperintensity volume. Albuminuria likely identifies greater brain microvascular disease burden.


title: Anxiolysis in the Surgical Management of a Compound Odontoma in a Pediatric Patient.

text: Among odontogenic tumors, odontoma is the most frequent. The common treatment contemplates a conservative approach. While this procedure is generally accepted and tolerated, some difficulties may be encountered in the case of pediatric patients. Indeed, negative feelings of tension, apprehension, nervousness, and fear are likely to occur. The present report is aimed at discussing the management of a compound odontoma in a pediatric patient under anxiolysis with diazepam on an outpatient basis. The surgery was carried out without complications, and the discharge was completed safely. Oral premedication with diazepam should be considered to avoid more invasive sedation procedures in anxious pediatric patients.


title: The influence of esmolol on right ventricular function in early experimental endotoxic shock.

text: The mechanism by which heart rate (HR) control with esmolol improves hemodynamics during septic shock remains unclear. Improved right ventricular (RV) function, thereby reducing venous congestion, may play a role. We assessed the effect of HR control with esmolol during sepsis on RV function, macrocirculation, microcirculation, end-organ-perfusion, and ventricular-arterial coupling. Sepsis was induced in 10 healthy anesthetized and mechanically ventilated sheep by continuous IV administration of lipopolysaccharide (LPS). Esmolol was infused after successful resuscitation of the septic shock, to reduce HR and stopped 30-min after reaching targeted HR reduction of 30%. Venous and arterial blood gases were sampled and the small intestines' microcirculation was assessed by using a hand-held video microscope (CytoCam-IDF). Arterial and venous pressures, and cardiac output (CO) were recorded continuously. An intraventricular micromanometer was used to assess the RV function. Ventricular-arterial coupling ratio (VACR) was estimated by catheterization-derived single beat estimation. The targeted HR reduction of >30% by esmolol infusion, after controlled resuscitation of the LPS induced septic shock, led to a deteriorated RV-function and macrocirculation, while the microcirculation remained depressed. Esmolol improved VACR by decreasing the RV end-systolic pressure. Stopping esmolol showed the reversibility of these effects on the RV and the macrocirculation. In this animal model of acute severe endotoxic septic shock, early administration of esmolol decreased RV-function resulting in venous congestion and an unimproved poor microcirculation despite improved cardiac mechanical efficiency.


title: A rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

text: Late complications after a laparoscopic inguinal hernia repair are extremely rare and have only recently entered into the literature. One such late complication is mesh infection, of which there have been a handful of cases reported in the literature. Mesh infections occurring many years after inguinal hernia repairs are not only of significance because they are not well documented in the literature, and the pathogenesis and risk factors contributing to their development are not well understood. This report details a rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology.


title: Anterolateral Versus Medial Plating of Distal Extra-articular Tibia Fractures: A Biomechanical Model.

text: Both medial and anterolateral plate applications have been described for the treatment of distal tibia fractures, each with distinct advantages and disadvantages. The objective of this study was to compare the biomechanical properties of medial and anterolateral plating constructs used to stabilize simulated varus and valgus fracture patterns of the distal tibia. In 16 synthetic tibia models, a 45° oblique cut was made to model an Orthopedic Trauma Association type 43-A1.2 distal tibia fracture in either a varus or valgus injury pattern. Each fracture was then reduced and plated with a precontoured medial or anterolateral distal tibia plate. The specimens were biomechanically tested in axial and torsional loading, cyclic axial loading, and load to failure. For the varus fracture pattern, medial plating showed less fracture site displacement and rotation and was stiffer in both axial and torsional loading (P<.05). For the valgus fracture pattern, there was no statistically significant difference between medial and anterolateral plating. There were no significant differences between the 2 constructs for either fracture pattern with respect to ultimate load, displacement, or energy absorption in load to failure testing. When used to stabilize varus fracture patterns, medial plates showed superior biomechanical performance compared with anterolateral plates. In this application, the medial plates functioned in anti-glide mode. For valgus fracture patterns, no biomechanical differences between anterolateral and medial plating were observed. In clinical practice, surgeons should take this biomechanical evidence into account when devising a treatment strategy for fixation of distal tibia fractures.


title: Bariatric surgery for type 2 diabetes.

text: Bariatric surgery provides substantial, sustained weight loss and major improvements in glycaemic control in severely obese individuals with type 2 diabetes. However, uptake of surgery in eligible patients is poor, and the barriers are difficult to surmount. We examine the indications for and efficacy and safety of conventional bariatric surgical procedures and their effect on glycaemic control in type 2 diabetes. How surgical gastrointestinal interventions achieve these changes is of great research interest, and is evolving rapidly. Old classifications about restriction and malabsorption are inadequate, and we explore understanding of putative mechanisms. Some bariatric procedures improve glycaemic control in people with diabetes beyond that expected for weight loss, and understanding this additional effect could provide insights into the pathogenesis of type 2 diabetes and assist in the development of new procedures, devices, and drugs both for obese and non-obese patients.


title: Next-generation sequence analysis of genes associated with obesity and nonalcoholic fatty liver disease-related cirrhosis in extreme obesity.

text: OBJECTIVES Genome-wide association studies (GWAS) have led to the identification of single nucleotide polymorphisms in or near several loci that are associated with the risk of obesity and nonalcoholic fatty liver disease (NAFLD). We hypothesized that missense variants in GWAS and related candidate genes may underlie cases of extreme obesity and NAFLD-related cirrhosis, an extreme manifestation of NAFLD. METHODS We performed whole-exome sequencing on 6 Caucasian patients with extreme obesity [mean body mass index (BMI) 84.4] and 4 obese Caucasian patients (mean BMI 57.0) with NAFLD-related cirrhosis. RESULTS Sequence analysis was performed on 24 replicated GWAS and selected candidate obesity genes and 5 loci associated with NAFLD. No missense variants were identified in 19 of the 29 genes analyzed, although all patients carried at least 2 missense variants in the remaining genes without excess homozygosity. One patient with extreme obesity carried 2 novel damaging mutations in BBS1 and was homozygous for benign and damaging MC3R variants. In addition, 1 patient with NAFLD-related cirrhosis was compound heterozygous for rare damaging mutations in PNPLA3. CONCLUSIONS These results indicate that analyzing candidate loci previously identified by GWAS analyses using whole-exome sequencing is an effective strategy to identify potentially causative missense variants underlying extreme obesity and NAFLD-related cirrhosis.


title: The effectiveness of an oral opioid rescue medication algorithm for postoperative pain management compared to PCIA : A cohort analysis.

text: BACKGROUND Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA). MATERIAL AND METHODS This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0-10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management. RESULTS Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st-3rd quartile: 6 (3.75-8) vs. 5 (3-7), p = 0.023; maximum pain intensity: 7 (5-9) vs. 5 (3-8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47-154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = -2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = -1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management. CONCLUSION In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.


title: Robotic extended pelvic lymphadenectomy for intermediate- and high-risk prostate cancer.

text: BACKGROUND Accurate staging of prostate cancer is enhanced by a thorough evaluation of the pelvic lymph nodes. Limited data are available regarding robotic extended pelvic lymphadenectomy (PLA) in this setting. OBJECTIVE Analyze our experience performing robotic extended PLA. DESIGN, SETTING, AND PARTICIPANTS A total of 143 consecutive men with intermediate- or high-risk clinically localized adenocarcinoma of the prostate underwent robotic extended PLA and radical prostatectomy between September 2010 and November 2011 by a single surgeon. SURGICAL PROCEDURE Lymph node packets were sent separately from bilateral common, external, and internal iliacs, obturators, node of Cloquet, and anterior prostatic fat. MEASUREMENTS Descriptive statistics were used to summarize lymph node yields and positive nodes. Clinical variables were examined in logistic regression models to predict lymph node positivity. RESULTS AND LIMITATIONS Median lymph node yield was 20 (range: 9-65, interquartile range: 15-25). Eighteen patients (13%) were found to have metastatic prostate cancer in the lymph nodes. The mean number of positive nodes found was 2.9 (range: 1-11). In 14 of 18 node-positive patients (78%), the extent of nodal invasion was outside the boundaries of a limited PLA. For four patients with positive nodes (22%), prostate biopsy predicted unilateral disease but PLA revealed contralateral positive lymph nodes. A total of 82% of patients experienced no complications, and most Clavien grade 1-2 complications consisted of anastomotic leakage, urinary retention, ileus, and lymphocele. Only 4% of patients experienced a grade 3 complication. Under multivariate regression analysis, prostate-specific antigen (PSA), clinical stage, and maximum biopsy core tumor volume were identified as significant predictors of finding positive pelvic lymph nodes (area under the curve: 91%). The main limitations include short follow-up and lack of randomization. CONCLUSIONS Robotic extended bilateral PLA for prostate cancer up to the common iliac bifurcation increases nodal yield and positive nodal rate and can be performed safely. PSA, clinical stage, and maximum biopsy core volume are predictors for lymph node invasion. Long-term follow-up is needed to evaluate for therapeutic benefit.


title: Minimally invasive esthetic ridge preservation with growth-factor enhanced bone matrix.

text: OBJECTIVES Extraction socket preservation procedures are critical to successful esthetic implant therapy. Conventional surgical approaches are technique sensitive and often result in alteration of the soft tissue architecture, which then requires additional corrective surgical procedures. This case series report presents the ability of flapless surgical techniques combined with a growth factor-enhanced bone matrix to provide esthetic ridge preservation at the time of extraction for compromised sockets. CLINICAL CONSIDERATIONS When considering esthetic dental implant therapy, preservation, or further enhancement of the available tissue support at the time of tooth extraction may provide an improved esthetic outcome with reduced postoperative sequelae and decreased treatment duration. Advances in minimally invasive surgical techniques combined with recombinant growth factor technology offer an alternative for bone reconstruction while maintaining the gingival architecture for enhanced esthetic outcome. The combination of freeze-dried bone allograft (FDBA) and rhPDGF-BB (platelet-derived growth factor-BB) provides a growth-factor enhanced matrix to induce bone and soft tissue healing. CONCLUSIONS The use of a growth-factor enhanced matrix is an option for minimally invasive ridge preservation procedures for sites with advanced bone loss. Further studies including randomized clinical trials are needed to better understand the extent and limits of these procedures. CLINICAL SIGNIFICANCE The use of minimally invasive techniques with growth factors for esthetic ridge preservation reduces patient morbidity associated with more invasive approaches and increases the predictability for enhanced patient outcomes. By reducing the need for autogenous bone grafts the use of this technology is favorable for patient acceptance and ease of treatment process for esthetic dental implant therapy.


title: RECENT CHANGES IN INFECTIOUS DISEASES IN EUROPEAN WILDLIFE.

text: Many infectious diseases originating from, or carried by, wildlife affect wildlife conservation and biodiversity, livestock health, or human health. We provide an update on changes in the epidemiology of 25 selected infectious, wildlife-related diseases in Europe (from 2010-16) that had an impact, or may have a future impact, on the health of wildlife, livestock, and humans. These pathogens were selected based on their: 1) identification in recent Europe-wide projects as important surveillance targets, 2) inclusion in European Union legislation as pathogens requiring obligatory surveillance, 3) presence in recent literature on wildlife-related diseases in Europe since 2010, 4) inclusion in key pathogen lists released by the Office International des Epizooties, 5) identification in conference presentations and informal discussions on a group email list by a European network of wildlife disease scientists from the European Wildlife Disease Association, or 6) identification as pathogens with changes in their epidemiology during 2010-16. The wildlife pathogens or diseases included in this review are: avian influenza virus, seal influenza virus, lagoviruses, rabies virus, bat lyssaviruses, filoviruses, canine distemper virus, morbilliviruses in aquatic mammals, bluetongue virus, West Nile virus, hantaviruses, Schmallenberg virus, Crimean-Congo hemorrhagic fever virus, African swine fever virus, amphibian ranavirus, hepatitis E virus, bovine tuberculosis ( Mycobacterium bovis), tularemia ( Francisella tularensis), brucellosis ( Brucella spp.), salmonellosis ( Salmonella spp.), Coxiella burnetii, chytridiomycosis, Echinococcus multilocularis, Leishmania infantum, and chronic wasting disease. Further work is needed to identify all of the key drivers of disease change and emergence, as they appear to be influencing the incidence and spread of these pathogens in Europe. We present a summary of these recent changes during 2010-16 to discuss possible commonalities and drivers of disease change and to identify directions for future work on wildlife-related diseases in Europe. Many of the pathogens are entering Europe from other continents while others are expanding their ranges inside and beyond Europe. Surveillance for these wildlife-related diseases at a continental scale is therefore important for planet-wide assessment, awareness of, and preparedness for the risks they may pose to wildlife, domestic animal, and human health.


title: Initial experience of transanal total mesorectal excision with rigid or flexible transanal platforms in cadavers.

text: BACKGROUND Transanal total mesorectal excision (taTME) is expected to provide benefits in the removal of the complete mesorectum for low rectal lesions, and several clinical studies regarding this technique have been reported. However, a transanal platform has not yet been standardized, and diverse transanal endoluminal surgery access devices have been used, based on individual surgeon preferences. In the present study, we performed laparoscopy-assisted taTME in cadavers and compared the characteristics of four different platforms. METHODS Between January 2013 and April 2015, laparoscopy-assisted taTME was performed on six fresh cadavers. Flexible [SILS™ Port (Covidien), GelPOINT(®) Path Transanal Access Platform (Applied Medical)] and rigid [TEO(®) (Karl Storz Endoskope), TEM (Richard Wolf)] transanal access platforms were used on three cadavers each. RESULTS All cadavers were male, with a mean age of 69.2 (range 57-86) years. The mean operation time was 146.3 (range 140-155) min with flexible platforms and 206.7 (range 150-260) min with rigid platforms. The mean specimen length was 23 (range 18-26) cm. Complete or nearly complete mesorectal specimens were obtained in all cases, except for one case using the TEM platform. Flexible platforms (SILS and GelPOINT) provided a short set-up time, relatively atraumatic retraction, and easy application of familiar laparoscopic instruments; a narrow operative field was its limitation. The rigid platforms (TEO and TEM) enabled larger and more stable operative fields and space than did the SILS platform, but they were limited by a narrow view, prolonged set-up time, rigidity, and long channels relative to the short distance from the anus to the rectal closure site. CONCLUSION In this preliminary study, laparoscopy-assisted taTME was a feasible and safe procedure using both rigid and soft platforms, despite some limitations of each platform.


title: Two-Phase Contiguous Supported Lipid Bilayer Model for Membrane Rafts via Polymer Blotting and Stenciling.

text: The supported lipid bilayer has been portrayed as a useful model of the cell membrane compatible with many biophysical tools and techniques that demonstrate its appeal in learning about the basic features of the plasma membrane. However, some of its potential has yet to be realized, particularly in the area of bilayer patterning and phase/composition heterogeneity. In this work, we generate contiguous bilayer patterns as a model system that captures the general features of membrane domains and lipid rafts. Micropatterned polymer templates of two types are investigated for generating patterned bilayer formation: polymer blotting and polymer lift-off stenciling. While these approaches have been used previously to create bilayer arrays by corralling bilayers patches with various types of boundaries impenetrable to bilayer diffusion, unique to the methods presented here, there are no physical barriers to diffusion. In this work, interfaces between contiguous lipid phases define the pattern shapes, with continuity between them allowing transfer of membrane-bound biomolecules between the phases. We examine effectors of membrane domain stability including temperature and cholesterol content to investigate domain dynamics. Contiguous patterning of supported bilayers as a model of lipid rafts expands the application of the SLB to an area with current appeal and brings with it a useful toolset for characterization and analysis. These combined tools should be helpful to researchers investigating lipid raft dynamics and function and biomolecule partitioning studies. Additionally, this patterning technique may be useful for applications such as bioseparations that exploit differences in lipid phase partitioning or creation of membranes that bind species like viruses preferentially at lipid phase boundaries, to name a few.


Validating QT-Interval Measurement Using the Apple Watch ECG to Enable Remote Monitoring During the COVID-19 Pandemic.


title: Transanal total mesorectal excision: surgical technique description and outcomes.

text: Minimally invasive techniques (MIS) have been evolving quickly in colorectal surgery during the last two decades. Transanal total mesorectal excision (taTME) was developed as a combination of skills acquired from different MIS approaches such as Transanal Endoscopic Microsurgery (TEM), Transanal Minimally Invasive Surgery (TAMIS) and Natural Orifices Transluminal Endoscopic Surgery (NOTES). TaTME allows for a better visualization of surgical planes of dissection and achievement of rectal resection following oncologic principles. We here present the standardized taTME technique in use at the Hospital Clínic de Barcelona and our published outcomes in rectal cancer.


High-Flow Nasal Cannula to Prevent Desaturation in Endotracheal Intubation: A Word of Caution.


title: Initiation of Levodopa-Carbidopa Intestinal Gel Infusion Using Telemedicine (Video Communication System) Facilitates Efficient and Well-Accepted Home Titration in Patients with Advanced Parkinson's Disease.

text: BACKGROUND Levodopa-carbidopa intestinal gel (LCIG; Duodopa®) is used for continuous infusion in advanced Parkinson's disease. To achieve optimal effect, the LCIG dose is individually titrated, traditionally conducted during hospitalization in Sweden. However, dose adjustment depends on surrounding conditions, physical activity, and emotional stress, which is why titration at home could be beneficial. Telemedicine (TM) using a video communication system offers alternative titration procedures, allowing LCIG initiation at home. OBJECTIVE Study objectives were to show the feasibility of TM for LCIG home titration, evaluate resource use, and assess patient, neurologist, and nurse satisfaction. METHODS Four clinics enrolled 15 patients to observe efficiency and feasibility of TM-based monitoring. RESULTS Patient median (range) age was 67 (52-73) years and time since diagnosis was 10 (7-23) years. Median time between LCIG initiation and end of TM-assisted titration was 2.8 (2.0-13.8) days. Median time required for home titration by neurologists, nurses, and patients was (hours:minutes) 1 : 14 (0 : 29-1 : 52), 5 : 49 (2 : 46-10 : 3), and 8 : 53 (4 : 11-14 : 11), respectively. Neurologists and nurses considered this to be less time than required for hospital titration. TM allowed patients 92% free time from start to end of titration. Technical problems associated with TM contacts were rare, mostly related to digital link, and quickly resolved. Patients, neurologists, and nurses were satisfied using TM. No serious adverse events were reported; there was one device complaint (tube occlusion). CONCLUSIONS In this study, TM-assisted LCIG titration at home was resource-efficient, technically feasible, well-accepted and was deemed satisfactory by patients, neurologists, and nurses.


title: Diffusion-weighted imaging score of the brain stem: A predictor of outcome in acute basilar artery occlusion treated with the Solitaire FR device.

text: BACKGROUND AND PURPOSE The prognosis for ischemic stroke due to acute basilar artery occlusion is very poor: Early recanalization remains the main factor that can improve outcomes. The baseline extent of brain stem ischemic damage can also influence outcomes. We evaluated the validity of an easy-to-use DWI score to predict clinical outcome in patients with acute basilar artery occlusion treated by mechanical thrombectomy. MATERIALS AND METHODS We analyzed the baseline clinical and DWI parameters of 31 patients with acute basilar artery occlusion, treated within 24 hours of symptom onset by using a Solitaire FR device. The DWI score of the brain stem was assessed with a 12-point semiquantitative score that separately considered each side of the medulla, pons, and midbrain. Clinical outcome was assessed at 180 days by using the mRS. According to receiver operating characteristic analyses, the cutoff score determined the optimal positive predictive value for outcome. The Spearman rank correlation coefficient assessed the correlation between the DWI brain stem score and baseline characteristics. RESULTS Successful recanalization (Thrombolysis in Cerebral Infarction 3-2b) was achieved in 23 patients (74%). A favorable outcome (mRS ≤ 2) was observed in 11 patients (35%). An optimal DWI brain stem score of <3 predicted a favorable outcome. The probability of a very poor outcome (mRS ≥ 5) if the DWI brain stem score was ≥5 reached 80% (positive predictive value) and 100% if this score was ≥6. Interobserver reliability of the DWI brain stem score was excellent, with an intraclass correlation coefficient of 0.97 (95% CI, 0.96-0.99). The DWI brain stem score was significantly associated with baseline tetraplegia (P = .001) and coma (P = .005). CONCLUSIONS In patients with acute basilar artery occlusion treated by mechanical thrombectomy, the baseline DWI brain lesion score seems to predict clinical outcome.


title: Informing critical care drug requirements in response to the COVID-19 pandemic.

text: OBJECTIVES The main aim was to develop a process to estimate critical care drug requirements to robustly inform regional procurement planning and preparedness in response to the COVID-19 pandemic. The objectives were to identify critical care drugs required, obtain patient usage data and consider current regional practice to establish the requirement. METHOD Health and Social Care (HSC) Trusts across Northern Ireland (NI) identified critical care drugs required and an estimation of average daily usage data. The Microsoft Excel database was constructed to compile Trust data and establish regional requirement. The database was refined further according to real-world data from NI HSC Trusts, Intensive Care National Audit and Research Centre report on COVID-19 in critical care, daily regional COVID-19 figures and other available National data. Components of a tool originally developed for H1N1 and updated for COVID-19 were adapted to reflect the NI context and used in the regional database. The database was clinically reviewed to ensure that it accurately reflected current regional practice given the evolving nature of the pandemic. RESULTS The critical care drugs required in the pandemic, usage data and current regional practice were identified to establish requirement. A regional database was constructed and used to produce a model for calculating approximate critical drug requirements. The model was used to map critical drug requirements to available stock in Trusts and wholesalers/suppliers, enabling the identification of treatment capacity for these medicines regionally, both currently and for projected surges. Data have also been used in the preparation of weekly regional situation reports provided to both the HSC Board and the Department of Health. CONCLUSION The process developed is a robust approach to assist in informing regional critical care drug requirements in response to the COVID-19 pandemic. Further application has been demonstrated in regional procurement planning and preparedness.


title: Orthopaedic Guidelines for the COVID-19 Post-Outbreak Period: Experience from Wuhan, People's Republic of China.

text: Currently, the coronavirus disease 2019 (COVID-19) crisis has rapidly spread worldwide. As the earliest outbreak area of the pandemic, Wuhan, People's Republic of China, is gradually recovering to its normal state under the effective control of government authorities. Outpatient services in major hospitals are now being restored. An accumulation of asymptomatic infections is a potential risk for medical personnel, especially when there is crowding in hospitals. As the biggest center for orthopaedic patients in Wuhan, our orthopaedic outpatient department admits >300 patients per day. Optimal guidelines on how to handle this huge number of patients during the post-outbreak stage of the COVID-19 pandemic, particularly with regard to potential asymptomatic infection, are urgently needed for orthopaedic surgeons. We have developed and proposed applicable guidelines to fill this knowledge gap, including the necessary protective strategies for medical personnel in orthopaedic outpatient and inpatient wards as well as during surgery. We also have provided mental health recommendations for health-care workers. To the best of our knowledge, these guidelines are the first of their kind for orthopaedic surgeons who are slowly reestablishing medical activity following the pandemic.


title: COVID-19 in Neonates and Infants: Progression and Recovery.

text: Between March 10, 2020 and April 17, 2020, of 8/70 (11.4%) SARS-CoV-2 positive infants that presented, 5/8 (63%) developed fever, 4/8 (50%) had lower respiratory tract involvement, 2/8 (25%) had neutropenia and thrombocytosis, and 4/8 infants (50%) were treated for suspected sepsis with broad-spectrum antibiotics. Only 1/8 (13%) required pediatric intensive care. All patients were eventually discharged home well.


COVID-19 & Allergy: Allergists Workload During the Pandemic.


title: Sickness absence after carpal tunnel release: a systematic review of the literature.

text: Objectives The aim of this systematic review was to provide an overview of time to return to work (RTW) after carpal tunnel release (CTR), including return to different occupations and working patterns. Methods A systematic search from inception to 2016 was conducted using nine electronic databases, trial registries and grey literature repositories. Randomized controlled trials and observational studies reporting RTW times after CTR were included. Study risk of bias was assessed using Cochrane risk of bias assessment tools. Time to RTW was summarized using median and range. Results A total of 56 relevant studies were identified: 18 randomized controlled trials and 38 observational studies. Only 4 studies were rated as having a low risk of bias. Reported RTW times ranged from 4-168 days. Few studies reported occupational information. Among 6 studies, median time to return to non-manual work was 21 days (range 7-41), compared with 39 days for manual work (range 18-101). Median time to return to modified or full duties was 23 days (ranges 12-50 and 17-64, respectively), as reported by 3 studies. There was no common method of defining, collecting or reporting RTW data. Conclusions This review highlights wide variation in reported RTW times after CTR. Whilst occupational factors may play a role, these were poorly reported, and there is currently limited evidence to inform individual patients of their expected duration of work absence after CTR. A standardized definition of RTW is needed, as well as an agreed method of collecting and reporting related data.


title: Short-term Outcome of Robot-assisted and Open IPAA: An Observational Single-center Study.

text: BACKGROUND The potential advantages of robot-assisted laparoscopy are being increasingly investigated, although data on its efficacy in benign colorectal surgery are scarce. OBJECTIVE We compared the early postoperative outcome in robot-assisted IPAA with open surgery procedures. DESIGN This was an observational study based on prospectively collected data obtained from chart reviews. SETTING The single-center data set covers patients operated on from January 13, 2004, to September 16, 2014, at a specialist center. PATIENTS Patients with ulcerative colitis undergoing IPAA surgery were included. MAIN OUTCOME MEASURES Study end points included the duration of operation, admission length, complications (Clavien-Dindo), reoperations, and readmissions. RESULTS Eighty-one robot-assisted and 170 open IPAA procedures were performed. The duration of operation was significantly longer for robot-assisted laparoscopic procedures (mean difference, 154 minutes; CI, 140-170). During a mean follow-up of 102 days, no significant differences in the distribution of complications were found (Spearman p = 0.12; p = 0.07), and no postoperative deaths occurred in either group. Postoperative admission length was shorter following robot-assisted procedures (mean difference, -1.9; CI, -3.5 to -0.3), whereas 40% of patients were readmitted, compared with 26% of patients who had open surgery (OR, 1.9; CI, 1.1-3.4). Pouch failure occurred in 3 patients (1 following robot-assisted laparoscopy; 2 following open surgery). On multivariate regression analyses, robot-assisted laparoscopy was associated with a significantly longer duration of operation (mean difference, 159 minutes; CI, 144-174), and more readmissions for any cause (OR, 2; CI, 1.1-3.7). LIMITATIONS This was a nonrandomized, single-center observational study. CONCLUSION In this implementation phase, robot-assisted IPAA surgery offers acceptable short-term outcomes. The limitations of this observational study call for randomized controlled trials with long-term follow-up and exploration of functional results.


title: Predictors of bleeding in patients with acute coronary syndromes treated with prasugrel.

text: BACKGROUND When considering antiplatelet therapy for acute coronary syndrome (ACS), it is essential to balance benefits (less thrombotic/ischaemic events) versus bleeding risks related to intense platelet inhibition via antagonism of P2Y12 receptors. This analysis aimed to identify predictors of bleeding events among A Comparison of Prasugrel at the Time of PCI or as Pretreatment at the Time of Diagnosis in Patients with NSTEACS (ACCOAST) study population. METHODS AND RESULTS The ACCOAST study randomised 4033 patients with non-ST-segment elevation myocardial infarction (NSTEMI) to (A) a 30 mg prasugrel loading dose (LD) followed by coronary angiography with an additional 30 mg prasugrel at the time of percutaneous coronary intervention (PCI) or (B) a placebo LD followed by a 60 mg prasugrel at the time of PCI. Patients received standard of care, including use of aspirin. Independent predictors of Thrombolysis in Myocardial Infarction (TIMI) major bleeding not related to coronary artery bypass grafting (CABG) within 7 days were assessed using stepwise Cox proportional model for time to first occurrence of the event. Non-CABG-related TIMI major or minor bleeding was similarly analysed. Non-CABG-related TIMI major bleeding occurred in 36 (0.9%) patients, and TIMI major or minor bleeding occurred in 81 (2.0%) patients. Independent predictors for TIMI major bleeding alone were pretreatment with prasugrel LD (HR 3.02; 95% CI 1.42 to 6.43), femoral access (HR 2.45; 95% CI 1.11 to 5.38), female sex (HR 2.57; 95% CI 1.32 to 5.00), placement of >1 stent (HR 2.50; 95% CI 1.26 to 4.95) and age (HR 1.05; 95% CI 1.02 to 1.09). Pretreatment with prasugrel LD (HR 3.05; 95% CI 1.84 to 5.07), femoral access (HR 3.06; 95% CI 1.74 to 5.38), female sex (HR 2.62; 95% CI 1.67 to 4.12), performed PCI (HR 2.21; 95% CI 1.23 to 3.99), therapy with glycoprotein IIb/IIIa inhibitors (HR 1.88; 95% CI 1.06 to 3.33) and age (increased bleed per year of age HR 1.04; 95% CI 1.02 to 1.06) were independent predictors of TIMI major or minor bleeding through 7 days. CONCLUSIONS Pretreatment, age, gender and procedural variables predicted bleeding risk in patients with NSTEMI. CLINICAL REGISTRATION NO NCT01015287.


title: The timing, extent, progression and regression of deep vein thrombosis in immobile stroke patients: observational data from the CLOTS multicenter randomized trials.

text: BACKGROUND Deep vein thrombosis (DVT) is an important complication of stroke, but the evidence to support commonly used prophylactic strategies is conflicting. OBJECTIVES To describe the incidence, extent, associated clinical features and evolution of DVT after stroke. PATIENTS/METHODS The CLOTS trials 1 and 2 together randomized 5632 immobile stroke patients in 135 hospitals in nine countries. We screened patients for asymptomatic DVT with compression duplex ultrasound (CDU) at about 7-10 days and again at about 25-30 days after enrollment. RESULTS Six hundred and forty-one (11.4%) of 5632 patients had DVT detected on the first CDU scan at a median of 8 days (interquartile range [IQR] 7-10 days) after enrollment, and an additional 176 (3.1%) had a DVT on the second CDU scan at a median of 28 days (IQR 26-30 days). Of the 817 with DVTs, 289 (35%) were symptomatic and 39 (5%) had pulmonary embolism (PE) confirmed by imaging. Six hundred and seventy-six (83%) were unilateral, 141 (17%) were bilateral, 322 (39%) were limited to calf veins, 172 (21%) were popliteal, and 323 (40%) were femoral. Among the 542 patients with DVT and a weak leg, the DVT affected the weaker leg in 396 (73%), the stronger leg in 59 (11%), and was bilateral in 87 (16%). Among the 318 patients with a DVT detected on the first CDU scan who had a second scan, the DVT regressed in 148 (47%), stayed the same in 140 (44%), and progressed in only 30 (9%). CONCLUSIONS Although most DVTs develop within the first week, some develop later, and some early DVTs progress. Any prophylaxis needs to be started early but ideally continued for at least 4 weeks.


title: Non-antipsychotic catecholaminergic drugs for antipsychotic-induced tardive dyskinesia.

text: BACKGROUND Tardive dyskinesia (TD) is a disabling movement disorder associated with the prolonged use of antipsychotic medication. Several strategies have been examined in the treatment of TD. Currently, however, there is no clear evidence of the effectiveness of these drugs in TD and they have been associated with many side effects. One particular strategy would be to use pharmaceutical agents which are known to influence the catecholaminergic system at various junctures. OBJECTIVES 1. To determine the effects of any of the following drugs for antipsychotic-induced TD in people with schizophrenia or other chronic mental illnesses.i. Drugs which influence the noradrenergic system.ii. Dopamine receptor agonists.iii. Dopamine receptor antagonists.iv. Dopamine-depletor drugs.v. Drugs that increase the production or release of dopamine.2. To examine whether any improvement occurred with short periods of intervention (less than 6 weeks) and, if this did occur, whether this effect was maintained at longer periods of follow-up.3. To examine if there was a differential effect for the various compounds.4. To examine whether the use of non-antipsychotic catecholaminergic drugs are most effective in those with more recent onset TD (less than five years). SEARCH METHODS We retrieved 712 references from searching the Cochrane Schizophrenia Group Trials Register (July 2015 and April 2017). We also inspected references of all identified studies for further trials and contacted authors of trials for additional information. SELECTION CRITERIA We selected studies if they were randomised controlled trials focusing on people with schizophrenia or other chronic mental illnesses and antipsychotic-induced tardive dyskinesia. We compared the use of catecholaminergic interventions versus placebo, no intervention, or any other intervention for the treatment of antipsychotic-induced tardive dyskinesia. DATA COLLECTION AND ANALYSIS We independently extracted data from these trials and we estimated risk ratios (RRs) with 95% confidence intervals (CIs). We assumed that people who left the studies early had no improvement. MAIN RESULTS There are 10 included trials (N = 261) published between 1973 and 2010; eight are new from the 2015 and 2017 update searches. Forty-eight studies are excluded. Participants were mostly chronically mentally ill inpatients in their 50s, and studies were primarily of short (2 to 6 weeks) duration. The overall risk of bias in these studies was unclear, mainly due to poor reporting of allocation concealment and generation of the sequence. Studies were also not clearly blinded and we are unsure if data are incomplete or selectively reported, or if other biases were operating.One small, three-arm trial found that both alpha-methyldopa (N = 20; RR 0.33, 95% CI 0.14 to 0.80; low-quality evidence) and reserpine (N = 20; RR 0.52 95% CI 0.29 to 0.96; low-quality evidence) may lead to a clinically important improvement in tardive dyskinesia symptoms compared with placebo after 2 weeks' treatment, but found no evidence of a difference between alpha-methyldopa and reserpine (N = 20; RR 0.60, 95% CI 0.19 to 1.86; very low quality evidence). Another small trial compared tetrabenazine and haloperidol after 18 weeks' treatment and found no evidence of a difference on clinically important improvement in tardive dyskinesia symptoms (N = 13; RR 0.93, 95% CI 0.45 to 1.95; very low quality evidence). No study reported on adverse events.For remaining outcomes there was no evidence of a difference between any of the interventions: alpha-methyldopa versus placebo for deterioration of tardive dyskinesia symptoms (1 RCT; N = 20; RR 0.33, 95% CI 0.02 to 7.32; very low quality evidence), celiprolol versus placebo for leaving the study early (1 RCT; N = 35; RR 5.28, 95% CI 0.27 to 102.58; very low quality evidence) and quality of life (1 RCT; N = 35; RR 0.87, 95% CI 0.68 to 1.12; very low quality evidence), alpha-methyldopa versus reserpine for deterioration of tardive dyskinesia symptoms (1 RCT; N = 20; not estimable, no reported events; very low quality evidence), reserpine or carbidopa/levodopa versus placebo for deterioration of tardive dyskinesia symptoms (2 RCTs; N = 37; RR 1.18, 95% CI 0.35 to 3.99; very low quality evidence), oxypertine versus placebo for deterioration of mental state (1 RCT; N = 42; RR 2.20, 95% CI 0.22 to 22.45; very low quality evidence), dopaminergic drugs (amantadine, bromocriptine, tiapride, oxypertine, carbidopa/levodopa) versus placebo for leaving the study early (6 RCTs; N = 163; RR 1.29, 95% CI 0.65 to 2.54; very low quality evidence), and tetrabenazine versus haloperidol for deterioration of tardive dyskinesia symptoms (1 RCT; N = 13; RR 1.17, 95% CI 0.09 to 14.92) and leaving the study early (1 RCT; N = 13; RR 0.23, 95% CI 0.01 to 4.00). AUTHORS' CONCLUSIONS Although there has been a large amount of research in this area, many studies were excluded due to inherent problems in the nature of their cross-over designs. Usually data are not reported before the cross-over and the nature of TD and its likely response to treatments make it imprudent to use this data. The review provides little usable information for service users or providers and more well-designed and well-reported studies are indicated.


title: Laboratory surveillance for SARS-CoV-2 in India: Performance of testing & descriptive epidemiology of detected COVID-19, January 22 - April 30, 2020.

text: Background & objectives India has been reporting the cases of coronavirus disease 2019 (COVID-19) since January 30, 2020. The Indian Council of Medical Research (ICMR) formulated and established laboratory surveillance for COVID-19. In this study, an analysis of the surveillance data was done to describe the testing performance and descriptive epidemiology of COVID-19 cases by time, place and person. Methods The data were extracted from January 22 to April 30, 2020. The frequencies of testing performance were described over time and by place. We described cases by time (epidemic curve by date of specimen collection; seven-day moving average), place (area map) and person (attack rate by age, sex and contact status), and trends were represented along with public health measures and events. Results Between January 22 and April 30, 2020, a total of 1,021,518 individuals were tested for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Testing increased from about 250 individuals per day in the beginning of March to 50,000 specimens per day by the end of April 2020. Overall, 40,184 (3.9%) tests were reported positive. The proportion of positive cases was highest among symptomatic and asymptomatic contacts, 2-3-fold higher than among those with severe acute respiratory infection, or those with an international travel history or healthcare workers. The attack rate (per million) by age was highest among those aged 50-69 yr (63.3) and was lowest among those under 10 yr (6.1). The attack rate was higher among males (41.6) than females (24.3). The secondary attack rate was 6.0 per cent. Overall, 99.0 per cent of 736 districts reported testing and 71.1 per cent reported COVID-19 cases. Interpretation & conclusions The coverage and frequency of ICMR's laboratory surveillance for SARS-CoV-2 improved over time. COVID-19 was reported from most parts of India, and the attack rate was more among men and the elderly and common among close contacts. Analysis of the data indicates that for further insight, additional surveillance tools and strategies at the national and sub-national levels are needed.


title: Wire escalation in emergent revascularization procedures of internal carotid artery occlusions: the use of high tip stiffness microguidewires.

text: OBJECTIVE We examined the usefulness and safety of high tip stiffness cardiac microguidewires in the endovascular revascularization of selected cases of internal carotid artery (ICA) occlusion. METHODS Files of patients with acute ischemic symptoms due to ICA occlusions managed from August 2010 to August 2016 by urgent endovascular revascularization were retrospectively reviewed with a waiver of informed consent. Cases where there was escalation to stiff tipped cardiovascular microguidewires after at least two failed attempts to cross the carotid occlusion with standard neuro-microguidewires were included. Radiological and interventional data were recorded. RESULTS 63 patients with acute carotid occlusions underwent emergent endovascular revascularization in the study period; 5/63 patients met the inclusion criteria. In 4/5 patients, there was no angiographic evidence of the remnant origin of the ICA; in 1/5 there was a wide round shaped proximal calcified cap that precluded soft guidewire entry. In all cases, antegrade wiring was achieved only after switching to stiffer guidewires designed for the management of chronic cardiac occlusions. The use of these stiffer tip wires was considered of critical importance in achieving the successful performance of the ICA revascularization procedure. In all patients, revascularization was achieved, and 90 day modified Rankin Scale score ranged from 0 to 2. CONCLUSIONS When regular neuro-guidewires do not allow antegrade wiring in cases of ICA occlusion, wire escalation to high tip stiffness guidewires may improve success. These wires, designed to deal with chronic total coronary occlusions, can serve as a platform for new neuro-guidewires to be used in the challenging field of resistant supra-aortic occlusions.


title: Risk factors analysis and nomogram construction of non-survivors in critical patients with COVID-19.

text: A pandemic named coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbroke in China since December 2019. This disease has caused more than 70000 deaths worldwide. We intend to analyze the risk factors of death and establish a prognosis nomogram for critical patients with COVID-19. We analyzed the clinical data of COVID-19 patients in Zhongnan Hospital of Wuhan University who were critical cases with COVID-19 before March 20, 2020. Data were collected at admission and compared between survivors and non-survivors and analyzed by univariable and multivariable logistic regression analysis. Finally, 104 patients were included, and 50 of whom died. Age [ OR 5.73 (95% CI, 1.14-28.81)], chest tightness [OR 5.50 (95%CI, 1.02-29.64)], AST [OR 6.57 (95%CI, 1.33-32.48)]and BUN [5.59 (95%CI, 1.05-29.74)] at admission were considered to predict the risk of death in critical patients and were selected to construct the nomogram. Subsequently, we established a nomogram model and validated it. The sensitivity and specificity of the nomogram were 96.0% and 74.1%, respectively. The AUC was 0.893 (95% CI, 0.807-0.980).


title: The Silver Lining to COVID-19: Avoiding Diabetic Ketoacidosis Admissions with Telehealth.

text: Background: The Stay at Home order in Colorado and The Stay Safe at Home order in California during COVID-19 pandemic have forced a majority of the endocrinologists/diabetologists to adapt to providing diabetes care remotely through telehealth. This may provide increased access to diabetes health care in certain settings. However, health care disparities continue to challenge availability of diabetes technologies for underprivileged communities. We report our experience with two patients providing diabetes care effectively and preventing hospital admissions by using telehealth. Methods: Two adult patients with type 1 diabetes (T1D): one new onset and the other one with established T1D are presented where telehealth facilitated by Clarity Software and the "Share" feature with the use of Dexcom G6 continuous glucose monitoring (CGM) for management of diabetic ketosis and hyperglycemia. Results: Both patients were managed effectively virtually despite higher risk of diabetic ketoacidosis (DKA). Shared glucose data through CGM facilitated frequent insulin dose adjustments, increased fluid and carbohydrate intake, and prevented hospital admissions in both cases. In the case of new onset patient with T1D, most of the education was done remotely by certified diabetes care and education specialists. Conclusion: Acute diabetes complication like DKA increases morbidity and mortality in addition to adding cost to the health care system. The current pandemic of COVID-19 has allowed newer ways (with the help of newer technologies) to manage high-risk patients with T1D and DKA through telehealth and may result in lasting benefits to people with T1D.


title: COVID-19 in a Long-Term Care Facility - King County, Washington, February 27-March 9, 2020.

text: On February 28, 2020, a case of coronavirus disease (COVID-19) was identified in a woman resident of a long-term care skilled nursing facility (facility A) in King County, Washington.* Epidemiologic investigation of facility A identified 129 cases of COVID-19 associated with facility A, including 81 of the residents, 34 staff members, and 14 visitors; 23 persons died. Limitations in effective infection control and prevention and staff members working in multiple facilities contributed to intra- and interfacility spread. COVID-19 can spread rapidly in long-term residential care facilities, and persons with chronic underlying medical conditions are at greater risk for COVID-19-associated severe disease and death. Long-term care facilities should take proactive steps to protect the health of residents and preserve the health care workforce by identifying and excluding potentially infected staff members and visitors, ensuring early recognition of potentially infected patients, and implementing appropriate infection control measures.


title: Utility of nociceptive flexion reflex threshold and bispectral index to predict movement responses under propofol anaesthesia.

text: INTRODUCTION The nociceptive flexion reflex threshold (NFRT) is a promising tool to monitor analgesia during general anaesthesia. Clinical studies have shown that the NFRT allows to predict movement responses to painful stimuli under a combined anaesthetic regime of sedative and opioid agents. Experimental studies indicated that the NFRT is also able to predict such movement responses under an exclusively sedative regime like propofol mono-anaesthesia. Therefore, we performed this study to investigate the ability of the NFRT to predict movement responses to painful stimuli in patients during a clinical propofol mono-anaesthesia. METHODS We investigated 140 cardiac surgery patients during their postoperative phase under propofol mono-anaesthesia. NFRT and bispectral index (BIS) were determined in each patient right before endotracheal suctioning or painful electrical test stimulation. Prediction probabilities were calculated to quantify how accurate each measure is able to predict movement responses to the stimuli. RESULTS The 124 patients included in the analysis received a median propofol dosage of 3.2 (2.5-3.9) [median (IQR)] mg/kg/h. The included patients showed 287 movement responses after a total of 725 investigated stimuli. The prediction probabilities for positive movement responses were 0.63 (95%CI: 0.59-0.67) for the NFRT and 0.69 (95%CI: 0.65-0.73) for the BIS. CONCLUSIONS The NFRT allows the prediction of movement responses under propofol mono-anaesthesia, which confirms its utility as a monitor to predict movement responses under general anaesthesia. The BIS allows an even more accurate prediction, although it does not reflect the physiological structures of movement suppression, but correlates closely with the dose of propofol. TRIAL REGISTRATION German clinical trial register (DRKS00003062, Deutsches Register Klinischer Studien).


Understanding the cytokine storm during COVID-19: Contribution of preexisting chronic inflammation.


title: Evaluation of methods based on creatinine and cystatin C to estimate glomerular filtration rate in chronic kidney disease.

text: PURPOSE Estimated glomerular filtration rate (GFR) is a useful tool for the detection of chronic kidney disease (CKD). Several methods have been proposed, but findings can vary in specific groups such as patients with diabetes, elderly and high and low body mass index and, also, with the stage of CKD. The objective of this study was comparing the accuracy of the currently used equations for estimating GFR with that of the gold standard technetium-(99m)-diethylene triamine pentaacetic acid (99mTc-DTPA). METHODS We performed a cross-sectional study of 129 patients with all five CKD stages. GFR was estimated using the following: 24-h urine creatinine clearance, Cockcroft-Gault equation, MDRD equation, CKD-EPI equation, Hoek's cystatin C equation, and isotopic 99mTc-DTPA (as gold standard). We evaluated agreement in the whole study population and according to age, sex, weight, and diabetes. RESULTS All methods had good agreement. The best agreement was observed with the cystatin C [intraclass coefficient correlation (ICC) 95 % confidence interval (95 % CI), 0.87 (0.82-0.91)], followed by CKD-EPI [ICC 0.83 (0.77-0.88)]. Twenty-four-hour urine creatinine clearance showed the worst agreement in patients older than 65 years [ICC 0.70 (0.56-0.79)]. The Cockcroft-Gault equation showed the worst agreement in younger than 65 years [ICC 0.64 (0.42-0.79)]. The best agreement for classification in the correct CKD stage was with the cystatin C equation [κ = 0.80 (0.74-0.87)]. GFR was overestimated with all methods in CKD stages 4 and 5. CONCLUSIONS The methods used in clinical practice are adequate for classification of CKD. Cystatin C is the most accurate method, followed by CKD-EPI. The Cockcroft-Gault equation is not accurate in young patients. Twenty-four-hour urine creatinine clearance loses accuracy in patients aged older than 65 years.


title: Routine Shunting During Carotid Endarterectomy in Patients With Acute Watershed Stroke.

text: AIM To evaluate the protective role of routine shunting in patients with acute watershed stroke (WS) undergoing carotid endarterectomy (CEA). METHODS A total of 138 patients with symptomatic carotid stenosis (SCS) who underwent CEA after acute ischemic stroke from March 2008 to March 2015 were included in this study. Transient ischemic attacks were excluded. These patients were divided into 2 groups according to the topographic pattern of the stroke on magnetic resonance imaging: group 1, territorial strokes (TS) caused by emboli of carotid origin, and group 2, WS caused by a hemodynamic mechanism related to an SCS. Primary end points were 30-day mortality and postoperative neurological morbidity. The insertion of a Pruitt carotid shunt was performed systematically. RESULTS Ninety (65.2%) patients presented a TS of carotid origin and were included in group 1, and 48 (34.8%) of the 138 patients had a WS related to an SCS and were included in group 2. The median time between clinical onset of the cerebral ischemic event and surgery was 9 days (range: 0-89 days). Postoperative mortality was 0%. Seven (5.1%) patients had an aggravation of the neurological status during the postoperative period, of whom 2 presented a complete regression of the symptoms in less than 1 hour (definitive postoperative neurologic morbidity: 3.6%). Postoperative neurologic morbidity rate was significantly higher in the TS group (7 of 90; 7.8%) compared to the WS group (0 of 48; P = .04). No other independent predictive factor of neurologic morbidity after CEA for an SCS was found. CONCLUSIONS Our results suggest that routine shunting should be considered in case of acute WS since it may play a protective role. Further studies are eagerly awaited to better define the timing and the best treatment option for both acute WS and TS related to an SCS in order to reduce postoperative neurologic morbidity.


Early clinical response to a high consequence infectious disease outbreak: insights from COVID-19.