title: Mortalities, amyloidosis and other diseases in free-living red squirrels (Sciurus vulgaris) on Jersey, Channel Islands.

text: Between 2007 and 2014, 337 free-living red squirrels (Sciurus vulgaris) on Jersey, Channel Islands, were examined post mortem as part of a mortality and disease surveillance scheme. Road traffic accidents (RTAs) were attributable for 50.7 per cent (171/337) of the casualties, 34.4 per cent (116/337) succumbed to diseases including fatal exudative dermatitis (FED), 7.1 per cent (24/337) to predation, 6.5 per cent (22/337) to other trauma and 1.2 per cent (4/337) to suspected poisoning. Cat predation accounted for 5 per cent (17/337) of mortalities. Pathologies were diverse and individual animals were often identified with more than one disease process. Squirrelpox virus (SQPV) particles were not detected in selected cases examined by transmission electron microscopy (TEM). Amyloid was identified in 19.3 per cent (65/337) of squirrels, often in conjunction with inflammatory lesions like hepatic capillariasis. A consistent cause of amyloid accumulation was not identified, although there was a significant association of amyloidosis with hepatic capillariasis and FED. In addition to RTAs, amyloidosis and FED have been identified as important causes of squirrel morbidity and mortality on Jersey, while the underlying aetiology and predisposing factors for these two disease complexes are presently unclear. Disease, fragmented woodlands, an increasingly suburban habitat, along with various anthropogenic factors, may jeopardise the long-term viability of this island red squirrel population.


title: Globe penetration in a cat following maxillary nerve block for dental surgery.

text: CLINICAL SUMMARY Dental treatment was carried out in an 8.5-year-old castrated male domestic shorthair cat found to have tooth resorption. Right mandibular, and right and left maxillary nerve blocks were administered using a 1 ml syringe attached to a 25 G x 5/8 inch needle and an intraoral technique. The following day the cat displayed blepharospasm of the right eye. The ocular signs progressed and 5 days later an ophthalmologist confirmed a blind, glaucomatous right eye. It was suspected that the eye had suffered a penetrating injury during dental surgery. Enucleation of the right eye was performed and gross and histopathological examination revealed a penetrating wound consistent with a needle tract injury. PRACTICAL RELEVANCE Complications arising from veterinary dental regional anaesthesia appear to be rare; however, it may be that they are under-reported. This case report highlights the risks involved and reviews the safest and most efficacious regional anaesthesia technique for the feline maxilla.


title: Development and in vitro studies of a polyethylene terephthalate-gold nanoparticle scaffold for improved biocompatibility.

text: Polyethylene terephthalate (PET) mesh is one of the most commonly used synthetic biomaterials for tension-free hernia repair. In an effort to improve the biocompatibility of PET mesh, gold nanoparticles (AuNP) in various concentrations were conjugated to the PET surface to develop PET-AuNP scaffolds. These novel scaffolds were characterized with Fourier transform infrared spectroscopy (FT-IR), scanning electron microscopy (SEM), and differential scanning calorimetry (DSC) to assess the addition of functional groups, presence of AuNPs, and thermal stability of the modified PET mesh, respectively. The biocompatibility of the PET-AuNP scaffolds was evaluated through in vitro cell culture assays. The cellularity of cells exposed to the PET-AuNP scaffolds, as well as the scaffolds' ability to reduce reactive oxygen species, was assessed using L929 murine fibroblasts. Antimicrobial properties of AuNPs conjugated to PET mesh were tested against the bacteria Pseudomonas aeruginosa. Results from the FT-IR showed presence of COOH groups while SEM displayed bonding of AuNPs to the PET surface. DSC results indicated that the PET more than likely did not undergo any detrimental degradation due to the surface modification. Results from the in vitro studies showed that AuNPs, in optimal concentrations (1× concentrations), enhanced cellularity, reduced ROS, and reduced bacteria adhesion to PET. These studies demonstrated enhanced biocompatibility of the AuNP conjugated PET mesh over pristine PET mesh.


title: COVID-19 infection during pregnancy: fetus as a patient deserves more attention.

text: The novel coronavirus disease 2019 (COVID-19) pandemic is causing concern also for the management and outcome of COVID-19-positive pregnant women and their offspring, as reported cases are rare. Current evidence suggests the association of COVID-19 infection in pregnancy with both severe maternal morbidity requiring intensive care and perinatal complications (preterm birth with consequent neonatal morbidity and even perinatal death). Most of the reported cases focused specifically on the maternal outcomes and possible vertical transmission, but less attention has been paid to fetus as a patient in such pregnancies. The use of antenatal steroids and fetal neuroprotection with magnesium sulfate is clearly underreported. Several recently issued guidelines suggest lowering the upper gestational age for antenatal steroid administration and also advocate extreme caution or even restraining from the use of magnesium sulfate. Also, the rate of cesarean deliveries among COVID-19 women is unacceptably high. Here we provide arguments for NOT changing the existing guidelines and caution against cesarean delivery that was the prevalent delivery mode in the reported cases and case series.


title: Sepsis-Induced Thymic Atrophy Is Associated with Defects in Early Lymphopoiesis.

text: Impaired T lymphopoiesis is associated with immunosuppression of the adaptive immune response and plays a role in the morbidity and mortality of patients and animal models of sepsis. Although previous studies examined several intrathymic mechanisms that negatively affect T lymphopoiesis, the extrathymic mechanisms remain poorly understood. Here, we report a dramatic decrease in the percentage of early T lineage progenitors (ETPs) in three models of sepsis in mice (cecal ligation and puncture, lipopolysaccharide continuous injection, and poly I:C continuous injection). However, septic mice did not show a decrease in the number of bone marrow (BM) precursor cells. Instead, the BM progenitors for ETPs expressed reduced mRNA levels of CC chemokine receptor (CCR) 7, CCR9 and P-selectin glycoprotein ligand 1, and exhibited impaired homing capacity in vitro and in vivo. Furthermore, RNA-Seq analysis and real-time PCR showed a marked downregulation of several lymphoid-related genes in hematopoietic stem and progenitor cells. Hematopoietic stem and progenitor cells differentiated into myeloid cells but failed to generate T lymphocytes in vitro and in vivo. Our results indicate that the depletion of ETPs in septic mice might be a consequence of an impaired migration of BM progenitors to the thymus, as well as a defect in lymphoid lineage commitment. Stem Cells 2016;34:2902-2915.


title: Stent-assisted coiling versus coiling alone in unruptured intracranial aneurysms in the matrix and platinum science trial: safety, efficacy, and mid-term outcomes.

text: BACKGROUND AND PURPOSE Stent-assisted coiling may result in less aneurysm recanalization but more complications than coiling alone. We evaluated outcomes of coiling with and without stents in the multicenter Matrix and Platinum Science Trial. MATERIALS AND METHODS All patients in the Matrix and Platinum Science Trial with unruptured intracranial aneurysms treated per protocol were included. Baseline patient and aneurysm characteristics, procedural details, neurologic outcomes, angiographic outcomes, and safety data were analyzed. RESULTS Overall, 137 of 361 (38%) patients were treated with a stent. Stent-coiled aneurysms had wider necks (≥4 mm in 62% with stents versus 33% without, P < .0001) and lower dome-to-neck ratios (1.3 versus 1.8, P < .0001). Periprocedural serious adverse events occurred infrequently in those treated with and without stents (6.6% versus 4.5%, P = .39). At 1 year, total significant adverse events, mortality, and worsening of mRS were similar in treatment groups, but ischemic strokes were more common in stent-coiled patients than in coiled patients (8.8% versus 2.2%, P = .005). However, multivariate analysis confirmed that at 2 years after treatment, prior cerebrovascular accident (OR, 4.7; P = .0089) and aneurysm neck width ≥4 mm (OR, 4.5; P = .02) were the only independent predictors of ischemic stroke. Stent use was not an independent predictor of ischemic stroke at 2 years (OR, 1.1; P = .94). Stent use did not predict target aneurysm recurrence at 2 years, but aneurysm dome size ≥10 mm (OR, 9.94; P < .0001) did predict target aneurysm recurrence. CONCLUSIONS Stent-coiling had similar outcomes as coiling despite stented aneurysms having more difficult morphology than coiled aneurysms. Increased ischemic events in stent-coiled aneurysms were attributable to baseline risk factors and aneurysm morphology.


title: Vaginal cuff thermal injury by mode of colpotomy at total laparoscopic hysterectomy: a randomized clinical trial.

text: STUDY OBJECTIVE To evaluate if the use of Valleylab mode ("V mode") (Covidien, Mansfield, MA) electrothermal energy for colpotomy during total laparoscopic hysterectomy (LH) results in a smaller margin of thermal injury to the upper vagina compared with traditional cut/coagulate (cut/coag) electrothermal energy. DESIGN Prospective randomized clinical trial (Canadian Task Force classification I). SETTING University medical center. PATIENTS A total of 101 subjects who underwent LH between June 2010 and August 2012. INTERVENTIONS Subjects were randomized to colpotomy by V mode electrothermal energy or cut/coag electrothermal energy. MEASUREMENTS AND MAIN RESULTS The primary end point was the median depth of thermal injury measured in millimeters. The secondary end points included the proportion of subjects who developed granulation tissue, induration, infection, or dehiscence at the vaginal cuff at 4 weeks, 3 months, or 6 months postoperatively. There was no significant difference in the median depth of thermal injury in the cut/coag and V mode arms (anterior margin: 0.68 mm vs 0.63 mm [p = .94], posterior margin: 0.66 mm vs 0.70 mm [p = .87], respectively). Twenty-seven percent of subjects in each arm developed at least 1 of the clinical end points at 4 weeks, 3 months, or 6 months postoperatively (granulation tissue: 6%-18% vs 8%-21%, induration: 0%-2% vs 4%-5%, infection: 0%-4% vs 0%-10%, dehiscence: 2% vs 0% in the cut/coag and V mode arms, respectively), with no difference between arms (p = 1.0). CONCLUSION The V mode does not reduce the depth of thermal injury compared with cut/coag electrothermal energy when used for colpotomy incision during total laparoscopic hysterectomy (Clinical Trials.gov ID: NCT02080546).


SARS-CoV-2 pandemics: The lack of critical reflection addressing short- and long-term challenges.


title: What characterises work and workplaces that retain their employees following acquired brain injury? Systematic review.

text: OBJECTIVES The objective of this study was to conduct a systematic review assessing workplace factors related to work retention (or return to work) in employees with acquired brain injury (ABI). Additionally, we aimed to synthesise the evidence and state of knowledge on this subject. METHODS A database search was performed in nine relevant electronic databases. Inclusion criteria were quantitative peer-reviewed publications empirically investigating the relationship between work/workplace factors and work retention in employees following ABI. The methodological quality was determined by Effective Public Health Practice Project scoring, and evidence was synthesised narratively. RESULTS Thirteen studies were included. We found moderate evidence for a negative relationship between manual work and work retention. We also found limited evidence for a U-shaped relationship between workload and complete work retention at 6 months and no relationship at 12 months; a positive relationship between managers, compared with non-managers, and faster work retention; a positive relationship between large enterprise size defined as ≥250 employees, and no relationship between large enterprise size, defined as ≥1000 employees, and work retention. CONCLUSION Relative to individual factors, there is little evidence on specific workplace factors' relationship to work retention among employees with ABI. For most workplace factors, there were too few high-quality studies to designate evidence as more than limited or insufficient. Future studies should replicate rigorous studies of well-defined modifiable workplace factors related to work retention. PROSPERO REGISTRATION NUMBER CRD42018082201.


title: Systolic flow displacement correlates with future ascending aortic growth in patients with bicuspid aortic valves undergoing magnetic resonance surveillance.

text: OBJECTIVES Altered systolic blood flow in the ascending aorta has been correlated with increased aortic growth in patients with bicuspid aortic valves (BAVs). We used conventional, 2-dimensional (2D) phase contrast magnetic resonance imaging (PC-MRI) to assess the relationship between altered flow and future growth in patients with BAV. MATERIALS AND METHODS Aortic MRI data were reviewed for 17 adult patients with BAV with right-left leaflet fusion undergoing surveillance imaging who had 2D PC-MRI through their ascending aortas on an initial study, follow-up studies more than 1 year later, and an initial maximum aortic diameter of less than 4.5 cm. Diameters were measured at standard levels by 2 blinded reviewers. Normalized systolic flow displacement was calculated at peak systole from the PC-MRI data, and correlation with the interval aortic growth was performed, with adjustment for clinical/demographic factors. RESULTS The average follow-up interval was 2.9 ± 1.3 years. Systolic flow displacement at the initial study strongly correlated with ascending aortic growth rate (r = 0.71, P < 0.005) with moderate, non-significant correlation between initial diameter and growth (r = 0.45, P = 0.214). Aortic growth was 4 times faster in patients with initial flow displacement of 0.2 or greater (n = 9) compared with those (n = 8) with initial flow displacement less than 0.2 (0.8 ± 0.4 vs 0.2 ± 0.3 mm/y; P = 0.002). CONCLUSIONS Systolic flow displacement calculated from conventional 2D PC-MRI in the ascending aorta correlates with future aortic growth in patients undergoing routine surveillance imaging for BAV. With a cutoff valve of 0.2, flow displacement may be used to identify a subset of patients likely to have elevated growth rates and may better risk-stratify patients with BAV for aortic disease progression than vessel diameter alone.


Remdesivir in Patients with Acute or Chronic Kidney Disease and COVID-19.


title: Effect of padding duration on radiation dose and image interpretation in prospectively ECG-triggered coronary CT angiography.

text: OBJECTIVE Prospectively ECG-triggered coronary CT angiography images are acquired during a window in middiastole. Additional surrounding x-ray beam on time, or padding, can be variably set, and the increased padding results in additional available phases for analysis. The purpose of this study was to assess the effect of padding duration on image interpretability and its incident effect on radiation dose. SUBJECTS AND METHODS We prospectively evaluated imaging of 886 patients undergoing consecutive prospectively ECG-triggered coronary CT angiographic examinations at three centers and compared the findings in patients stratified by padding duration. We assessed the effect of padding duration on image interpretability and radiation dose. RESULTS The mean patient age was 56 +/- 12 years, and 58% of the patients were men. The median heart rate was 55 beats/min (interquartile range, 50-61 beats/min). Padding duration was 0, 1-99, and 100-150 milliseconds for 268, 482, and 136 patients, respectively, with no difference in image interpretability rate between groups (per patient, 98.8%, 97.3%, and 97.1%; per artery, 99.2%, 99.2%, and 99.1%). The groups differed in median radiation dose (2.3 mSv [interquartile range, 1.5-3.2 mSv]; 3.8 mSv [interquartile range, 2.3-4.7 mSv]; 5.5 mSv [interquartile range, 3.8-6.1 mSv]; p < 0.001). Independent of patient and scan parameters, increased padding was associated with greater radiation dose (45% increase per 100-millisecond increase in padding, p < 0.001). CONCLUSION In a large multicenter study of coronary CT angiography of patients with excellent heart rate control, the use of minimal padding was associated with a substantial reduction in radiation dose with preserved image interpretability. Use of no or reduced padding should be considered in dose-reduction strategies.


title: Origin, transmission, diagnosis and management of coronavirus disease 2019 (COVID-19).

text: Coronavirus has emerged as a global health treat due to its accelerated geographic spread over the last two decades. This article reviews the current state of knowledge concerning the origin, transmission, diagnosis and management of coronavirus disease 2019 (COVID-19). Historically, it has caused two pandemics: severe acute respiratory syndrome and Middle East respiratory syndrome followed by the present COVID-19 that emerged from China. The virus is believed to be acquired from zoonotic source and spreads through direct and contact transmission. The symptomatic phase manifests with fever, cough and myalgia to severe respiratory failure. The diagnosis is confirmed using reverse transcriptase PCR. Management of COVID-19 is mainly by supportive therapy along with mechanical ventilation in severe cases. Preventive strategies form the major role in reducing the public spread of virus along with successful disease isolation and community containment. Development of a vaccine to eliminate the virus from the host still remains an ongoing challenge.


title: "I wouldn't really believe statistics" - Challenges with influenza vaccine acceptance among healthcare workers in Singapore.

text: BACKGROUND Influenza vaccine acceptance among healthcare workers (HCWs) is a worldwide problem, but relatively little research has focussed on Asia, including Singapore. Despite widespread access and recommendations from public health authorities, influenza vaccine uptake remains suboptimal among HCWs. METHODS Our qualitative study used focus group discussions to identify and explain factors limiting influenza vaccine acceptance among HCWs in Singapore. A total of 73 doctors, nurses, allied health and ancillary staff across three public hospitals were included. RESULTS Challenges identified include a fear of contracting influenza from vaccination exacerbated by negative anecdotes regarding vaccine safety and efficacy, distrust of published efficacy data, uncertainty regarding relevance of existing data for Singapore, reluctance to introduce chemicals or overmedicate, pain from injection, low risk attributed to influenza and limited awareness of influenza transmission with a preference for alternatives in patient protection. Differences in attitudes were observed across vocational groups. Lack of overt promotion by hospital leadership in some institutions, perceived vaccine hesitancy among doctors, access, and work culture that implicitly encourages working through illness were further barriers. CONCLUSION Our findings highlight a combination of misperceptions about influenza vaccination and cognitive biases at the individual level, and challenges at the institutional level limiting uptake. Findings indicate an urgent need to provide targeted education and communication. Rather than providing more data, we recommend a widely-disseminated, locally-compiled synthesis addressing specific concerns of hesitant HCWs. Tailoring interventions to specific vocational groups should be considered. Institutional norms and culture may have a powerful influence in setting default behaviours: more effort is needed in improving influenza vaccine promotion and priority at some institutions, integrating vaccine-related communication with other infection control communication and addressing influenza vaccine hesitancy among doctors as a priority. Finally, further study of strategies to address cognitive biases affecting influenza vaccine acceptance in Singapore is desirable.


title: Implementing a mobile stroke unit program in the United States: why, how, and how much?

text: IMPORTANCE There are many ways a mobile stroke unit (MSU) might prove valuable for patients with ischemic and hemorrhagic stroke, such as earlier recognition, more accurate triage, improved management of blood pressure and other critical physiological variables, and eventually earlier implementation of effective therapies. The MSU may be particularly valuable for treatment of patients with acute ischemic stroke with tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, the most evidence-based effective emergency treatment for the most prevalent stroke diagnosis. OBJECTIVES To review existing data on prehospital stroke treatment, especially relevant to MSU technology, to identify gaps in our understanding of MSU feasibility, especially relevant to applying the MSU strategy in the United States, and to describe the Houston MSU program and clinical trial. EVIDENCE REVIEW Published data from English-language journals in PubMed from 1995 to present reviewing early treatment with tPA and prehospital stroke evaluation and treatment. FINDINGS The MSU may result in an overall shift toward earlier evaluation and treatment with tPA, particularly into the first hour after symptom onset, leading to substantially better outcomes. As a result of improved clinical outcomes owing to earlier treatment, the costs of an MSU program may be offset by a reduction in the costs of long-term stroke care and an increase in quality-adjusted life-years, thereby supporting more widespread use of this technology. To make MSU deployment more practical, the vascular neurologist aboard the MSU must be replaced by a remote vascular neurologist connected to the MSU by telemedicine, reducing manpower requirements and costs. CONCLUSIONS AND RELEVANCE The MSU strategy could dramatically transform the way acute stroke is managed in the United States. A prospective study evaluating the logistics, outcomes, and cost-effectiveness of this approach is needed and under way.


title: Laparoscopic uterosacral ligament suspension and sacral colpopexy: results and complications.

text: INTRODUCTION AND HYPOTHESIS We describe our techniques, outcomes, and complications with laparoscopic procedures for correcting pelvic organ prolapse (POP). We hypothesized that laparoscopic abdominal sacrocolpopexy (ASC) gives better anatomic results than laparoscopic uterosacral ligament suspension (USLS), without increased complications. METHODS This was a retrospective cohort study of 290 patients who underwent laparoscopic suspensions in a 2-year period. Anatomic measurements using the Pelvic Organ Prolapse Quantification (POP-Q) system were collected. Subjective data were obtained from the Pelvic Floor Distress Inventory Short-Form 20 (PFDI) questionnaire. The anatomic improvement for each stage and complication rates were analyzed. The difference in the risk of mesh erosion between patients undergoing concomitant total hysterectomy and those who had a prior hysterectomy was determined. In 102 patients with stage 2 prolapse, a comparison between ASC and USLS in anatomic and subjective results and complication rates was performed. RESULTS Anatomic success rates ranged between 86 % and 95 %. Overall mesh erosion rate was 1.2 %, showing no difference between concomitant total laparoscopic hysterectomy (0 %) and prior hysterectomy (2.1 %, p = 0.155). ASC resulted in statistically significantly better anterior-compartment support than USLS (p = 0.043). There was no difference in apex or posterior compartment position or in PFDI scores. CONCLUSION Laparoscopic ASC may be better than USLS for correcting anterior-compartment prolapse, with only a minor risk of mesh erosion.


title: Laparoscopic greater curve plication in Asia: initial experience.

text: BACKGROUND This study aimed to evaluate the effectiveness and safety of laparoscopic greater curve plication (LGCP) for the treatment of obesity in ethnic Chinese in Hong Kong. METHODS Twenty-seven consecutive Chinese patients (23 females; mean age 37.6 ± 8.9 years) received LGCP for the treatment of obesity from September 2010 to December 2011. Mean baseline body weight (BW) and body mass index (BMI) were 84.6 ± 17.5 kg and 31.2 ± 4.7 kg/m(2), respectively. RESULTS All procedures were performed laparoscopically with conversion to open surgery in one patient. There was neither mortality nor any postoperative complications. Mean follow-up was 10.6 ± 6.5 months. Mean procedure time was 117.9 ± 22.3 min and mean hospital stay was 2.6 ± 0.7 days. Mean BMI loss was 4.1 ± 1.6, 4.8 ± 2.0 and 5.2 ± 2.5 kg/m(2) at 3, 6 and 12 months. Mean % EBL was 67.3 ± 42.1, 66.4 ± 35.9 and 60.2 ± 25.5 % at 3, 6 and 12 months. Mean % EBL in BMI >35 group (n = 7) was 38.2 ± 11.1, 43.5 ± 14.0 and 50.6 ± 21.6 % at 3, 6 and 12 months. Mean % EBL in BMI <35 group (n = 20) was 76.5 ± 44.2, 76.5 ± 38.2 and 65.0 ± 27.0 % at 3, 6 and 12 months. CONCLUSIONS LGCP is safe and effective in achieving significant weight loss in obese ethnic Chinese patients. However, weight loss in BMI <35 is more pronounced. It is a very valid alternative to other procedures in Asian population.


title: Physico-Mechanical Properties of Coprocessed Excipient MicroceLac® 100 by DM(3) Approach.

text: PURPOSE To determine the effect of relative humidity (RH) and hydroxypropyl methylcellulose (HPMC) on the physico-mechanical properties of coprocessed MacroceLac(®) 100 using 'DM(3)' approach. METHODS Effects of RH and 5% w/w HPMC on MacroceLac(®) 100 Compressibility Index (CI) and tablet mechanical strength (TMS) were evaluated by 'DM(3)'. The 'DM(3)' approach evaluates material properties by combining 'design of experiments', material's 'macroscopic' properties, 'molecular' properties, and 'multivariate analysis' tools. A 4X4 full-factorial experimental design was used to study the relationship of MacroceLac(®) 100 molecular properties (moisture content, dehydration, crystallization, fusion enthalpy, and moisture uptake) and macroscopic particle size and shape on CI and TMS. A physical binary mixture (PBM) of similar composition to MacroceLac(®) 100 was also evaluated. Multivariate analysis of variance (MANOVA), principle component analysis, and partial least squares (PLS) were used to analyze the data. RESULTS MANOVA CI ranking was: PBM-HPMC > PBM > MicroceLac(®)100 > MicroceLac(®)100-HPMC (p < 0.0001). MANOVA showed PBM's and PBM-HPMC's TMS values were lower than MicroceLac(®)100 and MicroceLac(®)100-HPMC (p < 0.0001). PLS showed that % RH, HPMC, and several molecular properties significantly affected CI and TMS. CONCLUSIONS Significant MicroceLac(®)100 changes occurred with % RH exposure affecting performance attributes. HPMC physical addition did not prevent molecular or macroscopic matrix changes.


title: Endonasal Suturing of Nasoseptal Flap to Nasopharyngeal Fascia Using the V-Loc™ Wound Closure Device: 2-Dimensional Operative Video.

text: We present a case of cerebrospinal fluid (CSF) leak after endoscopic endonasal resection of a large clival chordoma in an obese patient. The leak was at the lower reconstruction at the craniocervical junction and had failed repositioning. Using the V-Loc™ wound closure device (Covidien, New Haven, Connecticut) to suture the nasoseptal flap to the nasopharyngeal fascia, a water-tight seal was created and, along with a lumbar drain, the patient healed successfully.CSF leak after an endoscopic endonasal approach (EEA) to intradural pathologies remains one of the more common complications.1-4 Various closure techniques have been developed5-8 with success in mitigating this risk, but all have their limitations and rely on multiple layers including vascularized flaps like the nasoseptal flap.9-11 Endonasal suturing of graft materials offers the advantage of creating a water-tight seal. We present the use of the V-Loc™ wound closure device (Covidien) to successfully seal a postoperative CSF leak. The absorbable V-Loc™ wound closure device does not require the surgeon to tie knots, which is the most challenging step in a deep, 2-dimensional corridor. The suture is barbed and is anchored by threading the needle through a prefabricated loop at the end of the suture which locks in place. Each throw of the suture through tissue maintains the suture line as the barbs catch the tissue and prevent retraction. After successful closure, the needle can simply be cut off.The V-Loc™ wound closure device (Covidien) is a safe and effective adjunct to reconstruction after endoscopic endonasal skull base surgery as it provides an option for graft/flap suturing.A written release from the patient whose name or likeness is submitted as part of this Work is on file.


Protecting wild animals.


title: The significance of regional hemoglobin oxygen saturation values and limb-to-arm ratios of near-infrared spectroscopy to detect critical limb ischemia.

text: This study examines the application of near-infrared spectroscopy to noninvasively detect critical limb ischemia using regional hemoglobin oxygen saturation in percentage values and regional hemoglobin oxygen saturation limb-to-arm ratios. The regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios were calculated in 61 patients with critical limb ischemia (group A). Measurements were performed in rest at four fixed spots at the most affected lower limb and at a reference spot at both upper arms. Similar measurements were performed in the left lower limb of 30 age-matched control patients without peripheral arterial disease (group B). The regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios were significantly different at all measured spots between the groups (all p < 0.001), except for the regional hemoglobin oxygen saturation limb-to-arm ratios of the distal vastus lateralis (p = 0.056). However, a broad overlap of individual regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios was found in both groups, which resulted in poor discriminative predictive value of single measurements. Single measurements of regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios at all measured spots have poor discriminative predictive value in detection of critical limb ischemia. Measurement of regional hemoglobin oxygen saturation values and regional hemoglobin oxygen saturation limb-to-arm ratios at any of the measurement spots has no added value in detecting lower limb ischemia in individuals compared with current diagnostic modalities.


title: Incorporating the service multiplier method in respondent-driven sampling surveys to estimate the size of hidden and hard-to-reach populations: case studies from around the world.

text: BACKGROUND Estimating the sizes of populations at highest risk for HIV is essential for developing and monitoring effective HIV prevention and treatment programs. We provide several country examples of how service multiplier methods have been used in respondent-driven sampling surveys and provide guidance on how to maximize this method's use. METHODS Population size estimates were conducted in 4 countries (Mauritius- intravenous drug users [IDU] and female sex workers [FSW]; Papua New Guinea-FSW and men who have sex with men [MSM]; Thailand-IDU; United States-IDU) using adjusted proportions of population members reporting attending a service, project or study listed in a respondent-driven sampling survey, and the estimated total number of population members who visited one of the listed services, projects, or studies collected from the providers. RESULTS The median population size estimates were 8866 for IDU and 667 for FSW in Mauritius. Median point estimates for FSW were 4190 in Port Moresby and 8712 in Goroka, Papua New Guinea, and 2,126 for MSM in Port Moresby and 4200 for IDU in Bangkok, Thailand. Median estimates for IDU were 1050 in Chiang Mai, Thailand, and 15,789 in 2005 and 15,554 in 2009 in San Francisco. CONCLUSION Our estimates for almost all groups in each country fall within the range of other regional and national estimates, indicating that the service multiplier method, assuming all assumptions are met, can produce informative estimates. We suggest using multiple multipliers whenever possible, garnering program data from the widest possible range of services, projects, and studies. A median of several estimates is likely more robust to potential biases than a single estimate.


title: Oncologic patient with COVID-19 discovered incidentally by PET/CT examination: (A COVID–19-pandémia orvosszakmai kérdései)

text: The scientific literature of coronavirus-disease 2019 (COVID-19) is rapidly expanding. There is a growing evidence on the discrepancy between clinical symptoms and radiologic findings in many patients. This case report gives details about a patient with only mild symptoms but relatively severe radiological findings. The 75-year-old patient suffering from oncologic disease had a planned a F18-fluoro-deoxy-glucose positron-emission tomography/computer tomography scan with a routine oncological indication where incidental radiomorphologic findings of pneumonia suspect for COVID-19 were detected. After immediate isolation, the patient was transferred to the corresponding medical department, where further investigations verified the diagnosis of COVID-19. With this case, our aim is to raise the awareness for the importance of the instant evaluation of chest computer tomography series when performing planned imaging examination, especially in frail patients. With this practice, potential radiomorphologic findings of pneumonia suspect for COVID-19 could be identified in time, which fundamentally determines further patient management steps. Orv Hetil. 2020; 161(23): 971-976.


title: Absence of Bordetella pertussis Among Infants Hospitalized for Bronchiolitis in Finland, 2008-2010.

text: In 169 Finnish infants hospitalized for bronchiolitis at age <6 months in 2008-2010, nasopharyngeal aspirates were tested by polymerase chain reaction for Bordetella pertussis and 16 viruses. Respiratory viruses were detected in 89% (71% with respiratory syncytial virus), but no infant had B. pertussis. The latter finding may reflect a positive effect from the broadening of the Finnish pertussis vaccination program in 2005.


title: Infectious disease-specific health literacy in Tibet, China.

text: This study was aimed to develop an instrument to assess infectious disease-specific health literacy (IDSHL) in the general population of Tibet, China and identify the association between IDSHL and reported infectious disease-related symptoms. A survey using a standardized questionnaire, which included 25 questions on knowledge, behaviors and skills regarding infectious diseases, was conducted in the general population of Tibet, China between September 2011 and November 2011. The 25 questions formed the index system of the instrument assessing IDSHL (total scores: 25 scores). Factors associated with index scores of IDSHL were identified by general linear model. The association between the index score of IDSHL and the occurrence of the five selected infectious disease symptoms (fever, diarrhea, rash, jaundice or conjunctivitis) were investigated using multivariate unconditional logistic regression. Among 5717 eligible participants in the survey, 4631 participants completed all of the 25 questions in the instrument. The instrument was reliable and valid as measured by the Cronbach's alpha coefficient and split-half coefficient, and the confirmatory factor analysis. Only 1.0% (48/4631) answered ≥80% of the 25 questions correctly (score ≥ 20). Significant factors associated with lower health literacy score included female gender, older age, Tibetan group, lower education level, underlying diseases and more undeveloped area. For each increasing score of IDSHL, reports of fever, diarrhea or jaundice in the prior year were significantly decreased by 3% (p = 0.015), 4% (p = 0.004) and 16% (p < 0.001), respectively. Accurately measuring IDSHL could help identify those individuals with poor IDSHL, who could be targeted with specific interventions to improve health.


title: Common Co-morbidities Are Challenging in the Diagnosis of Middle East Respiratory Syndrome (MERS-CoV) in Saudi Arabia.

text: BACKGROUND AND OBJECTIVE Middle East respiratory syndrome coronavirus (MERS-CoV) is a relatively recent human disease reported initially in Saudi Arabia in September, 2012. Morbidities investigation includes a process of excluding other possible options until certain suspected cases are confirmed. MATERIAL AND METHODS In this study, we formulated a model under the authorization of the Saudi Ministry of Health to accurately identify cases among admitted suspected cases depending on specific signs and symptoms. Real-time polymerase chain reaction was used for confirmation of the positive cases. RESULTS The results showed that the number of patients with combined symptoms of fever/sore throat and fever/cough/SOB was significantly higher in confirmed cases than in non-confirmed cases (p<0.05). Besides, the number of confirmed MERS-CoV cases was significantly higher among cases included in the study than excluded cases. It was also clearly demonstrated that fever combined with other symptoms represents 60% of the confirmed cases, which is significantly higher than for cases with other combined symptoms (p<0.0001). CONCLUSION To the best of our knowledge, there are no appropriate diagnostic models that can differentiate human MERS-CoV infection among other respiratory infections. Therefore, we recommend the adoption of this newly established model of MERS-CoV to short- list corona suspected cases in Saudi Arabia.


25th International Congress of the European Association for Endoscopic Surgery (EAES) Frankfurt, Germany, 14-17 June 2017 : Poster Presentations.


title: Distribution and growth rate of COVID-19 outbreak in Tamil Nadu: A log-linear regression approach.

text: Background Most of the countries are affected with the pandemic outbreak of the coronavirus infection. Understanding the severity and distribution in various regions will help in planning the controlling measures. Objectives The objective was to assess the distribution and growth rate of COVID-19 infection in Tamil Nadu, India. Methods The data on the number of infections of COVID-19 have been obtained from the media reports released by the Government of Tamil Nadu. The data contain information on the incidence of the disease for the first 41 days of the outbreak started on March 7, 2020. Log-linear model has been used to estimate the progression of the COVID-19 infection in Tamil Nadu. Separate models were employed to model the growth rate and decay rate of the disease. Spatial Poisson regression was used to identify the high-risk areas in the state. Results : The models estimated the doubling time for the number of cases in growth phase as 3.96 (95% confidence interval [CI]: 2.70, 9.42) days and halving time in the decay phase as 12.08 (95% CI: 6.79, 54.78) days. The estimated median reproduction numbers were 1.88 (min = 1.09, max = 2.51) and 0.76 (min = 0.56, max = 0.99) in the growth and decay phases, respectively. The spatial Poisson regression identified 11 districts as high risk. Conclusion The results indicate that the outbreak is showing decay in the number of infections of the disease which highlights the effectiveness of controlling measures.


title: Application of the transorally inserted anvil (OrVil) after laparoscopy-assisted total gastrectomy.

text: BACKGROUND Laparoscopy-assisted total gastrectomy (LATG) is not a commonly performed procedure due to the surgical difficulty associated with reconstruction. Although various reconstruction methods have been reported, a standard technique has not yet been established. In this study, we compared the short-term outcomes of LATG reconstructed by mini-laparotomy and by the newly developed transorally inserted anvil (OrVil). METHODS From April 2006, a series of 45 patients underwent LATG. Of these, 15 were reconstructed by mini-laparotomy and 30 by OrVil. Short-term outcomes were compared between the two groups. RESULTS Operation time was significantly shortened and intraoperative blood loss significantly reduced by the use of OrVil. The postoperative course, including morbidity, did not differ between the two groups. CONCLUSIONS LATG using OrVil for the treatment of early gastric cancer is a technically feasible surgical procedure with sufficient lymph node dissection, satisfactory early recovery, and acceptable morbidity. It will be necessary to perform this novel technique in a large number of patients to confirm its feasibility.


title: Biosafety measures for preventing infection from COVID-19 in clinical laboratories: IFCC Taskforce Recommendations.

text: Coronavirus disease 2019 (COVID-19) is the third coronavirus outbreak that has emerged in the past 20 years, after severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). One important aspect, highlighted by many global health organizations, is that this novel coronavirus outbreak may be especially hazardous to healthcare personnel, including laboratory professionals. Therefore, the aim of this document, prepared by the COVID-19 taskforce of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC), is to provide a set of recommendations, adapted from official documents of international and national health agencies, on biosafety measures for routine clinical chemistry laboratories that operate at biosafety levels 1 (BSL-1; work with agents posing minimal threat to laboratory workers) and 2 (BSL-2; work with agents associated with human disease which pose moderate hazard). We believe that the interim measures proposed in this document for best practice will help minimazing the risk of developing COVID-19 while working in clinical laboratories.


COVID umbrella trials multiply.


title: Microarrays--new possibilities for detecting biological factors hazardous for humans and animals, and for use in environmental protection.

text: Both the known biological agents that cause infectious diseases, as well as modified (ABF-Advanced Biological Factors) or new, emerging agents pose a significant diagnostic problem using previously applied methods, both classical, as well as based on molecular biology methods. The latter, such as PCR and real-time PCR, have significant limitations, both quantitative (low capacity), and qualitative (limited number of targets). The article discusses the results of studies on using the microarray method for the identification of viruses (e.g. Orthopoxvirus group, noroviruses, influenza A and B viruses, rhino- and enteroviruses responsible for the FRI (Febrile Respiratory Illness), European bunyaviruses, and SARS-causing viruses), and bacteria (Mycobacterium spp., Yersinia spp., Campylobacter spp., Streptococcus pneumoniae, Salmonella typhi, Salmonella enterica, Staphylococcus aureus, Neisseria meningitidis, Clostridium difficile , Helicobacter pylori), including multiple antibiotic-resistant strains. The method allows for the serotyping and genotyping of bacteria, and is useful in the diagnosis of genetically modified agents. It allows the testing of thousands of genes in one experiment. In addition to diagnosis, it is applicable for gene expression studies, analysis of the function of genes, microorganisms virulence, and allows the detection of even single mutations. The possibility of its operational application in epidemiological surveillance, and in the detection of disease outbreak agents is demonstrated.


title: Novel methods of closing 10-mm laparoscopic port-site wounds.

text: Ten-millimeter ports are often used in laparoscopic surgery. Closure of these port sites can be difficult. In this article, we describe two novel methods of closing 10-mm laparoscopic port-site wounds, which are simple, effective, easy, and do not require any special instruments.


title: Auriculotherapy to control chemotherapy-induced nausea and vomiting in patients with cancer: protocol of a systematic review.

text: BACKGROUND Due to the worldwide rise in cancer incidence, and therefore the rise in the need for antineoplastic chemotherapy, it is important for both healthcare professionals and patients alike that the side effects of chemotherapy, such as chemotherapy-induced nausea and vomiting (CINV), are treated and prevented. Auriculotherapy is a type of acupuncture and may be a low-cost and safe antiemetic measure to control the side effects of chemotherapy. The goal of this systematic review is to synthesize the available evidence in the literature regarding the auriculotherapy effects to treat CINV in people with cancer. METHODS The review will only include randomized controlled trials (RCTs) that compare the clinical effects of the auriculotherapy intervention (used alone or as an add-on), with sham auriculotherapy, routine treatment with antiemetic drugs, or other non-pharmacological interventions in patients with cancer with CINV who are undergoing chemotherapy. The outcomes to be evaluated are nausea and vomiting: in acute, delayed, or anticipated stages, when induced by chemotherapy. A comprehensive search for studies will be carried out in these databases: MEDLINE via PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, ICTRP, LILACS, CUMED, IBECS, BVS MTCI Americas, Web of Science, Scopus, PEDro, CNKI, and CBMdisc up until December 31, 2018. Only articles in English, Portuguese, and Spanish will be selected. Two independent reviewers will evaluate full texts, extract data, and assess the risk of bias of eligible articles. The quality of evidence will be assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). A meta-analysis will be undertaken to assess the interventions and outcomes' homogeneity, assessing statistical heterogeneity using the Cochran's Q test and quantified using Higgins' inconsistency index. If there is insufficient data for a meta-analysis, a narrative synthesis will be presented. This protocol has been prepared according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. DISCUSSION The results of this systematic review will summarize the strength of evidence for the use of auriculotherapy in the control of CINV of patients with cancer and will be used to identify evidence gaps. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018117513.


title: Concise Review: Patency of Small-Diameter Tissue-Engineered Vascular Grafts: A Meta-Analysis of Preclinical Trials.

text: Several patient groups undergoing small-diameter (<6 mm) vessel bypass surgery have limited autologous vessels for use as grafts. Tissue-engineered vascular grafts (TEVG) have been suggested as an alternative, but the ideal TEVG remains to be generated, and a systematic overview and meta-analysis of clinically relevant studies is lacking. We systematically searched PubMed and Embase databases for (pre)clinical trials and identified three clinical and 68 preclinical trials ([>rabbit]; 873 TEVGs) meeting the inclusion criteria. Preclinical trials represented low to medium risk of bias, and binary logistic regression revealed that patency was significantly affected by recellularization, TEVG length, TEVG diameter, surface modification, and preconditioning. In contrast, scaffold types were less important. The patency was 63.5%, 89%, and 100% for TEVGs with a median diameter of 3 mm, 4 mm, and 5 mm, respectively. In the group of recellularized TEVGs, patency was not improved by using smooth muscle cells in addition to endothelial cells nor affected by the endothelial origin, but seems to benefit from a long-term (46-240 hours) recellularization time. Finally, data showed that median TEVG length (5 cm) and median follow-up (56 days) used in preclinical settings are relatively inadequate for direct clinical translation. In conclusion, our data imply that future studies should consider a TEVG design that at least includes endothelial recellularization and bioreactor preconditioning, and we suggest that more standard guidelines for testing and reporting TEVGs in large animals should be considered to enable interstudy comparisons and favor a robust and reproducible outcome as well as clinical translation.


title: Description of the Use of Plasma Exchange in Dogs With Cutaneous and Renal Glomerular Vasculopathy.

text: Cutaneous and renal glomerular vasculopathy (CRGV) is a rare disease affecting dogs, with a recent apparent increase in prevalence since 2012 in the UK. This disease is characterized by a vasculopathy affecting small vessels of the kidney and skin, leading to thrombotic microangiopathy. The underlying etiology remains unknown although clinicopathological and histological findings resemble features of certain forms of thrombotic microangiopathy in people, for which plasma exchange (PEX) is considered an important component of therapy. The objective of the present study is to describe the use of PEX as adjunctive treatment in dogs diagnosed with CRGV. A retrospective review of dogs diagnosed with CRGV between 2014 and 2016 treated with PEX was performed. Clinical records were reviewed and data relating to signalment, diagnostic tests and management strategies were summarized. Information and complications relating to PEX were recorded. Six dogs were diagnosed with CRGV (n = 2 ante-mortem, n = 4 post-mortem) and underwent PEX as part of their therapy. All dogs had cutaneous lesions and were azotemic with oliguria or anuria. All dogs underwent at least one PEX cycle; one dog had a single cycle PEX, three dogs two cycles PEX, and two dogs had one cycle PEX and one cycle of prolonged intermittent renal replacement treatment. Complications seen during PEX therapy included hypothermia (n = 4), tachycardia (n = 2), hypotension (n = 2), and hypocalcemia (n = 6). Two dogs survived to discharge, the remaining four dogs were euthanized. The positive outcome in two dogs treated with PEX despite the reported high mortality rate once acute kidney injury with oliguria/anuria occurs does not confirm success of this treatment. However, survival in two dogs that were initially oligoanuric highlights that further consideration and evaluation of PEX for this patient group is warranted for this specific disease. Additional studies are urgently needed to identify the underlying etiology of CRGV before more targeted therapies can be developed. Based on our findings, further evaluation of the role of PEX in this specific disease are warranted.


title: The synthetic LPS binding peptide 19-2.5 interferes with clotting and prevents degradation of high molecular weight kininogen in plasma.

text: Sepsis and septic shock are life-threatening conditions and remain an important medical problem, emphasizing the need to identify novel therapeutic approaches. Coagulation dysfunction, hypotension, disturbed microcirculation and multiorgan failure occur frequently. These severe conditions result from an overwhelming inflammatory response, induced by pathogen and damage associated molecular patterns (PAMPs and DAMPs) released into the bloodstream. In the present study, we demonstrated that the synthetic Lipopolysaccharid (LPS)-binding peptide 19-2.5 interferes with the activation of the coagulation and contact system. Moreover, binding of LPS to high molecular weight kininogen (HK), one of the major LPS carrier in blood, could be prevented by the peptide. Thus, peptide 19-2.5 might represent a promising target in the treatment of endotoxemia and sepsis, not only by its anti-inflammatory potential, but also by the anticoagulant effect, together with its ability to prevent degradation of HK.


title: Adjunctive use of eptifibatide for complication management during elective neuroendovascular procedures.

text: OBJECTIVE A rare complication of neuroendovascular procedures is acute thromboembolism. In the setting of intraprocedural or periprocedural embolism, thrombolytics present a potentially useful therapeutic strategy. A series of patients in whom eptifibatide (a platelet glycoprotein IIb/IIIa receptor inhibitor) was used in the treatment of iatrogenic thromboembolic events occurring during elective neuroendovascular procedures is described. METHODS Consecutive cases between May 2009 and July 2011 in which eptifibatide was administered were identified and individually reviewed for inclusion in this study (n=12). All study patients received a uniform, weight based bolus dose of 180 μg/kg of eptifibatide administered either intra-arterially through the guide catheter or intravenously. Eptifibatide infusion (2 μg/kg/min) for 24 h after bolus dose administration was continued at the discretion of the surgeon. Procedural details are described and illustrative cases presented. RESULTS Three major categories of thromboembolic events were isolated in the course of review of study cases: acute focal neurological decline and no radiographic findings of flow limitation (eight patients), radiographic findings with or without symptoms (two patients) and persistent particulate debris during flow reversal as part of a carotid revascularization procedure (two patients). Following eptifibatide administration, no patient experienced hemorrhagic complications, and neurologic improvement to baseline level was noted in 10 of 12 patients. CONCLUSION Eptifibatide may be an effective therapeutic strategy in the event of thromboembolism during elective neuroendovascular procedures.


title: Detection of enteric viruses in Hungarian surface waters: first steps towards environmental surveillance.

text: Waterborne viruses infect the human population through the consumption of contaminated drinking water and by direct contact with polluted surface water during recreational activity. Although water related viral outbreaks are a major public health concern, virus detection is not a part of the water quality monitoring scheme, mainly due to the absence of routine analysis methods. In the present study, we implemented various approaches for water concentration and virus detection, and tested on Hungarian surface water samples. Eighty samples were collected from 16 sites in Hungary. Samples were concentrated by glass wool and membrane filtration. Human adenoviruses were detected by conventional and quantitative real-time polymerase chain reaction (PCR) methods in 56% (45/80) of the samples; viral titers ranged from 8.60 × 10(1) to 3.91 × 10(4) genome copies per liter. Noroviruses and enteroviruses were detected in 30% (24/80) and 13% (10/80) of samples, respectively, by reverse transcription-PCR assays. Results indicate a high prevalence of viral human pathogens in surface waters, suggesting the necessity of a detailed survey focusing on the quality of natural bathing waters and drinking water sources.


title: Comparison of bispectral index targeted end-tidal concentration of desflurane during three phases of orthotopic liver transplantation.

text: Background and Aims Reduced inhalational anaesthetic requirement in end-stage liver disease during living donor orthotopic liver transplantation (LD-OLT) is due to increased endogenous opioids. This study evaluated the changes in bi-spectral index (BIS) monitored end-tidal desflurane (ETDes) requirements during 'dissection', 'anhepatic', and 'neohepatic' phases of LD-OLT. Methods This prospective, cohort study included 40 adults undergoing LD-OLT under general anaesthesia (GA). All patients received BIS-guided desflurane GA. ETDes requirements in three phases of LD-OLT (primary objective); relationship between inhalational anaesthetic requirements and severity of liver disease; and effect of changes in mean arterial pressure (MAP) and body temperature on ETDes concentration for all three phases were also evaluated. Results ETDes during the 'dissection' phase (2.92 ± 0.65%) was > 'anhepatic' (2.68 ± 0.85%, P = 0.049) and 'neohepatic' phases (2.58 ± 0.71%, P = 0.005). Patients with model of end-stage liver disease (MELD) score < 20 returned significantly greater ETDes than those with MELD score ≥20 during the 'dissection' (MELD <20: 3.11 ± 0.49%; MELD ≥20: 2.58 ± 0.77%, P = 0.01) and 'anhepatic'(MELD <20: 2.96 ± 0.76%; MELD ≥20: 2.17 ± 0.79%, P = 0.003) phases. A positive correlation was observed between ETDes(r = 0.584, P = 0.001) and temperature in the 'dissection' phase only. Conclusion In patients undergoing LD-OLT, BIS monitoring guidance of depth of desflurane GA suggests lower desflurane requirements during 'anhepatic' and the 'neohepatic' phase of surgery. Also, the desflurane requirement is greater in patients with lesser severity of liver disease.


title: Endolumenal rectal resection and transanal natural orifice specimen extraction (NOSE) without rectal stump opening: a novel, clean surgical technique in a porcine model.

text: Minimally invasive surgery has been continuously evolving over the past 20 years. The use of natural orifice specimen extraction (NOSE) is one of the most recent contributions to minimally invasive methods. The anus has been widely used in NOSE procedures. However, an open rectal stump carries the highest risk of contamination compared with other translumenal approaches to the peritoneal cavity. In this study, the feasibility of a novel NOSE method was tested in a porcine model. This technique combined abdominal and transanal approaches. The abdominal approach was used in rectal mobilization; this was followed by a transanal recto-rectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. Once IPT was established, a second ligature was placed around the rectum, approximating the proximal and distal resection margins. The specimen was resected and extracted by making a full-thickness incision through 2 bowel walls distal to the previously placed ligatures. Anastomosis was achieved by applying the stapler. The technique was found to be feasible. A substantial length of bowel was resected in all experiments. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. Although more investigation is warranted, this procedure has the potential to limit surgical site infections by using aseptic bowel manipulation during colorectal resection and transanal specimen extraction.


title: Evaluation of the antimicrobial activity of lysostaphin-coated hernia repair meshes.

text: Bacterial infections by antibiotic-resistant Staphylococcus aureus strains are among the most common postoperative complications in surgical hernia repair with synthetic mesh. Surface coating of medical devices/implants using antibacterial peptides and enzymes has recently emerged as a potentially effective method for preventing infections. The objective of this study was to evaluate the in vitro antimicrobial activity of hernia repair meshes coated by the antimicrobial enzyme lysostaphin at different initial concentrations. Lysostaphin was adsorbed on pieces of polypropylene (Ultrapro) mesh with binding yields of ∼10 to 40% at different coating concentrations of between 10 and 500 μg/ml. Leaching of enzyme from the surface of all the samples was studied in 2% (wt/vol) bovine serum albumin in phosphate-buffered saline buffer at 37°C, and it was found that less than 3% of adsorbed enzyme desorbed from the surface after 24 h of incubation. Studies of antibacterial activity against a cell suspension of S. aureus were performed using turbidity assay and demonstrated that the small amount of enzyme leaching from the mesh surface contributes to the lytic activity of the lysostaphin-coated samples. Colony counting data from the broth count (model for bacteria in wound fluid) and wash count (model for colonized bacteria) for the enzyme-coated samples showed significantly decreased numbers of CFU compared to uncoated samples (P < 0.05). A pilot in vivo study showed a dose-dependent efficacy of lysostaphin-coated meshes in a rat model of S. aureus infection. The antimicrobial activity of the lysostaphin-coated meshes suggests that such enzyme-leaching surfaces could be efficient at actively resisting initial bacterial adhesion and preventing subsequent colonization of hernia repair meshes.


title: Laparoscopic distal pancreatectomy and splenectomy for malignant tumors.

text: INTRODUCTION Laparoscopic distal pancreatectomy has become the gold standard for benign tumors. As more surgeons have expertise in open and laparoscopic pancreatic surgery, increasing numbers of benign-appearing tumors are being removed via minimally invasive techniques and found to have malignancy on final pathology. Because of our growing experience in laparoscopic distal pancreatectomy, we have begun removing preoperatively suspected malignancies in the distal pancreas with minimally invasive techniques. METHODS All cases were collected prospectively in a database and analyzed retrospectively. All cases begun laparoscopically with the intention of performing the resection with minimally invasive techniques were considered even if the operation was ultimately converted to an open procedure. RESULTS A total of 12 cases have been attempted of which four required hand assistance and one required conversion to an open approach due to delayed bleeding from a calcified splenic artery that had been transected with laparoscopic GIA stapler device. In total, eight (67%) patients had malignant disease and four (33%) were found to have benign tumors. The median lymph node retrieval is 8 (range 3-16) with no positive margins. The morbidity rate is 17% with one reoperation (8%) and one mortality (8%) at 30 and 90 days. CONCLUSIONS The laparoscopic approach to malignant pancreatic tumors is feasible with similar morbidity and mortality rates to benign series. When tumors are next to the confluence of the splenic portal vein, a hand-assisted approach may be adviseable. Calcified splenic arteries should be sought on preoperative imaging and either transected in non-calcified segments or controlled via open techniques via the hand port.


title: Expression levels of TLRs involved in viral recognition in PBMCs from HIV-1-infected patients failing antiretroviral therapy.

text: OBJECTIVE The aim of this study was to evaluate whether gene expression of Toll-like receptor (TLR)-3, TLR4, TLR7 and TLR9 was impaired in patients with chronic HIV-1 infection who were failing to respond to antiretroviral therapy. METHODS Transcripts encoding TLRs were assayed by quantitative real time RT-PCR on peripheral blood mononuclear cells derived from patients with HIV-1 infection who were responding or not responding to antiretroviral therapy and healthy control subjects. RESULTS Chronic HIV-1-infected patients who failed to respond to therapy showed reduced expression of TLRs 3, 4 and 9, together with increased expression of TLR7, as compared to healthy subjects. Moreover, a trend towards a higher expression of TLR3 and TLR9 was observed in responder patients compared with non-responders. In addition, we found lower levels of TRLs 3, 7 and 9 in patients with high levels of HIV-1 RNA compared to those with lower levels of viremia. CONCLUSIONS These findings demonstrate that in chronic HIV-1-positive patients who were failing to respond to the therapy, there were substantial changes in TLRs expression. This is likely to be an important determinant of the clinical course of HIV-1 infection.


title: Feasibility of combined surgical and endovascular carotid access for interventional treatment of ischemic stroke.

text: BACKGROUND Rapid recanalization of occluded vessels is crucial for good clinical outcome in acute ischemic stroke. Endovascular treatment is usually performed via a transfemoral approach, but catheterization of the carotid arteries can be problematic in cases of difficult anatomy or vascular pathologies in some cases. OBJECTIVE To describe our experience with a technique involving surgical access to the carotid artery and consecutive transcarotid endovascular thrombectomy in patients with acute stroke. METHODS In a retrospective review of a prospectively maintained registry we identified 6 patients who underwent acute endovascular thrombectomy via a surgical access to the carotid artery. RESULTS Admission National Institute of Health Stroke Scale (NIHSS) ranged from 7 to 23. Intracranial recanalization (thrombolysis in cerebral infarction, TICI≥2b) was achieved in all patients (100%). Recanalization was achieved within 19±5 min after establishing carotid access. One patient developed a small neck hematoma, which was surgically removed without complications. No complications related to endovascular therapy were seen. At 3 months' follow-up, five patients had survived. Three patients (50%) had regained excellent neurological function (modified Rankin Scale, mRS 0-1). CONCLUSIONS Surgical carotid access for endovascular stroke treatment is feasible, with considerable advantages, in patients with expected problematic access or for whom transfemoral endovascular carotid access has failed.


title: The implication of ocular manifestation of COVID-19 for medical staff and patients - systematic review.

text: INTRODUCTION SARS-CoV-2 (severe acute respiratory syndrome-coronavirus-2) is a coronavirus that causes COVID-19 (coronavirus disease 2019) with mild to severe respiratory illness. It is a highly contagious disease transmitted through direct or indirect contact with infected people or contaminated surfaces, mainly through respiratory droplets, but other routes are being investigated. OBJECTIVE It is known that coronaviruses (CoVs) can cause a variety of ocular pathologies in animals, including conjunctivitis, anterior uveitis, retinitis, and optic neuritis, many of which are severe. However, there is no evidence of the SARS-CoV-2 presence in the eye tissue of asymptomatic patients, even if the symptomatic incidence is low. This systematic review presents updated literature on this issue. ABBREVIATED DESCRIPTION OF THE STATE OF KNOWLEDGE COVID-19 has now spread throughout the continents and poses a global threat to public health. The risk of rapidly overloading health care systems and causing substantial mortality worldwide is real. On 11 March 2020, the World Health Organization (WHO) announced coronavirus as a global pandemic. Several studies described a few cases with initial ocular symptoms followed by systemic symptoms of the disease. SUMMARY Although the frequency of transmission of SARS-CoV-2 infection through the eye is low, ocular symptoms are not uncommon in COVID-19. In some cases, eye symptoms may be the first signs of illness. This implies the need for hygienic recommendations and use of personal protective equipment (PPE) for medical staff and other services to minimize COVID-19 infection of both health-care workers and patients. A triage for ophthalmic outpatient clinic is mandatory.


title: Interhemispheric symmetry of µ-rhythm phase-dependency of corticospinal excitability.

text: Oscillatory activity in the µ-frequency band (8-13 Hz) determines excitability in sensorimotor cortex. In humans, the primary motor cortex (M1) in the two hemispheres shows significant anatomical, connectional, and electrophysiological differences associated with motor dominance. It is currently unclear whether the µ-oscillation phase effects on corticospinal excitability demonstrated previously for the motor-dominant M1 are also different between motor-dominant and motor-non-dominant M1 or, alternatively, are similar to reflect a ubiquitous physiological trait of the motor system at rest. Here, we applied single-pulse transcranial magnetic stimulation to the hand representations of the motor-dominant and the motor-non-dominant M1 of 51 healthy right-handed volunteers when electroencephalography indicated a certain µ-oscillation phase (positive peak, negative peak, or random). We determined resting motor threshold (RMT) as a marker of corticospinal excitability in the three µ-phase conditions. RMT differed significantly depending on the pre-stimulus phase of the µ-oscillation in both M1, with highest RMT in the positive-peak condition, and lowest RMT in the negative-peak condition. µ-phase-dependency of RMT correlated directly between the two M1, and interhemispheric differences in µ-phase-dependency were absent. In conclusion, µ-phase-dependency of corticospinal excitability appears to be a ubiquitous physiological trait of the motor system at rest, without hemispheric dominance.


Thoughts on the scientific evidences in the Covid-19 era.


title: Topographic distribution of cerebral infarct probability in patients with acute ischemic stroke: mapping of intra-arterial treatment effect.

text: BACKGROUND Since proof emerged that IA treatment (IAT) is beneficial for patients with acute ischemic stroke, it has become the standard method of care. Despite these positive results, recovery to functional independence is established in only about one-third of treated patients. The effect of IAT is commonly assessed by functional outcome, whereas its effect on brain tissue salvage is considered a secondary outcome measure (at most). Because patient and treatment selection needs to be improved, understanding the treatment effect on brain tissue salvage is of utmost importance. OBJECTIVE To introduce infarct probability maps to estimate the location and extent of tissue damage based on patient baseline characteristics and treatment type. METHODS Cerebral infarct probability maps were created by combining automatically segmented infarct distributions using follow-up CT images of 281 patients from the MR CLEAN trial. Comparison of infarct probability maps allows visualization and quantification of probable treatment effects. Treatment impact was calculated for 10 Alberta Stroke Program Early CT Score (ASPECTS) and 27 anatomical regions. RESULTS The insular cortex had the highest infarct probability in both control and IAT populations (47.2% and 42.6%, respectively). Comparison showed significant lower infarct probability in 4 ASPECTS and 17 anatomical regions in favor of IAT. Most salvaged tissue was found within the ASPECTS M2 region, which was 8.5% less likely to infarct. CONCLUSIONS Probability maps intuitively visualize the topographic distribution of infarct probability due to treatment, which makes it a promising tool for estimating the effect of treatment.


title: Snake constriction rapidly induces circulatory arrest in rats.

text: As legless predators, snakes are unique in their ability to immobilize and kill their prey through the process of constriction, and yet how this pressure incapacitates and ultimately kills the prey remains unknown. In this study, we examined the cardiovascular function of anesthetized rats before, during and after being constricted by boas (Boa constrictor) to examine the effect of constriction on the prey's circulatory function. The results demonstrate that within 6 s of being constricted, peripheral arterial blood pressure (PBP) at the femoral artery dropped to 1/2 of baseline values while central venous pressure (CVP) increased 6-fold from baseline during the same time. Electrocardiographic recordings from the anesthetized rat's heart revealed profound bradycardia as heart rate (fH) dropped to nearly half of baseline within 60 s of being constricted, and QRS duration nearly doubled over the same time period. By the end of constriction (mean 6.5±1 min), rat PBP dropped 2.9-fold, fH dropped 3.9-fold, systemic perfusion pressure (SPP=PBP-CVP) dropped 5.7-fold, and 91% of rats (10 of 11) had evidence of cardiac electrical dysfunction. Blood drawn immediately after constriction revealed that, relative to baseline, rats were hyperkalemic (serum potassium levels nearly doubled) and acidotic (blood pH dropped from 7.4 to 7.0). These results are the first to document the physiological response of prey to constriction and support the hypothesis that snake constriction induces rapid prey death due to circulatory arrest.


title: Pre- and postoperative nutritional deficiencies in obese patients undergoing laparoscopic sleeve gastrectomy.

text: BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has been identified as an innovative surgical approach for the treatment of obesity and is increasingly applied worldwide. However, data on outcome of LSG regarding nutrient deficiencies, protein status, and body composition are scarce. METHODS Obese subjects (54; f:m = 4:1) scheduled for LSG were included in this study. Micronutrient analysis, protein status assessment, and bioimpedance measures were performed before and 1, 3, 6, and 12 months after LSG. RESULTS In 51% of the subjects, at least one micronutrient deficiency was found prior to surgery. Baseline concentrations were below normal for 25-OH vitamin D (27%), iron (29%), vitamin B6 (11%), vitamin B12 (9%), folate (6%), and potassium (7%). Frequencies of deficiencies for vitamin B12, folate, iron, and vitamin B6 tended to increase following LSG within the first year after intervention. Also, parameters of protein status (albumin, transferrin, cholinesterase, and total protein) decreased. After surgery, bioimpedance measures indicated a reduction of total body fat, but also of body cell mass. CONCLUSIONS Preoperative micronutrient deficiencies were common in morbid obese individuals scheduled for LSG. LSG had a modest effect on micronutrient status by further reducing iron, vitamin B12, vitamin B6, and folate within the first year after intervention. Our data suggest that especially obese patients with preoperative deficits require control and supplementation of micronutrients and protein in the postoperative period.


title: Knowledge, attitudes, and practices of Sudanese residents towards COVID-19.

text: Background Coronavirus disease 2019 (COVID-19) is a severe acute respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Sufficient knowledge, positive attitudes, and correct practices are crucial for the prevention of COVID-19. Aims This study aimed at assessing the knowledge, attitudes and practices of a sample of Sudanese residents towards COVID-19. Methods A cross-sectional community-based survey was conducted on 812 participants, including both sexes and aged 18 years and above, with the exclusion of health care workers. Considerable care was taken to include people with different education levels. Results Among the survey respondents (n=812), 45.8% were women, 40.4% held a bachelor's degree, 5.7% were uneducated, and 51.1% were aged 18-25 years. The overall correct rate of the knowledge questionnaire was 78.2%; 66.9% agreed that religious gatherings and events should be cancelled to prevent the spread of COVID-19; 34.1% of respondents wore medical masks; and 57.9% avoided shaking hands in recent days. Conclusion This study showed that sampled Sudanese residents have incomplete knowledge and poor practices towards COVID-19. However, we found that women and people aged 18-25 years were more knowledgeable and had more positive attitudes towards COVID-19. We hope that concerned authorities will establish awareness programmes to improve the ability to combat this disease.


Cardiopulmonary resuscitation after hospital admission with covid-19.


title: Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal.

text: The first confirmed case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 20, 2020, in Snohomish County, Washington. At the epicenter of COVID-19 in the United States, the Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, and University of Washington are at the forefront of delivering care to patients with cancer during this public health crisis. This Special Feature highlights the unique circumstances and challenges of cancer treatment amidst this global pandemic, and the importance of organizational structure, preparation, agility, and a shared vision for continuing to provide cancer treatment to patients in the face of uncertainty and rapid change.


title: Propensity score-matched comparison of non-anatomical resection and radiofrequency ablation for hepatocellular carcinoma in patients with up to three tumours, each measuring up to 3 cm in diameter.

text: Background Non-anatomical liver resection (NAR) and radiofrequency ablation (RFA) are treatment options for early-stage hepatocellular carcinoma (HCC). The aim was to compare the outcomes of NAR and RFA for HCC in patients with three or fewer tumour nodules, each measuring not more than 3 cm in maximum diameter. Methods Eligible patients undergoing NAR or RFA with curative intent between September 2002 and December 2014 were identified. A propensity score-matching analysis was performed to reduce bias, and outcomes in these patients were analysed. Results From a total of 199 patients, 1:1 propensity score matching identified 70 matched pairs. Patients having NAR had a longer hospital stay (median 10 days versus 4 days for those who had RFA; P < 0·001) and a higher morbidity rate (24 versus 10 per cent respectively; P = 0·042). Patients who had NAR had slightly better recurrence-free survival but this failed to reach statistical significance in univariable analysis (P = 0·064). There was no significant difference in overall survival between the two groups (P = 0·475). RFA was identified as an independent risk factor for recurrence-free survival (hazard ratio (HR) 1·57; P = 0·041) in multivariable analysis. Local recurrence was significantly more common in patients receiving RFA (23 versus 1 per cent; P < 0·001). Conclusion RFA was an independent risk factor for shorter recurrence-free survival, with a significantly higher local recurrence rate than NAR. Despite these differences, overall survival was not affected.


title: Coarctation of the aorta: management, indications for intervention, and advances in care.

text: OPINION STATEMENT Coarctation of the aorta (CoAo) accounts for 9 % of congenital heart defects. Balloon angioplasty has been the conventional endovascular treatment of choice for both native and recurrent coarctation in adults. Recent advancement in stent technology with the development of the covered stents has enhanced the scope for percutaneous management of both native CoAo and post-surgical CoAo. Stent implantation provides better hemodynamic results with larger acute diameter gain and better long-term hemodynamic benefit. Stenting also decreases the incidence of aneurysm formation. The development of biodegradable stents may revolutionize the percutaneous management of coarctation, as the degradation of the stent scaffold within 6 months of implantation will further decrease the incidence of restenosis. In the future stenting may suffice and obviate the need for open repair. Until then, surgical repair of CoAo is the preferred method in both infants and complicated lesions, leaving stenting to adults with focal and uncomplicated disease.


title: [Pericardial effusion in a cat with feline infectious peritonitis].

text: This case report describes the disease progression of a male cat with pericardial effusion. Clinical signs (dyspnea, lethargy, and weakness) started very acutely. The initial laboratory profile showed only an increase in alanine aminotransferase enzyme activity. Diagnostic imaging revealed pericardial effusion. Effusion analysis showed a Rivalta-positive, modified transudate. Detection of feline coronavirus antigen in macrophages was negative. General condition and laboratory parameters dramatically worsened within seven days. Therefore, the owners decided to euthanize the cat. Even if effusion variables are macroscopically and microscopically suspicious for FIP, a definitive diagnosis of FIP could only be made by histology (including immunhistochemical staining).


title: Examining the Specificity of Forms and Functions of Aggressive Behavior in Boys With Fragile X Syndrome.

text: Limited information is available concerning the specificity of the forms and functions of aggressive behavior exhibited by boys with fragile X syndrome (FXS). To investigate these relationships, we conducted indirect functional assessments of aggressive behavior exhibited by 41 adolescent boys with FXS and 59 age and symptom-matched controls with intellectual and developmental disability (IDD) and compared the data between groups. Results showed that boys with FXS were more likely to exhibit specific forms of aggressive behavior (i.e., scratching others and biting others) compared to controls, but the sources of reinforcement identified for aggression were similar across groups. Boys with FXS who were prescribed psychotropic medications were more likely to be older and to exhibit more forms of aggression. The implications for the treatment of aggressive behavior during this critical developmental period in FXS are discussed.


title: Search query interest for gastrointestinal symptoms associated with COVID-19 diagnosis: an infodemiology study.

text: BACKGROUND The coronavirus disease 2019 (COVID-19) is a novel viral illness that has rapidly spread worldwide. While the disease primarily presents as a respiratory illness, gastrointestinal symptoms such as diarrhea have been reported in up to a third of confirmed cases, and patients may have mild symptoms that do not prompt medical attention. Internet-based infodemiology approaches offer an approach to studying symptoms at a population level, even in patients who do not seek medical care. OBJECTIVE This study aimed to determine if a correlation exists between internet searches for gastrointestinal symptoms and confirmed case count of COVID-19 in the United States. METHODS The search terms chosen for analysis in this study include common gastrointestinal symptoms such as diarrhea, nausea, vomiting, and abdominal pain. Furthermore, fever and cough were used as positive controls and constipation as a negative control. Daily query shares for the selected symptoms were obtained from Google Trends between October 1, 2019 and June 15, 2020 for all U.S. states. These shares were divided into two time periods: pre-COVID-19 (prior to March 1) and post-COVID-19 (March 1-June 15). Confirmed COVID-19 case number was obtained from the Johns Hopkins University Center for Systems Science and Engineering data repository. Moving averages of the daily query shares (normalized to baseline pre-COVID-19) were then analyzed against the confirmed disease case count and daily new cases to establish a temporal relationship. RESULTS While the relative search query share of many symptoms including nausea, vomiting, abdominal pain, and constipation remained near or below baseline throughout the time period studied, there was a notable increase in searches for the positive controls, fever and cough, as well as for diarrhea. This increase in daily search queries for fever, cough, and diarrhea preceded the rapid rise in case number by about 10-14 days. Search volume for these terms began declining after mid-March despite continued rise in cumulative cases and daily new case count. CONCLUSIONS Google searches for symptoms may precede the actual rise in cases and hospitalizations during pandemics. During the current COVID-19 pandemic, this study demonstrates that internet search queries for fever, cough, and diarrhea increase prior to confirmed case count by available testing during the early weeks of the pandemic in the U.S. While search volume eventually decreased significantly as cases continued to rise, internet query search data may still be a useful tool at a population level to identify areas of active disease transmission at the cusp of new outbreaks. CLINICALTRIAL


title: Utilization of iron (III)-doped nanoshells for in vivo marking of nonpalpable tumors using a VX2 rabbit model.

text: BACKGROUND We aimed to evaluate the potential for ultrasound (US) visible biodegradable nanoshells (NS) as an alternative to wire-guided localization for nonpalpable tumors in vivo. METHODS VX2 tumor was injected in bilateral thighs of 22 New Zealand rabbits and after 5 to 10 days, 1 tumor was marked with a wire as a control and the contralateral tumor was injected with 1 mL of 500 nm gas-filled silica NS under Doppler US. Tumors were excised after 24 hours. Chi-square was used for significance, P = .05. RESULTS One rabbit was excluded on postoperative day 1 due to equipment failure, no ill effects were observed from the NS. The NS were used to localize and resect 100% of marked tissue, 4/21 wires were displaced (P < .05). CONCLUSIONS We have shown that preoperatively injected US visible silica NS can be successfully used to mark nonpalpable tumors in vivo more consistently than WL.


title: Minimally Invasive Treatment of Liver Hydatidosis.

text: BACKGROUND AND OBJECTIVES Open surgery has been the mainstay treatment for liver hydatidosis in the past. Today, for treatment of simple and uncomplicated cysts, we have a variety of choices: antihelmintic therapy, the PAIR (puncture, aspiration, injection, and respiration) technique, and the laparoscopic approach. We reviewed our series of 267 cases of hepatic hydatidosis submitted to surgery over a period of 20 years, from 1995 through 2014, comparing the results of these minimally invasive treatments. METHODS In 92 patients (25.7% of cases) who presented with complicated liver hydatid cysts, we performed open surgery. In 16.4% of cases (59 patients), we used a laparoscopic approach, and in 208 patients (57.9% of cases), we used the PAIR technique. All patients were monitored after surgery for a mean of 61.7 months (range, 16-127). Postoperative follow-up consisted of clinical examination, laboratory investigation, abdominal ultrasound, and magnetic resonance imaging. RESULTS Almost all patients (198, 95.2%) treated with the PAIR technique and 55 patients (93.2%) treated with the laparoscopic approach were cured. Six patients (2.8%) from the echo-guided puncture group had to undergo a repeat of the procedure because the cavity did not disappear after 2 years. In 4 patients (2%), we performed open surgery for 2 biliary fistulas and 2 hepatic abscesses. Four patients from the laparoscopic group needed additional procedures. Open surgery was necessary in 2 patients for a recurrence after 2 years; 1 patient had developed a liver abscess and the other had a biliary fistula. CONCLUSIONS In conclusion, open surgery remains the viable option for complicated cysts, with biliary communication, with multiple daughter vesicles, or with calcified walls. For simple, uncomplicated hydatid cysts, both methods (the PAIR technique and laparoscopic procedure) are safe and efficient, with very good results and low morbidity rates.


Incisional Hernia: Difficult Cases 2.


title: Splenic blood-flow response following myocardial infarction in rat.

text: During physiological stress (e.g., exercise, hypoxia), blood flow is shunted to specific anatomical regions to protect critical organs; yet, splenic blood flow in these circumstances remains to be investigated. Despite being classically viewed as a non-critical organ, recent experimental and epidemiological evidence suggests the spleen plays a significant role in cardiovascular pathophysiology. We hypothesized that splenic blood flow is prioritized in the development of heart failure (i.e., chronic state of reduced cardiac output). Five-week-old male Wistar rats were randomized for either myocardial infarction (MI; n = 58) or sham (n = 56) surgery. At 2, 5, and 9 weeks post-surgery, Doppler ultrasound measurements of the splenic, left renal, left common carotid, and left femoral arteries were performed. Cardiac function was assessed at all time points using echocardiography and at 9 weeks post-surgery using invasive hemodynamic analysis. Splenic and cerebral blood flow was preferentially maintained at 9 weeks post-MI, whereas blood flow to the lower limb and kidney were reduced. Spleen size increased by 5 weeks post-MI and remained elevated. Splenic blood flow was maintained in conditions of decreased cardiac output, when other tissues showed decreased blood flow. The maintenance of blood flow in the face of decreased cardiac output indicates that splenic function is being prioritized during heart failure.


title: Formation of the arterivirus replication/transcription complex: a key role for nonstructural protein 3 in the remodeling of intracellular membranes.

text: The replication/transcription complex of the arterivirus equine arteritis virus (EAV) is associated with paired membranes and/or double-membrane vesicles (DMVs) that are thought to originate from the endoplasmic reticulum. Previously, coexpression of two putative transmembrane nonstructural proteins (nsp2 and nsp3) was found to suffice to induce these remarkable membrane structures, which are typical of arterivirus infection. Here, site-directed mutagenesis was used to investigate the role of nsp3 in more detail. Liberation of the hydrophobic N terminus of nsp3, which is normally achieved by cleavage of the nsp2/3 junction by the nsp2 protease, was nonessential for the formation of DMVs. However, the substitution of each of a cluster of four conserved cysteine residues, residing in a predicted luminal loop of nsp3, completely blocked DMV formation. Some of these mutant nsp3 proteins were also found to be highly cytotoxic, in particular, exerting a dramatic effect on the endoplasmic reticulum. The functionality of an engineered N glycosylation site in the cysteine-containing loop confirmed both its presence in the lumen and the transmembrane nature of nsp3. This mutant displayed an interesting intermediate phenotype in terms of DMV formation, with paired and curved membranes being formed, but DMV formation apparently being impaired. The effect of nsp3 mutations on replicase polyprotein processing was investigated, and several mutations were found to influence processing of the region downstream of nsp3 by the nsp4 main protease. When tested in an EAV reverse genetics system, none of the nsp3 mutations was tolerated, again underlining the crucial role of the protein in the arterivirus life cycle.


Audio Interview: Acute Lung Injury in Covid-19.


title: Measuring multimorbidity beyond counting diseases: systematic review of community and population studies and guide to index choice.

text: OBJECTIVES To identify and summarise existing indices for measuring multimorbidity beyond disease counts, to establish which indices include mental health comorbidities or outcomes, and to develop recommendations based on applicability, performance, and usage. DESIGN Systematic review. DATA SOURCES Seven medical research databases (Medline, Web of Science Core Collection, Cochrane Library, Embase, PsycINFO, Scopus, and CINAHL Plus) from inception to October 2018 and bibliographies and citations of relevant papers. Searches were limited to English language publications. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original articles describing a new multimorbidity index including more information than disease counts and not focusing on comorbidity associated with one specific disease. Studies were of adults based in the community or at population level. RESULTS Among 7128 search results, 5560 unique titles were identified. After screening against eligibility criteria the review finally included 35 papers. As index components, 25 indices used conditions (weighted or in combination with other parameters), five used diagnostic categories, four used drug use, and one used physiological measures. Predicted outcomes included mortality (18 indices), healthcare use or costs (13), hospital admission (13), and health related quality of life (7). 29 indices considered some aspect of mental health, with most including it as a comorbidity. 12 indices are recommended for use. CONCLUSIONS 35 multimorbidity indices are available, with differing components and outcomes. Researchers and clinicians should examine existing indices for suitability before creating new ones. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017074211.


title: Anti-lyssaviral activity of interferons κ and ω from the serotine bat, Eptesicus serotinus.

text: UNLABELLED Interferons (IFNs) are cytokines produced by host cells in response to the infection with pathogens. By binding to the corresponding receptors, IFNs trigger different pathways to block intracellular replication and growth of pathogens and to impede the infection of surrounding cells. Due to their key role in host defense against viral infections, as well as for clinical therapies, the IFN responses and regulation mechanisms are well studied. However, studies of type I IFNs have mainly focused on alpha interferon (IFN-α) and IFN-β subtypes. Knowledge of IFN-κ and IFN-ω is limited. Moreover, most studies are performed in humans or mouse models but not in the original host of zoonotic pathogens. Bats are important reservoirs and transmitters of zoonotic viruses such as lyssaviruses. A few studies have shown an antiviral activity of IFNs in fruit bats. However, the function of type I IFNs against lyssaviruses in bats has not been studied yet. Here, IFN-κ and IFN-ω genes from the European serotine bat, Eptesicus serotinus, were cloned and functionally characterized. E. serotinus IFN-κ and IFN-ω genes are intronless and well conserved between microchiropteran species. The promoter regions of both genes contain essential regulatory elements for transcription factors. In vitro studies indicated a strong activation of IFN signaling by recombinant IFN-ω, whereas IFN-κ displayed weaker activation. Noticeably, both IFNs inhibit to different extents the replication of different lyssaviruses in susceptible bat cell lines. The present study provides functional data on the innate host defense against lyssaviruses in endangered European bats. IMPORTANCE We describe here for the first time the molecular and functional characterization of two type I interferons (IFN-κ and -ω) from European serotine bat (Eptesicus serotinus). The importance of this study is mainly based on the fact that very limited information about the early innate immune response against bat lyssaviruses in their natural host serotine bats is yet available. Generally, whereas the antiviral activity of other type I interferons is well studied, the functional involvement of IFN-κ and -ω has not yet been investigated.


title: Identification of the Fusion Peptide-Containing Region in Betacoronavirus Spike Glycoproteins.

text: UNLABELLED The fusion peptides (FP) play an essential role in fusion of viral envelope with cellular membranes. The location and properties of the FPs in the spike (S) glycoproteins of different coronaviruses (CoV) have not yet been determined. Through amino acid sequence analysis of S proteins of representative CoVs, we identified a common region as a possible FP (pFP) that shares the characteristics of FPs of class I viral fusion proteins, including high Ala/Gly content, intermediate hydrophobicity, and few charged residues. To test the hypothesis that this region contains the CoV FP, we systemically mutated every residue in the pFP of Middle East respiratory syndrome betacoronavirus (MERS-CoV) and found that 11 of the 22 residues in the pFP (from G953 to L964, except for A956) were essential for S protein-mediated cell-cell fusion and virus entry. The synthetic MERS-CoV pFP core peptide (955IAGVGWTAGL964) induced extensive fusion of liposome membranes, while mutant peptide failed to induce any lipid mixing. We also selectively mutated residues in pFPs of two other β-CoVs, severe acute respiratory syndrome coronavirus (SARS-CoV) and mouse hepatitis virus (MHV). Although the amino acid sequences of these two pFPs differed significantly from that of MERS-CoV and each other, most of the pFP mutants of SARS-CoV and MHV also failed to mediate membrane fusion, suggesting that these pFPs are also the functional FPs. Thus, the FPs of 3 different lineages of β-CoVs are conserved in location within the S glycoproteins and in their functions, although their amino acid sequences have diverged significantly during CoV evolution. IMPORTANCE Within the class I viral fusion proteins of many enveloped viruses, the FP is the critical mediator of fusion of the viral envelope with host cell membranes leading to virus infection. FPs from within a virus family, like influenza viruses or human immunodeficiency viruses (HIV), tend to share high amino acid sequence identity. In this study, we determined the location and amino acid sequences of the FPs of S glycoproteins of 3 β-CoVs, MERS-CoV, SARS-CoV, and MHV, and demonstrated that they were essential for mediating cell-cell fusion and virus entry. Interestingly, in marked contrast to the FPs of influenza and HIV, the primary amino acid sequences of the FPs of β-CoVs in 3 different lineages differed significantly. Thus, during evolution the FPs of β-CoVs have diverged significantly in their primary sequences while maintaining the same essential biological functions. Our findings identify a potential new target for development of drugs against CoVs.


title: Benefits and drawbacks of SILS cholecystectomy: a report of 60 SILS cholecystectomies with conventional instrumentation from an academic center.

text: BACKGROUND Single-incision laparoscopic surgery is a rapidly emerging approach to gallbladder disease. METHODS From February 2009 to September 2010, 60 patients were subjected to single-incision laparoscopic cholecystectomy. In all the patients, a 12-mm incision was made in the umbilicus and a 2-trocar technique was applied. Gallbladder was suspended with 2 sutures and the procedure was accomplished with standard partly reusable laparoscopic instruments. RESULTS In all, 41 women (68.3%) and 19 men (31.7%) were enrolled in this study. Mean age was 50.7 years (range = 17-72 years), mean body mass index was 26.2 kg/m(2) (range = 18.3-37.7 kg/m(2)) and mean operative time was 52.6 minutes (range = 30-120 minutes). No mortality or morbidity was recorded and hospital stay was less than 24 hours. At follow-up visits, no complications were recorded and cosmesis was excellent. CONCLUSION Single-incision laparoscopic cholecystectomy can be safely performed with conventional instrumentation with minimal cost.


The future of sleep-disordered breathing: A public health crisis.