title: Gastro-esophageal reflux disease symptoms and demographic factors as a pre-screening tool for Barrett's esophagus.

text: BACKGROUND Barrett's esophagus (BE) occurs as consequence of reflux and is a risk factor for esophageal adenocarcinoma. The current "gold-standard" for diagnosing BE is endoscopy which remains prohibitively expensive and impractical as a population screening tool. We aimed to develop a pre-screening tool to aid decision making for diagnostic referrals. METHODOLOGY/PRINCIPAL FINDINGS A prospective (training) cohort of 1603 patients attending for endoscopy was used for identification of risk factors to develop a risk prediction model. Factors associated with BE in the univariate analysis were selected to develop prediction models that were validated in an independent, external cohort of 477 non-BE patients referred for endoscopy with symptoms of reflux or dyspepsia. Two prediction models were developed separately for columnar lined epithelium (CLE) of any length and using a stricter definition of intestinal metaplasia (IM) with segments ≥ 2 cm with areas under the ROC curves (AUC) of 0.72 (95%CI: 0.67-0.77) and 0.81 (95%CI: 0.76-0.86), respectively. The two prediction models included demographics (age, sex), symptoms (heartburn, acid reflux, chest pain, abdominal pain) and medication for "stomach" symptoms. These two models were validated in the independent cohort with AUCs of 0.61 (95%CI: 0.54-0.68) and 0.64 (95%CI: 0.52-0.77) for CLE and IM ≥ 2 cm, respectively. CONCLUSIONS We have identified and validated two prediction models for CLE and IM ≥ 2 cm. Both models have fair prediction accuracies and can select out around 20% of individuals unlikely to benefit from investigation for Barrett's esophagus. Such prediction models have the potential to generate useful cost-savings for BE screening among the symptomatic population.


title: Multidisciplinary consensus on assessment of unruptured intracranial aneurysms: proposal of an international research group.

text: BACKGROUND AND PURPOSE To address the increasing need to counsel patients about treatment indications for unruptured intracranial aneurysms (UIA), we endeavored to develop a consensus on assessment of UIAs among a group of specialists from diverse fields involved in research and treatment of UIAs. METHODS After composition of the research group, a Delphi consensus was initiated to identify and rate all features, which may be relevant to assess UIAs and their treatment by using ranking scales and analysis of inter-rater agreement (IRA) for each factor. IRA was categorized as very high, high, moderate, or low. RESULTS Ultimately, 39 specialists from 4 specialties agreed (high or very high IRAs) on the following key factors for or against UIA treatment decisions: (1) patient age, life expectancy, and comorbid diseases; (2) previous subarachnoid hemorrhage from a different aneurysm, family history for UIA or subarachnoid hemorrhage, nicotine use; (3) UIA size, location, and lobulation; (4) UIA growth or de novo formation on serial imaging; (5) clinical symptoms (cranial nerve deficit, mass effect, and thromboembolic events from UIAs); and (6) risk factors for UIA treatment (patient age and life expectancy, UIA size, and estimated risk of treatment). However, IRAs for features rated with low relevance were also generally low, which underlined the existing controversy about the natural history of UIAs. CONCLUSIONS Our results highlight that neurovascular specialists currently consider many features as important when evaluating UIAs but also highlight that the appreciation of natural history of UIAs remains uncertain, even within a group of highly informed individuals.


title: A randomized controlled trial comparing post-operative pain in single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy.

text: INTRODUCTION An increasing body of evidence is being published about single-incision laparoscopic cholecystectomy (SILC), but there are no well-powered trials with an adequate evaluation of post-operative pain. This randomized trial compares SILC against four-port laparoscopic cholecystectomy (LC) with post-operative pain as the primary endpoint. METHODS Hundred patients were randomized to either SILC (n = 50) or LC (n = 50). Exclusion criteria were (1) Acute cholecystitis; (2) ASA 3 or above; (3) Bleeding disorders; and (4) Previous open upper abdominal surgery. Patients and post-operative assessors were blinded to the procedure performed. The site and severity of pain were compared at 4 h, 24 h, 14 days and 6 months post-procedure using the visual analog scale; non-inferiority was assumed when the lower boundary of the 95% confidence interval of the difference was above -1 and superiority when p ≤ 0.05. RESULTS The study arms were demographically similar. At 24 h post-procedure, SILC was associated with less pain at extra-umbilical sites (rest: p = 0.004; movement: p = 0.008). Pain data were inconclusive at 24 h at the umbilical site on movement; SILC was otherwise non-inferior for pain at all other points. Operating duration was longer in SILC (79.46 vs 58.88 min, p = 0.003). 8% of patients in each arm suffered complications (p = 1.000). Re-intervention rates, analgesic use, return to function, and patient satisfaction did not differ significantly. CONCLUSIONS SILC has improved short-term pain outcomes compared to LC and is not inferior in both short-term and long-term pain outcomes. The operating time is longer, but remains feasible in routine surgical practice.


title: Features and applications of Ent35-MccV hybrid bacteriocin: current state and perspectives.

text: Bacteriocins are peptides of ribosomal synthesis that are active against bacteria related to the producing strain. They have been widely used in the food industry as biopreservatives. The generation of hybrid peptides by combining the genes that encode two different bacteriocins has made it possible to study the mechanisms of action of the bacteriocins that compose them and also develop new peptides with improved biotechnological applications. Hybrid bacteriocins may be obtained in several ways. In our laboratory, by combining enterocin CRL35 and microcin V (Ent35-MccV), we obtained a broad-spectrum peptide that is active against both Gram-positive and Gram-negative bacteria. Ent35-MccV is sensitive to the action of intestinal proteases and is heat resistant, which makes it a good candidate for use as a biopreservative. For this reason, the peptide was tested in skim milk and beef burgers as food models. We also obtained more potent variants of the hybrid by modifying the central amino acid of the hinge region that connects the two bacteriocins. This review also discusses future applications and perspectives regarding the Ent35-MccV and other hybrid peptides.Key Points• Ent35-MccV is a new broad-spectrum bacteriocin.• The mechanism of action of bacteriocins can be studied using hybrid peptides.• Genetic engineering allows obtaining improved bacteriocin derivatives.• Hybrid peptides can be used in the food, pharmaceutical, and veterinary applications.


title: Serosurvey for selected viral infections in free-ranging jaguars (Panthera onca) and domestic carnivores in Brazilian Cerrado, Pantanal, and Amazon.

text: We investigated the exposure of jaguar (Panthera onca) populations and domestic carnivores to selected viral infections in the Cerrado, Amazon, and Pantanal biomes of Brazil. Between February 2000 and January 2010, we collected serum samples from 31 jaguars, 174 dogs (Canis lupus familiaris), and 35 domestic cats (Felis catus). Serologic analyses for antibodies to rabies virus, canine distemper virus (CDV), feline immunodeficiency virus (FIV), and for feline leukemia virus (FeLV) antigen were conducted. The jaguars from Cerrado and Pantantal were exposed to rabies virus, while the jaguars from the Pantanal and the dogs from all three areas were exposed to CDV. Two cats from the Amazonian site were antigen-positive for FeLV, but no jaguars had FeLV antigen or FIV antibody. Canine distemper and rabies viruses should be carefully monitored and considered potential threats to these jaguar populations. Currently FIV and FeLV do not appear to represent a health threat for jaguar populations in this area. Domestic dogs and cats in these areas should be vaccinated, and the movement of domestic animals around protected areas should be restricted.


title: A Reappraisal of Anterior Communicating Artery Aneurysms: A Case for Stent-Assisted Embolization.

text: BACKGROUND Wide-necked anterior communicating artery aneurysms represent a subset of lesions with challenging endovascular treatment despite new endoluminal and intrasaccular devices. OBJECTIVE To assess the long-term clinical and angiographic outcomes of stent-assisted embolization for wide-necked anterior communicating artery aneurysms. METHODS Between March 2008 and March 2014, 32 patients with unruptured wide-necked AComm aneurysms were treated using stent-assisted embolization. The Glasgow Outcome Scale was reviewed at the time of discharge and at latest follow-up. Ischemic and hemorrhagic events were also recorded and analyzed. Aneurysm occlusion was evaluated post-intervention and on subsequent follow-up evaluations. RESULTS Successful stent deployment was achieved in all cases, but in 1 patient the coils could not be contained inside the aneurysm, and the procedure was aborted without complications. The distal segment of the stent was positioned in the ipsilateral A2 in 16 patients, in the contralateral A2 in 15 patients, and in the contralateral A1 in 1 patient. There were no periprocedural thromboembolic or hemorrhagic complications. The rate of major complications was 6%. One patient developed intracranial hemorrhage related to antiplatelet therapy and another had ischemic events due to in-stent stenosis. Angiographic follow-up was available for 26 aneurysms and during a mean follow-up of 22 months, 81% of the lesions were completely occluded and 8% had a small residual neck. The retreatment rate for residual aneurysms was 3%. CONCLUSION Our long-term results suggest that stent-assisted embolization for anterior communicating artery aneurysms may be considered an excellent treatment option with an adequate combination of safety profile and effectiveness.


title: Immediate Regrafting of the Split Thickness Skin Graft Donor Site Assists Healing.

text: BACKGROUND Delayed or even lack of healing of a split-thickness skin graft (STSG) donor site is a potential problem with elderly patients or those with poor wound healing capabilities. A proactive solution that may minimize this risk is to regraft that donor site using otherwise discarded skin graft remnants. METHODS A prospective, nonrandomized, consecutive study was designed to compare the time to healing of the commonly used anterior thigh STSG donor site in patients who had routine dressings (n = 113) versus those with comorbidities known to adversely affect wound healing and had planned regrafting (n = 204). Those comorbidities included age (≥65 years), diabetes mellitus, peripheral vascular disease, chronic renal disease, and chronic steroid use. RESULTS The average number of comorbidities in the regrafted subgroup versus those not regrafted was 1.41 and 0.31, respectively. This was considered to be a significant difference (P < 0.0001) confirming the validity in predicting patients at risk for adverse donor-site healing that would benefit by regrafting. The mean time required for donor-site reepithelialization of those regrafted was 17.2 days compared with 17.8 days for those not regrafted (P = 0.2395), which was not significantly different. CONCLUSIONS Regrafting the STSG donor site of patients with known comorbidities, that is, those expected to have delayed healing in general, had a mean time to reepithelialization comparable with conventionally treated individuals. This was considered a direct consequence of recycling rather than discarding any excess skin graft materials when so indicated and can be a proactive solution to a potentially cumbersome dilemma.


title: Coordination of deep hip muscle activity is altered in symptomatic femoroacetabular impingement.

text: Diagnosis of femoroacetabular impingement (FAI) is increasing, yet the associated physical impairments remain poorly defined. This morphological hip condition can cause joint pain, stiffness, impaired function, and eventually hip osteoarthritis. This exploratory study compared coordination of deep hip muscles between people with and without symptomatic FAI using analysis of muscle synergies (i.e., patterns of activity of groups of muscles activated in synchrony) during gait. Fifteen individuals (11 males) with symptomatic FAI (clinical examination and imaging) and 14 age- and sex-comparable controls without morphological FAI underwent testing. Intramuscular fine-wire and surface electrodes recorded electromyographic activity of selected deep and superficial hip muscles. A non-negative matrix factorization algorithm extracted three synergies which were compared between groups. Information regarding which muscles were activated together in the FAI group (FAI group synergy vector) was used to reconstruct individual electromyography patterns and compare groups. Variance accounted for (VAF) by three synergies was less for the control (94.8 [1.4]%) than FAI (96.0 [1.0]%) group (p = 0.03). VAF of obturator internus was significantly higher in the FAI group (p = 0.02). VAF of the reconstructed individual electromyography patterns with the FAI or control group vector were significantly higher for the FAI group (p < 0.01). Following reconstruction, VAF of quadratus femoris was significantly more reduced in controls (p = 0.04), indicating greater between-subject variability. Coordination of deep hip muscles in the synergy related to hip joint control during early swing differed between groups. This phase involves movement towards the impingement position, which has relevance for the interpretation of synergy differences and potential clinical importance. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1494-1504, 2017.


Thinking Globally, Acting Locally - The U.S. Response to Covid-19.


title: The emerging role and significance of circular RNAs in viral infections and antiviral immune responses: possible implication as theranostic agents.

text: Circular RNAs (circRNAs) are ubiquitously expressed, covalently closed rings, produced by pre-mRNA splicing in a reversed order during post-transcriptional processing. Circularity endows 3'-5'-linked circRNAs with stability and resistance to exonucleolytic degradation which raises the question whether circRNAs may be relevant as potential therapeutic targets or agents. High stability in biological systems is the most remarkable property and a major criterion for why circRNAs could be exploited for a range of RNA-centered medical applications. Even though various biological roles and regulatory functions of circRNAs have been reported, their in-depth study is challenging because of their circular structure and sequence-overlap with linear mRNA counterparts. Moreover, little is known about their role in viral infections and in antiviral immune responses. We believe that an in-depth and detailed understanding of circRNA mediated viral protein regulations will increase our knowledge of the biology of these novel molecules. In this review, we aimed to provide a comprehensive basis and overview on the biogenesis, significance and regulatory roles of circRNAs in the context of antiviral immune responses and viral infections including hepatitis C virus infection, hepatitis B virus infection, hepatitis delta virus infection, influenza A virus infection, Epstein-Barr virus infection, kaposi's sarcoma herpesvirus infection, human cytomegalovirus infection, herpes simplex virus infection, human immunodeficiency virus infection, porcine epidemic diarrhea virus infection, ORF virus infection, avian leukosis virus infection, simian vacuolating virus 40 infection, transmissible gastroenteritis coronavirus infection, and bovine viral diarrhea virus infection. We have also discussed the critical regulatory role of circRNAs in provoking antiviral immunity, providing evidence for implications as therapeutic agents and as diagnostic markers.


title: Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for large pheochromocytoma: Comparative outcomes.

text: OBJECTIVES To evaluate operative and oncological outcomes of laparoscopic adrenalectomy through a transperitoneal approach and retroperitoneal approach for large (>5 cm in diameter) pheochromocytomas. METHODS We retrospectively compared the results of a transperitoneal approach with those of a retroperitoneal approach in 22 patients (mean age 57.5 years, range 38-76 years) with unilateral large pheochromocytomas (12 right, 10 left). The mean body mass index, operation time, pneumoperitoneum time, estimated blood loss, fluctuation in blood pressure and complication rate were compared between the two approaches. RESULTS The mean tumor diameter (range) was 7.0 cm (range 5.2-15.5 cm), and no significant differences were observed between the transperitoneal approach and retroperitoneal approach in any baseline clinical parameter. For right-sided procedures, significant differences were found for operation time (113 vs 85 min), pneumoperitoneum time (93 vs 64 min) and estimated blood loss (96 vs 23 mL; P < 0.05, transperitoneal approach and retroperitoneal approach, respectively). No open conversion or recurrence was reported, but one right transperitoneal approach case required blood transfusion. No difference in these parameters was noted on the left side. CONCLUSIONS For right side procedures, the retroperitoneal approach is feasible, safer and faster than the transperitoneal approach for large pheochromocytomas. Early transection of the feeding artery is beneficial for managing the tumor and reducing the risk of bleeding.


title: Management of patients with COPD during the COVID-19 pandemic.

text: Patients with COPD have an increased risk for severity of COVID-19. Flu-like symptoms with dyspnea may distinguish COVID-19 infection from dyspnea due to a COPD-related exacerbation. Management of COPD with COVID-19 warrants standard-of-care treatment with antimicrobial agents and corticosteroids, though limiting the dose and duration of steroids use may be warranted due to the risk of increased viral shedding. Modalities to treat acute respiratory failure can be used with some caveats. Patients with COPD and COVID-19 infection who treat their illness at home should self-isolate, use nebulizers in ways that avoid viral aerosolization, and frequently disinfect room surfaces.


These methods from psychiatry can help you beat stress during the coronavirus pandemic.


title: Clinical significance of nutritional risk screening for older adult patients with COVID-19.

text: OBJECTIVES The aim of this study was to assess the nutritional risks among older patients with COVID-19 and their associated clinical outcomes using four nutritional risk screening (NRS) tools: Nutrition Risk Screening 2002 (NRS 2002), Malnutrition Universal Screening Tool (MUST), Mini Nutrition Assessment Shortcut (MNA-sf), and Nutrition Risk Index (NRI). METHODS We retrospectively analyzed the data of patients with COVID-19 older than 65 years who were treated in our hospital from January 28, 2020 to March 5, 2020, and explored the relationship between nutritional risk and clinical outcomes. RESULTS A total of 141 patients with COVID-19 (46 common COVID-19, 73 severe COVID-19, and 22 extremely severe COVID-19) were enrolled in the study. NRS 2002 identified 85.8% of patients as having risk, with being identified 41.1% by MUST, 77.3% by MNA-sf, and 71.6% by NRI. The agreement strength was moderate between NRS 2002 and MNA-sf, NRI, fair between MUST and MNA-sf, NRI, fair between MNA-sf and NRI, poor between NRS 2002 and MUST (P < 0.01). After adjustment for confounding factors in multivariate regression analysis, patients in the risk group had significantly longer LOS, higher hospital expenses (except MNA-sf), poor appetite, heavier disease severity, and more weight change(kg) than normal patients by using NRS 2002, MNA-sf, and NRI(P < 0.05). CONCLUSIONS The NRS 2002, MNA-sf, and NRI are useful and practical tools with respect to screening for patients with COVID-19 who are at nutritional risk, as well as in need of additional nutritional intervention.


title: Biologic meshes in perineal reconstruction following extra-levator abdominoperineal excision (elAPE).

text: Recent improvements in the outcome for low rectal cancer have focused on the reconstruction of the perineal defect following greater acceptance of the need for a wider perineal excision encompassing the levator ani complex. In this article we look at the use of biologic materials to close the perineal defect and compare this with the use of other techniques.


title: Single-Incision Laparoscopic Sterilization of the Cheetah (Acinonyx jubatus).

text: OBJECTIVE To describe laparoscopic ovariectomy and salpingectomy in the cheetah (Acinonyx jubatus) using single-incision laparoscopic surgery (SILS). STUDY DESIGN Prospective cohort. ANIMALS Female cheetahs (Acinonyx jubatus) (n = 21). METHODS Cheetahs were randomly divided to receive either ovariectomy (n = 11) or salpingectomy (n = 10). The use and complications of a SILS port was evaluated in all of cheetahs. Surgery duration and insufflation volumes of carbon dioxide (CO2 ) were recorded and compared across procedures. RESULTS Laparoscopic ovariectomy and salpingectomy were performed without complications using a SILS port. The poorly-developed mesosalpinx and ovarian bursa facilitated access to the uterine tube for salpingectomy in the cheetah. The median surgery duration for ovariectomy was 24 minutes (interquartile range 3) and for salpingectomy was 19.5 minutes (interquartile range 3) (P = .005). The median volume of CO2 used for ovariectomy was 11.25 L (interquartile range 3.08) and for salpingectomy was 4.90 L (interquartile range 2.52), (P = .001) CONCLUSIONS: Laparoscopic ovariectomy and salpingectomy can be performed in the cheetah using SILS without perioperative complications. Salpingectomy is faster than ovariectomy and requires less total CO2 for insufflation.


title: [Infectious diarrhea - key reflections for approaching this problem].

text: Diarrhea is a frequent and complex entity which is caused by a large number of infectious and non-infectious reasons. A detailed clinical and epidemiological history will define whether an additional laboratory work-up and treatment is indicated. Acute diarrhea is predominantly caused by viral or bacterial pathogens and is usually of short duration without any therapeutic intervention. A parasitic or non-infectious cause must be primarily considered if the diarrhea persists over two weeks. Work-up of stool specimens must target the most likely pathogens or other causes considered. The key element of treatment of acute diarrhea is rehydration. An empirical anti-infective therapy may be considered in critically ill patients, persistent or chronic diarrhea as well as in selected epidemiological or risk situations.


title: Potential COVID-19 therapeutics from a rare disease: Weaponizing lipid dysregulation to combat viral infectivity.

text: The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in the death of more than 328,000 persons worldwide in the first 5 months of 2020. Herculean efforts to rapidly design and produce vaccines and other antiviral interventions are ongoing. However, newly evolving viral mutations, the prospect of only temporary immunity, and a long path to regulatory approval pose significant challenges and call for a common, readily available and inexpensive treatment. Strategic drug repurposing combined with rapid testing of established molecular targets could provide a pause in disease progression. SARS-CoV-2 shares extensive structural and functional conservation with SARS-CoV-1 including engagement of the same host cell receptor (ACE2) localized in cholesterol-rich microdomains. These lipid-enveloped viruses encounter the endosomal/lysosomal host compartment in a critical step of infection and maturation. Niemann-Pick type C (NP-C) disease is a rare, monogenic neurodegenerative disease caused by deficient efflux of lipids from the late endosome/lysosome (LE/L). The NP-C disease-causing gene (NPC1) has been strongly associated with viral infection, as a filovirus receptor (e.g., Ebola) and through LE/L lipid trafficking. This suggests NPC1 inhibitors or NP-C disease mimetics could serve as anti-SARS-CoV-2 agents. Fortunately, there are such clinically approved molecules that elicit antiviral activity in pre-clinical studies, without causing NP-C disease. Inhibition of NPC1 may impair viral SARS-CoV-2 infectivity via several lipid-dependent mechanisms, which disturb the microenvironment optimum for viral infectivity. We suggest that known mechanistic information on NPC1 could be utilized to identify existing and future drugs to treat COVID-19.


title: Ability of the immune system to fight viruses highlighted by cytometry and TCR clonotype assessments: lessons taken prior to COVID-19 virus pandemic outbreak.

text: The intriguing aspects of SARS-CoV-2 virus are the high rate of spread and rapid progression of pneumonitis. Confronted with thousands of deaths daily worldwide, we have to build quickly the rationale behind the treatment, taking advantage from past analogues. When a new virus strikes, T-cell receptor (TCR) gamma/delta cells are in the first line of defence, activated by stress molecules and recognising some epitopes in a process that is major histocompatibility complex (MHC) independent but still specific, e.g. cytomegalovirus (CMV), as well as participating in the regulatory mechanism - both characteristics are useful in fighting SARS-CoV-2. The fatalities are mostly due to pneumonitis, in the course of which an overwhelming inflammatory process impairs blood oxygenation, calling for artificial ventilation. In fatal COVID-19 cases the balance between the immune response and the inflammatory outcome fails, due to which the patients at risk, mostly aged, have higher levels of anti-SARS-CoV-2 antibodies and an enhanced inflammatory process in the lung. Apparently there is no feedback control over the antibody production. The investigational use of convalescent plasma, providing antibodies taken from patients who have recovered, was shown to be effective, likely through exerting idiotype associated negative control of antibody production. Similarly, the use of mesenchymal stem cells (MSC) may assist the body regulatory mechanisms, knowing the anti-inflammatory potential of these cells. The use of these two immunotherapeutic tools is understandable on the grounds of basic immunology, whose knowledge may direct the medical community in efforts to fight the virus.


title: TRPV4 antagonism prevents mechanically-induced myotonia.

text: OBJECTIVE Myotonia is caused by involuntary firing of skeletal muscle action potentials and causes debilitating stiffness. Current treatments are insufficiently efficacious and associated with side effects. Myotonia can be triggered by voluntary movement (electrically-induced myotonia) or percussion (mechanically-induced myotonia). Whether distinct molecular mechanisms underlie these triggers is unknown. Our goal was to identify ion channels involved in mechanically-induced myotonia and to evaluate block of the channels involved as a novel approach to therapy. METHODS We developed a novel system to enable study of mechanically-induced myotonia using both genetic and pharmacologic mouse models of myotonia congenita. We extended ex vivo studies of excitability to in vivo studies of muscle stiffness. RESULTS As previous work suggests activation of transient receptor potential vanilloid 4 (TRPV4) channels by mechanical stimuli in muscle, we examined the role of this cation channel. Mechanically-induced myotonia was markedly suppressed in TRPV4-null muscles and in muscles treated with TRPV4 small molecule antagonists. The suppression of mechanically-induced myotonia occurred without altering intrinsic muscle excitability such that myotonia triggered by firing of action potentials (electrically-induced myotonia) was unaffected. When injected intraperitoneally, TRPV4 antagonists lessened the severity of myotonia in vivo by approximately 80%. INTERPRETATION These data demonstrate for the first time that there are distinct molecular mechanisms triggering electrically- and mechanically-induced myotonia. Our data indicates that activation of TRPV4 during muscle contraction plays an important role in triggering myotonia in vivo. Elimination of mechanically-induced myotonia by TRPV4 inhibition offers a new approach to treating myotonia. This article is protected by copyright. All rights reserved.


title: Standards of practice for superficial femoral and popliteal artery angioplasty and stenting.

text: This is a Standards of Practice document endorsed by CIRSE. The authors performed a literature review and provide recommendations and quality improvement guidelines based on the most recent and highest level of evidence available to date on the field of Superficial Femoral and Popliteal Artery Angioplasty and Stenting. Standards for the use of basic and more advanced endovascular techniques in the femoropopliteal arteries are reported and relevant aspects of case selection, imaging, follow-up, and overall patient management are presented to guide endovascular practice in Europe.


title: Shoulder surgery in the beach chair position is associated with diminished cerebral autoregulation but no differences in postoperative cognition or brain injury biomarker levels compared with supine positioning: the anesthesia patient safety foundation beach chair study.

text: BACKGROUND Although controversial, failing to consider the gravitational effects of head elevation on cerebral perfusion is speculated to increase susceptibility to rare, but devastating, neurologic complications after shoulder surgery in the beach chair position (BCP). We hypothesized that patients in the BCP have diminished cerebral blood flow autoregulation than those who undergo surgery in the lateral decubitus position (LDP). A secondary aim was to examine whether there is a relationship between patient positioning during surgery and postoperative cognition or serum brain injury biomarker levels. METHODS Patients undergoing shoulder surgery in the BCP (n = 109) or LDP (n = 109) had mean arterial blood pressure (MAP) and regional cerebral oxygen saturation (rScO2) monitored with near-infrared spectroscopy. A continuous, moving Pearson correlation coefficient was calculated between MAP and rScO2, generating the variable cerebral oximetry index (COx). When MAP is in the autoregulated range, COx approaches zero because there is no correlation between cerebral blood flow and arterial blood pressure. In contrast, when MAP is below the limit of autoregulation, COx is higher because there is a direct relationship between lower arterial blood pressure and lower cerebral blood flow. Thus, diminished autoregulation would be manifest as higher COx. Psychometric testing was performed before surgery and then 7 to 10 days and 4 to 6 weeks after surgery. A composite cognitive outcome was determined as the Z-score. Serum S100β, neuron-specific enolase, and glial fibrillary acidic protein were measured at baseline, after surgery, and on postoperative day 1. RESULTS After adjusting for age and history of hypertension, COx (P = 0.035) was higher and rScO2 lower (P < 0.0001) in the BCP group than in the LDP group. After adjusting for baseline composite cognitive outcome, there was no difference in Z-score 7 to 10 days (P = 0.530) or 4 to 6 weeks (P = 0.202) after surgery between the BCP and the LDP groups. There was no difference in serum biomarker levels between the 2 position groups CONCLUSIONS : Compared with patients in the LDP, patients undergoing shoulder surgery in the BCP are more likely to have higher COx indicating diminished cerebral autoregulation and lower rScO2. There were no differences in the composite cognitive outcome between the BCP and the LDP groups after surgery after accounting for baseline Z-score.


Further thoughts on "Beyond Munchausen by proxy: identification and treatment of child abuse in a medical setting".


title: Opportunistic Salpingectomy Does Not Affect Ovarian Reserve or Surgical Outcomes in Patients Undergoing Laparoscopic Myomectomy.

text: OBJECTIVE To determine whether opportunistic salpingectomy in patients undergoing laparoscopic myomectomy has any deleterious effects on ovarian reserve and surgical risk. STUDY DESIGN We performed a retrospective review of patients who had no desire for future child bearing and who were undergoing laparoscopic myomectomy for symptomatic myomas at 4 institutions. Among them, 41 patients concurrently underwent opportunistic salpingectomy (the opportunistic salpingectomy group) and 65 patients did not undergo salpingectomy at the time of laparoscopic myomectomy (the no-salpingectomy group). The primary and secondary outcome measures were change of ovarian reserve determined by the rate of decline in the anti-Müllerian hormone (AMH) level from before surgery to 3 months post-surgery, and surgical outcomes. RESULTS Baseline characteristics were similar between groups. There were also no differences in surgical outcomes, such as operative time, operative bleeding, hospital stay, or complications between groups. The decline rate in AMH was 18.6% (interquartile range (IQR) 2.6-46.8%) in the opportunistic salpingectomy group and 10.4% (IQR 2.6-46.8%) in the no-salpingectomy group, with no significant difference between groups (p = 0.593). CONCLUSION Opportunistic salpingectomy at the time of laparoscopic myomectomy was not associated with negative effects on ovarian reserve or increased surgical risk.


title: Stent-assisted basilar reconstruction for a traumatic vertebral dissection with a large basilar artery thrombosis.

text: An individual in their 30s presented with quadriplegia and coma 7 h after a 30-foot free-fall. Angiography confirmed left vertebral artery dissection causing vertebral artery occlusion (thrombolysis in myocardial infarction (TIMI) 0) and basilar artery thrombosis. Deployment of six self-expanding intracranial stents (right P1 to left V3) resulted in recanalization (TIMI 3). Postoperative MRI demonstrated a large brainstem infarction; the patient was 'locked-in'. In the following 6 months, the patient recovered to ambulation and independence. Aggressive recanalization for symptomatic vertebrobasilar dissection/occlusion may be considered. Despite major diffusion-weighted imaging brainstem lesions, recovery is possible.


title: Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia.

text: PURPOSE Once open abdomen therapy has succeeded, the problem of closing the abdominal wall must be addressed. We present a new four-stage procedure involving the application of a two-component mesh and vacuum conditioning for abdominal wall closure of even large defects. The aim is to prevent the development of a giant ventral hernia and the eventual need for the repair of the abdominal wall. METHODS Nineteen of 62 patients treated by open abdomen over a two-year period could not receive primary abdominal wall closure. To achieve closure in these patients, we applied the following four-stage procedure: stage 1: abdominal damage control and conditioning of the abdominal wall; stage 2: attachment of a tailored two-component mesh of polyglycolic acid (PGA) and large pore polypropylene (PP) in intraperitoneal position (IPOM) plus placement of a vacuum bandage; stage 3: vacuum therapy for 3-4 weeks to allow granulation of the mesh and optimization of dermatotraction; stage 4: final skin suture. During stage 3, eligible patients were weaned from respirator and mobilized. RESULTS The abdominal wall gap in the 19 patients ranged in size from 240 cm(2) to more than 900 cm(2). An average of 3.44 vacuum dressing changes over 19 days were required to achieve 60-100 % granulation of the surface area, so final skin suture could be made. Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days. No mesh-related hematomas, seromas, or intestinal fistulas were observed. CONCLUSION The four-stage procedure presented here is a viable option for achieving abdominal wall closure in patients treated with open abdomen, enabling us to avoid the development of planned giant ventral hernias. It has few complications and has the special advantage of allowing mobilization of the patients before final skin closure. Long-term course in a large number of patients must still confirm this result.


title: Improvement of left atrial function and left atrial reverse remodeling after minimally invasive radiofrequency ablation evaluated by 2-dimensional speckle tracking echocardiography.

text: OBJECTIVE The present study was aimed at demonstrating the beneficial effect of minimally invasive radiofrequency surgical ablation on left atrial remodeling using 2-dimensional speckle-tracking echocardiography. METHODS The study population consisted of 33 patients (mean age, 64.6 ± 6.9 years; 84.8% men) with paroxysmal lone atrial fibrillation undergoing minimally invasive radiofrequency surgical ablation at our institution (University Hospital Maastricht, Maastricht, The Netherlands) from 2007 to 2011. The control group included 20 age- and gender-matched healthy adults. The left atrial peak systolic strain, peak strain rate, peak early diastolic strain rate, and peak negative strain rate were measured. Left atrial reverse remodeling was defined as a reduction in the left atrial volume index of 15% or greater. RESULTS The peak systolic strain was lower in patients with atrial fibrillation than in the controls (P < .001). It had increased significantly at 3 months (P < .001) and 12 months (P = .01) after surgery. Similarly, the peak strain rate (P < .001) was lower in patients with atrial fibrillation but had increased 3 months (P = .004) and 12 months (P = .001) after surgery. Finally, the peak early diastolic strain rate (P < .001) and peak negative strain rate (P < .001) were less negative at baseline compared with the rates in the controls. Both indexes had improved significantly at the follow-up examinations (3 months, P = .008 and P = .02; 12 months, both P = .01). Left atrial reverse remodeling occurred in 60.6% of patients at 3 months and 72.7% at 12 months postoperatively. CONCLUSIONS Minimally invasive radiofrequency ablation resulted in significant left atrial reverse remodeling and significant improvement in left atrial compliance and function after restoration of sinus rhythm, as demonstrated by 2-dimensional speckle-tracking echocardiography analysis. Our findings need to be confirmed by additional and larger prospective studies.


Infectious diseases. Amid heightened concerns, new name for novel coronavirus emerges.


title: Human coronavirus-induced neuronal programmed cell death is cyclophilin d dependent and potentially caspase dispensable.

text: Human coronaviruses (HCoV) are recognized respiratory pathogens. Some HCoV strains, including HCoV-OC43, can invade the central nervous system, where they infect neurons, with unclear consequences. We have previously reported that HCoV-OC43 infection of human neurons activates the unfolded-protein response and caspase-3 and induces cell death and that the viral spike (S) glycoprotein is involved in the process. We now report on underlying mechanisms associated with the induction of programmed cell death (PCD) after infection by the reference HCoV-OC43 virus (rOC/ATCC) and a more neurovirulent and cytotoxic HCoV-OC43 variant harboring two point mutations in the S glycoprotein (rOC/U(S183-241)). Even though caspase-3 and caspase-9 were both activated after infection, the use of caspase inhibitors neither reduced nor delayed virus-induced PCD, suggesting that these proteases are not essential in the process. On the other hand, the proapoptotic proteins BAX, cytochrome c (CytC), and apoptosis-inducing factor (AIF) were relocalized toward the mitochondria, cytosol, and nucleus, respectively, after infection by both virus variants. Moreover, LA-N-5 neuronal cells treated with cyclosporine (CsA), an inhibitor of the mitochondrial permeabilization transition pore (mPTP), or knocked down for cyclophilin D (CypD) were completely protected from rOC/ATCC-induced neuronal PCD, underlining the involvement of CypD in the process. On the other hand, CsA and CypD knockdown had moderate effects on rOC/U(S183-241)-induced PCD. In conclusion, our results are consistent with mitochondrial AIF and cyclophilin D being central in HCoV-OC43-induced PCD, while caspases appear not to be essential.


title: Bronchoscopy in lung cancer: navigational modalities and their clinical use.

text: INTRODUCTION More than 150,000 solitary pulmonary nodules are reported each year in the United States. As the popularity of low dose CT scan use for screening grows, these numbers are likely to increase substantially over the coming years. More than 10 million CT scans of the chest were performed in the United States alone in 2012, highlighting the potential for this clinical scenario. Detecting a nodule on either a chest radiograph or a CT scan frequently leads to a cascade of further investigations to establish a definite diagnosis. Thoracic surgery is frequently performed to obtain a tissue diagnosis in these cases, however, for what often turns out to be a benign abnormality. AREAS COVERED During the last decade, several new technologies have been introduced to the field of bronchoscopy. As experience with these technologies has increased, the body of published literature has grown. Expert commentary: In this review, we assess the most important and interesting articles in the field. The value and the limitations of the various options will be discussed based on the actual evidence.


title: Understanding COVID-19 in Nepal.

text: The novel coronavirus COVID-19 (SARS-CoV-2) was first reported in 31 December 2019 in Wuhan City, China. The first case of COVID-19 was officially announced on 24 January, 2020, in Nepal. Nine COVID-19 cases have been reported in Nepal. We aim to describe our experiences of COVID-19 patients in Nepal. Keywords: COVID-19; experience; Nepal.


title: Heparin priming of EUS-FNA needles does not adversely affect tissue cytology or immunohistochemical staining.

text: Background and study aims Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) or biopsy (FNB) is an indispensable diagnostic tool. Improvements in needling technique have led to increasing tissue yields. Blood clogging of the needle can cause difficulties with specimen handling and stylet passage, which improves when the needle is primed with heparin before use. However, the effect of heparin on cytology, histology or immunochemistry (IHC) of FNA and FNB specimens is unknown. The goal of the study was to evaluate heparin priming on cytologic/histologic appearance, IHC staining, ease of stylet passage, and specimen bloodiness. Patients and methods This was a retrospective study of patients undergoing EUS-FNA/FNB. Needle sizes were 25 gauge (g), 22 g, and 19 g. Heparin priming of the needle was done and the stylet replaced ("dry heparin") or suction attached without replacing the stylet ("wet heparin"). Smears and cellblocks were examined by pathologists, and IHC staining were done as needed. Specimen bloodiness was compared with matched controls. Results Adequate tissue yields were obtained in all samples (37 heparin, 36 no heparin). Heparin priming did not exhibit negative effects on cytologic or histologic interpretation of the specimens, nor IHC. There was no difference in cellblock bloodiness between the heparin primed needle specimens and the non-heparin control group. . Conclusions Heparin priming of EUS-FNA or FNB needles does not negatively affect cytologic or histologic interpretation, nor interfere with IHC. In addition, heparin priming does not increase specimen bloodiness. When the "wet suction" technique is used for EUS-FNA, heparin priming can be used instead of saline priming of the EUS needle.


Critical Care Medicine After the 2014-2015 Ebola Outbreak: Are We Ready If It Happens Again?


Covid-19: What is the R number?


Cocaine-induced full-thickness tissue necrosis: a case series.


title: An option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: A single-layer suturing technique for the stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures.

text: We report an option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. We detail a single-layer suturing technique for the endoscopic linear stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures. From June 2013 to February 2017, we performed TLDG with delta-shaped gastroduodenostomy in 20 patients with gastric cancer. The linear stapler was closed and fired to attach the posterior walls of the remnant stomach and the duodenum together. After creating a good view of the greater curvature side of the entry hole for the stapler by retracting the knotted suture on the lesser curvature side toward the ventral side, we performed single-layer entire-thickness continuous suturing of this hole using a 15-cm-long barbed suture running from the greater curvature side to the lesser curvature side. We placed the second and third stitches between the seromuscular layer of the remnant stomach and the entire-thickness layer of the duodenum while suturing the duodenal mucosa as minutely as possible. In addition, we routinely added one or two entire-thickness knotted sutures at the site near the greater curvature side. We placed similar additional knotted sutures at the site with a broad pitch. TLDG with this reconstruction technique was successfully performed in all patients with no occurrences of anastomotic leakage or intraabdominal abscess around the anastomosis. It is suggested that this method can be one option for delta-shaped gastroduodenostomy in TLDG due to its cost-effectiveness and feasibility.


title: Oligonucleotides and the COVID-19 Pandemic: A Perspective.

text: The present global health emergency involving the emergence and rapid spread of a novel coronavirus has prompted the world scientific community to consider how it can help to fight this growing viral pandemic. With few safe and effective drugs available to combat this threat to humanity and the normal functioning of our society, the oligonucleotide research community is uniquely positioned to apply its technology and expertise to help alleviate the crisis, thanks to its capacity for rational drug design, swift development cycles, and pursuing targets undruggable by conventional treatment strategies.


Selection of the ideal disinfectant.


Mapping the genomic landscape & diversity of COVID-19 based on >3950 clinical isolates of SARS-CoV-2: Likely origin & transmission dynamics of isolates sequenced in India.


title: A novel way to facilitate left ventricular lead implantation: Jailed catheter technique.

text: An important therapeutic modality for heart failure with left ventricular dyssynchrony, left ventricular lead placement, cannot be achieved due to anatomic challenges in some cases. In the current case, a novel implantation technique to overcome an anatomic difficulty, angled takeoff of the side branch of the coronary sinus, was presented.


title: Personalized ventilation as a control measure for airborne transmissible disease spread.

text: The protective role of personalized ventilation (PV) against plausible airborne transmissible disease was investigated using cough droplets released from a 'coughing machine' simulating the human cough at different distances (1, 1.75 and 3 m) from the PV user. Particle image velocimetry was used to characterize and visualize the interaction between the cough-generated multiphase flow and PV-induced flow in the inhalation zone of the thermal breathing manikin. A dose-response model for unsteady imperfectly mixed environment was used to estimate the reduction in infection risk of two common diseases that can be transmitted by airborne mode. PV was able to both reduce the peak aerosol concentration levels and shorten the exposure time at all the examined injection distances. PV could reduce the infection risks of two diseases, influenza A and tuberculosis, by between 27 and 65 per cent. The protection offered by PV is less effective at a distance of 1.75 m than the other distances, as shown in the risk assessment results, as the PV-generated flow was blown off by the cough-generated flow for the longest time. Results of this study demonstrate the ability of desktop PV to mitigate the infection risk of airborne transmissible disease.


title: The Z-advancement flap for reconstruction of lateral nasal tip and medial alar defects.

text: BACKGROUND Reconstruction of lateral nasal tip and medial alar defects is challenging. Contour, symmetry, and skin texture of the nose, along with adequate nasal airway patency, should be preserved. The Z-advancement flap is a novel reconstruction technique designed for optimal cosmesis and function. OBJECTIVE To evaluate the aesthetic and functional outcomes of Z-advancement flap nasal reconstruction. MATERIALS AND METHODS Twenty-nine consecutive patients with defects 1 cm or less in diameter on the lateral nasal tip or medial ala underwent Z-advancement flap repair. Patients completed a survey assessing cosmesis and airway patency. Three physicians evaluated standardized photographs on visibility of scar lines, erythema and telangiectasia, and contour and symmetry of the ala and nostril opening. RESULTS Twenty-eight (96%) patients completed survey questionnaires. All patients were satisfied with the look and feel of their reconstructed nose. Twenty-four (86%) saw no visible scar or abnormality. Postoperative photographs were available for review in 19 (66%) patients. In 95% to 96% of physician ratings, scars were invisible or visible only on close inspection, and alar symmetry was unchanged or only slightly altered. In 88%, nostril opening symmetry was unchanged or slightly altered. CONCLUSIONS The Z-advancement flap preserves aesthetic subunits of the nose to produce excellent cosmesis and patient satisfaction for defects of the lateral nasal tip or medial ala 1 cm or less in diameter.


title: Cardiac imaging studies in the COVID-19 pandemic.

text: COVID-19 is an acute respiratory syndrome caused by coronavirus-2 (SARS COV2). The different cardiac imaging methods have issued specific recommendations for the different imaging methods in this pandemic, so it is essential to emphasize the recommendations for carrying out these studies.


COVID-19 and Older Adults: The Time for Gerontology-Curriculum across Social Work Programs is Now!


title: Does triage to critical care during a pandemic necessarily result in more survivors?

text: OBJECTIVE The 2009 H1N1 pandemic reinforced the need for a planned response to increased demand for critical care. Triage protocols have been proposed incorporating the exclusion of specified subgroups of patients from critical care. There have been no studies that explore the theoretical underpinning of triage at referral, and it is not clear under what circumstances triage would confer the intended benefits. We sought to explore the mechanisms whereby triage could lead to fewer deaths across a critical care population in the context of a pandemic. DESIGN We constructed a mathematical model based on queuing theory to compare the estimated short-term survival achieved by using a critical care service with and without triage at referral. Illustrative scenarios concerning a hypothetical critical care population were constructed to explore the roles of length of stay and critical care survival in determining the impact of triage and to identify "tipping points" of demand at which triage would result in more survivors. SETTING Not applicable as this was a data-free mathematical modeling exercise. MAIN RESULTS We identified circumstances in which triage would be expected to result in more survivors and circumstances in which it would not. In some scenarios, excluding patient groups solely on the basis of anticipated length of stay could be effective due to a more efficient use of critical care bed days. CONCLUSIONS The impact of triage is dependent on the level of demand and on the scale of achievable differences between included and excluded groups in terms of anticipated length of stay and critical care survival. It cannot be assumed that triage can or will result in fewer deaths. It should be remembered that there are considerations other than population-level short-term survival when determining the objectives of triage and its ethical implementation.


title: Use of thermal imagery for estimation of core body temperature during precooling, exertion, and recovery in wildland firefighter protective clothing.

text: BACKGROUND Monitoring core body temperature to identify heat stress in first responders and in individuals participating in mass gatherings (e.g., marathons) is difficult. OBJECTIVE This study utilized high-sensitivity thermal imaging technology to predict the core temperature of human subjects at a distance while performing simulated field operations wearing thermal protective garments. METHODS Six male subjects participating in a study of precooling prior to exertion in wildland firefighter thermal protective clothing had thermal images of the face captured with a high-resolution thermal imaging camera concomitant with measures of core and skin temperature before, during, and after treadmill exercise in a heated room. Correlations and measures of agreement between core temperature and thermal imaging-based temperature were performed. RESULTS The subjects walked an average (± standard deviation) of 42.6 (±5.9) minutes and a distance of 4.2 (±0.6) km on the treadmill. Mean heart rate at the end of exercise was 152 (±33) bpm and core body temperature at the end of exercise was 38.3°C (±0.7°C). A visual relationship and a strong correlation between core temperature and thermal imaging of the face were identified in all subjects, with the closest relationship and best agreement occurring during exercise. The Bland-Altman test of agreement during exercise revealed the majority of measurement pairs to be within two standard deviations of the measured temperature. CONCLUSIONS High-resolution thermal imaging in the middle-wave infrared spectrum (3-5 μm) can be used to accurately estimate core body temperature during exertion in a hot room while participants are wearing wildland firefighting garments. Although this technology is promising, it must be refined. Using alternative measurement sites such as the skin over the carotid artery, using multiple measurement sites, or adding pulse detection may improve the estimation of body temperature by thermal imagery.


title: How to Minimize the Impact of Pandemic Events: Lessons From the COVID-19 Crisis.

text: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the current pandemic of coronavirus disease 2019 (COVID-19). This pandemic is characterized by a high variability in death rate (defined as the ratio between the number of deaths and the total number of infected people) across world countries. Several possible explanations have been proposed, but it is not clear whether this variability is due to a single predominant factor or instead to multiple causes. Here we addressed this issue using multivariable regression analysis to test the impact of the following factors: the hospital stress (defined as the ratio between the number of infected cases and the total number of hospital beds), the population median age, and the quality of the National Health System (NHS). For this analysis, we chose countries of the world with over 3000 infected cases as of April 1, 2020. Hospital stress was found to be the crucial factor in explaining the variability of death rate, while the others had negligible relevance. Different procedures for quantifying cases of infection and death for COVID-19 could affect the variability in death rate across countries. We therefore applied the same statistical approach to Italy, which is divided into 20 Regions that share the same protocol for counting the outcomes of this pandemic. Correlation between hospital stress and death rate was even stronger than that observed for countries of the world. Based on our findings and the historical trend for the availability of hospital beds, we propose guidelines for policy-makers to properly manage future pandemics.


title: Does the use of a barbed polyglyconate absorbable suture have an impact on urethral anastomosis time, urethral stenosis rates, and cost effectiveness during robot-assisted radical prostatectomy?

text: OBJECTIVE To evaluate the use of a single needle driver with the V-Loc (Covidien, Dublin, Ireland) running suture and compare this with the use of 2 needle drivers with polyglactin interrupted sutures (IS) in dividing the dorsal venous complex (DVC) and forming the urethrovesical anastomosis (UVA) during robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS A prospective cohort study was performed to compare V-Loc (n = 40) with polyglactin (n = 40) sutures. Division of the dorsal venous complex and formation of the UVA during robot-assisted radical prostatectomy using V-Loc or polyglactin sutures were studied. Preoperative, intraoperative, and postoperative parameters were measured. RESULTS V-Loc sutures were associated with a statistically significant reduction in mean dorsal vein suture time (3.15 minutes V-Loc vs 3.75 minutes IS, P = .02) and UVA anastomosis time (8.5 minutes V-Loc vs 11.5 minutes IS, P = .001). No significant difference was noted between operative time (121 minutes V-Loc vs 130 minutes IS, P = .199), delayed healing rates (5% V-Loc vs 7.5% IS, P = .238), continence rate at 12 months (97.5% V-Loc vs 95% IS, P = .368), and urethral stenosis rates (2.5% V-Loc vs 2.5% IS, P = .347) in both groups. CONCLUSION The use of a V-Loc running suture with a single needle driver is a feasible, reproducible, and economic technique with no significant difference in continence rates and urethral stenosis rates, compared with the use of a traditional interrupted suture.


In Response to COVID-19 Pandemic Physicians Already Know What to Do.


How Twitter conversations using hashtags #regionalanesthesia and #regionalanaesthesia have changed in the COVID-19 era.


Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series.


title: Underestimation of COVID-19 cases in Japan: an analysis of RT-PCR testing for COVID-19 among 47 prefectures in Japan.

text: BACKGROUND Under the unique Japanese policy to restrict reverse transcriptase-polymerase chain reaction (RT-PCR) testing against severe acute respiratory syndrome coronavirus 2, a nationwide number of its confirmed cases and mortality remains to be low. Yet the information is lacking on geographical differences of these measures and their associated factors. AIM Evaluation of prefecture-based geographical differences and associated predictors for the incidence and number of RT-PCR tests for COVID-19. DESIGN Cross-sectional study using regression and correlation analysis. METHODS We retrieved domestic laboratory-confirmed cases, deaths, and the number of RT-PCR testing for COVID-19 from January 15 to April 6, 2020 in 47 prefectures in Japan, using publicly-available data by the Ministry of Health, Labour and Welfare. We did descriptive analyses of these three measures and identified significant predictors for the incidence and RT-PCR testing through multiple regression analyses and correlates with the number of deaths through correlation analysis. RESULTS The median prefectural-level incidence and number of RT-PCR testing per 100,000 population were 1.14 and 38.6, respectively. Multiple regression analyses revealed that significant predictors for the incidence were prefectural-level population (p < 0.001) and the number of RT-PCR testing (p = 0.03); and those for RT-PCR testing were the incidence (p = 0.025), available beds (p = 0.045) and cluster infections (p = 0.034). CONCLUSION Considering bidirectional association between the incidence and RT-PCR testing, there may have been an underdiagnosed population for the infection. The restraint policy for RT-PCR testing should be revisited to meet the increasing demand under the COVID-19 epidemic.


title: Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis.

text: BACKGROUND Supplemental oxygen is often administered liberally to acutely ill adults, but the credibility of the evidence for this practice is unclear. We systematically reviewed the efficacy and safety of liberal versus conservative oxygen therapy in acutely ill adults. METHODS In the Improving Oxygen Therapy in Acute-illness (IOTA) systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, HealthSTAR, LILACS, PapersFirst, and the WHO International Clinical Trials Registry from inception to Oct 25, 2017, for randomised controlled trials comparing liberal and conservative oxygen therapy in acutely ill adults (aged ≥18 years). Studies limited to patients with chronic respiratory diseases or psychiatric disease, patients on extracorporeal life support, or patients treated with hyperbaric oxygen therapy or elective surgery were excluded. We screened studies and extracted summary estimates independently and in duplicate. We also extracted individual patient-level data from survival curves. The main outcomes were mortality (in-hospital, at 30 days, and at longest follow-up) and morbidity (disability at longest follow-up, risk of hospital-acquired pneumonia, any hospital-acquired infection, and length of hospital stay) assessed by random-effects meta-analyses. We assessed quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO, number CRD42017065697. FINDINGS 25 randomised controlled trials enrolled 16 037 patients with sepsis, critical illness, stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had emergency surgery. Compared with a conservative oxygen strategy, a liberal oxygen strategy (median baseline saturation of peripheral oxygen [SpO2] across trials, 96% [range 94-99%, IQR 96-98]) increased mortality in-hospital (relative risk [RR] 1·21, 95% CI 1·03-1·43, I2=0%, high quality), at 30 days (RR 1·14, 95% CI 1·01-1·29, I2=0%, high quality), and at longest follow-up (RR 1·10, 95% CI 1·00-1·20, I2=0%, high quality). Morbidity outcomes were similar between groups. Findings were robust to trial sequential, subgroup, and sensitivity analyses. INTERPRETATION In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes. Supplemental oxygen might become unfavourable above an SpO2 range of 94-96%. These results support the conservative administration of oxygen therapy. FUNDING None.


Covid-19: Scotland "on track" to eliminate virus.


title: Electrochemical and biological characterization of thin-film platinum-iridium alloy electrode coatings: a chronic in vivo study.

text: OBJECTIVE To evaluate the electrochemical properties, biological response, and surface characterization of an electrodeposited Platinum-Iridium (Pt-Ir) electrode coating on cochlear implants subjected to chronic stimulation in vivo. APPROACH Electrochemical impedance spectroscopy (EIS), charge storage capacity (CSC), charge injection limit (CIL), and voltage transient (VT) impedance were measured bench-top before and after implant and in vivo. Coated Pt-Ir and uncoated Pt electrode arrays were implanted into cochlea of normal hearing rats and stimulated for ~4 hours/day, 5 days/week for 5 weeks. Neural function was monitored using electrically-evoked auditory brainstem responses. After explant, the electrode surfaces were assessed, and cochleae examined histologically. MAIN RESULTS When measured on bench-top before and after stimulation, Pt-Ir coated electrodes had significantly lower VT impedance (p < 0.001) and significantly higher CSC (p < 0.001) and CIL (p < 0.001) compared to uncoated Pt electrodes. In vivo, the CSC and CIL of Pt-Ir were significantly higher than Pt throughout the implantation period (p = 0.047 and p < 0.001, respectively); however, the VT impedance (p = 0.3) was not. There was no difference in foreign body response between material cohorts, although cochleae implanted with coated electrodes contained small deposits of Pt-Ir. There was no evidence of increased neural loss or loss of neural function in either group. Surface examination revealed no Pt corrosion on any electrodes. SIGNIFICANCE Electrodeposited Pt-Ir electrodes demonstrated significant improvements in electrochemical performance on the bench-top and in vivo compared to uncoated Pt. Neural function and tissue response to Pt-Ir electrodes were not different from uncoated Pt, despite small deposits of Pt-Ir in the tissue capsule. Electrodeposited Pt-Ir coatings offer promise as an improved electrode coating for active neural prostheses.


Rendezvous biliary recanalization combining percutaneous and endoscopic techniques using a diathermic dilator for bile duct obstruction.


title: A laparoendoscopic single-site surgery approach to mesh sacrohysteropexy.

text: Although laparoendoscopic single-site surgery (LESS) has spread across surgical disciplines, this has not been the case for the repair of uterovaginal prolapse. We describe the use of this technique for mesh sacrohysteropexy to correct a global prolapse classified as stage II on the pelvic organ prolapse quantification (POP-Q) system. The procedure involved intraoperative modification of a commercially available single incision port. At the 18 months followup, the patient was free of symptoms and had no objective prolapse.


title: The experimental induction of leukoencephalomyelopathy in cats.

text: Leukoencephalomyelopathy of undetermined etiology has been described in specific pathogen-free cats. A study was established to assess if the long-term feeding of a gamma-irradiated diet could induce this disease. Cats fed exclusively on diet irradiated at 25.7-38.1 kGy ("typical" dose) and 38.1-53.6 kGy (high-end dose), respectively, developed typical lesions with attendant, progressively severe ataxia between study days 140 and 174. The onset of ataxia at day 140 and the number of animals affected at this time were similar in animals fed each ration. A maximum ataxia "score" was first reached by an animal on the high-end dose diet on day 167 and by 2 cats fed the "typical-end" dose diet 21 days later. Ataxic cats and 1 animal euthanized on day 93 prior to the onset of ataxia exhibited varying degrees of Wallerian degeneration in the spinal cord and brain, similar to the spontaneous disease. The elevated total antioxidant status of spinal cord segments and hepatic superoxide dismutase concentration of cats fed typical and high-end treated diets suggested free-radical involvement in the pathogenesis. The significantly elevated peroxide concentrations of the irradiated diets (1,040% and 6,440% of untreated values) may have resulted in increased oxidative insult, a factor possibly exacerbated by the treated diets' reduced vitamin A content. This study has reproduced leukoencephalomyelopathy in cats similar to spontaneous outbreaks by feeding a gamma-irradiated dry diet with elevated peroxide and reduced vitamin A concentrations.


Covid-19: WHO raises concerns about new cases in Beijing.


title: Totally robotic rectal resection: an experience of the first 100 consecutive cases.

text: INTRODUCTION Robotic surgery provides an alternative option for a minimal access approach. It provides a stable platform with high definition three-dimensional views and improved access, which enhances the capabilities for precise dissection in a narrow surgical field. These distinctive features have made it an attractive option for colorectal surgeons. AIM The aim of this study was to present a standardised technique for single-docking robotic rectal resection and to analyse clinical outcomes of the first 100 robotic rectal procedures performed in a single centre between May 2013 and April 2015. METHOD Prospectively collected data related to 100 consecutive patients who underwent single-docking robotic rectal surgery was analysed for surgical and oncological outcomes. RESULTS Sixty-six patients were male, the median age was 67 years (range-24-92). Eighteen patients had neo-adjuvant chemoradiotherapy whilst 23 patients had BMI >30. Procedures performed included anterior resection (n = 74), abdominoperineal resection (n = 10), completion proctectomy (n = 9), restorative proctectomy with ileal pouch-anal anastomosis (IPAA) (n = 5) and Hartmann's procedure (n = 2). The median operating time was 240 min (range-135-456), and median blood loss was 10 ml (range 0-200). There was no conversion or intra-operative complication. Median length of stay was 7 days (range, 3-48) and readmission rate was 12 %. Thirty-day mortality was zero. Postoperatively, two patients had an anastomotic leak whilst two had small bowel obstruction. The median lymph node harvest was 18 (range, 6-43). CONCLUSION The single-docking robotic technique should be considered as an alternative option for rectal surgery. This approach is safe and feasible and in our study it has demonstrated favourable clinical outcomes.


title: Blood sphingolipidomics in healthy humans: impact of sample collection methodology.

text: We used a HPLC-MS/MS methodology for determination of a basic metabolomic profile (18:1,18:0 sphingoid backbone, C(14)-C(26) N-acyl part) of "normal" sphingolipid levels in human serum and plasma. Blood was collected from healthy males and nonpregnant females under fasting and nonfasting conditions with and without anticoagulants. Sphingolipids analyzed included sphingoid bases, sphingosine and dihydrosphingosine, their 1-phosphates (S1P and dhS1P), molecular species (C(n)-) of ceramide (Cer), sphingomyelin (SM), hexosylceramide (HexCer), lactosylceramide (LacCer), and Cer 1-phosphate (Cer1P). SM, LacCer, HexCer, Cer, and Cer1P constituted 87.7, 5.8, 3.4, 2.8, and 0.15% of total sphingolipids, respectively. The abundant circulating SM was C(16)-SM (64.0 µM), and it increased with fasting (100 µM). The abundant LacCer was C(16)-LacCer (10.0 µM) and the abundant HexCer was C(24)-HexCer (2.5 µM). The abundant Cer, C(24)-Cer (4.0 µM), was not influenced by fasting; however, levels of C(16)-C(20) Cers were decreased in response to fasting. S1P levels were higher in serum than plasma (0.68 µM vs. 0.32 µM). We also determined levels of sphingoid bases and SM species in isolated lipoprotein classes. HDL(3) was the major carrier of S1P, dhS1P, and Sph, and LDL was the major carrier of Cer and dhSph. Per particle, VLDL contained the highest levels of SM, Cer, and S1P. HPLC-MS/MS should provide a tool for clinical testing of circulating bioactive sphingolipids in human blood.


Collaborating to achieve Global Vaccine Action Plan goals.


title: Magnetic resonance imaging findings in epileptic cats with a normal interictal neurological examination: 188 cases.

text: Epilepsy is a common neurological condition in dogs and cats. Although an increased likelihood of significant brain lesions with age has been identified in neurologically normal dogs with epileptic seizures, the underlying aetiology of epileptic seizures in cats that present with normal physical and neurological examinations remains unknown. In this cross-sectional study, the authors examined MRI findings in a large population of cats with a normal interictal physical and neurological examination. They hypothesised that age would have an impact on the prevalence of detectable lesions. First, following the guidelines for dogs and in accordance with previous studies, the authors divided the cats into three age groups (aged one year or younger, between one and six, and older than six) and calculated the proportion of cats with a detectable lesion on MRI in these groups. In the first group, 3/32 cats (9.4 per cent) had significant MRI abnormalities that were all consistent with congenital malformation; in the second group, only 5/92 (5.4 per cent) MRI scans were abnormal and in the third group, 15/ 65 (23.1 per cent) cats showed abnormal findings that were predominantly lesions of neoplastic origin. Second, to investigate the impact of age further, data were investigated as a continuous variable using receiver operating characteristic analysis. This indicated an optimal cut-off age of five years, above which MRI abnormalities were more likely, with an increase in the odds of a significant structural lesion increasing by 14 per cent per year.


title: Single-port-access, hand-assisted laparoscopic surgery for benign large adnexal tumors versus single-port pure laparoscopic surgery for adnexal tumors.

text: BACKGROUND Single-port-access hand-assisted laparoscopic surgery (SPA-HALS) is a method intended to provide surgical outcomes with advantages similar to those of SPA-pure laparoscopic surgery (SPA-PLS) for patients with benign large adnexal tumors and to reduce the spillage of tumor contents. This study aimed to assess the feasibility and methodology of SPA-HALS for benign large adnexal tumors and to compare the surgical outcomes of SPA-HALS and SPA-PLS performed by a single surgeon (H.-J. R.). METHODS Between March 2009 and February 2011, 139 patients underwent SPA adnexal surgery. The SPA-PLS procedure was performed for 96 candidates for conventional laparoscopic adnexal surgery, whereas SPA-HALS was performed for 43 patients with large adnexal tumors. The patient demographics and surgical outcomes of these two groups were compared. RESULTS The median adnexal tumor size was larger in the patients who underwent SPA-HALS than in those who underwent SPA-PLS (10.9 vs. 6.3 cm; p < 0.001). Spillage occurred for four patients in the SPA-HALS group (10.3%) compared with 33 patients in the SPA-PLS group (31.3%) (p = 0.005). The relative risk of spillage was 4.43 times higher in the SPA-PLS than in the SPA-HALS group (95% confidence interval [CI], 1.45-13.53). Adnexa-conserving surgery was significantly more frequent in the SPA-HALS group than in the SPA-PLS group (76.7% vs. 43.8%; p < 0.001). Additional procedures were less frequent in the SPA-HALS group (16.3% vs. 33.3%, p = 0.043). The median estimated blood loss was significantly lower in the SPA-HALS group (50 vs. 105 ml; p = 0.001). The two groups did not differ significantly in median operation time (75 vs. 70 min), complication rate (0% vs. 3.1%), or postoperative hospital stay (2 vs. 2 days). CONCLUSION The findings showed that SPA-HALS extracorporeal adnexal surgery allows for thorough evaluation of peritoneal structure and complete surgery of benign large adnexal tumors while retaining the advantages of SPA adnexal surgery. Furthermore, this technique may reduce the intraperitoneal spillage rate for benign large adnexal tumors.


title: COVID-19 with rheumatic diseases: a report of 5 cases.

text: The coronavirus disease 2019 (COVID-19), the result of an infection with the new virus, SARS-CoV-2, is rapidly spreading worldwide. It is largely unknown whether the occurrence of COVID-19 in patients with rheumatic immune diseases has some specific manifestations, or makes them more prone to rapidly progress into severe COVID-19. In this case report, we describe the clinical features of 5 rheumatic immune disease patients with the concomitant presence of COVID-19. Amongst these patients, 4 had rheumatoid arthritis (RA) and 1 had systemic sclerosis (SSc). Two patients had a history of close contact with a COVID-19 patient. The age of the patients ranged between 51 and 79 years. Fever (80%), cough (80%), dyspnea (40%), and fatigue (20%) were the most common presenting symptoms. Laboratory investigations revealed leukopenia and lymphopenia in 2 patients. In all the patients, chest computerized tomography (CT) revealed patchy ground glass opacities in the lungs. During the hospital stay, the condition of two patients remained the same (i.e., mild COVID-19), two patients progressed to the severe COVID-19, and one patient worsened to the critically ill COVID-19. These patients were treated with antiviral agents for COVID-19, antibiotics for secondary bacterial infections, and immunomodulatory agents for rheumatic immune diseases. All the patients responded well, were cured of COVID-19, and subsequently discharged.


title: Effects of preoperative proton pump inhibitor administration on bleeding after gastric endoscopic submucosal dissection: A systematic review and meta-analysis.

text: BACKGROUND AND AIM The efficacy of using proton pump inhibitors (PPIs) prior to gastric endoscopic submucosal dissection (ESD) to reduce gastric bleeding remains controversial. This study aimed to systematically review the literature to evaluate the efficacy of preoperative PPI use to reduce post-ESD bleeding. METHODS PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched to identify randomized trials eligible for inclusion in the systematic review. Data from four studies (406 patients) were combined to calculate a pooled risk difference (RD) for developing post-ESD bleeding. RESULTS Compared with patients who received no premedication, the pooled RD for post-ESD bleeding in patients who received preoperavive PPI was -0.027 (95% confidence interval: -0.070-0.017, p = 0.228), without significant heterogeneity. Preoperavive PPI use significantly increased gastric pH (weighted mean difference: 1.289, 95% CI: 0.227-2.352, p = 0.0174). CONCLUSIONS This systematic review and meta-analysis showed that premedication with PPI had no advantage for the prevention of post-ESD bleeding, despite increasing gastric pH.


title: Does a hypnosis session reduce the required propofol dose during closed-loop anaesthesia induction?: A randomised controlled trial.

text: BACKGROUND Hypnosis has a positive effect on peri-operative anxiety and pain. OBJECTIVE The objective of this study was to assess the impact of a formal deep hypnosis session on the consumption of propofol for anaesthetic induction using automated administration of propofol guided by the bispectral index (BIS) in a closed loop. DESIGN A 1 : 1 randomised, usual-care-controlled, single-centre trial. SETTING Tertiary care centre in France from April 2014 to December 2015. PATIENTS Female adult patients scheduled for outpatient gynaecological surgery under general anaesthesia. INTERVENTION Before surgery, patients were randomised to receive either a deep hypnosis session or routine care. Anaesthetic induction was performed automatically by propofol without opioids and was assisted by the BIS in a closed loop. MAIN OUTCOME MEASURES The primary endpoint was the propofol dose required for anaesthesia induction, defined as a BIS less than 60 for at least 30 s. RESULTS Data for 31 patients in the hypnosis group and 35 in the control group were analysed. There was no evidence of a difference in the mean required propofol dose for anaesthetic induction between the hypnosis and the control groups (2.06 mg kg (95% confidence interval [1.68 to 2.43]) versus 1.79 mg kg (95% CI [1.54 to 2.03]), P = 0.25, respectively). CONCLUSION The current study, which was designed to determine the effect of a deep hypnosis session on anaesthesia induction using an automated tool for propofol administration, failed to detect a difference in the required dose of propofol. TRIAL REGISTRATION ClinicalTrials.gov, NCT02249364.


title: Postoperative pain control: videothoracoscopic versus conservative mini-thoracotomic approach.

text: OBJECTIVES The management of postoperative pain in thoracic surgery is an open issue. The aim of this study was to compare postoperative pain after a videothoracoscopic lobectomy versus a mini-thoracotomy approach. METHODS Between April 2011 and January 2013 we enrolled in a prospective, non-randomized study 145 patients undergoing pulmonary lobectomy with lymphadenectomy for Stage I lung cancer. In 75 cases (Group A), surgery was performed through a videothoracoscopic approach. In 70 cases (Group B), surgery was undertaken through a conservative mini-thoracotomy. Pain was assessed by visual analogue scale and lung function by spirometry and six-minute walking test (6MWT) before surgery, at 48 h and 1 month after surgery. RESULTS Patients were stratified by age, sex, lung function, type and duration of surgery. Length of hospital stay (median, days) was 4 for Group A and 6 for Group B (P = 0.088). The differences between mean postoperative pain values were significant at 1, 12, 24 and 48 h (6.24 vs 8.74, 5.16 vs 7.66, 4.19 vs 6.89 and 2.23 vs 5.33; P = 0.000). In Group A, mean preoperative forced expiratory volume in 1 second values were 2.65 ± 0.61, and 1.83 ± 0.65 and 2.09 ± 0.65, respectively, at 48 h and 1 month (P = 0.028); in Group B, they were 2.71 ± 0.71 preoperatively and 1.33 ± 0.52 and 1.82 ± 0.63, respectively, at 48 h and 1 month. In Group A, mean preoperative 6MWT values (m) were 426.85 ± 51.18, and 371.23 ± 55.36 and 392.07 ± 56.12, respectively, at 48 h and 1 month; in Group B, they were 421.76 ± 56.65 preoperatively and 312.03 ± 48.54 and 331.83 ± 47.99, respectively, at 48 h and 1 month (P = 0.000). CONCLUSIONS The videothoracoscopic approach in the treatment of Stage I lung cancer reduces postoperative pain, which seems to allow a rapid functional recovery of patients.


title: Visual timing abilities of a harbour seal (Phoca vitulina) and a South African fur seal (Arctocephalus pusillus pusillus) for sub- and supra-second time intervals.

text: Timing is an essential parameter influencing many behaviours. A previous study demonstrated a high sensitivity of a phocid, the harbour seal (Phoca vitulina), in discriminating time intervals. In the present study, we compared the harbour seal's timing abilities with the timing abilities of an otariid, the South African fur seal (Arctocephalus pusillus pusillus). This comparison seemed essential as phocids and otariids differ in many respects and might, thus, also differ regarding their timing abilities. We determined time difference thresholds for sub- and suprasecond time intervals marked by a white circle on a black background displayed for a specific time interval on a monitor using a staircase method. Contrary to our expectation, the timing abilities of the fur seal and the harbour seal were comparable. Over a broad range of time intervals, 0.8-7 s in the fur seal and 0.8-30 s in the harbour seal, the difference thresholds followed Weber's law. In this range, both animals could discriminate time intervals differing only by 12 % and 14 % on average. Timing might, thus be a fundamental cue for pinnipeds in general to be used in various contexts, thereby complementing information provided by classical sensory systems. Future studies will help to clarify if timing is indeed involved in foraging decisions or the estimation of travel speed or distance.


title: Emergent laparoscopy in treatment of perforated peptic ulcer: a local experience from a tertiary centre in Saudi Arabia.

text: UNLABELLED BACKGROUND/ PURPOSE: Perforated peptic ulcer (PPU) is still an existing disease that occurs frequently in the 21st century despite of the wide availability of antiulcer medication and Helicobacter eradication. The current study aimed to evaluate the hypothesis that its outcome might be improved by using the laparoscopy. The outcome of treatment in terms of complications, mortality and hospital stay with relevant to laparoscopy was analyzed. PATIENTS AND METHODS This prospective descriptive study was carried on the period of 3 years from July 2009 till July 2012. All patients with acute abdominal pain that was clinically diagnosed as having perforated peptic ulcer were included. Excluded from this study were those patients with concomitant bleeding from the ulcer and evidence of gastric outlet obstructions. Also excluded were those with evidence of large perforation more than 10 mm and patients with symptoms of more than 36 h durations for fear of septic shock. RESULTS Forty seven patients were studied out of a total 53 PPU patients; they were 41 males and 6 females with the male to female ratio of 6.8:1. Their age ranged from 19 to 55 years with the mean age of 39.5 ± 8.6 years. Forty five patients were successfully treated by laparoscopy while only 2 cases that were early presented with signs of hypovolumic shock were converted into laparotomy due to severe bleeding. The mean hospital stay was 75 ± 12.6 h. Post operative complications included death of one patient in the postoperative period at the Intensive care unit (ICU) plus post operative fever in the 2 patients who underwent laparotomy and it was amenable to treatment. CONCLUSIONS Laparoscopic repair of a perforated peptic ulcer is an amenable and feasible technique within the hands of experienced laparoscopic surgeon when the cases are early and properly diagnosed.


title: Risk factors for exposure to feline pathogens in California mountain lions (Puma concolor).

text: The primary challenge to mountain lion population viability in California is habitat loss and fragmentation. These habitat impacts could enhance disease risk by increasing contact with domestic animals and by altering patterns of exposure to other wild felids. We performed a serologic survey for feline pathogens in California mountain lions (Puma concolor) using 490 samples from 45 counties collected from 1990 to 2008. Most mountain lions sampled were killed because of depredation or public safety concerns and 75% were adults. Pathogens detected by serosurvey in sampled mountain lions included feline panleukopenia virus (39.0%), feline calicivirus (33.0%), feline coronavirus (FCoV, 15.1%), feline herpesvirus (13.0%), heartworm (12.4%), feline leukemia virus (5.4%), and canine distemper virus (3%). An outbreak of heartworm exposure occurred from 1995 to 2003 and higher than expected levels of FCoV-antibody-positive mountain lions were observed from 2005 to 2008, with foci in southern Mendocino and eastern Lake counties. We show that the majority of mountain lions were exposed to feline pathogens and may be at risk of illness or fatality, particularly kittens. Combined with other stressors, such as ongoing habitat loss, infectious disease deserves recognition for potential negative impact on mountain lion health and population viability.


COVID-19 Transmission and Children: The Child is Not to Blame.


title: Assessment of periprocedural hemodynamic changes in arteriovenous malformation vessels by endovascular dual-sensor guidewire.

text: Endovascular embolization is an important modality in the treatment of brain AVMs. Nowadays staged embolization is the method of choice for the prevention of perioperative hemorrhagic complications. Current theory suggests that simultaneous occlusion of more than 60% of AVM volume induces significant redistribution local blood flow. That, in turn, may lead to hemorrhage due to AVM rupture. Aside from angiographic findings, there is still no method that predicts the degree of safe partial embolization. Intraluminal measurement of flow velocity and pressure in the vicinity of the AVM nidus might allow detecting the changes in local hemodynamics. That can provide a valuable data and shed the light on the origin of vascular catastrophes. Ten patients underwent 12 embolization sessions with intraluminal flow velocity and pressure monitoring. The measurements were performed by dual-sensor guidewire. The "Combomap" (Volcano) system with Combowire microguidewires was chosen for measurements, as there is a documented experience of safe use of said guidewires in the cerebral vasculature. The findings observed during the study matched empirical data as well as the current physiological hypothesis of AVM hemorrhage. In conjunction with DSA runs, intraluminal flow velocity and pressure monitoring has the potential to become a valuable tool in AVM treatment.


title: Outcome of laparoscopic ovariohysterectomy or ovariectomy in dogs with von Willebrand disease or factor VII deficiency: 20 cases (2012-2014).

text: OBJECTIVE To describe surgical techniques and perioperative management of dogs with von Willebrand disease (VWD) or factor VII (FVII) deficiency undergoing laparoscopic ovariohysterectomy or ovariectomy and evaluate outcomes. DESIGN Retrospective case series. ANIMALS 20 client-owned dogs with VWD (n = 16) or FVII deficiency (4). PROCEDURES Dogs with VWD or FVII deficiency that underwent laparoscopic ovariohysterectomy or ovariectomy between 2012 and 2014 were retrospectively identified via a multi-institutional review of medical records. RESULTS Median expression of von Willebrand factor was 19% (interquartile range, 18% to 30%). All 16 dogs with VWD were Doberman Pinschers, and all were pretreated with desmopressin; 4 also received cryoprecipitate. One of 4 dogs with FVII deficiency received plasma preoperatively, and 1 was treated with desmopressin; 2 dogs received no preoperative treatment. Laparoscopic ovariectomy was performed in 9 dogs with VWD and 2 dogs with FVII deficiency, laparoscopic ovariectomy with gastropexy was performed in 6 dogs with VWD and 1 dog with FVII deficiency, and laparoscopic-assisted ovariohysterectomy was performed in 1 dog with VWD and 1 dog with FVII deficiency. Iatrogenic splenic laceration requiring conversion to laparotomy occurred during trocar insertion in 1 dog with VWD. No postoperative complications, including signs of hemorrhage, were reported for any dogs. CONCLUSIONS AND CLINICAL RELEVANCE Laparoscopic ovariohysterectomy or ovariectomy in dogs with VWD or FVII deficiency pretreated with desmopressin, cryoprecipitate, or plasma transfusions were not associated with clinical signs of hemorrhage, suggesting that minimally invasive ovariohysterectomy or ovariectomy may be considered in female dogs affected with these coagulopathies.


title: Endovascular treatment in older adults with acute ischemic stroke in the MR CLEAN Registry.

text: OBJECTIVE To explore clinical outcomes in older adults with acute ischemic stroke treated with endovascular thrombectomy (EVT). METHODS We included consecutive patients (2014-2016) with an anterior circulation occlusion undergoing EVT from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry. We assessed the effect of age (dichotomized at ≥80 years and as continuous variable) on the modified Rankin Scale (mRS) score at 90 days, symptomatic intracranial hemorrhage (sICH), and reperfusion rate. The association between age and mRS was assessed with multivariable ordinal logistic regression, and a multiplicative interaction term was added to the model to assess modification of reperfusion by age on outcome. RESULTS Of the 1,526 patients, 380 (25%) were ≥80 years of age (referred to here as older adults). Older adults had a worse functional outcome than younger patients (adjusted common odds ratio [acOR] for an mRS score shift toward better outcome 0.31, 95% confidence interval [CI] 0.24-0.39). Mortality was also higher in older adults (51% vs 22%, adjusted odds ratio 3.12, 95% CI 2.33-4.19). There were no differences in proportion of patients with mRS scores of 4 to 5, sICH, or reperfusion rates. Successful reperfusion was more strongly associated with a shift toward good functional outcome in older adults than in younger patients (acOR 3.22, 95% CI 2.04-5.10 vs 2.00, 95% CI 1.56-2.57, p interaction = 0.026). CONCLUSION Older age is associated with an increased absolute risk of poor clinical outcome, while the relative benefit of successful reperfusion seems to be higher in these patients. These results should be taken into consideration in the selection of older adults for EVT.


title: Insufficient documentation for clinical efficacy of selenium supplementation in chronic autoimmune thyroiditis, based on a systematic review and meta-analysis.

text: By a systematic review and meta-analysis to investigate clinically relevant effects of selenium supplementation in patients with chronic autoimmune thyroiditis. Controlled trials in adults (≥18 years) with autoimmune thyroiditis, comparing selenium with or without levothyroxine substitution, versus placebo and/or levothyroxine substitution, were eligible for inclusion. Identified outcomes were serum thyrotropin (thyroid stimulating hormone) levels in LT4-untreated patients, thyroid ultrasound and health-related quality of life. Eleven publications, covering nine controlled trials, were included in the systematic review. Random effects model meta-analyses were performed in weighted mean difference for thyroid stimulating hormone, ultrasound and health-related quality of life. Quality of evidence was assessed per outcome, using GRADE. Meta-analyses showed no change in thyroid stimulating hormone, or improvements in health-related quality of life or thyroid echogenicity (ultrasound), between levothyroxine substitution-untreated patients assigned to selenium supplementation or placebo. Three trials found some improvement in wellbeing in patients receiving levothyroxine substitution, but could not be synthesized in a meta-analysis. The quality of evidence ranged from very low to low for thyroid stimulating hormone as well as ultrasound outcomes, and low to moderate for health-related quality of life, and was generally downgraded due to small sample sizes. We found no effect of selenium supplementation on thyroid stimulating hormone, health-related quality of life or thyroid ultrasound, in levothyroxine substitution-untreated individuals, and sporadic evaluation of clinically relevant outcomes in levothyroxine substitution-treated patients. Future well-powered RCTs, evaluating e.g. disease progression or health-related quality of life, are warranted before determining the relevance of selenium supplementation in autoimmune thyroiditis.


No advice to discontinue antirheumatic therapy for non-medical reasons in light of SARS-CoV-2. Response to: 'Treatment adherence of patients with sytemic rheumatic diseases in COVID-19 pandemic' by Fragoulis et al.


title: Molecular and clinical characterization of human respiratory syncytial virus in South Korea between 2009 and 2014.

text: Respiratory syncytial virus (RSV) can cause serious respiratory infections, second only to influenza virus. In order to know RSV's genetic changes we examined 4028 respiratory specimens from local hospital outpatients in Gyeonggi Province, South Korea over six consecutive years by real-time one-step RT-PCR; 183 patients were positive for RSV infection. To investigate the specific distribution of RSV genotypes, we performed partial sequencing of the glycoprotein gene. Of the 131 RSV-A specimens sequenced, 61 (43·3%) belonged to the ON1 genotype, 66 (46·8%) were NA1 genotype, 3 (2·1%) were GA5 genotype, and 1 (0·7%) belonged to the GA1 genotype. Of the 31 RSV-B specimens sequenced, 29 were BA9 genotype (87·9%) and 2 were BA10 genotype (6·1%). The most common clinical symptoms were fever, cough, nasal discharge, and phlegm; multiple logistic regression analysis showed that RSV-positive infection on pediatric patients was strongly associated with cough (OR = 2·8, 95% CI 1·6-5·1) and wheezing (OR = 2·8, 95% CI 1·7-4·4). The ON1 genotype was significantly associated with phlegm (OR = 11·8, 95% CI 3·8-46·7), while the NA1 genotype was associated with the pediatric patients' gender (males, OR = 2·4, 95% CI 1·1-5·4) and presence of chills (OR = 5·1, 95% CI 1·1-27·2). RSV subgroup B was showed association with nasal obstruction (OR = 4·6, 95% CI 1·2-20·0). The majority of respiratory virus coinfections with RSV were human rhinovirus (47·2%). This study contributes to our understanding of the molecular epidemiological characteristics of RSV, which promotes the potential for improving RSV vaccines.


title: Short-term outcomes of sleeve gastrectomy for morbid obesity: does staple line reinforcement matter?

text: BACKGROUND Stand-alone laparoscopic sleeve gastrectomy (LSG) has been found to be effective in producing weight loss but few large, one-center LSG series have been reported. Gastric leakage from the staple line is a life-threatening complication of LSG, but there is controversy about whether buttressing the staple line with a reinforcement material will reduce leaks. We describe a single-center, 518-patient series of LSG procedures in which a synthetic buttressing material (GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement) was used in the most recently treated patients. METHODS We retrospectively reviewed the medical records of all patients who underwent LSG in our unit between September 2007 and December 2011. Patients treated before August 2009 did not receive the staple line reinforcement material (n = 186), whereas all patients treated afterward did (n = 332). RESULTS The percentages of excess weight loss in the 518 patients (mean age, 41 years; 82% female; mean preoperative body mass index, 44 kg/m(2)) were 67% (79% follow-up rate) at 6 months postoperatively, 81% (64%) at 1 year, and 84% (30%) at 2 years. Type 2 diabetes resolved in 71 % of patients (91/128). Patients given reinforcement material had baseline characteristics similar to those in the no-reinforcement-material group, but had no postoperative staple line leaks or bleeding. The no-reinforcement group had three leaks (p = 0.045) and one case of bleeding. CONCLUSIONS LSG resulted in substantial short-term weight loss. Use of the bioabsorbable staple line reinforcement material may decrease leaks after LSG.