title: Prophylactic heparin in acute intracerebral hemorrhage: a propensity score-matched analysis of the INTERACT2 study.

text: BACKGROUND Indication and timing of pharmacological venous thromboembolism prophylaxis in intracerebral hemorrhage patients is controversial. AIMS To determine whether use of subcutaneous heparin during the first 7 days after spontaneous intracerebral hemorrhage increases risks of death and disability. METHODS Data are from the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) study. Patients with acute intracerebral hemorrhage (<6 hours) and elevated systolic blood pressure were included; patients received subcutaneous heparin following local best practice standards of care. Multivariable logistic regression and propensity score matched analysis were used to determine associations of heparin use on death and disability (modified Rankin scale) at 90 days. RESULTS In 2525 patients with available data, there were 465 (22.5%) who received subcutaneous heparin. They had higher death or major disability at 90 days in crude (odds ratio 2.29, 95% confidence interval 1.85-2.84; p < 0.001), adjusted (odds ratio 1.62, 95% confidence interval 1.26-2.09; p < 0.001) and propensity score matched (odds ratio 2.06, 95% confidence interval 1.53-2.77; p < 0.001) analyses. In propensity score matched analysis, heparin-treated patients had significant lower mortality (odds ratio 0.55, 95% CI 0.35-0.87; p = 0.01) but greater major disability (odds ratio 1.68, 95% confidence interval 1.25-2.28; p < 0.001) at 90 days. However, no mortality difference was found in analysis restricted to 48-hour survivors. CONCLUSIONS Use of subcutaneous heparin is associated with poor outcome in acute intracerebral hemorrhage, driven by increased residual disability. Despite the limitations of this study, and no clear relation of heparin with bleeding risk, we recommend careful consideration of the need for venous thromboembolism prophylaxis with heparin in intracerebral hemorrhage patients. TRIAL REGISTRATION http://www.clinicaltrials.gov NCT00716079.


title: QSAR prediction of HIV-1 protease inhibitory activities using docking derived molecular descriptors.

text: In this study, application of a new hybrid docking-quantitative structure activity relationship (QSAR) methodology to model and predict the HIV-1 protease inhibitory activities of a series of newly synthesized chemicals is reported. This hybrid docking-QSAR approach can provide valuable information about the most important chemical and structural features of the ligands that affect their inhibitory activities. Docking studies were used to find the actual conformations of chemicals in active site of HIV-1 protease. Then the molecular descriptors were calculated from these conformations. Multiple linear regression (MLR) and least square support vector machine (LS-SVM) were used as QSAR models, respectively. The obtained results reveal that statistical parameters of the LS-SVM model are better than the MLR model, which indicate that there are some non-linear relations between selected molecular descriptors and anti-HIV activities of interested chemicals. The correlation coefficient (R), root mean square error (RMSE) and average absolute error (AAE) for LS-SVM are: R=0.988, RMSE=0.207 and AAE=0.145 for the training set, and R=0.965, RMSE=0.403 and AAE=0.338 for the test set. Leave one out cross validation test was used for assessment of the predictive power and validity of models which led to cross-validation correlation coefficient QUOTE of 0.864 and 0.850 and standardized predicted relative error sum of squares (SPRESS) of 0.553 and 0.581 for LS-SVM and MLR models, respectively.


title: Uniportal video-assisted thoracoscopic lobectomy: Zhongshan experience.

text: BACKGROUND Uniportal video-assisted thoracoscopic surgery (VATS) is an emerging technique in the field of thoracic surgery. In this article, we aimed to describe uniportal VATS lobectomy that was conventionally performed in an Eastern center, which might help facilitate a good beginning in practice this technique. METHODS The indications of uniportal VATS lobectomy are merely equal, if not the same, to multiportal VATS lobectomy. All patients would receive a combination of epidural and general anesthesia, and were provided with patient-controlled analgesia (PCA) postoperatively. Generally, the patient was kept in a folding knife gesture (with the cranial side slightly raised up and caudal side pushed down) in lateral decubitus position. RESULTS In uniportal VATS lobectomy, the geographical view differed from multiportal VATS, while the thoracic cavity required carefully exploration to identify any unexpected invasion or metastasis. Since the incision was located at the anterior axillary line close to the anterior part of the hilar, the posterior part of the hilar, and diaphragm were far from the surgical incision. CONCLUSIONS Uniportal VATS, is not the happy ending in thoracic surgery. Beside its rapid progression, there remained a lot of questions to answer. Its uncovered benefits and drawbacks over traditional VATS, its possible improvements, and less invasive peri-operative managements could be the future topics. A comparison between uniportal versus multiportal VATS using high-level methodology is therefore required. With the development of surgical minds and instruments, uniportal VATS would have done more to the patients.


title: Persistence of Bacteriophage Phi 6 on Porous and Non-Porous Surfaces; Potential for use as Ebola or Coronavirus Surrogate.

text: The infection of healthcare workers during the 2013 -2016 Ebola outbreak raised concerns about fomite transmission. In the wake of the Coronavirus Disease 2019 (COVID-19) pandemic, investigations are ongoing to determine the role of fomites in coronavirus transmission as well. The bacteriophage Phi 6 has a phospholipid envelope and is commonly used in environmental studies as a surrogate for human enveloped viruses. The persistence of Phi 6 was evaluated as a surrogate for EBOV and coronaviruses on porous and nonporous hospital surfaces. Phi 6 was suspended in a body fluid simulant and inoculated onto 1 cm2 coupons of steel, plastic, and two fabric curtain types. The coupons were placed at two controlled absolute humidity (AH) levels; a low AH of 3.0 g/m3 and a high AH of 14.4 g/m3 Phi 6 declined at a slower rate on all materials under low AH conditions with a decay rate of 0.06 log10PFU/d to 0.11 log10PFU/d, as compared to the higher AH conditions with a decay rate of 0.65 log10PFU/h to 1.42 log10PFU/d. There was a significant difference in decay rates between porous and non-porous surfaces at both low AH (P < 0.0001) and high AH (P < 0.0001). Under these laboratory-simulated conditions, Phi 6 was found to be a conservative surrogate for EBOV under low AH conditions, in that it persisted longer than Ebola virus in similar AH conditions. Additionally, some coronaviruses persist longer than phi6 under similar conditions, therefore Phi6 may not be a suitable surrogate for coronaviruses.IMPORTANCE Understanding the persistence of enveloped viruses helps inform infection control practices and procedures in healthcare facilities and community settings. These data convey to public health investigators that enveloped viruses can persist and remain infective on surfaces, thus demonstrating a potential risk for transmission. Under these laboratory-simulated western indoor hospital conditions, Phi 6 was used to assess suitability as a surrogate for environmental persistence research related to enveloped viruses, including EBOV and coronaviruses.


title: Onyx in Brain Arteriovenous Malformation Embolisation.

text: INTRODUCTION Embolisation has long been used as an adjunct to surgical resection in the treatment of brain arteriovenous malformation (bAVM). The most commonly used embolic material, n-butylcyanoacrylate glue, requires experience and skill to handle its quick and unpredictable flow and polymerisation. A new liquid embolic agent, ethylene vinyl alcohol copolymer (Onyx), is less adhesive and polymerises slowly, which provides better control for radiologists performing embolisation. OBJECTIVE To report our experience in embolisation using Onyx alone or in combination with histoacryl for bAVM embolisation in our tertiary referral centre. METHODS We retrospectively reviewed the anatomy, technical conditions, complications and clinical outcome of all bAVM patients embolised at our centre using Onyx alone or in combination with n-butylcyanoacrylate glue. RESULTS Between 2010 and 2013, 13 patients [6 (46.2%) male; 7 (53.8%) female; aged, 14-57 years] were included, and a total of 31 embolisations were performed. Clinical presentation included hemorrhage [9 (69.2%)], seizures [2 (15.4%)], and headache [2 (15.4%)]. Most AVMs were located in the brain hemispheres [12 (92.3%)] and measured <3 cm [7 (53.8%]. Complete occlusion of the AVM was obtained in 2 (15.4%) patients; 11 (84.6%) patients had partial occlusion [6 (54.5%) had <50% nidus occlusion]. Complications occurred in four procedures involving 3 patients (morbidity, 23.1%). This resulted in the death of 1 patient (mortality, 7.7%) and complete recovery with no disability in 2 patients. CONCLUSION The total nidal occlusion achieved herein is comparable to other similar studies. Our morbidity and mortality were higher compared to other studies which may be attributed to the small number of patients. More data is being collected which may better reflect on our experience.


title: Divide and conquer: strategies to manage a nuclear medicine department during COVID-19.

text: The Covid-19 outbreak was declared a Public Health Emergency of International Concern by the World Health Organisation (WHO) on 30 January 2020. Since then, the virus has spread to affect more countries worldwide. During this period, our nuclear medicine at Singapore General Hospital segregated our staff and patients either by time, space, or both, to minimise contact and prevent the spread of the virus. We also made necessary changes to clinical practices and enforced strict infection control measures. We share our personal experience in managing a nuclear medicine department during this epidemic.


What Other Countries Can Learn From Italy During the COVID-19 Pandemic.


2016 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Boston, Massachusetts, USA, 16-19 March 2016 : Oral Presentations.


Promoting platelets is a therapeutic option to combat severe viral infection of the lung.


title: Prescribing opioids for chronic noncancer pain in primary care: risk assessment.

text: The use of opioids for patients with chronic noncancer pain has increased dramatically, and with increasing use there is increasing concern about the potential for abuse and addiction during long-term treatment. Clinicians should avoid viewing formal or subjective risk assessment as a means of classifying patients into 2 distinct categories: compliant patients and substance abusers. The provider who perceives a patient as compliant may have a complacent attitude toward aberrant drug-related behavior, presuming that these signs reflect inadequately controlled pain, to be addressed by dose escalation. The provider who perceives a patient as a substance abuser may refuse to provide treatment for pain, leaving the patient to seek either illicit drugs or prescribed treatment from another provider. In fact, in seemingly compliant patients, any noncompliant use of opioids presents a safety risk regardless of the explanations offered. Even in known or suspected drug abusers, chronic pain warrants the use of adequate pharmacotherapy, although treatment in such cases may exclude drugs with high abuse potential. Thus, all aberrant drug-related behavior should be addressed within a treatment plan that combines adequate pain care with suitable interventions for the aberrant behavior, following current best practice strategies. This approach is consistent with the approach taken with other health conditions, such as diabetes or hypertension, for which it is understood that noncompliance with therapy presents a risk of harm.


title: Remission of Barrett's esophagus with early neoplasia 5 years after radiofrequency ablation with endoscopic resection: a Netherlands cohort study.

text: BACKGROUND & AIMS Radiofrequency ablation (RFA), with or without endoscopic resection effectively eradicates Barrett's esophagus (BE) containing high-grade intraepithelial neoplasia and/or early-stage cancer. We followed patients who received RFA for BE containing high-grade intraepithelial neoplasia and/or early-stage cancer for 5 years to determine the durability of treatment response. METHODS We followed 54 patients with BE (2-12 cm), previously enrolled in 4 consecutive cohort studies in which they underwent focal endoscopic resection in case of visible lesions (n = 40 [72%]), followed by serial RFA every 3 months. Patients underwent high-resolution endoscopy with narrow-band imaging at 6 and 12 months after treatment and then annually for 5 years (median, 61 months; interquartile range, 53-65 months); random biopsy samples were collected from neosquamous epithelium and gastric cardia. After 5 years, endoscopic ultrasound and endoscopic resection of neosquamous epithelium were performed. Outcomes included sustained complete remission of neoplasia or intestinal metaplasia (IM), IM in gastric cardia, or buried glands in neosquamous epithelium. RESULTS After 5 years, Kaplan-Meier analysis showed sustained complete remission of neoplasia and intestinal metaplasia in 90% of patients; neoplasia recurred in 3 patients and was managed endoscopically. Focal IM in the cardia was found in 19 of 54 patients (35%), in 53 of 1143 gastric cardia biopsies (4.6%). The incidence of IM of the cardia did not increase over time; and IM was diagnosed based on only a single biopsy in 89% of patients. Buried glands were detected in 3 of 3543 neosquamous epithelium biopsies (0.08%, from 3 patients). No endoscopic resection samples had buried glands. CONCLUSIONS Among patients who have undergone RFA with or without endoscopic resection for neoplastic BE, 90% remain in remission at 5-year follow-up, with all recurrences managed endoscopically. This treatment approach is therefore an effective and durable alternative to esophagectomy; www.trialregister.nl number, NTR2938.


title: Development and validation of a simplified Stroke-Thrombolytic Predictive Instrument.

text: OBJECTIVES The Stroke-Thrombolytic Predictive Instrument (Stroke-TPI) predicts the probability of good and bad outcomes with and without recombinant tissue plasminogen activator (rtPA). We sought to rebuild and externally validate a simpler Stroke-TPI to support implementation in routine clinical care. METHODS Using the original derivation cohort of 1,983 patients from a combined database of randomized clinical trials (NINDS [National Institute of Neurological Disorders and Stroke] 1 and 2; ATLANTIS [Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke] A and B; and ECASS [European Cooperative Acute Stroke Study] II), we simplified the Stroke-TPI by reducing variables and interaction terms and by exploring simpler (3- and 8-item) stroke severity scores. External validation was performed in the ECASS III trial (n = 821). RESULTS The following 6 variables were most predictive of good outcomes: age, systolic blood pressure, diabetes, stroke severity, symptom onset to treatment time, and rtPA therapy. Treatment effect modifiers included onset to treatment time and systolic blood pressure. For the models predicting a bad outcome (modified Rankin Scale [mRS] score ≥5), significant variables included age, stroke severity, and serum glucose. rtPA therapy did not change the risk of a poor outcome. Compared with models using the full NIH Stroke Scale, models using the 3-item severity score showed similar discrimination and excellent calibration. External validation on ECASS III showed similar performance (C statistics 0.75 [mRS score ≤1] and 0.80 [mRS score ≤2]). CONCLUSION A simpler model using a 3-item stroke severity score, instead of the 15-item NIH Stroke Scale, has similar prognostic value and may be easier to use in routine care. Future studies are needed to test whether it can improve process and clinical outcomes.


title: Thrombotic microangiopathy, DIC-syndrome and COVID-19: link with pregnancy prothrombotic state.

text: For last months, humanity has faced a formidable unknown enemy, which is presented as a new coronavirus infection. Despite the fact that the causative agents of new diseases appear at a certain frequency and that the virus SARS-CoV-2 has certain common properties with its predecessors, at the moment we are dealing with a new unknown pathogenesis of the development of severe complications in patients with risk factors. A final understanding of pathological process mechanisms is the goal of the scientific community. Summarizing research data from different countries, it became obvious that in severe cases of viral infection, we are dealing with a combination of the systemic inflammatory response syndrome, disseminated intravascular coagulation and thrombotic microangiopathy (TMA). Thrombotic microangiopathy is represented by a group of different conditions in which thrombocytopenia, hemolytic anemia, and multiple organ failure occur. The article reflects the main types of TMA, pathogenesis and principles of therapy. The main participants in the process are described in detail, including the von Willebrand factor and ADAMTS-13. Based on the knowledge available, as well as new data obtained from patients with COVID-19, we proposed possible models for the implementation of conditions such as sepsis, TMA, and DIC in patients with severe new coronavirus infection. Through a deeper understanding of pathogenesis, it will be possible to develop more effective diagnosis and therapy.


title: Severe acute respiratory syndrome coronavirus 3a protein activates the mitochondrial death pathway through p38 MAP kinase activation.

text: The molecular mechanisms governing severe acute respiratory syndrome coronavirus-induced pathology are not fully understood. Virus infection and some individual viral proteins, including the 3a protein, induce apoptosis. However, the cellular targets leading to 3a protein-mediated apoptosis have not been fully characterized. This study showed that the 3a protein modulates the mitochondrial death pathway in two possible ways. Activation of caspase-8 through extrinsic signal(s) caused Bid activation. In the intrinsic pathway, there was activation of caspase-9 and cytochrome c release from the mitochondria. This was the result of increased Bax oligomerization and higher levels of p53 in 3a protein-expressing cells, which depended on the activation of p38 MAP kinase (MAPK) in these cells. For p38 activation and apoptosis induction, the 3a cytoplasmic domain was sufficient. In direct Annexin V staining assays, the 3a protein-expressing cells showed increased apoptosis that was attenuated with the p38 MAPK inhibitor SB203580. A block in nuclear translocation of the STAT3 transcription factor in cells expressing the 3a protein was also observed. These results have been used to present a model of 3a-mediated apoptosis.


title: Managing Diabetes in Pregnancy before, during and after COVID-19.

text: BACKGROUND Pregnant women with diabetes are identified as being more vulnerable to the severe effects of COVID-19 and advised to stringently follow social distancing measures. Here we review the management of diabetes in pregnancy before and during the lockdown. METHODS The majority of antenatal diabetes and obstetric visits are provided remotely, with pregnant women attending hospital clinics only for essential ultrasound scans and labour and delivery. On-line resources for supporting women planning pregnancy as well as for self-management of pregnant women with type 1 diabetes (T1D) using intermittent or continuous glucose monitoring (CGM) are provided. Retinal screening procedures, intrapartum care and the varying impact of lockdown on maternal glycaemic control are considered. Alternative screening procedures have for diagnosing hyperglycaemia during pregnancy and Gestational Diabetes (GDM) are discussed. Case histories describe the remote initiation of insulin pump therapy and automated insulin delivery in T1D pregnancy. RESULTS Initial feedback suggests that video consultations are well received and that the patient experiences for women requiring face-to-face visits are greatly improved. As the pandemic eases, formal evaluation of remote models of diabetes education and technology implementation, including women's views, will be important. CONCLUSIONS Research and audit activities will resume and we will find new ways for supporting pregnant women with diabetes to choose their preferred glucose monitoring and insulin delivery.


title: Hobi-like pestivirus: both biotypes isolated from a diseased animal.

text: A Hobi-like pestivirus pair consisting of cytopathogenic (cp) and non-cytopathogenic (noncp) strains, Italy 83/10cp and Italy 83/10ncp, was isolated from the lung of a heifer that died of respiratory disease. The noncp and cp viruses were isolated on Madin-Darby bovine kidney cells and separated by plaque purification and end point dilution. Analysis of the nearly full-length genomes revealed that the two viruses were very closely related to each other and to the noncp Hobi-like strain Italy 1/10-1, which had been isolated a few weeks earlier from the same herd. One major difference between noncp and cp viruses concerned the presence of a cellular Jiv sequence in the 3' domain of the NS2-encoding region of the cp strain. This is the first study, to our knowledge, reporting the isolation and molecular characterization of a Hobi-like virus pair.


title: Endovascular retrieval of a dislocated coil in the peroneal artery with a stent retriever.

text: We present a patient who underwent successful removal of a fully detached platinum coil from the peroneal artery using a Solitaire™ stent retriever (Covidien, Irvine, CA) that is usually used in endovascular stroke treatment.


Covid-19: Trump says risk to Americans is "very low".


title: American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer.

text: BACKGROUND The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity. METHODS A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved. RESULTS Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking. CONCLUSIONS Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.


Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary.


Response to: 'Emergency arising from patients' fear of taking antimalarials during these COVID-19 times: are antimalarials as unsafe for cardiovascular health as recent reports suggest?' by Santos-Mareno et al.


title: Can silicone models replace animal models in hands-on training for endovascular stroke therapy?

text: PURPOSE Since thrombectomy has become a standard treatment technique for stroke, there is great demand for well-trained interventionalists. We offer practical courses on both silicone models and porcine models, and conducted a survey to evaluate whether ex vivo training models could replace in vivo models in the future. METHODS In total, 110 neurointerventionalists participating in 30 training courses were included in our survey using a semi-structured questionnaire. RESULTS The level of experience in thrombectomy maneuvers was almost balanced in our sample (52% experienced and 48% less-experienced participants). Silicone models were regarded as useful training tools regardless of the participants' experience (p = 1.000): 94% of less-experienced and 92% of experienced participants considered a silicone model to be a useful introduction for training with animal models. Of the participants, 95% indicated that training on animal models was helpful and necessary, even if they already had experience in performing interventions in humans (p = 1.000). After joining this course, 97% of all participants felt well prepared to perform thrombectomies in humans. CONCLUSION Even experienced participants benefit from silicone models. Silicone models are a good preparation for animal models but cannot replace them. Categorizing participants depending on their experience and their individual needs before practical training may allow for more efficient endovascular training.


title: Pulmonary lobectomy techniques in infants and children.

text: Thoracoscopic pulmonary lobectomy (TPL) techniques in infants and children are presented practically with concise descriptions and numerous illustrations. TPL is the treatment of choice for congenital pulmonary airway malformation and intralobar pulmonary sequestration, both now commonly diagnosed prenatally. Timing of surgery is somewhat controversial in asymptomatic cases with small isolated lesions. Incomplete fissures and history of chest infections are most problematic. Thorough understanding of anatomic relations preoperatively is vital for successful outcome and thin-slice computed tomography with 3D reconstruction of vessels is valuable. Judicious placement of trocars and switching instruments between trocars improves visualization and safety. Specific techniques for all commonly performed TPL are included.


Commentary: Parental Leave Policies: Have We Come a Long Way, Baby?


title: Model-based optimal PEEP in mechanically ventilated ARDS patients in the intensive care unit.

text: BACKGROUND The optimal level of positive end-expiratory pressure (PEEP) is still widely debated in treating acute respiratory distress syndrome (ARDS) patients. Current methods of selecting PEEP only provide a range of values and do not provide unique patient-specific solutions. Model-based methods offer a novel way of using non-invasive pressure-volume (PV) measurements to estimate patient recruitability. This paper examines the clinical viability of such models in pilot clinical trials to assist therapy, optimise patient-specific PEEP, assess the disease state and response over time. METHODS Ten patients with acute lung injury or ARDS underwent incremental PEEP recruitment manoeuvres. PV data was measured at increments of 5 cmH2O and fitted to the recruitment model. Inspiratory and expiratory breath holds were performed to measure airway resistance and auto-PEEP. Three model-based metrics are used to optimise PEEP based on opening pressures, closing pressures and net recruitment. ARDS status was assessed by model parameters capturing recruitment and compliance. RESULTS Median model fitting error across all patients for inflation and deflation was 2.8% and 1.02% respectively with all patients experiencing auto-PEEP. In all three metrics' cases, model-based optimal PEEP was higher than clinically selected PEEP. Two patients underwent multiple recruitment manoeuvres over time and model metrics reflected and tracked the state or their ARDS. CONCLUSIONS For ARDS patients, the model-based method presented in this paper provides a unique, non-invasive method to select optimal patient-specific PEEP. In addition, the model has the capability to assess disease state over time using these same models and methods.


title: Transcaval invasion of right atrium by thymoma: resection via transient cava-pulmonary shunt.

text: Transcaval extension of the thymoma to the right atrium has very rarely been reported, and cardiopulmonary bypass is recommended for successful resection. An invasive thymoma with intravascular invasion of the superior vena cava, and the left innominate vein extending into the right atrium was presented. Intra-atrial extension was resected through a transient external shunt from the inferior vena cava to the main pulmonary artery. We discussed the feasibility of this surgical technique and possible advantages of cardiopulmonary bypass avoidance.


Peroral endoscopic fundoplication: a brand-new intervention for GERD.


title: A meta-analysis comparing the outcomes of LigaSure Small Jaw versus clamp-and-tie technique or Harmonic Focus Scalpel in thyroidectomy.

text: BACKGROUND LigaSure (LS) Small Jaw is a surgical hemostasis equipment that is newly introduced in thyroid surgery. The objective of this study is to assess the short-term efficacy and safety outcomes of LS Small Jaw compared with clamp-and-tie technique or Harmonic Focus Scalpel in thyroidectomy. METHODS A literature search was performed in the PubMed and Embase databases (until June 12, 2016) that reported the comparisons between LS Small Jaw and other techniques in thyroidectomy. Quality assessments were performed according to The Cochrane Collaboration's risk of bias tool and a modification of the Newcastle-Ottawa Scale in randomized controlled trials (RCTs) and non-RCTs, respectively. All statistical analyses were conducted using RevMan 5.3. RESULTS Finally, 7 studies with 813 patients were included into the meta-analysis, and all included studies were comparable with moderate-to-high quality. There was significant reduced operative time in LS Small Jaw, compared with clamp-and-tie (mean difference [MD] = -17.49, 95% confidence interval [CI]: -22.20 to 12.77, P < 0.00001) or Harmonic Focus Scalpel (MD = -2.29, 95% CI: -3.19 to 1.39, P < 0.00001). Besides, other perioperative outcomes including intraoperative blood loss and postoperative blood loss favored LS Small Jaw compared with clamp-and-tie. In terms of complications, less-temporary hypocalcemia rate was observed in LS Small Jaw compared with clamp-and-tie (odds ratio [OR] = 0.49, 95% CI: 0.27-0.90, P = 0.02), although no significant difference was detected compared with Harmonic Focus Scalpel (OR = 0.47, 95% CI: 0.14-1.56, P = 0.22). Other complications such as length of hospital stay, permanent hypocalcemia, temporary or permanent recurrent laryngeal nerve palsy, and hematomas were not significant. CONCLUSION In conclusion, LS Small Jaw is more favorable than clamp-and-tie technique or Harmonic Focus Scalpel in thyroidectomy.


Acute severe thrombocytopenia secondary to intraarterial low-osmolar iodinated contrast administered during coronary angiography.


title: An Enhanced Mechanistic Model For Capnography, With Application To CHF-COPD Discrimination.

text: Capnography records CO2 partial pressure in exhaled breath as a function of time or exhaled volume. Time-based capnography, which is our focus, is a point-of-care, noninvasive, effort-independent and widely available clinical monitoring modality. The generated waveform, or capnogram, reflects the ventilation-perfusion dynamics of the lung, and thus has value in the diagnosis of respiratory conditions such as chronic obstructive pulmonary disease (COPD). Effective discrimination between normal respiration and obstructive lung disease can be performed using capnogram-derived estimates of respiratory parameters in a simple mechanistic model of CO2 exhalation. We propose an enhanced mechanistic model that can capture specific capnogram characteristics in congestive heart failure (CHF) by incorporating a representation of the inertance associated with fluid in the lungs. The 4 associated parameters are estimated on a breath-by-breath basis by fitting the model output to the exhalations in the measured capnogram. Estimated parameters from 40 exhalations of 7 CHF and 7 COPD patients were used as a training set to design a quadratic discriminator in the parameter space, aimed at distinguishing between CHF and COPD patients. The area under the ROC curve for the training set was 0.94, and the corresponding equal-error-rate value of approximately 0.1 suggests classification accuracies of the order of 90% are attainable. Applying this discriminator without modification to 40 exhalations from each CHF and COPD patient in a fresh test set, and deciding on a simple majority basis whether the patient has CHF or COPD, results in correctly labeling all 8 out of the 8 CHF patients and 6 out of the 8 COPD patients in the test set, corresponding to a classification accuracy of 87.5%.


Impact of COVID-19 on tuberculosis control in China.


How could artificial intelligence aid in the fight against coronavirus?


title: Monoclonal antibodies and other targeted therapies for pancreatic cancer.

text: Pancreatic cancer continues to be a challenging disease to treat because of its aggressive nature, advanced stage at the time of diagnosis, and limited treatment options that are available. Traditional cytotoxic chemotherapy provides modest benefit to patients with pancreatic adenocarcinoma. Recently, a FOLFIRINOX regimen revealed improved response in overall and progression-free survival over single-agent gemcitabine in metastatic pancreatic cancer, but there is still much needed advancement in the systemic treatment of pancreatic cancer. There is a growing interest in the development of novel agents, while our understanding of molecular pathogenesis of pancreatic adenocarcinoma continues to expand. With identification of various molecular pathways in pancreatic cancer tumorigenesis, potential targets for drug development have been pursued with the use of monoclonal antibodies and small-molecule inhibitors. Although preclinical studies with multiple targeted therapies demonstrated encouraging results in pancreatic cancer, only erlotinib, an epidermal growth factor receptor inhibitor, showed a marginal survival benefit in a phase III clinical trial, when combined with gemcitabine. As further signaling pathways and their importance in pancreatic cancer tumorigenesis are better understood, further clinical trials will need to be designed to study these targeted agents as single agents, in combination with other novel agents or in combination with cytotoxic chemotherapy. In this review, we present the current knowledge on targeted therapy in pancreatic adenocarcinoma and its application in clinical practice.


title: Single-incision versus three-port conventional laparoscopic right hemicolectomy: is there any real need to go single?

text: BACKGROUND Preliminary results showed some benefits of single-incision laparoscopic surgery (SILS) over conventional laparoscopic colectomy, including better cosmesis, less postoperative pain, and faster recovery, but these results need further confirmation. In addition, the literature still lacks comparative studies between the two approaches to prove the above-mentioned advantages of SILS over conventional laparoscopy and, most importantly, its equivalent effectiveness in terms of initial oncological results. PATIENTS AND METHODS Two consecutive series of 10 patients undergoing three-port conventional laparoscopic right hemicolectomy (3PCL-RH) and single-incision laparoscopic right hemicolectomy, respectively, were compared in their short-term surgical and oncological outcomes. RESULTS Analysis of perioperative and postoperative outcomes revealed no significant differences between the two groups. In the SILS group an anastomotic leakage occurred, which was conservatively treated by continuous drainage, total parental nutrition, and antibiotic therapy. The analysis of oncological outcomes showed no differences in terms of length of distal tumor-free margin and harvest of lymph nodes. CONCLUSIONS Despite its feasibility for right hemicolectomy and its equivalent short-term surgical and oncological outcome compared with conventional laparoscopy, SILS demonstrated no significant advantages in terms of surgical incision length and postoperative course compared with 3PCL-RH. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of single-incision laparoscopic right hemicolectomy.


title: Use of target temperature management after cardiac arrest in Germany--a nationwide survey including 951 intensive care units.

text: INTRODUCTION Target temperature management (TTM) after cardiac arrest is recommended by international guidelines, which have been last updated in 2010. Here we investigate the status of implementation in a nationwide survey in Germany which took place in 2012. METHODS We conducted a nationwide telephone survey including a total of 951 German intensive care units (ICUs). ICUs were identified by using the online registry for hospitals in Germany. A questionnaire was used for the interview about basic data of the intensive care unit and about details concerning use and implementation of TTM after cardiac arrest. RESULTS The overall response rate was 91% (865/951). 86% (742/865) of ICUs used TTM after cardiac arrest and implementation peaked in 2010. 95% (702/736) of the ICUs using TTM perform treatment independently of the initial rhythm and 48% (355/738) apply TTM with the use of a feedback device for cooling and controlled re-warming. However, 22% (166/742) still use conventional methods like ice and cold infusion and only 61% (453/742) of the participants provided a written standard operating procedure (SOP). CONCLUSION With a delay of several years, TTM after cardiac arrest is now implemented in the majority of German ICUs. The moderate proportion of ICUs using SOPs for TTM and feedback-controlled cooling devices indicates the need of further improvement in post cardiac arrest care.


title: Infectious intracranial aneurysms: a systematic review of epidemiology, management, and outcomes.

text: Infectious intracranial aneurysms (IIAs) are a rare cerebrovascular complication of systemic infections induced by microbial infiltration and degradation of the arterial vessel wall. Studies on the epidemiology and management of IIAs are limited to case reports and retrospective single-center studies, and report a large variability in epidemiological features, management, and outcomes due to the limited sample size. We conducted a systematic review of all published papers on IIAs in the English literature using MEDLINE and SCOPUS database from January 1950 to June 2017. A total of 288 publications describing 1191 patients with IIA (1398 aneurysms) were included and reviewed for epidemiological features, disease features, treatment and outcome. All patients were merged into a single cohort and summary data are presented. The majority of reported IIAs are distally located, relatively small (<5 mm), involve the anterior circulation, are associated with a relatively high rate of rupture, and demonstrate a propensity to multiplicity of aneurysms. Sensitive diagnosis of IIAs requires digital subtraction angiography and not CT angiography or MR angiography. Treatment of ruptured, symptomatic, or enlarging IIAs has evolved over the last 50 years. Endovascular therapy is associated with a high success rate and low morbidity compared with microsurgical and medical management. A treatment algorithm for the management of patients with IIA in various contexts is proposed and the need for prospective multicenter studies is emphasized.


title: Mechanisms of lung aging.

text: Lung aging is associated with structural remodeling, a decline of respiratory function and a higher susceptibility to acute and chronic lung diseases. Individual factors that modulate pulmonary aging include basic genetic configuration, environmental exposure, life-style and biography of systemic diseases. However, the actual aging of the lung takes place in pulmonary resident cells and is closely linked to aging of the immune system (immunosenescence). Therefore, this article reviews the current knowledge about the impact of aging on pulmonary cells and the immune system, without analyzing those factors that may accelerate the aging process in depth. Hallmarks of aging include alterations at molecular, cellular and cell-cell interaction levels. Because of the great variety of cell types in the lung, the consequences of aging display a broad spectrum of phenotypes. For example, aging is associated with more collagen and less elastin production by fibroblasts, thus increasing pulmonary stiffness and lowering compliance. Decreased sympathetic airway innervation may increase the constriction status of airway smooth muscle cells. Aging of resident and systemic immune cells leads to a pro-inflammatory milieu and reduced capacity of fighting infectious diseases. The current review provides an overview of cellular changes occurring with advancing age in general and in several cell types of the lung as well as of the immune system. Thereby, this survey not only aims at providing a better understanding of the mechanisms of pulmonary aging but also to identify gaps in knowledge that warrant further investigations.


Partnerships, Not Parachutists, for Zika Research.


title: Laparo-endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison.

text: BACKGROUND Laparo-endoscopic single site (LESS) surgery is a recent development in minimally invasive surgery. Presented herein is the initial comparison of LESS donor nephrectomy (LESS-DN) and standard laparoscopic living donor nephrectomy (LLDN). OBJECTIVE To determine whether LESS-DN provides any measurable benefit over LLDN during the perioperative period and subsequent convalescence. DESIGN, SETTING, AND PARTICIPANTS Between November 2007 and November 2008, 18 consecutive patients underwent LESS-DN (17 left DN, 1 right DN). A contemporary matched-pair cohort of 17 patients undergoing standard LLDN was selected for retrospective comparison. INTERVENTIONS LESS-DN was performed through an intraumbilical novel multichannel port. The kidney was extracted through a slightly extended umbilical incision. MEASUREMENTS All data were prospectively accrued in an institutional review board-approved database. Convalescence data included visual analog pain scores and questionnaires containing patient-reported time to recovery end points. RESULTS AND LIMITATIONS One right-sided donor was converted to standard laparoscopy and excluded from analysis. Baseline demographics, operating time, blood loss, and hospital stay were comparable between groups. Compared to LLDN, patients undergoing LESS-DN had similar in-hospital analgesic requirements and mean visual analog scores at discharge. After discharge, patient-reported convalescence was faster in the LESS-DN group, including days on oral pain medication (20 vs 6; p=0.01), days off work (46 vs 18; p=0.0009), and days to 100% physical recovery (83 vs 29; p=0.03). Mean warm ischemia time was longer in the LESS-DN group (3 vs 6.1 min; p<0.0001); however, allograft function was immediate and comparable between groups. One allograft in the LESS-DN group thrombosed postoperatively. Regardless of laparoscopic approach, patients' global satisfaction with kidney donation and willingness to recommend their procedure to others were favorable and equivalent between groups. CONCLUSIONS This retrospective matched-pair comparison between LESS-DN and LLDN suggests that the single-port approach may be associated with quicker convalescence. In this initial series, LESS-DN had longer ischemia time, yet early allograft outcomes were comparable.


title: nirS-type denitrifying bacterial communities in relation to soil physicochemical conditions and soil depths of two montane riparian meadows in North China.

text: Mountain riparian zones are excellent buffers for protecting aquatic ecosystems from nutrient runoff in nitrogen deposition processes due to fertilization and manure. Denitrification is a critical process for transferring soil N to the atmosphere. Denitrifying bacterial communities in soil are indicative of the soil quality of a functional ecosystem. We investigated the effects of physicochemical properties of soil on the diversity and activity of denitrifiers in the top-soil and sub-soil of two typical montane riparian meadows: a multi-colored and a flood-plain meadow. Illumina MiSeq 2500 sequencing of nirS showed that the multi-colored meadow had greater diversity and abundance of nirS-type denitrifiers than the flood-plain meadow and that the total N content, ammonium content, and denitrification enzyme activity (DEA) in soil differed significantly between the two types of meadows. The abundances of dominant denitrifiers at phylum and genus levels showed different responses to the two soil layers of the two meadow types. In top-soils, the highest abundance of Firmicutes was recorded in the multi-colored meadow, while in the flood-plain meadow, there was the highest abundance of Proteobacteria. The Actinobacteria abundance was the highest in top-soil and sub-soil of the flood-plain meadow. The abundance of Chloroflexi was the highest in top-soil of the flood-plain meadow and in sub-soil of the multi-colored meadow. The diversity of denitrifying bacteria was strongly influenced by variations of soil properties down the soil profile. Spearman's rank correlation analyses showed that the diversity and community composition of denitrifying bacteria were strongly associated with most of the soil properties. Therefore, physicochemical soil properties, and particularly the organic carbon, nitrate, and ammonium contents, influence the diversity and abundance of denitrifiers in soil.


title: A well-characterised peak identification list of MALDI MS profile peaks for human blood serum.

text: MALDI MS profiling, using easily available body fluids such as blood serum, has attracted considerable interest for its potential in clinical applications. Despite the numerous reports on MALDI MS profiling of human serum, there is only scarce information on the identity of the species making up these profiles, particularly in the mass range of larger peptides. Here, we provide a list of more than 90 entries of MALDI MS profile peak identities up to 10 kDa obtained from human blood serum. Various modifications such as phosphorylation were detected among the peptide identifications. The overlap with the few other MALDI MS peak lists published so far was found to be limited and hence our list significantly extends the number of identified peaks commonly found in MALDI MS profiling of human blood serum.


title: The Effect of Hypothyroidism on a Composite of Mortality, Cardiovascular and Wound Complications After Noncardiac Surgery: A Retrospective Cohort Analysis.

text: BACKGROUND We tested the hypothesis that hypothyroidism, as defined by thyroid-stimulating hormone (TSH) concentration, is associated with a severity-weighted composite of mortality and major cardiovascular and infectious complications after noncardiac surgery. METHODS In this retrospective cohort study, we evaluated adults at the Cleveland Clinic Main Campus between 2005 and 2012, who had had available TSH concentrations within the 6 months before noncardiac surgery. Patients were categorized as (1) hypothyroid (patients who had diagnosis of hypothyroidism any time prior to surgery and increased TSH value (> 5.5 mIU/L) within 6 months prior to surgery); (2) treated (hypothyroid diagnosis and normal TSH concentrations [0.4-5.5 mIU/L]); and (3) euthyroid (no hypothyroid diagnosis and normal TSH concentrations). We conducted pairwise comparisons among the 3 groups using inverse propensity score weighting to control for observed confounding variables. Average relative effect generalized estimating equation model was used for the primary outcome composite of in-hospital cardiovascular morbidity, surgical wound complication or infection, and mortality. Logistic regression and Cox proportional hazards regression were used for secondary outcomes of intraoperative vasopressor use and duration of hospitalization, respectively. RESULTS We identified 800 hypothyroid patients (median TSH: 8.6 mIU/L [Q1, Q3: 6.5, 13.0]), 1805 treated patients (2.0 mIU/L [1.1, 3.2]), and 5612 euthyroid patients (1.7 mIU/L [1.1, 2.6]). There were no significant differences among the hypothyroid, treated, and euthyroid patients on the primary composite outcome (all P values ≥0.30). Hypothyroid patients were slightly more likely to receive vasopressor during surgery than either treated (odds ratio, 1.17; 99.2% confidence interval [CI], 1.01-1.36) or euthyroid (odds ratio, 1.12; 99.2% CI, 1.02-1.24) patients. Furthermore, hypothyroid patients were slightly but significantly less likely to be discharged at any given postoperative time than treated patients (hazard ratio, 0.92; 99.2% CI, 0.86-0.99). CONCLUSIONS Hypothyroidism was not associated with worse postoperative mortality, wound, or cardiovascular outcomes in noncardiac patients. Thus, postponing surgery to initiate thyroid replacement therapy in patients with hypothyroidism seems unnecessary.


title: Hypercoagulability of COVID-19 patients in Intensive Care Unit. A Report of Thromboelastography Findings and other Parameters of Hemostasis.

text: BACKGROUND The severe inflammatory state secondary to Covid-19 leads to a severe derangement of hemostasis that has been recently described as a state of disseminated intravascular coagulation (DIC) and consumption coagulopathy, defined as decreased platelet count, increased fibrin(ogen) degradation products such as D-dimer as well as low fibrinogen. AIMS Whole blood from 24 patients admitted at the intensive care unit because of Covid-19 was collected and evaluated with thromboelastography by the TEG point-of-care device on a single occasion and six underwent repeated measurements on two consecutive days for a total of 30 observations. Plasma was evaluated for the other parameters of hemostasis. RESULTS TEG parameters are consistent with a state of hypercoagulability as shown by decreased R and K values, and increased values of K angle and MA. Platelet count was normal or increased, prothrombin time and activated partial thromboplastin time were near(normal). Fibrinogen was increased and D-dimer was dramatically increased. C-reactive protein was increased. Factor VIII and von Willebrand factor (n=11) were increased. Antithrombin (n=11) was marginally decreased and protein C (n=11) was increased. CONCLUSION The results of this cohort of patients with Covid-19 are not consistent with acute DIC, rather they support hypercoagulability together with a severe inflammatory state. These findings may explain the events of venous thromboembolism observed in some of these patients and support antithrombotic prophylaxis/treatment. Clinical trials are urgently needed to establish the type of drug, dosage and optimal duration of prophylaxis.


title: Coronaviruses in South African bats.

text: Recent studies in several African countries have provided the first evidence for the presence of coronaviruses in African bats. Here we describe, for the first time, the detection of RNA of 3 unique coronavirus species in the tissues of South African bats.


title: COVID-2019: update on epidemiology, disease spread and management.

text: With each passing day, more cases of Coronavirus disease (COVID-2019) are being detected and unfortunately the fear of novel corona virus 2019 (2019-nCoV) becoming a pandemic disease has come true. Constant efforts at individual, national, and international level are being made in order to understand the genomics, hosts, modes of transmission and epidemiological link of nCoV-2019. As of now, whole genome sequence of the newly discovered coronavirus has already been decoded. Genomic characterization nCoV-2019 have shown close homology with bat-derived severe acute respiratory syndrome (SARS)-like coronaviruses, bat-SL-CoVZC45 and bat-SL-CoVZXC21. Structural analysis of the receptor binding site has confirmed that 2019-nCoV binds with the same ACE 2 receptor protein as human SARS virus. Compared to the previous coronavirus outbreaks, the overall mortality rate is relatively low for COVID-2019 (2-3%). Suspected cases must be quarantined till their test comes positive or they clear infection. At present, treatment of COVID-2019 is mostly based on the knowledge gained from the SARS and MERS outbreaks. Remdesivir, originally develop as a treatment for Ebola virus disease and Marburg virus infections, is being studied for it effectiveness against 2019-nCoV infection. Many other antiviral agents and vaccines are being tested but most of them are in phase I or II and hence unlikely to be of any benefit immediately with regards to current outbreak. Hence, the standard infection control techniques and preventive steps for healthy individuals and supportive care for the confirmed cases is the best available strategy to deal with current viral outbreak. .


title: Collective symbolic coping with disease threat and othering: a case study of avian influenza.

text: Much research studies how individuals cope with disease threat by blaming out-groups and protecting the in-group. The model of collective symbolic coping (CSC) describes four stages by which representations of a threatening event are elaborated in the mass media: awareness, divergence, convergence, and normalization. We used the CSC model to predict when symbolic in-group protection (othering) would occur in the case of the avian influenza (AI) outbreak. Two studies documented CSC stages and showed that othering occurred during the divergence stage, characterized by an uncertain symbolic environment. Study 1 analysed media coverage of AI over time, documenting CSC stages of awareness and divergence. In Study 2, a two-wave repeated cross-sectional survey was conducted just after the divergence stage and a year later. Othering was measured by the number of foreign countries erroneously ticked by participants as having human victims. Individual differences in germ aversion and social dominance orientation interacted to predict othering during the divergence stage but not a year later. Implications for research on CSC and symbolic in-group protection strategies resulting from disease threat are discussed.


title: Mechanisms of pain transmission and pharmacologic management.

text: BACKGROUND Pain sensation involves multiple signaling and modulatory pathways, employing a variety of neurotransmitters and other mediators. Inhibitory and facilitatory mechanisms affect the perception of stimuli as painful or non-painful, and in addition may affect the perceived intensity of pain. Endogenous opioids are key mediators in the descending pain suppression pathways. Additionally, monoaminergic neurotransmitters such as norepinephrine, serotonin and dopamine positively or negatively modulate pain signaling, depending on receptor type and location. The various mediators involved in pain signaling provide potential targets for pharmacological interventions. Single analgesic therapies may be limited in their ability to comprehensively target these complex pain signaling pathways. Therapeutic approaches acting on multiple pain transmission pathways through different mechanisms of action provide an opportunity to maximize efficacy and tolerability in the treatment of pain. SCOPE This article discusses the various physiologic processes involved in pain signaling and modulation, describes the mechanisms by which various classes of analgesic agents are believed to produce their clinical effects, and explores the potential benefits of a multiple-mechanism approach to analgesia. Published articles describing the physiologic processes involved in pain signaling and modulation and the mechanisms of analgesia for different drug classes were reviewed. MEDLINE searches were conducted to identify relevant studies published through August 2009 that evaluated the efficacy and tolerability of multiple-mechanism analgesic regimens. English language-only randomized controlled trials and meta-analyses of randomized controlled trials were considered. FINDINGS/CONCLUSION Multiple neurotransmitters and other mediators are involved in the endogenous modulation of pain signaling, providing numerous opportunities for intervention with different classes of analgesics. Data from numerous clinical trials indicate that multiple-mechanism approaches to analgesia provide comparable or superior analgesic efficacy with lower doses of the individual agents and reduced incidence of side effects. These data support current guidelines which endorse multiple-mechanism strategies for both acute and chronic pain management.


title: Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department.

text: STUDY OBJECTIVE Preoxygenation is important to prevent oxygen desaturation during emergency airway management. The purpose of this study is to describe the use of end tidal oxygen (eto2) during rapid sequence intubation in the emergency department. METHODS This study was carried out in 2 academic centers in Sydney, Australia, and New York City. We included patients undergoing rapid sequence intubation in the emergency department. A standard gas analyzer was used to measure eto2. Preoxygenation methods included nonrebreather mask and bag-valve-mask ventilation. We measured eto2 before preoxygenation and at administration of rapid sequence intubation medications. We also characterized peri-intubation SpO2, identifying instances of SpO2 less than 90%. RESULTS We included 100 patients during a 6-month period. Median eto2 level before and after preoxygenation was 53% (interquartile range [IQR] 43% to 65%) and 78% (IQR 64% to 86%), respectively. One fourth of patients achieved an eto2 level greater than 85%. Median eto2 level achieved varied with preoxygenation method, ranging from 80% (IQR 60% to 87%) for the nonrebreather mask group to 77% (IQR 65% to 86%) for the bag-valve-mask group. The method with the highest median eto2 level was nonrebreather mask at flush rate (86%; IQR 80% to 90%) and the lowest median eto2 level was nonrebreather mask at 15 L/min (57%; IQR 53% to 60%). Eighteen patients (18%) experienced oxygen desaturation (SpO2 <90%); of these, 14 (78%) did not reach an eto2 level greater than 85% at induction. CONCLUSION ETO2 varied with different preoxygenation techniques employed in the emergency department. Most patients undergoing rapid sequence intubation did not achieve maximal preoxygenation. Measuring ETO2 in the emergency department may be a valuable adjunct for optimizing preoxygenation during emergency airway management.


title: Pediatric achalasia. Single-center study of interventional treatment.

text: INTRODUCTION Esophageal achalasia is a rare entity in children. However, young age is a factor of failure of conservative treatment, emphasizing the role of surgery. In our institution laparoscopic Heller's cardiomyotomy is the chosen procedure for surgical treatment. AIM To assess the outcome of surgery for achalasia treatment in children operated on in a single institution. MATERIAL AND METHODS A retrospective analysis of consecutive patient records from the years 1997 to 2014 was performed. There were 11 patients. Their mean age was 13 years, ranging from 6 to 17. Duration of symptoms was 2 to 36 months, mean 16. All 11 patients were operated on with a laparoscopic approach. Pneumatic dilatation was used both pre- and postoperatively but in no case was sufficient on its own. Collected data included patient demographics, preoperative symptoms and their duration, diagnostic findings and therapeutic means. Surgical procedures, complications and long-term follow-up were analyzed. The follow-up lasted from 1 to 10 years and finished when the patient reached 18 years of age. RESULTS Twelve laparoscopic cardiomyotomies were performed with concomitant fundoplications, 10 Toupet and 2 Dor and one redo procedure. There were no deaths. Two perforations were repaired promptly. The success rate was 82%, though with subsequent dilatations. One failure was due to serious progression of the disease. CONCLUSIONS In our opinion, laparoscopic Heller's myotomy is the procedure of choice for treating achalasia in children. Endoscopic balloon dilatation may be used as a complementary treatment, especially as a primary redo procedure.


title: Shikani Optical Stylet versus Macintosh Laryngoscope for Intubation in Patients Undergoing Surgery for Cervical Spondylosis: A Randomized Controlled Trial.

text: BACKGROUND Airway management is critical in patients with cervical spondylosis, a population with a high incidence of difficult airway. Intubation with Shikani Optical Stylet (SOS) has become increasingly popular in difficult airway. We compared the effects of intubation with SOS versus Macintosh laryngoscope (MLS) in patients undergoing surgery for cervical spondylosis. METHODS A total of 270 patients scheduled for elective surgery for cervical spondylosis of spinal cord and nerve root type from August 2012 to January 2016 were enrolled and randomly allocated to the MLS or SOS group by random numbers. Patients were evaluated for difficult airway preoperatively, and Cormack-Lehane laryngoscopy classification was determined during anesthesia induction. Difficult airway was defined as Cormack-Lehane Grades III-IV. Patients were intubated with the randomly assigned intubation device. The success rate, intubation time, required assistance, immediate complications, and postoperative complaints were recorded. Categorical variables were analyzed by Chi-square test, and continuous variables were analyzed by independent samples t-test or rank sum test. RESULTS The success rate of intubation among normal airways was 100% in both groups. In patients with difficult airway, the success rates in the MLS and SOS groups were 84.2% and 94.1%, respectively (P = 0.605). Intubation with SOS took longer compared with MLS (normal airway: 25.1 ± 5.8 s vs. 24.5 ± 5.7 s, P = 0.426; difficult airway: 38.5 ± 8.5 s vs. 36.1 ± 8.2 s, P = 0.389). Intubation with SOS required less assistance in patients with difficult airway (5.9% vs. 100%, P< 0.001). The frequency of postoperative sore throat was lower in SOS group versus MLS group in patients with normal airway (22.0% vs. 34.5%, P = 0.034). CONCLUSIONS SOS is a safe and effective airway management device in patients undergoing surgery for cervical spondylosis. Compared with MLS, SOS appears clinically beneficial for intubation, especially in patients with difficult airway. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR-IOR-16007821; http://www.chictr.org.cn/showproj.aspx?proj=13203.


title: An integrative review of the limited evidence on international travel bans as an emerging infectious disease disaster control measure.

text: In our increasingly interconnected world, the potential for emerging infectious diseases (EIDs) to spread globally is of paramount concern. Travel bans-herein defined as the complete restriction of travel from at least one geographic region to at least one other international geographic region-are a potential policy solution to control the global spread of disease. The social, economic, and health-related consequences of travel bans, as well as the available evidence on the effectiveness of travel restrictions in preventing the global spread of influenza, have been previously described. However, the effectiveness of travel bans in reducing the spread of noninfluenza EIDs, characterized by different rates and modes of transmission, is less well understood. This study employs an integrative review approach to summarize the minimal evidence on effectiveness of travel bans to decrease the spread of severe acute respiratory syndrome (SARS), Middle Eastern respiratory syndrome (MERS), Ebola virus disease (EVD), and Zika virus disease (ZVD). We describe and qualify the evidence presented in six modeling studies that assess the effectiveness of travel bans in controlling these noninfluenza EID events. We conclude that there is an urgent need for additional research to inform policy decisions on the use of travel bans and other control measures to control noninfluenza EIDs in advance of the next outbreak.


Ready or Not….


title: Covid-19 pandemic impact on mental health: a web-based cross-sectional survey on a sample of Italian general practitioners.

text: BACKGROUND Since the World Health Organization declared the new 2019 coronavirus disease (Covid-19) outbreak first a Public Health Emergency of International Concern and then a pandemic, Italy held more than 195.350 cases and 26.380 deaths. Working in the frontline with suspected Covid-19 infection patients, general practitioners (GPs) are daily under both physical and psychological pressure. Methods: A web-based cross-sectional survey was carried out on italian GPs working in Genoa (Italy), to assess the impact of Covid-19 pandemic on mental health. The survey was anonymous and a free Google Forms® software was used. RESULTS One hundred thirty-one GPs completed the survey. Compared to GPs with absent or mild depressive symptoms (PHQ-9 < 10), GPs reporting moderate to severe depressive symptoms (N=30, 22.9%; PHQ-9 ≥ 10) reported more helplessness (96.7% vs. 79.2%, p=.025), spent more than three hours searching for COVID-19 information (43.3% vs. 19.8%, p=.024), perceived less adequate personal protective equipment (PPE) (6.7% vs. 23.8%, p=.049) and visited more COVID-19 infected patients (16.63 ± 27.30 vs. 9.52 ± 11.75, p=.041). Moreover, PHQ-9 ≥ 10 GPs reported a significant higher severity for both anxiety and insomnia (13.43 ± 4.96 vs. 4.88 ± 3.53 and 11.60 ± 5.53 vs. 4.84 ± 3.81, respectively; p<.001), and a worse quality of life in both mental (34.60 ± 7.45 vs. 46.01 ± 7.83, p<.001) and physical (43.50 ± 9.37 vs. 52.94 ± 4.78, p<.001) component summary. CONCLUSIONS Our results give early insight into the urgent need to provide continuity of care for patients at the community-level, adequate PPE to GPs and a clear guidance from public health institutions. A precarious healthcare system both at a national and regional level might have triggered negative mental health outcomes in Italian GPs.


title: Minimally invasive surgical instruments with an accessory channel capable of integrating fibre-optic cable for optical biopsy: a review of the state of the art.

text: This review article provides a comprehensive overview and classification of minimally invasive surgical instruments with an accessory channel incorporating fibreoptics or another auxiliary device for various purposes. More specifically, this review was performed with the focus on the newly emerging field of optical biopsy, its objective being to discuss primarily the instruments capable of carrying out the optical biopsy and subsequent tissue resection. Instruments housing the fibreoptics for other uses, as well as instruments with an accessory channel capable of housing the fibreoptics instead of their original auxiliary device after relevant design modifications, supplement the review. The entire Espacenet and Scopus databases were searched, yielding numerous patents and articles on conceptual and existing instruments satisfying the criteria. The instruments were categorised based on the function the fibreoptics or the auxiliary device serves. On the basis of their geometrical placement with respect to the tissue resector or manipulator, the subcategories were further defined. This subdivision was used to identify the feasibility of performing the optical biopsy and the tissue resection in an accurate and successive fashion. In general, the existing concepts or instruments are regarded as limited with regard to such a functionality, either due to the placement of their accessory channel with or without the fibreoptics or due to the operational restrictions of their tissue manipulators. A novel opto-mechanical biopsy harvester, currently under development at Delft University of Technology, is suggested as a promising alternative, ensuring a fast and accurate succession of the optical and the mechanical biopsies of a flat superficial tissue.


title: Changes in sevoflurane plasma concentration with delivery through the oxygenator during on-pump cardiac surgery.

text: BACKGROUND It is unclear what factors affect the uptake of sevoflurane administered through the membrane oxygenator during cardiopulmonary bypass (CPB) and whether this can be monitored via the oxygenator exhaust gas. METHODS Stable delivery of sevoflurane was administered to 30 elective cardiac surgery patients at 1.8 vol% (inspiratory) via the anaesthetic circuit and ventilator. During CPB, sevoflurane was administered in the oxygenator fresh gas supply (Compactflo Evolution™; Sorin Group, Milano, Italy). Sevoflurane plasma concentration (SPC) was measured using gas chromatography. Changes were correlated with bispectral index (BIS), patient temperature, haematocrit, plasma albumin concentration, oxygenator fresh gas flow, and the sevoflurane concentration in the oxygenator exhaust at predefined time points. RESULTS The mean SPC pre-bypass was 54.9 µg ml(-1) [95% confidence interval (CI): 50.6-59.1]. SPC decreased to 43.2 µg ml(-1) (95% CI: 40.3-46.1; P<0.001) after initiation of CPB, and was lower still during rewarming and weaning from bypass, 39.4 µg ml(-1) (95% CI: 36.6-42.3; P<0.001). BIS did not exceed a value of 55. SPCs were higher during hypothermia (P<0.001) and with an increase in oxygenator fresh gas flow (P=0.015), and lower with haemodilution (P=0.027). No correlation was found between SPC and the concentration of sevoflurane in the oxygenator exhaust gas (r=-0.04; 95% CI: -0.18 to 0.09; P=0.53). CONCLUSIONS The uptake of sevoflurane delivered via the membrane oxygenator during CPB seems to be affected by hypothermia, haemodilution, and changes in the oxygenator fresh gas supply flow. Measuring the concentration of sevoflurane in the exhaust from the oxygenator is not useful for monitoring sevoflurane administration during bypass.


title: SHORT DURATION IMMOBILIZATION OF ATLANTIC WALRUS ( ODOBENUS ROSMARUS ROSMARUS) WITH ETORPHINE, AND REVERSAL WITH NALTREXONE.

text: Forty adult, male Atlantic walruses ( Odobenus rosmarus rosmarus) were successfully immobilized for the attachment of global positioning system loggers on their tusks and collection of various biological samples. A standard dose of 7.8 mg etorphine was used for each animal, regardless of body size. All animals were reversed with an iv or im injection of 250 mg naltrexone, immediately after tag attachment. Twenty-seven of the animals were intubated and ventilated with 100% oxygen during the recovery period. The induction time was, on average, 4 min 51 sec ± 1 min 46 sec. Several animals had venous pH, and Pco2 levels that indicated severe acidosis and hypercarbia. All animals recovered within an average of 5 min 16 sec ± 2 min 47 sec after reversal. The total time from darting to recovery was 15 min 23 sec ± 3 min 33 sec. The use of naltrexone is recommended for reversal of etorphine immobilization in adult, male walruses, and the use of positive-pressure ventilation with oxygen is highly encouraged.


title: The impact of COVID-19 on patients with neuromyelitis optica spectrum disorder; a pilot study.

text: Neuromyelitis optica spectrum disorder (NMOSD) is a CNS neuroinflammatory disorder, mediated by the pathogenic autoantibody aquaporin-4 (AQP4-IgG). Current treatment includes long-term use of immunomodulatory therapies, leading to increased rates of infections among this population. It is of interest therefore, to study how the COVID-19 pandemic affects NMOSD patients in terms of their disease activity. A 15-point questionnaire was administered to 33 participants living in Northern California with NMOSD, MS and other related disorders. Although none of the participants were diagnosed with COVID-19, our results show that 2 participants with NMOSD experienced new onset of neurological symptoms and 2 experienced worsening of previous neurological symptoms - suggesting a possible effect of pandemic-related stress on this CNS autoimmune disorder.


title: Monitoring respiration and oxygen saturation in patients during the first night after elective bariatric surgery: A cohort study.

text: BACKGROUND Obstructive sleep apnoea and obese hypoventilation is not uncommon in patients with obesity. Residuals effect from surgery/anaesthesia and opioid analgesics may worsen respiration during the first nights after bariatric surgery. The aim of this observational study was to monitor respiration on the first postoperative night following elective bariatric surgery. METHODS This observational study aimed to determine the incidence and severity of hypo/apnea. Oxygen desaturation was analysed by continuous respiratory monitoring. RESULTS 45 patients were monitored with portable polygraphy equipment (Embletta, ResMed) during the first postoperative night at the general ward following elective laparoscopic bariatric surgery. Mean SpO2 was 93%; 10 patients had a mean SpO2 of less than 92% and 4 of less than 90%. The lowest mean SpO2 was 87%. There were 16 patients with a nadir SpO2 of less than 85%, lowest nadir SpO2 being 63%. An Apnoea Hypo/apnea Index (AHI) > 5 was found in 2 patients only (AHI 10 and 6), and an Oxygen Desaturation index (ODI) > 5 was found in 3 patients (24, 10 and 6, respectively). 3 patients had more prolonged (> 30 seconds) apnoea with nadir SpO2 81%, 83% and 86%. CONCLUSIONS A low mean SpO2 and short episodes of desaturation were not uncommon during the first postoperative night following elective bariatric surgery in patients without history of night time breathing disturbance. AHI and/or ODI of more than 5 were only rarely seen. Night-time respiration monitoring provided sparse additional information. Thus, it seems reasonable to have low risk patients at general ward already in their first night after bariatric surgery.


title: A Novel ¹¹¹In-Labeled Anti-Prostate-Specific Membrane Antigen Nanobody for Targeted SPECT/CT Imaging of Prostate Cancer.

text: UNLABELLED Prostate-specific membrane antigen (PSMA) is overexpressed in prostate cancer (PCa) and a promising target for molecular imaging and therapy. Nanobodies (single-domain antibodies, VHH) are the smallest antibody-based fragments possessing ideal molecular imaging properties, such as high target specificity and rapid background clearance. We developed a novel anti-PSMA Nanobody (JVZ-007) for targeted imaging and therapy of PCa. Here, we report on the application of the (111)In-radiolabeled Nanobody for SPECT/CT imaging of PCa. METHODS A Nanobody library was generated by immunization of a llama with 4 human PCa cell lines. Anti-PSMA Nanobodies were captured by biopanning on PSMA-overexpressing cells. JVZ-007 was selected for evaluation as an imaging probe. JVZ-007 was initially produced with a c-myc-hexahistidine (his) tag allowing purification and detection. The c-myc-his tag was subsequently replaced by a single cysteine at the C terminus, allowing site-specific conjugation of chelates for radiolabeling. JVZ-007-c-myc-his was conjugated to 2-(4-isothiocyanatobenzyl)-diethylenetriaminepentaacetic acid (p-SCN-DTPA) via the lysines, whereas JVZ-007-cys was conjugated to maleimide-DTPA via the C-terminal cysteine. PSMA targeting was analyzed in vitro by cell-binding experiments using flow cytometry, autoradiography, and internalization assays with various PCa cell lines and patient-derived xenografts (PDXs). The targeting properties of radiolabeled Nanobodies were evaluated in vivo in biodistribution and SPECT/CT imaging experiments, using nude mice bearing PSMA-positive PC-310 and PSMA-negative PC-3 tumors. RESULTS JVZ-007 was successfully conjugated to DTPA for radiolabeling with (111)In at room temperature. (111)In-JVZ007-c-myc-his and (111)In-JVZ007-cys internalized in LNCaP cells and bound to PSMA-expressing PDXs and, importantly, not to PSMA-negative PDXs and human kidneys. Good tumor targeting and fast blood clearance were observed for (111)In-JVZ-007-c-myc-his and (111)In-JVZ-007-cys. Renal uptake of (111)In-JVZ-007-c-myc-his was initially high but was efficiently reduced by coinjection of gelofusine and lysine. The replacement of the c-myc-his tag by the cysteine contributed to a further reduction of renal uptake without loss of targeting. PC-310 tumors were clearly visualized by SPECT/CT with both tracers, with low renal uptake (<4 percentage injected dose per gram) for (111)In-JVZ-007-cys already at 3 h after injection. CONCLUSION We developed an (111)In-radiolabeled anti-PSMA Nanobody, showing good tumor targeting, low uptake in nontarget tissues, and low renal retention, allowing excellent SPECT/CT imaging of PCa within a few hours after injection.


title: Hesitant Fuzzy Thermodynamic Method for Emergency Decision Making Based on Prospect Theory.

text: Due to the timeliness of emergency response and much unknown information in emergency situations, this paper proposes a method to deal with the emergency decision making, which can comprehensively reflect the emergency decision making process. By utilizing the hesitant fuzzy elements to represent the fuzziness of the objects and the hesitant thought of the experts, this paper introduces the negative exponential function into the prospect theory so as to portray the psychological behaviors of the experts, which transforms the hesitant fuzzy decision matrix into the hesitant fuzzy prospect decision matrix (HFPDM) according to the expectation-levels. Then, this paper applies the energy and the entropy in thermodynamics to take the quantity and the quality of the decision values into account, and defines the thermodynamic decision making parameters based on the HFPDM. Accordingly, a whole procedure for emergency decision making is conducted. What is more, some experiments are designed to demonstrate and improve the validation of the emergency decision making procedure. Last but not the least, this paper makes a case study about the emergency decision making in the firing and exploding at Port Group in Tianjin Binhai New Area, which manifests the effectiveness and practicability of the proposed method.


title: Replacing the stethoscope with ultrasound identification of lung sliding to confirm correct endotracheal tube placement for COVID19 patients - time for a paradigm shift?

text: Stethoscopes are well known to have the potential to spread virulent pathogens (Maki 2014) and in the ICU settings they seem to have an even more increased role(Thapa and Sapkota 2017). The current pandemic of COVID19 disease involves severe risks for the healthcare provider involved in initiating invasive ventilation for ARDS patients. Medical staff gets infected every day and a lot of colleagues already died due to the novel disease. As surface contamination is one of the common ways involved in disease spreading, the stethoscope, a ubiquity tool that needs to be in contact with both infected patient and the cephalic extremity of the health care practitioner may have a key role. Auscultation of both lungs with the stethoscope to differentiate between tracheal and bronchial intubation is still the standard of care in all the intubation protocols all around the world. The preoccupation to include the ultrasound as a tool for airway management is not new (Garg 2015) and ultrasound was showed to have better sensibility and specificity than auscultation (Ramsingh et al. 2016).


title: Long-term follow-up of five yr shows superior renal function with everolimus plus early calcineurin inhibitor withdrawal in the PROTECT randomized liver transplantation study.

text: BACKGROUND The 12-month (M) PROTECT study showed that de novo liver transplant recipients (LTxR) who switched from a calcineurin inhibitor (CNI)-based immunosuppression to a CNI-free everolimus (EVR)-based regimen showed numerically better renal function. Here, we present the five-yr follow-up data. METHODS PROTECT was a randomized controlled study in which LTxR received basiliximab and CNI-based immunosuppression ± corticosteroids. Patients were randomized 1:1 to receive EVR or continue CNI. Patients completing the core study could enter the extension study on their randomized treatment. RESULTS A total of 81 patients entered the extension study (41, EVR; 40, CNI). At M59 post-randomization, the adjusted mean eGFR was significantly higher in the EVR group, with a benefit of 12.4 mL/min using Cockcroft-Gault (95% CI: 1.2; 23.6; p = 0.0301). Also, there was a significant benefit for adjusted and unadjusted eGFR using the four-variable Modification of Diet in Renal Disease (MDRD4) or Nankivell formula. During the extension period, treatment failure rates were similar. SAEs occurred in 26 (63.4%) and 28 (70.0%) of the patients in EVR and CNI groups, respectively. CONCLUSION Compared with the CNI-based treatment, EVR-based CNI-free immunosuppression resulted in significantly better renal function and comparable patient and graft outcomes after five-yr follow-up.


The allergenicity of genetically modified foods from genetically engineered crops: A narrative and systematic review.


Dual antiplatelet therapy in patients with acute coronary syndrome during the coronavirus disease of 2019 pandemia: the right choice at the right time.


Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.


title: Influence of macrocyclic chelators on the targeting properties of (68)Ga-labeled synthetic affibody molecules: comparison with (111)In-labeled counterparts.

text: Affibody molecules are a class of small (7 kDa) non-immunoglobulin scaffold-based affinity proteins, which have demonstrated substantial potential as probes for radionuclide molecular imaging. The use of positron emission tomography (PET) would further increase the resolution and quantification accuracy of Affibody-based imaging. The rapid in vivo kinetics of Affibody molecules permit the use of the generator-produced radionuclide (68)Ga (T1/2=67.6 min). Earlier studies have demonstrated that the chemical nature of chelators has a substantial influence on the biodistribution properties of Affibody molecules. To determine an optimal labeling approach, the macrocyclic chelators 1,4,7,10-tetraazacylododecane-1,4,7,10-tetraacetic acid (DOTA), 1,4,7-triazacyclononane-N,N,N-triacetic acid (NOTA) and 1-(1,3-carboxypropyl)-1,4,7- triazacyclononane-4,7-diacetic acid (NODAGA) were conjugated to the N-terminus of the synthetic Affibody molecule ZHER2:S1 targeting HER2. Affibody molecules were labeled with (68)Ga, and their binding specificity and cellular processing were evaluated. The biodistribution of (68)Ga-DOTA-ZHER2:S1, (68)Ga-NOTA-ZHER2:S1 and (68)Ga-NODAGA-ZHER2:S1, as well as that of their (111)In-labeled counterparts, was evaluated in BALB/C nu/nu mice bearing HER2-expressing SKOV3 xenografts. The tumor uptake for (68)Ga-DOTA-ZHER2:S1 (17.9 ± 0.7%IA/g) was significantly higher than for both (68)Ga-NODAGA-ZHER2:S1 (16.13 ± 0.67%IA/g) and (68)Ga-NOTA-ZHER2:S1 (13 ± 3%IA/g) at 2 h after injection. (68)Ga-NODAGA-ZHER2:S1 had the highest tumor-to-blood ratio (60 ± 10) in comparison with both (68)Ga-DOTA-ZHER2:S1 (28 ± 4) and (68)Ga-NOTA-ZHER2:S1 (42 ± 11). The tumor-to-liver ratio was also higher for (68)Ga-NODAGA-ZHER2:S1 (7 ± 2) than the DOTA and NOTA conjugates (5.5 ± 0.6 vs.3.3 ± 0.6). The influence of chelator on the biodistribution and targeting properties was less pronounced for (68)Ga than for (111)In. The results of this study demonstrate that macrocyclic chelators conjugated to the N-terminus have a substantial influence on the biodistribution of HER2-targeting Affibody molecules labeled with (68)Ga.This can be utilized to enhance the imaging contrast of PET imaging using Affibody molecules and improve the sensitivity of molecular imaging. The study demonstrated an appreciable difference of chelator influence for (68)Ga and (111)In.


title: Effective new membrane for preventing postthoracotomy pleural adhesion by surface water induction technology.

text: BACKGROUND After thoracic surgery, adhesions between the pleura can cause substantial complications. This study investigated the effectiveness of a novel membrane utilizing surface water induction technology to prevent adhesions. METHODS Eight beagles were divided into an experimental group (five males) and a control group (three females). The experimental group underwent thoracotomy on both the left and right sides of the chest. Both sides received the membrane, and the membrane on one side was glued to the pleura using tissue adhesive. The control group underwent thoracotomy only on the left side. Two weeks postoperatively, all dogs were sacrificed and adhesions were evaluated macroscopically and microscopically. RESULTS Severe adhesion was seen between the parietal and visceral pleura in all control dogs, whereas the experimental group showed minor adhesion in only one dog on one side. CONCLUSIONS Our novel anti-adhesive membrane appeared highly effective in preventing postthoracotomy pleural adhesions.


title: Endovascular balloon-assisted embolization of intracranial and cervical arteriovenous malformations using dual-lumen coaxial balloon microcatheters and Onyx: initial experience.

text: BACKGROUND Ethylene vinyl alcohol copolymer (Onyx) is widely used for the embolization of arteriovenous malformations (AVMs) of the brain, head, and neck. Balloon-assisted Onyx embolization may provide additional unique advantages in the treatment of AVMs in comparison with traditional catheter-based techniques. OBJECTIVE To report our initial experience in performing balloon-assisted AVM embolization for brain and neck AVMs with the use of the new Scepter-C and Scepter-XC coaxial dual-lumen balloon microcatheters. METHODS Balloon-assisted transarterial embolization was performed in a series of 7 patients with AVMs (4 with brain AVMs, 1 with a dural arteriovenous fistula, and 2 with neck AVMs) by using Onyx delivered through the lumen of Scepter-C or Scepter XC coaxial balloon microcatheters. Following the initial balloon-catheter navigation into a feeding artery and the subsequent inflation of the balloon, the embolization was performed by using Onyx 18, Onyx 34, or both. RESULTS A total of 12 embolization sessions were performed via 17 arterial feeders in these 7 patients. In 1 patient, there was an arterial perforation from the inflation of the balloon; in all others, the embolization goals were successfully achieved with no adverse events. CONCLUSION The balloon microcatheters showed excellent navigability, and there were no problems with retrieval or with the repeated inflation and deflation of the balloons. A proximal Onyx plug, which is crucial in many AVM embolizations, was not necessary with this technique. Additionally, fluoroscopy and procedural times seemed lower with this technique compared with conventional embolization methods.


title: Diabetes and COVID-19

text: Summary According to previous reports, diabetes seems to be a risk factor which worsens the serious clinical events caused by COVID-19. But is diabetes per se a risk factor that increases the probability of getting the virus? This paper will discuss this point. There are not many research data on antidiabetic drugs in this context. The potential influence of glucose-lowering agents on the severity of COVID-19 has not been described yet. Dipeptidylpeptidase-4 (DPP-4) is a cell surface protein ubiquitously expressed in many tissues and it is also a soluble molecule found in serum/plasma fluids. DPP-4 is involved in infection of cells by some viruses. This paper reviews data about the use of DPP-4 inhibitors and others diabetes drugs on COVID-19 patients. As such, no available evidence has yet suggested that glucose-lowering drugs – including those targeting DPP4-related pathways – produce any significant harm or benefit in the context of human infections. However, insulin must remain the first-choice agent in the management of critically ill-hospitalized patients, while it is recommended to suspend other agents in unstable patients. This paper provides related French and international recommendations for people with diabetes who got infected by COVID-19 and upholds that infections may alter glucose control and may require additional vigilance.


title: Is It Time for Going Beyond the P-Value Paradigm With the Estimation of the Probability of Clinical Benefit as a Criterion for Assessing the Outcomes of a Clinical Trial? A Case Study in Patients With Major Depressive Disorder.

text: The conventional statistical methodologies for evaluating treatment effect are based on hypothesis testing (P-value). Alternative measurements of treatment effect have been proposed for anti-infective treatments using the probability of target attainment. A general framework is proposed to extend this methodology to other therapeutic areas. A disease trial model is used for estimating the probability of reaching a treatment effect associated with relevant clinical benefits, in complement to the evaluation of the probability of rejecting the null hypothesis. A case study is presented in depression, where disease status is evaluated using bounded clinical scores (Hamilton Depression Rating Scale), and detectable treatment effect is inversely proportional to placebo response. The β-regression approach is used to model Hamilton scale scores, and a placebo-related criterion is proposed for determining the clinical benefit. The probability of reaching a clinical benefit represents a reliable criterion for replacing the P-value paradigm in the assessment of the outcomes of clinical trials.


title: The Role of Pharmacists in the Fight Against COVID-19.

text: Pharmacists across various practice settings are joining the fight against COVID-19, empowered by the resources available through national, governmental and professional organizations. Long-term care pharmacists are instrumental in optimizing medication management and developing policies to reduce the risk of COVID-19 transmission among vulnerable residents.


title: Cerebral oxygenation monitoring during resuscitation by emergency medical technicians: a prospective multicenter observational study.

text: Aim To assess the feasibility and predictive ability of regional cerebral oxygen saturation monitoring during cardiopulmonary resuscitation by emergency medical technicians. Methods This prospective observational study included 33 cardiac arrest patients who received cardiopulmonary resuscitation in a prehospital setting. Patients were connected to a near-infrared spectrometer through two disposable probes immediately after entering the ambulance. The monitor, which showed regional cerebral oxygen saturation readings, was obscured by covering it with a sheet of paper. Regional cerebral oxygen saturation was measured continuously until hospital arrival. Outcome variables included the prehospital return of spontaneous circulation, survival to hospital admission, and survival at 90 days. Results For patients who survived >90 days after hospital admission (n = 2), the mean regional cerebral oxygen saturation values upon ambulance and hospital arrival were 24% and 60%, respectively; for patients who did not survive (n = 31), the mean regional cerebral oxygen saturation values were 15% and 17%, respectively. Regional cerebral oxygen saturation values increased to a greater extent between ambulance arrival and hospital arrival in patients who survived >90 days (median, 36%; interquartile range, 32-40%) than in those who did not survive (0; 0-6%; P = 0.07). Additionally, regional cerebral oxygen saturation values were not related to the prehospital return of spontaneous circulation or survival to hospital admission. Conclusion Regional cerebral oxygen saturation could be monitored during resuscitation by emergency medical technicians, and it can be used during physiological monitor-guided cardiopulmonary resuscitation.


Effects of vaccination against pandemic (H1N1) 2009 among Japanese children.


title: miRNA Expression Change in Dorsal Root Ganglia After Peripheral Nerve Injury.

text: The role of microRNAs (miRNAs) in the regulation of nerve injury-induced neuropathic pain is unclear. The aims of this study were to assess and compare miRNA expression profiles in dorsal root ganglia (DRG) following three different kinds of peripheral nerve injury, including spinal nerve ligation (SNL), dorsal root transection (DRT), and ventral root transection (VRT), in Sprague-Dawley rats. Responses to thermal and mechanical stimuli were measured preoperatively and on postoperative days (PODs) 1, 4, and 7. A miRNA microarray analysis was used to detect the miRNA expression profiles in injured L5 DRG from SNL, DRT, and VRT on POD 7. Validation of miRNA expression was performed by qPCR and in situ hybridization. Rats receiving SNL displayed significantly higher mechanical hypersensitivity, but those receiving DRT developed higher thermal hypersensitivity. The number of miRNAs that were significantly upregulated in L5 DRG was 49 (7.2%), 25 (3.7%), and 146 (21.5%) following SNL, DRT, and VRT, respectively. On the other hand, 35 (5.1%) miRNAs were significantly downregulated in the SNL group, 21 (3.1%) miRNAs in the DRT group, and 41 (6.0%) miRNAs in the VRT group. Of the four miRNAs that were mutually aberrant in all three models, two were significantly upregulated (twofold), miR-21 and miR-31, and two were significantly downregulated, miR-668 and miR-672. Using in situ hybridization, miRNA-21, miRNA-31, miRNA-668, and miRNA-672 were found to localize to neurons in the DRG. Collectively, the mutual abnormal miRNA expression of miR-21, miR-31, miR-668, and miR-677 implied that these miRNAs may be therapeutic targets for alleviating multiple forms of neuropathic pain.


Seropositivity for Avian Influenza H6 Virus among Humans, China.


title: Patients' Use of Social Media for Diabetes Self-Care: Systematic Review.

text: BACKGROUND Patient engagement with diabetes self-care is critical to reducing morbidity and mortality. Social media is one form of digital health that is available for diabetes self-care, although its use for peer-to-peer communication has not been systematically described, and its potential to support patient self-care is unclear. OBJECTIVE The primary aim of this systematic review was to describe the use of social media among patients (peer-to-peer) to manage diabetes and cardiovascular disease (CVD). The secondary aim was to assess patients' clinical outcomes, behavioral outcomes, quality of life, and self-efficacy resulting from peer-to-peer social media use. METHODS We conducted a literature search in the following databases: PubMed, EMBASE, Web of Science, CINAHL, and PsycINFO (January 2008 through April 2019). The inclusion criteria were quantitative studies that included peer-to-peer use of social media for self-care of diabetes mellitus (with all subtypes) and CVD, including stroke. RESULTS After an initial yield of 3066 citations, we selected 91 articles for a full-text review and identified 7 papers that met our inclusion criteria. Of these, 4 studies focused on type 1 diabetes, 1 study included both type 1 and 2 diabetes, and 2 studies included multiple chronic conditions (eg, CVD, diabetes, depression, etc). Our search did not yield any individual studies on CVD alone. Among the selected papers, 2 studies used commercial platforms (Facebook and I Seek You), 3 studies used discussion forums developed specifically for each study, and 2 surveyed patients through different platforms or blogs. There was significant heterogeneity in the study designs, methodologies, and outcomes applied, but all studies showed favorable results on either primary or secondary outcomes. The quality of studies was highly variable. CONCLUSIONS The future landscape of social media use for patient self-care is promising. However, current use is nascent. Our extensive search yielded only 7 studies, all of which included diabetes, indicating the most interest and demand for peer-to-peer interaction on diabetes self-care. Future research is needed to establish efficacy and safety in recommending social media use among peers for diabetes self-care and other conditions.


title: Lab-on-Chip Devices: Gaining Ground Losing Size.

text: Portable analytical devices are notably gaining relevance in the panorama of urgent testing. Such devices have the potential to play an important role as easy-to-handle tools in critical situations. Epidemic infectious disease agents (e.g., Ebola virus, Coronavirus, Zika virus) could be controlled more easily by testing travelers on-site at the country borders to prevent outbreaks from spreading. The increasing incidence of hospital-acquired infections caused by antibiotic resistant pathogens could be minimized by point-of-care microbial analysis as well as rapid screening tests of bacteria resistance. The threat of bioterrorism using novel unknown bioweapons has never been so high, thus, in-the-field early identification of the biological agent is crucial for triggering a coordinated response. Food allergies are a growing public health concern-allergic reactions can result in anaphylactic shock, which can prove fatal in minutes-thus, the ability to test foods for common allergens, rapidly and locally, before ingestion, would improve food safety for those with allergies. Lab-on-chip devices are becoming widely available for diverse applications and are becoming increasingly affordable. However, to shrink in price and size simultaneously, some trade-offs must be made. In this Perspective, we present considerations about product specifications, design concepts, and application scenarios.


Calendar of International Meetings.


Covid-19: Care home deaths in England and Wales double in four weeks.