title: Improved particle counting and size distribution determination of aggregated virus populations by asymmetric flow field-flow fractionation and multiangle light scattering techniques.

text: A method using a combination of asymmetric flow field-flow fractionation (AFFFF) and multiangle light scattering (MALS) techniques has been shown to improve the estimation of virus particle counts and the amount of aggregated virus in laboratory samples. The method is based on the spherical particle counting approach given by Wyatt and Weida in 2004, with additional modifications. The new method was tested by analyzing polystyrene beads and adenovirus samples, both having a well-characterized particle size and concentration. Influenza virus samples were analyzed by the new AFFFF-MALS technique, and particle size and aggregate state were compared with results from atomic force microscopy analysis. The limitations and source of possible errors for the new AFFFF-MALS analysis are discussed.


title: A multifaceted individualized pneumoperitoneum strategy for laparoscopic colorectal surgery: a multicenter observational feasibility study.

text: BACKGROUND While guidelines for laparoscopic abdominal surgery advise using the lowest possible intra-abdominal pressure, commonly a standard pressure is used. We evaluated the feasibility of a predefined multifaceted individualized pneumoperitoneum strategy aiming at the lowest possible intra-abdominal pressure during laparoscopic colorectal surgery. METHODS Multicenter prospective study in patients scheduled for laparoscopic colorectal surgery. The strategy consisted of ventilation with low tidal volume, a modified lithotomy position, deep neuromuscular blockade, pre-stretching of the abdominal wall, and individualized intra-abdominal pressure titration; the effect was blindly evaluated by the surgeon. The primary endpoint was the proportion of surgical procedures completed at each individualized intra-abdominal pressure level. Secondary endpoints were the respiratory system driving pressure, and the estimated volume of insufflated CO2 gas needed to perform the surgical procedure. RESULTS Ninety-two patients were enrolled in the study. Fourteen cases were converted to open surgery for reasons not related to the strategy. The intervention was feasible in all patients and well-accepted by all surgeons. In 61 out of 78 patients (78%), surgery was performed and completed at the lowest possible IAP, 8 mmHg. In 17 patients, IAP was raised up to 12 mmHg. The relationship between IAP and driving pressure was almost linear. The mean estimated intra-abdominal CO2 volume at which surgery was performed was 3.2 L. CONCLUSION A multifaceted individualized pneumoperitoneum strategy during laparoscopic colorectal surgery was feasible and resulted in an adequate working space in most patients at lower intra-abdominal pressure and lower respiratory driving pressure. ClinicalTrials.gov (Trial Identifier: NCT03000465).


title: Thermal ablation of malignant lung tumors.

text: BACKGROUND About 50 000 new cases of non-small-cell carcinoma of the lung are diagnosed in Germany each year. More than 20% of the affected patients cannot be offered radical resection because of comorbidity alone. The lung is also the second most common site of distant metastases of extrathoracic tumors; it is the only site of such metastases in 20% of cases. In recent years, image-guided thermoablation has been used with increasing frequency in patients who are unable to undergo surgery for medical reasons. METHODS The PubMed database was selectively searched for publications on the indications, complications, and results of the thermoablative techniques currently in clinical use, with special attention to radiofrequency ablation (RFA). RESULTS There is only a small evidence base to date concerning the treatment of malignant lung tumors with thermoablation. Retrospective and prospective case series have been published, but no randomized controlled trials have yet been conducted. RFA, the most common technique, involves the image-guided percutaneous placement of one or more probes in the tumor, to which thermal energy is then applied. For peripherally located tumors that measure less than 3 cm in diameter, local control of tumor growth can be achieved in about 90% of cases. The long-term results that are now available from smaller series provisionally indicate 5-year survival rates of 20% to 61%. The most common complication is pneumothorax requiring drainage, which occurs in about 10% of cases. In the intermediate term, thermoablation does not cause any clinically relevant loss of pulmonary function. CONCLUSION Image-guided thermoablation cannot now be considered an alternative to surgery for the treatment of malignant lung tumors with curative intent. It does, however, widen the spectrum of therapeutic options for patients who are medically unable to undergo a surgical procedure.


Reply to Facing COVID-19 in Ophthalmology Department.


title: Sequencing and In Silico Multi-aspect Analysis of S1 Glycoprotein in 793/B Serotype of Infectious Bronchitis Virus Isolated From Iran in 2003 and 2011.

text: Infectious bronchitis (IB) is an acute, highly contagious, and economically important viral disease of chickens. The S1 subunit from Spike (S) protein plays the major role in protective immunity and is involved in the host-virus interactions, as well as infectious bronchitis virus (IBV) serotyping. Aim of the present study was multi-aspect analysis of the molecular and immunological features of 5' part belonging to the S1 glycoprotein sequence of Iranian 793/B IBV strain isolates. This might ideally help in characterization, prevention, and vaccine development. The tissue samples were prepared, followed by virus isolation, reverse transcription polymerase chain reaction and restriction fragment length polymorphism analysis. In addition, sequencing and registration of the sequences in the National Center for Biotechnology Information were performed. Moreover, 12 sequences were retrieved from Fars province, Iran. The next steps included evaluation of conservation/variability along the sequences, phylogenetic analysis, estimation of the average evolutionary divergence over all the sequence pairs, predicting the phosphorylation/N-glycosylation/palmitoylation sites, and the final analysis of antigenicity. The findings of alignment, entropy plot, and pairwise similarity analysis revealed 17 hypervariable regions. The isolates belonging to Tehran were clustered in phylogenetic tree, and the most similar isolates to them were ADW11182 and ADW11183. Location of some of the N-glycosylation/phosphorylation/palmitoylation points indicated that these sites were conserved among the isolates. Furthermore, the frequency of epitopes and their scores reflect the high immunogenicity of S1 protein in 793/B serotype. Analysis of the primary and secondary structures demonstrated that their parameters had variable values and were different regarding the number and location of α-helix, β-strand, and coils. According to our findings, the Iranian isolates of 793/B serotype change their molecular characteristics during time and in different geographical regions. These alterations might account for failure in prevention programs and differences in virulence and pathogenicity.


title: Outcomes of Multimodality Therapy in Pediatric Patients With Ruptured and Unruptured Brain Arteriovenous Malformations.

text: BACKGROUND Brain arteriovenous malformations (BAVMs) are a frequent cause of pediatric hemorrhagic stroke, which frequently results in significant morbidity and mortality. OBJECTIVE To analyze the results of multimodality treatment for a consecutive series of pediatric patients with ruptured and unruptured BAVMs at a single institution. METHODS Forty patients <18 years of age were retrospectively reviewed. Results were divided by hemorrhage status, ie, ruptured or unruptured, and the intended curative treatment modality, ie, surgical resection or stereotactic radiosurgery. RESULTS Twenty-seven patients (68%) presented with hemorrhage, and 13 patients (32%) presented without hemorrhage. Among ruptured patients, 19 (70%) underwent surgery and 8 (30%) underwent stereotactic radiosurgery. In surviving patients who presented with hemorrhage, 23 of 26 (88%) had a modified Rankin Scale (mRS) score of 0 to 2 at the last follow-up, and 24 of 26 (92%) obtained radiographic cure. For unruptured BAVMs, all 6 patients with grade I to III BAVM obtained radiographic cure and had an mRS score of 0 to 1 at the last follow-up, whereas 1 of 5 patients (20%) with grade IV and V BAVM had BAVM obliteration and a mean mRS score of 1.8 at the last follow-up. In a total of 93.6 years of follow-up from date of presentation to last clinical follow-up, there was 1 hemorrhage (1.1%/y). Of 30 patients with radiographic obliteration, 2 patients had radiographic recurrence (7% incidence). CONCLUSION The majority of ruptured patients had an mRS score of 0 to 2 at the last follow-up and obtained radiographic cure. Unruptured patients with grade I to III BAVMs had superior outcomes compared with those with grade IV and V AVMs. Treatment of grade I to III BAVMs appears safe, and additional study is needed to determine optimal strategies for the management of unruptured grade IV and V BAVMs.


title: Functional cine MRI and transabdominal ultrasonography for the assessment of adhesions to implanted synthetic mesh 5-7 years after laparoscopic ventral hernia repair.

text: BACKGROUND Laparoscopic ventral hernia repair (LVHR) has gained worldwide acceptance, due to its minimally invasive character, feasibility and low rate of complications. Animal experiments have shown marked adhesions to the intraperitoneal mesh (IPM), the clinical consequences being unclear. This study aimed to describe the extension of adhesions to the mesh, 5-7 years after LVHR, using two validated non-invasive radiologic methods. METHODS Real-time transabdominal ultrasonography (TAU) and cine magnetic resonance imaging (MRI) was applied to 30 patients with prior LVHR and implantation of IPM (Intramesh W3, Cousin Biotech, France). The visceral slide was measured in nine predefined abdominal segments. Values <or=1 cm were defined as an area with adhesion. RESULTS The mean time between LVHR and TAU/cine MRI was 67 months (range, 58-80 months). We found adhesion to the mesh in 90% of the patients using TAU and 100% of the patients using cine MRI. In the latter, 65% were between the bowel and IPM. CONCLUSIONS LVHR is known to reduce recurrences and postoperative complications, while improving patient outcome. The intraperitoneal placement of the mesh has been shown to induce adhesions; the amount and extension in the clinical setting is unclear. The present study showed a marked proportion of adhesions to the mesh with an average surgery to scan time of 5.6 years, despite an anti-adhesive barrier on the visceral surface of the mesh. Together with existing data, this result increases the concern related to the long-term consequences of an IPM. As a consequence, a comprehensive and comparable test system for medical devices, i.e. IPM, is needed.


title: Minimizing Hemorrhagic Complications in Laparoscopic Sleeve Gastrectomy--a Randomized Controlled Trial.

text: BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has gained worldwide popularity in recent years. Hemorrhagic complications (HC) are usually the result of stapler line bleeding and are probably underreported. The previous incidence of HC in our department including minor bleeding and late hematomas was 15.0 %. The objective of this study is to assess the impact of stapler line reinforcement (SLR) and intraoperative blood pressure control on HC after LSG. METHODS Between February 2013 and March 2014, patients who were admitted to our department for LSG were randomly assigned to one of three arms: stapler line application of biologic glue--Evicel™ (E), over suture of the stapler line (S) or control (C). Surgical technique in all arms included blood pressure elevation to 140 mmHg before termination of the procedure. Data is presented as mean ± SD or median (IQR 25-75). RESULTS One hundred sixty-five patients were randomized: 49 to E, 49 to S, and 67 to C. There were no demographic differences between arms. Operative time was significantly longer in S than in E and C arms (74 ± 21 vs. 64 ± 23 and 54 ± 19 min, respectively). ∆Hb was significantly lower in the S group. Packed cells were used in two from E and one from C arms. Late infected hematoma occurred in three (1.8 %) patients: one from E and two from C arms. Leak rate was 1.2 %: one from S and one from C arms. LOS was the same. No patients were re-operated due to bleeding. CONCLUSIONS In this randomized trial, routine elevation of systolic blood pressure to 140 mmHg and over suture of the staple line in LSG minimized HC, with reasonable prolongation of the procedure.


title: The 21-item Barratt Impulsiveness Scale Revised (BIS-R-21): An alternative three-factor model.

text: Background and aims Due to its important role in both healthy groups and those with physical, mental and behavioral disorders, impulsivity is a widely researched construct. Among various self-report questionnaires of impulsivity, the Barratt Impulsiveness Scale is arguably the most frequently used measure. Despite its international use, inconsistencies in the suggested factor structure of its latest version, the BIS-11, have been observed repeatedly in different samples. The goal of the present study was therefore to test the factor structure of the BIS-11 in several samples. Methods Exploratory and confirmatory factor analyses were conducted on two representative samples of Hungarian adults (N = 2,457; N = 2,040) and a college sample (N = 765). Results Analyses did not confirm the original model of the measure in any of the samples. Based on explorative factor analyses, an alternative three-factor model (cognitive impulsivity; behavioral impulsivity; and impatience/restlessness) of the Barratt Impulsiveness Scale is suggested. The pattern of the associations between the three factors and aggression, exercise, smoking, alcohol use, and psychological distress supports the construct validity of this new model. Discussion The new measurement model of impulsivity was confirmed in two independent samples. However, it requires further cross-cultural validation to clarify the content of self-reported impulsivity in both clinical and nonclinical samples.


Life threatening transmural arteritis of the internal carotid artery: reconstructive treatment with flow diverting stents.


title: Independent lung ventilation with use of a double-lumen endotracheal tube for refractory hypoxemia and shock complicating severe unilateral pneumonia: A case report.

text: Background The indications for independent lung ventilation (ILV) in critical care settings have not been fully clarified, especially because extracorporeal membrane oxygenation (ECMO) is being used increasingly in cases of severe respiratory failure. Case report A 90-year-old man presented with severe unilateral pneumonia, and despite conventional mechanical ventilation management with use of a single lumen endotracheal tube and high positive endo-expiratory pressure (PEEP), oxygenation and hemodynamics deteriorated. We then performed ILV using a double-lumen endotracheal tube (DLT) and two ventilators, each set at a different respiratory mode. With continuous administration of a neuromuscular blocking agent, the ventilator for the left lung (non-affected lung) was set to pressure-controlled ventilation (PCV) mode, whereas the ventilator for the right lung (affected lung) was set to bi-level mode, 1 breath/min, and high PEEP. ILV and the high PEEP applied to the affected lung prevented hyperinflation of the non-affected lung and increased pulmonary blood perfusion on the non-affected side. Thus, ILV immediately improved oxygenation and hemodynamics by correcting ventilation/perfusion mismatch. Discussion Although ECMO is a valid treatment option for patients with severe respiratory failure, it is highly invasive intervention. ILV performed with use of a DLT is less invasive and more useful than ECMO. Thus, ILV should be kept in mind as a treatment option, especially in cases of refractory respiratory failure and circulatory failure in which the pathophysiology of the left and right lungs differs markedly.


title: Near-infrared spectroscopy after out-of-hospital cardiac arrest.

text: BACKGROUND Cerebral hypoperfusion may aggravate neurological damage after cardiac arrest. Near-infrared spectroscopy (NIRS) provides information on cerebral oxygenation but its relevance during post-resuscitation care is undefined. We investigated whether cerebral oxygen saturation (rSO2) measured with NIRS correlates with the serum concentration of neuron-specific enolase (NSE), a marker of neurological injury, and with clinical outcome in out-of-hospital cardiac arrest (OHCA) patients. METHODS We performed a post hoc analysis of a randomised clinical trial (COMACARE, NCT02698917) comparing two different levels of carbon dioxide, oxygen and arterial pressure after resuscitation from OHCA with ventricular fibrillation as the initial rhythm. We measured rSO2 in 118 OHCA patients with NIRS during the first 36 h of intensive care. We determined the NSE concentrations from serum samples at 48 h after cardiac arrest and assessed neurological outcome with the Cerebral Performance Category (CPC) scale at 6 months. We evaluated the association between rSO2 and serum NSE concentrations and the association between rSO2 and good (CPC 1-2) and poor (CPC 3-5) neurological outcome. RESULTS The median (inter-quartile range (IQR)) NSE concentration at 48 h was 17.5 (13.4-25.0) μg/l in patients with good neurological outcome and 35.2 (22.6-95.8) μg/l in those with poor outcome, p < 0.001. We found no significant correlation between median rSO2 and NSE at 48 h, rs = - 0.08, p = 0.392. The median (IQR) rSO2 during the first 36 h of intensive care was 70.0% (63.5-77.0%) in patients with good outcome and 71.8% (63.3-74.0%) in patients with poor outcome, p = 0.943. There was no significant association between rSO2 over time and neurological outcome. In a binary logistic regression model, rSO2 was not a statistically significant predictor of good neurological outcome (odds ratio 0.99, 95% confidence interval 0.94-1.04, p = 0.635). CONCLUSIONS We found no association between cerebral oxygenation measured with NIRS and NSE concentrations or outcome in patients resuscitated from OHCA. TRIAL REGISTRATION ClinicalTrials.gov, NCT02698917 . Registered on 26 January 2016.


title: Ectodomain shedding of angiotensin converting enzyme 2 in human airway epithelia.

text: Angiotensin-converting enzyme 2 (ACE2) is a terminal carboxypeptidase and the receptor for the SARS and NL63 coronaviruses (CoV). Loss of ACE2 function is implicated in severe acute respiratory syndrome (SARS) pathogenesis, but little is known about ACE2 biogenesis and activity in the airways. We report that ACE2 is shed from human airway epithelia, a site of SARS-CoV infection. The regulation of ACE2 release was investigated in polarized human airway epithelia. Constitutive generation of soluble ACE2 was inhibited by DPC 333, implicating a disintegrin and metalloprotease 17 (ADAM17). Phorbol ester, ionomycin, endotoxin, and IL-1beta and TNFalpha acutely induced ACE2 release, further supporting that ADAM17 and ADAM10 regulate ACE2 cleavage. Soluble ACE2 was enzymatically active and partially inhibited virus entry into target cells. We determined that the ACE2 cleavage site resides between amino acid 716 and the putative transmembrane domain starting at amino acid 741. To reveal structural determinants underlying ACE2 release, several mutant and chimeric ACE2 proteins were engineered. Neither the juxtamembrane stalk region, transmembrane domain, nor the cytosolic domain was needed for constitutive ACE2 release. Interestingly, a point mutation in the ACE2 ectodomain, L584A, markedly attenuated shedding. The resultant ACE2-L584A mutant trafficked to the cell membrane and facilitated SARS-CoV entry into target cells, suggesting that the ACE2 ectodomain regulates its release and that residue L584 might be part of a putative sheddase "recognition motif." Thus ACE2 must be cell associated to serve as a CoV receptor and soluble ACE2 might play a role in modifying inflammatory processes at the airway mucosal surface.


title: Long-term improvements in pulmonary function 5 years after bariatric surgery.

text: BACKGROUND Obesity is associated with reduced pulmonary function. We evaluated pulmonary function and status of asthma and obstructive sleep apnoea syndrome (OSAS) before and 5 years after bariatric surgery. METHODS Spirometry was performed at baseline and 5 years postoperatively. Information of asthma and OSAS were recorded. Of 113 patients included, 101 had undergone gastric bypass, 10 duodenal switch and 2 sleeve gastrectomy. RESULTS Eighty (71%) patients were women, mean preoperative age was 40 years and preoperative weight was 133 kg in women and 158 kg in men. Five years postoperatively, weight reduction was 31% (42 kg; p < 0.001) in women and 24% (38 kg; p < 0.001) in men. Forced expiratory volume in 1 s (FEV1) increased 4.1% (116 ml; p < 0.001) in women and 6.7% (238 ml; p = 0.003) in men. Forced vital capacity (FVC) increased 5.8% (209 ml; p < 0.001) in women and 7.6% (349 ml; p < 0.001) in men. Gender and weight loss were independently associated with the improvements in FEV1 and FVC. At follow-up, FEV1 had increased 36% of the difference towards the estimated normal FEV1, and there was a corresponding 70% recovery of FVC. These improvements occurred despite an expected decline in pulmonary function by age during the study period. Of the asthmatics and OSAS patients, 48 and 80%, respectively, were without symptoms 5 years postoperatively. CONCLUSIONS Pulmonary function measured with spirometry was significantly improved 5 years after bariatric surgery, despite an expected age-related decline during this period. Symptoms of asthma and OSAS also improved.


title: Taxane-based chemohormonal therapy for metastatic hormone-sensitive prostate cancer.

text: BACKGROUND There has been considerable development in the treatment of advanced prostate cancer over the last decade. A number of agents, including docetaxel, cabazitaxel, abiraterone acetate, enzalutamide and sipuleucel-T, have been reported to improve outcomes in men with castration-resistant disease and their use is being explored in hormone-sensitive prostate cancer. OBJECTIVES To assess the effects of early taxane-based chemohormonal therapy for newly diagnosed, metastatic, hormone-sensitive prostate cancer. SEARCH METHODS We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Google Scholar, and Web of Science), trials registries, other sources of grey literature, and conference proceedings, up to 10 August 2018. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized or quasi-randomized controlled trials in which participants were administered taxane-based chemotherapy with systemic androgen deprivation therapy (ADT) within 120 days of beginning ADT versus ADT alone at the time of diagnosis of metastatic disease. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model. We rated the quality of evidence according to the GRADE approach. MAIN RESULTS The search identified three studies in which 2,261 participants were randomized to receive either ADT alone, or taxane-based chemotherapy at a dose of 75mg per square meter of body surface area at three-weekly intervals for six or nine cycles in addition to ADT.Primary outcomesEarly treatment with taxane-based chemotherapy in addition to ADT probably reduces death from any cause compared to ADT alone (hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.68 to 0.87; moderate-certainty evidence); this would result in 94 fewer deaths per 1,000 men (95% CI 51 to 137 fewer deaths). We downgraded the certainty of evidence due to study limitations related to potential performance bias. Based on the results of one study with 375 participants, the addition of taxane-based chemotherapy to ADT may increase the incidence of Grade III to V adverse events compared to ADT alone (risk ratio (RR) 2.98, 95% CI 2.19 to 4.04; low-certainty evidence); this would result in 405 more Grade III to V adverse events per 1,000 men (95% CI 243 to 621 more events). We downgraded the certainty of evidence due to study limitations and imprecision.Secondary outcomesEarly taxane-based chemotherapy in addition to ADT probably reduces the risk of prostate cancer-specific death (RR 0.79, 95% CI 0.70 to 0.89; moderate-certainty evidence). We downgraded the certainty of evidence due to study limitations related to potential performance and detection bias. The addition of taxane-based chemotherapy also probably reduces disease progression compared to ADT alone (HR 0.63, 95% CI 0.56 to 0.71; moderate-certainty evidence). We downgraded the certainty of evidence because of study limitations related to potential performance bias. The addition of taxane-based chemotherapy to ADT may result in a large increase in the risk of treatment discontinuation due to adverse events (RR 79.41, 95% CI 4.92 to 1282.78; low-certainty evidence). We downgraded the certainty of evidence due to study limitations and imprecision. This estimate is derived from a single study with no events in the control arm but a discontinuation rate of 20% in the intervention arm. Taxane-based chemotherapy may increase the incidence of adverse events of any grade (RR 1.11, 95% CI 1.06 to 1.17; low-certainty evidence). We downgraded our assessment of the certainty of evidence due to very serious study limitations. There may be a small improvement, which may not be clinically important, in quality of life at 12 months with combination treatment (mean difference (MD) 2.85 on the Functional Assessment of Cancer Therapy-Prostate scale, 95% CI 0.13 higher to 5.57 higher; low-certainty evidence). We downgraded the certainty of evidence for study limitations related to potential performance, detection and attrition bias. AUTHORS' CONCLUSIONS Compared to ADT alone, the early (within 120 days of beginning ADT) addition of taxane-based chemotherapy to ADT for hormone-sensitive prostate cancer probably prolongs both overall and disease-specific survival and delays disease progression. There may be an increase in toxicity with taxane-based chemotherapy in combination with ADT. There may also be a small, clinically unimportant improvement in quality of life at 12 months with taxane-based chemotherapy and ADT treatment.


title: Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese.

text: BACKGROUND This study aimed to determine the incidence, etiology, and management options for symptomatic stenosis (SS) after laparoscopic sleeve gastrectomy (LSG). METHODS A retrospective study reviewed morbidly obese patients who underwent LSG between October 2008 and December 2010 to identify patients treated for SS. RESULTS In this study, 230 patients (83% female) with a mean age of 49.5 years and a mean body mass index (BMI) of 43 kg/m(2) underwent LSG. In 3.5% of these patients (100% female; mean age, 42 years; mean BMI, 42.6 kg/m(2)), SS developed. The LSG procedure was performed using a 36-Fr. bougie and tissue-reinforced staplers. Four patients had segmental staple-line imbrication, and seven patients underwent contrast study, with 71.4% demonstrating a fixed narrowing. Endoscopy confirmed short-segment stenoses: seven located at mid-body and one located near the gastroesophageal junction. Endoscopic management was 100% successful. The mean number of dilations was 1.6, and the median balloon size was 15 mm. The mean time from surgery to initial endoscopic intervention was 48.8 days, and the mean time from the first dilation to toleration of a solid diet was 49.6 days. Two patients were referred to our institution after undergoing LSG at another facility. The mean time to the transfer was 28.5 days. The two patients had a mean age of 35 years and a mean BMI of 42.3 kg/m(2). Both patients experienced immediate SS after perioperative complications comprising one staple-line hematoma and one leak. Contrast studies demonstrated minimal passage of contrast through a long-segment stenosis. Both patients underwent multiple endoscopic dilation procedures and endoluminal stenting, ultimately requiring laparoscopic conversion to Roux-en-Y gastric bypass. The mean time from the initial surgery to the surgical revision was 77 days, and the mean time after the first intervention to tolerance of a solid diet was 82 days. CONCLUSION Symptomatic short-segment stenoses after LSG may be treated successfully with endoscopic balloon dilation. Long-segment stenoses that do not respond to endoscopic techniques may ultimately require conversion to Roux-en-Y gastric bypass.


title: Panel 1: Epidemiology, natural history, and risk factors.

text: BACKGROUND The First International Symposium on Recent Advances in Otitis Media (OM) with Effusion was held in Columbus, Ohio, in 1975. The symposium has been organized in the United States every 4 years since, followed by a research conference to (a) assess major research accomplishments, (b) identify important research questions and opportunities, (c) develop consensus on definitions and terminology, and (d) establish priorities with short- and long-term research goals. One of the principal areas reviewed quadrennially is Epidemiology, Natural History, and Risk Factors. OBJECTIVE To provide a review of recent literature on the epidemiology, natural history, and risk factors for OM. DATA SOURCES AND REVIEW METHODS A search of OM articles in English published July 2007 to June 2011 was conducted using PubMed and related databases. Those with findings judged of importance for epidemiology, public health, and/or statistical methods were reviewed. RESULTS The literature has continued to expand, increasing understanding of the worldwide burden of OM in childhood, complications from treatment failures, and comorbidities. Novel risk factors, including genetic factors, have been examined for OM susceptibility. Population-based studies in Canada, the United States, and other countries confirmed reductions in OM prevalence. Although most studies concentrated on acute OM (AOM) or OM with effusion (OME), a few examined severe chronic suppurative OM (CSOM), a major public health problem in developing countries and for certain indigenous populations around the world. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Recent publications have reinforced earlier epidemiological findings, while extending our knowledge in human population groups with high burden of OM.


title: Low protein silage associated with rumen impaction in suckler cows.

text: Rumen impaction associated with low protein diets in a suckler cowCampylobacteriosis in suckler cowsPlant toxicity in ewesListerial encephalitis in ewes ITALIC! Chorioptes bovis-associated infertility in ramsThese are among matters discussed in the disease surveillance report for January 2016 from SAC Consulting: Veterinary Services (SAC C VS).


title: Comparison of totally laparoscopic total gastrectomy using an endoscopic linear stapler with laparoscopic-assisted total gastrectomy using a circular stapler in patients with gastric cancer: A single-center experience.

text: AIM To evaluate the safety and efficacy of totally laparoscopic total gastrectomy (TLTG) with esophagojejunostomy using a linear stapler compared with laparoscopic-assisted total gastrectomy (LATG) using a circular stapler in gastric cancer patients. METHODS We retrospectively reviewed 687 patients who underwent laparoscopic total gastrectomy for gastric cancer at a single institution from August 2008 to August 2014. The patients were divided into two groups according to the type of operation: 421 patients underwent TLTG and 266 underwent LATG. Clinicopathologic characteristics and surgical outcomes in the two groups were compared and analyzed. RESULTS The TLTG group had higher mean ages at the time of operation (57.78 ± 11.20 years and 55.69 ± 11.96 years, P = 0.020) and more histories of abdominal surgery (20.2% and 12.4%, P = 0.008) compared with the LATG group. Surgical outcomes such as intraoperative and postoperative transfusions, combined operations, pain scores and administration of analgesics, and complications were similar between the two groups. However, compared with the LATG group, the TLTG group required a shorter operation time (149 min vs 170 min, P < 0.001), had lower postoperative hematocrit change (3.49% vs 4.04%, P = 0.002), less intraoperative events (3.1% vs 10.2%, P < 0.001), less intraoperative anastomosis events (2.4% vs 7.1%, P = 0.003), faster postoperative recovery such as median time to first flatus (3.30 d vs 3.60 d, P < 0.001), faster median commencement of soft diet (4.30 d vs 4.60 d, P < 0.001) and shorter length of postoperative hospital stay (6.75 d vs 7.02 d, P = 0.005). CONCLUSION The intracorporeal method for reconstruction of esophagojejunostomy using a linear stapler may be considered a feasible procedure comparing with extracorporeal anastomosis using circular stapler because TLTG is simpler and more straightforward than LATG. Therefore, TLTG can be recommended as an appropriate procedure for gastric cancer.


title: Total laparoscopic sigmoid and rectal surgery in combination with transanal endoscopic microsurgery: a preliminary evaluation in China.

text: BACKGROUND This study was designed to evaluate the feasibility and safety of total laparoscopic sigmoid and rectal surgery without abdominal incision in combination with transanal endoscopic microsurgery (TEM). METHODS From May 2010 to October 2011, 34 patients with colon and rectal tumors were treated by total laparoscopic surgery without abdominal incision, and the clinical data of these patients were reviewed. RESULTS All operations could be successfully accomplished without conversion to open surgery. No diverting ileostomy was created. The average operative time was 151.60 (range, 125-185) minutes. The average blood loss was 200.20 (range, 55-450) ml. All resection margins were negative. Six patients developed postoperative anastomotic leakage. There were no reports of other complications in all patients. CONCLUSIONS This preliminary study indicated that total laparoscopic sigmoid and rectal surgery in combination with TEM was a safe, feasible, and minimally invasive technique. This advanced surgical technique was developed by combining laparoscopy with the concept of natural orifice transluminal endoscopic surgery.


Medusa's ugly head again: from SARS to MERS-CoV.


title: Leukocyte count is a modulating factor for the mortality benefit of bivalirudin in ST-segment-elevation acute myocardial infarction: the HORIZONS-AMI trial.

text: BACKGROUND Although the reduction in mortality with bivalirudin compared with unfractionated heparin plus glycoprotein IIb/IIIa inhibitors in the Harmonizing Outcome with Revascularization and Stent in Acute Myocardial Infarction (HORIZONS-AMI) trial has been attributed to lower rates of major bleeding, alternative mechanisms have not been investigated in depth. We sought to investigate whether there might be an interaction between white blood cell (WBC) count and bivalirudin for the risk of mortality, and whether this interaction is independent of major bleeding. METHODS AND RESULTS Among the 3602 patients enrolled in the HORIZONS-AMI trial, WBC count was available in 3433 (95.3%) patients. Patients were stratified according to WBC tertiles. At 1-year follow-up, bivalirudin was associated with significantly lower rates of mortality and cardiac mortality compared with unfractionated heparin plus glycoprotein IIb/IIIa inhibitors in patients in the upper WBC tertile (all-cause death: 4.1% versus 9.3%, respectively; P=0.0004; cardiac death: 2.0% versus 6.9%; respectively; P<0.0001) but not in patients in the mid-WBC or lower WBC tertiles. The reduction of mortality with bivalirudin across WBC tertiles was independent of major bleeding, and a significant interaction was apparent for 1-year all-cause mortality and cardiac mortality between WBC and bivalirudin therapy. Similar findings were apparent at 3 years. CONCLUSIONS In patients with ST-segment-elevation myocardial infarction, a significant interaction between bivalirudin therapy and admission WBC count was apparent for 1-year mortality. The reduction in mortality was independent of major bleeding, suggesting that other mechanisms may be implicated in the survival benefit observed with bivalirudin. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00433966.


title: Evaluation of blind thoracoscopic-assisted placement of three double-lumen endobronchial tube designs for one-lung ventilation in dogs.

text: OBJECTIVE To describe a technique for blind thoracoscopic-assisted double-lumen endobronchial tube (DLT) placement for achieving one-lung ventilation (OLV) using 3 different DLT designs and to evaluate whether thoracic auscultation could reliably confirm OLV in dogs. STUDY DESIGN Prospective randomized study. ANIMALS Mature female hound dogs (n = 6). METHODS Physical examination, baseline blood work and thoracic radiography confirmed the absence of preexisting disease in all dogs. Thoracoscopic observation was established through a subxiphoid portal and used for evaluation of differential lung lobe ventilation. Each dog was sequentially intubated using 1 of 3 DLT designs in random order; Robertshaw left-sided tube (RS-L), Carlens left-sided tube (C-L), Dr. White right-sided tube (DW-R). Incidence of initial and overall (after a maximum of 3 DLT manipulations) correct and complete OLV (CC-OLV) was recorded. After each blind thoracoscopic-assisted DLT placement, bronchoscopic evaluation was performed to document correct DLT position. RESULT Blind DLT placement achieved overall CC-OLV in all dogs using RS-L, 66% using C-L, and all using DW-R. Successful initial left-sided OLV (L-OLV) was statistically more likely when RS-L DLTs were used compared to C-L or DW-R. Of cases where overall CC-OLV was achieved, correct DLT position was present in only 44% of intubations. CONCLUSIONS Blind DLT placement produced successful CC-OLV in all dogs using at least one DLT design evaluated. Use of thoracoscopic assistance may obviate the need for bronchoscopic observation during DLT placement in dogs. However, bronchoscopic observation may still refine DLT positioning in dogs after blind thoracoscopic-assisted DLT placement.


title: Identifying Lesbian, Gay, Bisexual, and Transgender Search Terminology: A Systematic Review of Health Systematic Reviews.

text: Research on the health of lesbian, gay, bisexual, and transgender (LGBT) populations can provide important information to address existing health inequalities. Finding existing research in LGBT health can prove challenging due to the plethora of terminology used. We sought to describe existing search strategies and to identify more comprehensive LGBT search terminology. We iteratively created a search string to identify systematic reviews and meta-analyses about LGBT health and implemented it in Embase, PubMed/MEDLINE, and PsycINFO databases on May 28-29, 2015. We hand-searched the journal LGBT Health. Inclusion criteria were: systematic reviews and meta-analyses that addressed LGBT health, used systematic searching, and used independent coders for inclusion. The published search terminology in each record and search strings provided by authors on request were cross-referenced with our original search to identify additional terminology. Our search process identified 19 systematic reviews meeting inclusion criteria. The number of search terms used to identify LGBT-related records ranged from 1 to 31. From the included studies, we identified 46 new search terms related to LGBT health. We removed five search terms as inappropriate and added five search terms used in the field. The resulting search string included 82 terms. There is room to improve the quality of searching and reporting in LGBT health systematic reviews. Future work should attempt to enhance the positive predictive value of LGBT health searches. Our findings can assist LGBT health reviewers in capturing the diversity of LGBT terminology when searching.


title: FLAIR signal increase of the fluid within the resection cavity after glioma surgery: generally valid as early recurrence marker?

text: OBJECTIVE Recent studies have indicated that a signal intensity increase of the fluid within the resection cavity on FLAIR images may predict tumor recurrence after glioma surgery. The aim of this study was to assess the increase in FLAIR signal intensity in a large patient cohort and in subgroups to assess its prognostic value for early tumor recurrence in glioma patients. METHODS A total of 212 patients (213 cases) who had undergone surgery for an intracranial glioma (WHO Grade IV [n = 103], WHO Grade III [n = 57], and WHO Grade II [n = 53]) were included in this retrospective study. FLAIR signal within the resection cavity at the time of tumor recurrence/last contact and on the previous MRI study was assessed qualitatively and quantitatively. Appearance of FLAIR signal increase was studied over time using Kaplan-Meier estimates in subgroups. RESULTS Patients with WHO Grade II glioma and connection of the resection cavity to CSF who did not undergo radiotherapy did not regularly develop this sign and were excluded from further analysis. For the remaining 87 cases, FLAIR signal intensity increase was observed in 27 cases. Recurrent disease was found in 26 of these 27 cases, resulting in a specificity of 80.0%, a sensitivity of 31.7%, and positive and negative predictive values of 96.3% and 6.7%, respectively. In 4 cases this sign had been observed prior (range 2.8-8.5 months) to tumor recurrence defined by standard criteria. Quantitative analysis underlined the results of qualitative analysis, but it did not add a diagnostic value. CONCLUSIONS Signal intensity increase of the fluid within the resection cavity on FLAIR images is a rare but highly specific and early sign for tumor recurrence/tumor progression in completely and incompletely resected high-grade glioma without connection of the resection cavity to CSF and with radiotherapy.


title: Idle medical students review emerging COVID-19 research.

text: The coronavirus disease (COVID-19) pandemic is causing wide-spread interruptions in medical education. With little warning, clinical rotations were cancelled and medical students were sent home. While pre-clinical students transitioned to online curricula, clinical students were left without discreet educational goals. Simultaneously, medical doctors were scrambling to maintain competence in the face of rapidly evolving COVID-19 information. Here, we describe an education program that integrates medical students into interdisciplinary teams to review emerging COVID-19 research that directly answers questions sent in by medical doctors.


title: Restenosis after microsurgical non-patch carotid endarterectomy in 586 patients.

text: BACKGROUND Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic (>50%) and asymptomatic (>60%) carotid artery stenosis. Here we report the midterm results of a microsurgical non-patch technique and compare these findings to those in the literature. METHODS From 1998 to 2009 we treated 586 consecutive patients with CEA. CEA was performed, under general anesthesia, with a surgical microscope using a non-patch technique. Somatosensory evoked potential and transcranial Doppler were continuously monitored. Cross-clamping was performed under EEG burst suppression and adaptive blood pressure increase. Follow-up was performed by an independent neurologist. Mortality at 30 days and morbidity such as major and minor stroke, peripheral nerve palsy, hematoma and cardiac complications were recorded. The restenosis rate was assessed using duplex sonography 1 year after surgery. RESULTS A total of 439 (75%) patients had symptomatic and 147 (25%) asymptomatic stenosis; 49.7% of the stenoses were on the right-side. Major perioperative strokes occurred in five (0.9%) patients [n = 4 (0.9%) symptomatic; n = 1 (0.7%) asymptomatic patients]. Minor stroke was recorded in six (1%) patients [n = 4 (0.9%) symptomatic; n = 2 (1.3%) asymptomatic patients]. Two patients with symptomatic stenoses died within 1 month after surgery. Nine patients (1.5%) had reversible peripheral nerve palsies, and nine patients (1.5%) suffered a perioperative myocardial infarction. High-grade (>70%) restenosis at 1 year was observed in 19 (3.2%) patients [n = 12 (2.7%) symptomatic; n = 7 (4.7%) asymptomatic patients]. CONCLUSIONS The midterm rate of restenosis was low when using a microscope-assisted non-patch endarterectomy technique. The 30-day morbidity and mortality rate was comparable or lower than those in recently published surgical series.


title: Restoration of lumbar lordosis after minimally invasive transforaminal lumbar interbody fusion: a systematic review.

text: BACKGROUND Transforaminal lumbar interbody fusion (TLIF) is a well-accepted surgical technique for the treatment of degenerative spinal conditions and spinal deformity. The TLIF procedure can be performed open or using minimally invasive techniques. While several studies have found that minimally invasive TLIF (MI-TLIF) has advantages over open TLIF procedures with less blood loss, postoperative pain and hospital length of stay, opponents of the minimally invasive technique cite the lack of restoration of lumbar lordosis as a major drawback. With the increasing awareness of restoring sagittal alignment parameters in degenerative and deformity procedures, surgeons should understand the capabilities of different procedures to achieve surgical goals. To our knowledge, few studies have specifically studied the radiographic restoration of lumbar lordosis after MI-TLIF procedures. The purpose of this study was to perform a systematic review of the literature describing the sagittal lumbar radiographic parameter changes after MI-TLIF. METHODS Following PRISMA guidelines, systematic review was performed. With the assistance of a medical librarian, a highly-sensitive search strategy formulated on 1/19/2018 utilized the following search terms: "minimally invasive procedures," "transforaminal lumbar interbody fusion," "lumbar interbody fusion," "diagnostic imaging," "radiographs," "radiography," "x-rays," "lordosis," "lumbar vertebrae," "treatment," "outcome," and "lumbosacral" using Boolean operators 'AND' and 'OR'. Three databases were searched (PubMed/Medline, Embase, and Cochrane Library). An online system (www.covidence.org) was used to standardize article review. All studies were independently analyzed by two investigators and discrepancies mitigated by a third reviewer. Study selection for each cycle was Yes/No/Maybe. Cycles were: (1) (Title/Abstract); (2) (Full Text); (3) (Extraction). Inclusion criteria were: (1) All study designs, (2) MI-TLIF procedures, (3) Reporting total lumbar lordosis (LL) and/or segmental lordosis (SL) pre- and postoperatively. Exclusion criteria were: (1) non MI-TLIF procedures (ALIF, XLIF, LLIF, conventional TLIF, OLIF), (2) No reported LL or SL. RESULTS The search yielded 4,036 results with 836 duplicates leaving 3,200 studies for review. Cycle 1 eliminated 3,153 studies as irrelevant, thus, 47 were eligible for full-text review. Cycle 2 excluded 31 studies for No English full text (9), Oral/Poster (8), Wrong intervention/outcome (10), Duplicate listing (2), Full text not available (1), Literature review (1) resulting in 16 included studies. Study designs were: Randomized-controlled trial (3), Case series (6) and Retrospective (7). Mean # of subjects were 32.0 (range 8-95). Weighted-mean LL was 39.6°±9.2 (range 28-57) and postoperative LL was 45.0°±7.4 (range 36-67) with a LL post-pre difference of 5.2°±5.9 (range -7 to 15). Weighted-mean preoperative SL was 12.7°±4.3 (range 5-21) and postoperative SL was 15.0°±4.5 (range 5-22) with a SL post-pre difference of 2.1°±1.7 (range 0-8). CONCLUSIONS The current literature on MI-TLIF and restoration of LL/SL is limited to 16 published studies, 44% of which are retrospective. The published evidence supporting LL and SL restoration with MI-TLIF is sparse with variable results. This systematic review demonstrates the need for future high-level studies to fully elucidate the capabilities of MI-TLIF procedures for restoring lumbar and segmental lordosis.


title: Clinical Presentation of COVID-19: A Systematic Review Focusing on Upper Airway Symptoms.

text: AIM Pharyngodynia, nasal congestion, rhinorrhea, smell, and taste dysfunctions could be the presenting symptoms of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2. The aim was to perform a systematic review of current evidences on clinical presentation of COVID-19, focusing on upper airway symptoms in order to help otolaryngologists identifying suspected cases. METHODS We searched PubMed and Web of Science electronic databases. RESULTS We included 5 retrospective clinical studies for a total of 1556 hospitalized patients with COVID-19, 57.5% were male and mean age was 49.1 years. Pooled data revealed that pharyngodynia was present in 12.4% of patients, nasal congestion in 3.7%, and rhinorrhea was rare. No reports on COVID-19 and olfactory/gustative disorders matched inclusion criteria but preliminary evidences suggested they could be present. Common symptoms were fever (85.6%), cough (68.7%), and fatigue (39.4%). Frequent comorbidities were hypertension (17.4%), diabetes (3.8%), and coronary heart disease (3.8%); 83% of patients had alterations on chest computed tomography that were bilateral in 89.5% of cases. Ground-glass opacity was the most common finding (50%). Lymphopenia (77.2%) and leucopenia (30.1%) were common. Critical cases with complications were 9%, intensive care unit admission was required in 7.3%, invasive ventilation in 3.4%, and mortality was 2.4%. CONCLUSION Otolaryngologists should know that pharyngodynia, nasal congestion, olfactory, and gustative disorders could be the presenting symptoms of COVID-19. Clinical presentation together with radiological and laboratory findings could help to identify suspected cases.


title: Sensitive and broadly reactive reverse transcription-PCR assays to detect novel paramyxoviruses.

text: We have developed a set of reverse transcription-PCR assays for the detection and identification of known and novel paramyxoviruses in clinical specimens. Primers were designed from the conserved motifs of the polymerase pol gene sequences to detect members of the Paramyxovirinae or Pneumovirinae subfamily or groups of genera within the Paramyxovirinae subfamily. The consensus-degenerate hybrid oligonucleotide primer design and seminested or nested PCR assay design were used to enhance the breadth of reactivity and sensitivity of the respective assays. Using expressed RNA and 10-fold dilution series of virus-infected tissue culture isolates from different members of the family or genera, these assays were able to detect on average between 100 and 500 copies of template RNA. The assays were specific to the respective group of genera or subfamily viruses. This set of primers enhances our ability to look for novel viruses in outbreaks and diseases of unknown etiology.


title: Case series of lower-extremity chronic wounds managed with an antibacterial foam dressing bound with gentian violet and methylene blue.

text: OBJECTIVE To evaluate an antibacterial dressing for the management of lower-extremity chronic wounds with critical colonization. DESIGN A case series of n = 15 patients with lower-extremity chronic wounds were treated with an antibacterial foam dressing consisting of polyvinyl alcohol (PVA) foam bound with gentian violet and methylene blue (Hydrofera Blue; Hydrofera, LLC, Willimantic, Connecticut). SETTING An outpatient clinic in Ontario, Canada. PATIENTS The dressing was applied to diabetic foot ulcers (n = 8) and other venous/leg wound etiologies (n = 7). The study population was clinically challenging due to high mean body weight, extended wound durations, and high diabetes prevalence. MAIN OUTCOME MEASURES Wounds were assessed for clinical signs of superficial and deep/surrounding bacterial burden using the validated NERDS and STONEES mnemonic and with semiquantitative bacterial swabs. Changes in wound size, pain, and other clinical parameters were also recorded. MAIN RESULTS Improvements in surface critical colonization and pain score at the end of the study period were noted in some patients, especially in patients with diabetic foot ulcers. A decreasing wound size was observed in 8 of the 14 patients (57%) at week 4. One patient was excluded from wound size change analysis. CONCLUSIONS An antibacterial foam dressing consisting of PVA foam bound with gentian violet and methylene blue showed encouraging results in a clinically challenging study population. This dressing may be a suitable option for lower-extremity chronic wounds demonstrating an increased superficial bacterial burden. Further investigation focused on identifying the characteristics of patients who are most responsive to the dressing is warranted.


title: COVID-19 in an elderly woman with acute functional decline.

text: A woman in her late eighties was referred to Accident and Emergency because of acute functional decline with falls and increasing confusion. SARS-CoV-2 infection was confirmed 48 hours later. Many older people and residents of care homes are vulnerable to functional decline with acute illness. Healthcare professionals should be aware that such symptoms may be due to COVID-19.


title: Area under the concentration-time curve to minimum inhibitory concentration ratio as a predictor of vancomycin treatment outcome in methicillin-resistant Staphylococcus aureus bacteraemia.

text: There have been few clinical studies on the association between the 24-h area under the concentration-time curve (AUC24) to minimum inhibitory concentration (MIC) ratio and vancomycin treatment outcomes in methicillin-resistant Staphylococcus aureus (MRSA) infections. Patients with MRSA bacteraemia between July 2009 and January 2012 were analysed retrospectively. All adult patients treated with vancomycin for ≥72 h without dialysis were included. The MIC was determined by Etest and broth microdilution (BMD). Initial steady-state AUC24 was estimated using a Bayesian model, and the AUC24/MIC cut-off value for differentiating treatment success and failure was calculated by classification and regression tree (CART) analysis. In total, 76 patients were enrolled; vancomycin treatment failure occurred in 20 patients (26.3%). Catheter-related infection was the most frequent (35.5%), followed by surgical site infection (26.3%), whilst 25 (32.9%) had complicated infections. In univariate analysis, decreased MRSA vancomycin susceptibility (MIC≥1.5 mg/L) and vancomycin trough levels (15-20 mg/L) were not associated with treatment outcomes. In the CART analysis, low initial vancomycin AUC24/MIC (<430 by Etest; <398.5 by BMD) was associated with a higher treatment failure rate (50.0% vs. 25.0%, P=0.039 by Etest; 45.0% vs. 23.2%; P=0.065 by BMD). In multivariate analysis, low initial vancomycin AUC24/MIC was a significant risk factor for treatment failure [adjusted odds ratio (aOR)=4.39, 95% confidence interval (CI), 1.26-15.35 by Etest; aOR=3.73, 95% CI 1.10-12.61 by BMD]. In MRSA bacteraemia, a low initial vancomycin AUC24/MIC is an independent risk factor for vancomycin treatment failure.


title: Inactivated virus vaccines from chemistry to prophylaxis: merits, risks and challenges.

text: The aim of this review is to make researchers aware of the benefits of an efficient quality control system for prediction of a developed vaccine's efficacy. Two major goals should be addressed when inactivating a virus for vaccine purposes: first, the infectious virus should be inactivated completely in order to be safe, and second, the viral epitopes important for the induction of protective immunity should be conserved after inactivation in order to have an antigen of high quality. Therefore, some problems associated with the virus inactivation process, such as virus aggregate formation, protein crosslinking, protein denaturation and degradation should be addressed before testing an inactivated vaccine in vivo.


title: Characterization and analysis of the full-length genome of a strain of the European QX-like genotype of infectious bronchitis virus.

text: In recent years, strains of infectious bronchitis virus belonging to the QX-like genotype have been causing huge economic losses in commercial chicken flocks in different countries in Europe. In order to expand the knowledge of the molecular features of these viruses, we have sequenced and characterized the complete genome of European QX-like IBV strain CK/SWE/0658946/10, which was isolated in 2010 in Sweden. The genome is 27664 nucleotides in length, comprising six genes and 5' and 3' untranslated regions. The ORF1a, spike and nucleocapsid genes were under strong positive selective pressure that resulted in genetic diversity in relation to classical IBV isolates. The full-length genome of the CK/SWE/0658946/10 strain has the highest nucleotide sequence identity (93.18%) to ITA/90254/2005 and the lowest nucleotide identity (89.10%) to strain CQ04-1. Phylogenetic analysis of partial S1 gene sequences of IBV strains showed that the European QX-like genotype comprises strains that have been predominantly circulating in this continent for the past decade.


title: Virtual empathy and liver cancer.

text: My first call was a 56 y/o male with hepatitis C-induced cirrhosis. He successfully cleared the virus with treatment and was very compliant with his surveillance ultrasounds for hepatocellular carcinoma (HCC). Exactly the first day our institution, as most in the state, chose to close elective clinics due to the COVID-19 pandemic I received the results from his magnetic resonance imaging (MRI), confirming that the lesion in the previous week's ultrasound was indeed HCC. Video-visits were in the horizon but not yet available, so I had the task of explaining to him over the phone that this time the test showed he had cancer. I have gone through this process countless times, face to face in a ritual that involves silent moments while sensing the subtle feeling of fear in my patient's faces being covered by stoicism.


title: Reconstructive challenges in the extended endoscopic transclival approach.

text: OBJECTIVE We wanted to present our experience with the extended endoscopic approach to clival pathology, focusing on cerebrospinal fluid leak and reconstruction challenges. METHODS We examined a consecutive series of 37 patients undergoing the extended endoscopic approach for skull base tumours, 9 patients with clival pathology. Patients were examined for the incidence of post-operative cerebrospinal fluid leak in relation to tumour pathology, location, size, reconstruction and lumbar drain. RESULTS The overall incidence of post-operative cerebrospinal fluid leak was 10.8 per cent. Seventy-five per cent of patients who had a post-operative cerebrospinal fluid leak underwent a transclival approach (p < 0.05). All patients with clival pathology who underwent an intradural dissection had a post-operative cerebrospinal fluid leak (p < 0.05). CONCLUSION Post-operative cerebrospinal fluid leak rates after the extended endoscopic approach have improved significantly after advancements including the vascularised nasoseptal flap. Despite this, transclival approaches continue to pose much difficulty. Further investigation is necessary to develop technical improvements that can meet the unique challenges associated with this region.


title: Longer stent retrievers enhance thrombectomy performance in acute stroke.

text: BACKGROUND Longer stent retrievers have recently become available and have theoretical advantages over their shorter counterparts. We aim to evaluate whether stent retriever length impacts reperfusion rates in stroke thrombectomy. METHODS This was a retrospective analysis of a prospectively collected thrombectomy database in which equal diameter (4 mm) stent retrievers were used as the first-line strategy for intracranial internal carotid or middle cerebral artery M1 or M2 occlusions along with a balloon guide catheter from June 2011 to March 2017. The population was dichotomized into long (Trevo 4×30 mm/Solitaire 4×40 mm) or short (Trevo 4×20 mm/Solitaire 4×20 mm) retrievers. The primary outcome was first-pass modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 reperfusion. RESULTS Of 1126 thrombectomies performed within the study period, 420 were included. Age, gender, National Institutes of Health Stroke Scale, ASPECTS, IV tissue plasminogen activator use, stroke etiology, occlusion site, time from last-known-normal to puncture, distribution of Trevo and Solitaire, and the use of newer generation local thromboaspiration devices were comparable between the long and short retrievers. The short retriever group had more frequent hypertension, dyslipidemia, and atrial fibrillation. First-pass mTICI 2b/3 reperfusion was more common in the long retriever group (62% vs 50%; P=0.01). Parenchymal hematomas type 2, subarachnoid hemorrhage, 90-day modified Rankin Scale score 0-2, and mortality were comparable. Multivariable analysis indicated that long retriever (OR 2.2; 95% CI 1.3 to 3.6; P=0.001), radiopaque device (OR 2.1; 95% CI 1.2 to 3.4; P=0.003), and adjuvant local aspiration (OR 2.4; 95% CI 1.3 to 4.3; P=0.003) were independently associated with first-pass reperfusion. CONCLUSIONS The use of longer stent retrievers is an independent predictor of first-pass mTICI 2b/3 reperfusion. First-pass reperfusion was also associated with the use of radiopaque devices and adjuvant local aspiration.


title: Viral and bacterial interactions in pneumonia.

text: Respiratory tract infections are the most common infectious illnesses that afflict humans. In general, viral infections of the upper respiratory tract result in mild self-limiting symptoms. However, more serious lower respiratory tract infections can lead to the development of pneumonia. While viral infections alone may cause pneumonia, it is increasingly clear that they also play an important role in increasing the risk of bacterial infection and have been shown to substantially worsen clinical outcomes from bacterial pneumonia. Advances in our understanding of the immune response to these infections are beginning to demonstrate how these microorganisms can interact, subvert the normally effective immune response and facilitate the development of more severe and even life-threatening disease.


title: Incidence of port-site incisional hernia after single-incision laparoscopic surgery.

text: BACKGROUND AND OBJECTIVES Single-incision laparoscopic surgery is gaining popularity among minimally invasive surgeons and is now being applied to a broad number of surgical procedures. Although this technique uses only 1 port, the diameter of the incision is larger than in standard laparoscopic surgery. The long-term incidence of port-site hernias after single-incision laparoscopic surgery has yet to be determined. METHODS All patients who underwent a single-incision laparoscopic surgical procedure from May 2008 through May 2009 were included in the study. Single-incision laparoscopic surgical operations were performed either by a multiport technique or with a 3-trocar single-incision laparoscopic surgery port. The patients were seen at 30 to 36 months' follow-up, at which time they were examined for any evidence of port-site incisional hernia. Patients found to have hernias on clinical examination underwent repairs with mesh. RESULTS A total of 211 patients met the criteria for inclusion in the study. The types of operations included were cholecystectomy, appendectomy, sleeve gastrectomy, gastric banding, Nissen fundoplication, colectomy, and gastrojejunostomy. We found a port-site hernia rate of 2.9% at 30 to 36 months' follow-up. CONCLUSION Port-site incisional hernia after single-incision laparoscopic surgical procedures remains a major setback for patients. The true incidence remains largely unknown because most patients are asymptomatic and therefore do not seek surgical aid.


A COVID-19 model.


title: The learning curve of laparoendoscopic single-site (LESS) cholecystectomy: definable, short, and safe.

text: BACKGROUND The applications of laparoendoscopic single-site (LESS) surgery, including cholecystectomy, are occurring quickly, although little is generally known about issues associated with the learning curve of this new technique including operative time, conversion rates, and safety. STUDY DESIGN We prospectively followed all patients undergoing LESS cholecystectomy, and compared operations undertaken at our institutions in cohorts of 25 patients with respect to operative times, conversion rates, and complications. RESULTS One-hundred fifty patients of mean age 46 years underwent LESS cholecystectomy. No significant differences in operative times were demonstrable between any of the 25-patient cohorts operated on at our institution. A significant reduction in operative times (p < 0.001) after completion of 75 LESS procedures was, however, identified with the experience of a single surgeon. No significant reduction in the number of procedures requiring an additional trocar(s) or conversion to open operations was observed after completion of 25 LESS cholecystectomies. Complication rates were low, and not significantly different between any 25-patient cohorts. CONCLUSIONS For surgeons proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency. Operative complications and conversions were infrequent and unchanged across successive 25-patient cohorts, and were similar to those reported for multi-incision laparoscopic cholecystectomy after the learning curve.


A simple method for dilating tracheostomal stenosis.


title: Sacral neuromodulation compared with injection of bulking agents for faecal incontinence following obstetric anal sphincter injury - a randomized controlled trial.

text: AIM The purpose of this trial was to compare the effectiveness of sacral neuromodulation (SNM) with a submucosal injection of collagen (Permacol®) in women with faecal incontinence following obstetric anal sphincter injury (OASIS). METHOD This single-blinded randomized controlled trial at two hospital units in Norway included women with faecal incontinence following OASIS. Eligible women who had had a successful percutaneous nerve evaluation were randomly assigned to SNM or Permacol®. The primary outcome was the difference in the St Mark's incontinence score between baseline and 6 months. Secondary outcomes were changes in the disease-specific quality of life (FIQL) and urinary incontinence (ICIQ-UI-SF) scores. RESULTS Fifty-eight women were randomly assigned to SNM (n = 30) and Permacol® (n = 28). The reduction in the St Mark's score between baseline and 6 months was 11.2 (SD 5.3) in the SNM group vs 2.3 (SD 5.0) in the Permacol® group, resulting in a difference of 8.9 (95% CI: 6.1-11.7, P < 0.0001). The differences in the four scales of FIQL (lifestyle, coping, depression, embarrassment) were 0.90 (95% CI: 0.50-1.30, P < 0.001), 1.05 (0.62-1.47, P < 0.001), 0.52 (95% CI: 0.16-0.87, P = 0.005) and 0.95 (95% CI: 0.50-1.40, P < 0.001), respectively, in favour of SNM. The difference in the ICIQ-UI-SF was 5.0 (95% CI: 1.97-8.02, P = 0.002) in favour of SNM. There were nine minor adverse events in the SNM group compared with seven in the Permacol® group (P = 0.77). CONCLUSION SNM was superior to Permacol® in terms of reduction of St Mark's score, ICIQ-UI-SF and the change of the FIQL in women with faecal incontinence following OASIS.


title: Development of an ex vivo respiratory pediatric model of bronchopulmonary dysplasia for aerosol deposition studies.

text: Ethical restrictions are limitations of in vivo inhalation studies, on humans and animal models. Thus, in vitro or ex vivo anatomical models offer an interesting alternative if limitations are clearly identified and if extrapolation to human is made with caution. This work aimed to develop an ex vivo infant-like respiratory model of bronchopulmonary dysplasia easy to use, reliable and relevant compared to in vivo infant data. This model is composed of a 3D-printed head connected to a sealed enclosure containing a leporine thorax. Physiological data and pleural-mimicking depressions were measured for chosen respiratory rates. Homogeneity of ventilation was assessed by 81mkrypton scintigraphies. Regional radioaerosol deposition was quantified with 99mtechnetium-diethylene triamine pentaacetic acid after jet nebulization. Tidal volumes values are ranged from 33.16 ± 7.37 to 37.44 ± 7.43 mL and compliance values from 1.78 ± 0.65 to 1.85 ± 0.99 mL/cmH2O. Ventilation scintigraphies showed a homogenous ventilation with asymmetric repartition: 56.94% ± 9.4% in right lung and 42.83% ± 9.36 in left lung. Regional aerosol deposition in lungs exerted 2.60% ± 2.24% of initial load of radioactivity. To conclude the anatomical model satisfactorily mimic a 3-months old BPD-suffering bronchopulmonary dysplasia and can be an interesting tool for aerosol regional deposition studies.


title: Single-incision laparoscopic hepatectomy for benign and malignant hepatopathy: initial experience in 8 Chinese patients.

text: BACKGROUND The single-incision laparoscopic surgery (SILS) technique has been used in many surgical procedures, but there are few reports regarding liver surgeries. The purpose of this study was to perform single-incision laparoscopic hepatectomy (SILH) using standard laparoscopic instrumentation in 8 Chinese patients. The advantages and prospective future applications of SILH are also described. METHODS Selected patients were hospitalized between December 2009 and November 2011. The procedure was accomplished through a 2.5-cm transabdominal wall incision using a laparoscope and 2 other instruments without the assistance of any articulating instruments or single multiport trocar. RESULTS All procedures were successfully performed without the need for supplemental trocars. Postoperative pathological examinations were supportive of the preoperative diagnoses. No complications such as perioperative hemorrhage or infections occurred. CONCLUSION SILH appears to be a safe approach and the results are cosmetically favorable. The accumulation of SILH experience and the development of instrumentation are needed for extensive use of this technique in hepatectomies.


title: Outcome after stroke thrombolysis in patients >80 years treated within 3 hours vs >3-4.5 hours.

text: OBJECTIVE To determine outcomes and risks of IV thrombolysis (IVT) in patients with acute ischemic stroke (AIS) >80 years of age within 3 hours compared to >3 to 4.5 hours recorded in the Safe Implementation of Treatment in Stroke (SITS) International Stroke Thrombolysis Registry. METHODS A total of 14,240 (year 2003-2015) patients >80 years of age with AIS were treated with IVT ≤4.5 hours of stroke onset (3,558 in >3-4.5 hours). Of these, 8,658 (2,157 in >3-4.5 hours) were treated otherwise according to the European Summary of Product Characteristics (EU SmPC) criteria for alteplase. Outcomes were 3-month functional independence (modified Rankin Scale score 0-2), mortality, and symptomatic intracerebral hemorrhage (SICH)/SITS. Results were compared between the groups treated in >3 to 4.5 and ≤3 hours. RESULTS Median age was 84 years; 61% were female in both groups. Median NIH Stroke Scale score was 12 vs 14 in the >3- to 4.5- and ≤3-hour group, respectively. Three-month functional independence was 34% vs 35% (adjusted odds ratio [aOR] 0.78, 95% confidence interval [CI] 0.69-0.89, p < 0.001); mortality was 31% vs 32% (aOR 1.10, 95% CI 0.97-1.25, p = 0.13); and SICH/SITS was 2.7% vs 1.6% (aOR 1.72, 95% CI 1.25-2.35, p = 0.001). In EU SmPC-compliant patients, 3-month functional independence was 36 vs 37% (aOR 0.79, 95% CI 0.68-0.92, p = 0.002), mortality was 29% vs 29.6% (aOR 1.10, 95% CI 0.95-1.28, p = 0.20), and SICH/SITS was 2.7% vs 1.6% (aOR 1.62, 95% CI 1.12-2.34, p = 0.01). CONCLUSIONS In this observational study, unselected patients >80 years of age treated with IVT after 3 hours vs earlier had a slightly higher rate of SICH and similar unadjusted functional outcome but poorer adjusted outcome. The absolute difference between the treatment groups is small, and elderly patients should not be denied IVT in the later time window solely because of age without other contraindications.


title: Intensity matters: effects of cadence and power output on corticospinal excitability during arm cycling are phase and muscle dependent.

text: The present study investigated the effects of cadence and power output on corticospinal excitability to the biceps (BB) and triceps brachii (TB) during arm cycling. Supraspinal and spinal excitability were assessed using transcranial magnetic stimulation (TMS) of the motor cortex and transmastoid electrical stimulation (TMES) of the corticospinal tract, respectively. Motor-evoked potentials (MEPs) elicited by TMS and cervicomedullary motor-evoked potentials (CMEPs) elicited by TMES were recorded at two positions during arm cycling corresponding to mid-elbow flexion and mid-elbow extension (i.e., 6 and 12 o'clock made relative to a clock face, respectively). Arm cycling was performed at combinations of two cadences (60 and 90 rpm) at three relative power outputs (20, 40, and 60% peak power output). At the 6 o'clock position, BB MEPs increased ~11.5% as cadence increased and up to ~57.2% as power output increased ( P < 0.05). In the TB, MEPs increased ~15.2% with cadence ( P = 0.013) but were not affected by power output, while CMEPs increased with cadence (~16.3%) and power output (up to ~19.1%, P < 0.05). At the 12 o'clock position, BB MEPs increased ~26.8% as cadence increased and up to ~96.1% as power output increased ( P < 0.05), while CMEPs decreased ~29.7% with cadence ( P = 0.013) and did not change with power output ( P = 0.851). In contrast, TB MEPs were not different with cadence or power output, while CMEPs increased ~12.8% with cadence and up to ~23.1% with power output ( P < 0.05). These data suggest that the "type" of intensity differentially modulates supraspinal and spinal excitability in a manner that is phase- and muscle dependent. NEW & NOTEWORTHY There is currently little information available on how changes in locomotor intensity influence excitability within the corticospinal pathway. This study investigated the effects of arm cycling intensity (i.e., alterations in cadence and power output) on corticospinal excitability projecting to the biceps and triceps brachii during arm cycling. We demonstrate that corticospinal excitability is modulated differentially by cadence and power output and that these modulations are dependent on the phase and the muscle examined.


Inclusion of Children in Clinical Trials of Treatments for Coronavirus Disease 2019 (COVID-19).


title: Predicting response to pregabalin from pretreatment pain quality: clinical applications of the pain quality assessment scale.

text: OBJECTIVE The aim of this study is to assess the Pain Quality Assessment Scale (PQAS) in predicting pregabalin in peripheral neuropathic pain (NP). STUDY DESIGN Post hoc analysis of a double-blind, placebo-controlled, enriched enrollment, randomized withdrawal trial evaluating pregabalin in 99 patients with NP who completed the PQAS, which comprises 20 questions regarding individual pain domains and qualities that are scored into three scales: paroxysmal, deep, and surface. METHODS Patients rated the average pain intensity and pain quality using the PQAS at baseline; average pain intensity was assessed again after 40 days of treatment with pregabalin. Associations between pretreatment PQAS scores and treatment response were estimated using Pearson's r. Logistic regression was used to identify pretitration PQAS scores contributing unique variance to predicting treatment response. RESULTS Fifty participants provided baseline PQAS scores and received pregabalin for the entire length of the study. Nine of 23 PQAS baseline scales and items were significantly associated with treatment response to pregabalin: the paroxysmal and deep scales, and the items assessing the following pain domains and qualities: intensity, electric, tingling, cramping, radiating, throbbing, and deep (P values range, 0.002-0.045; rs range, 0.28-0.43). The PQAS items assessing sharp, hot, and unpleasant pain items demonstrated nonsignificant trends (P < 0.10) to be associated with treatment response. In the logistic regression analysis, pretitration PQAS scores had 77% sensitivity and 83% specificity to correctly identify pregabalin responders. Significantly correlated PQAS items had a sensitivity of 85% and specificity of 76%. CONCLUSION Pretitration PQAS scores reliably predicted pregabalin responders in patients with NP.


title: Comprehensive simulation-enhanced training curriculum for an advanced minimally invasive procedure: a randomized controlled trial.

text: BACKGROUND There is no comprehensive simulation-enhanced training curriculum to address cognitive, psychomotor, and nontechnical skills for an advanced minimally invasive procedure. OBJECTIVES 1) To develop and provide evidence of validity for a comprehensive simulation-enhanced training (SET) curriculum for an advanced minimally invasive procedure; (2) to demonstrate transfer of acquired psychomotor skills from a simulation laboratory to live porcine model; and (3) to compare training outcomes of SET curriculum group and chief resident group. SETTING University. METHODS This prospective single-blinded, randomized, controlled trial allocated 20 intermediate-level surgery residents to receive either conventional training (control) or SET curriculum training (intervention). The SET curriculum consisted of cognitive, psychomotor, and nontechnical training modules. Psychomotor skills in a live anesthetized porcine model in the OR was the primary outcome. Knowledge of advanced minimally invasive and bariatric surgery and nontechnical skills in a simulated OR crisis scenario were the secondary outcomes. Residents in the SET curriculum group went on to perform a laparoscopic jejunojejunostomy in the OR. Cognitive, psychomotor, and nontechnical skills of SET curriculum group were also compared to a group of 12 chief surgery residents. RESULTS SET curriculum group demonstrated superior psychomotor skills in a live porcine model (56 [47-62] versus 44 [38-53], P<.05) and superior nontechnical skills (41 [38-45] versus 31 [24-40], P<.01) compared with conventional training group. SET curriculum group and conventional training group demonstrated equivalent knowledge (14 [12-15] versus 13 [11-15], P = 0.47). SET curriculum group demonstrated equivalent psychomotor skills in the live porcine model and in the OR in a human patient (56 [47-62] versus 63 [61-68]; P = .21). SET curriculum group demonstrated inferior knowledge (13 [11-15] versus 16 [14-16]; P<.05), equivalent psychomotor skill (63 [61-68] versus 68 [62-74]; P = .50), and superior nontechnical skills (41 [38-45] versus 34 [27-35], P<.01) compared with chief resident group. CONCLUSION Completion of the SET curriculum resulted in superior training outcomes, compared with conventional surgery training. Implementation of the SET curriculum can standardize training for an advanced minimally invasive procedure and can ensure that comprehensive proficiency milestones are met before exposure to patient care.


title: Retro-rectus repair of complex incisional hernia leads to low recurrence rate.

text: BACKGROUND To assess the outcome of retro-rectus repair of complex abdominal wall repair (CAWR) in a single institution in relation to the use of biologic and synthetic mesh. METHOD A retrospective review was undertaken of complex abdominal wall repairs performed by a single surgical team, assessing the outcome of the retro-rectus repair and factors affecting the outcome. RESULTS Between 2007 and 2013, 57 (33 male) patients underwent CAWR retro-rectus repair. The material used was assessed as either synthetic or biologic (cross-linked porcine dermal collagen). The Ventral Hernia Working Group grades were similar between groups of patients having a repair with synthetic and biologic mesh. Median follow-up in the synthetic group was 18 months (1-80.5) and 18.4 months (0.5-70.7) in the biologic group. There was no statistical difference in seroma, wound infection or haematoma rates. No fistulae occurred in either group. Overall recurrence was 3.4% and there was no statistical difference between groups. CONCLUSION The retro-rectus repair technique is associated with a low rate of recurrence and is now the technique of choice. The choice of material, biologic or synthetic, in Ventral Hernia Working Group grades 1-3 remains controversial.


title: Analysis of ORF5 and full-length genome sequences of porcine reproductive and respiratory syndrome virus isolates of genotypes 1 and 2 retrieved worldwide provides evidence that recombination is a common phenomenon and may produce mosaic isolates.

text: UNLABELLED Recombination is currently recognized as a factor for high genetic diversity, but the frequency of such recombination events and the genome segments involved are not well known. In the present study, we initially focused on the detection of recombinant porcine reproductive and respiratory syndrome virus (PRRSV) isolates by examining previously published data sets of ORF5 sequences (genotypes 1 and 2) obtained worldwide. We then examined full-length genome sequences in order to determine potential recombination breakpoints along the viral genome. For ORF5, 11 sets of genotype 1 sequences from different geographical areas, including 2 Asian, 1 American, and 7 European regions, and three sets of genotype 2, including sets from China, Mexico, and the United States, were analyzed separately. Potential recombination breakpoints were detected in 10/11 genotype 1 sets, including 9 cases in which the clustering of at least one isolate was different before and after the breakpoints. In genotype 2, potential breakpoints and different tree clustering of at least one strain before and after the breakpoint were observed in 2 out of 3 sets. The results indicated that most of the ORF5 data sets contained at least one recombinant sequence. When the full-length genome sequences were examined, both genotype 1 and 2 sets presented breakpoints (10 and 9, respectively), resulting in significantly different topologies before and after the breakpoints. Mosaic genomes were detected in genotype 1 sequences. These results may have significant implications for the understanding of the molecular epidemiology of PRRSV. IMPORTANCE PRRSV is one of the most important viruses affecting swine production worldwide, causing big economic losses and sanitary problems. One of the key questions on PRRSV arises from its genetic diversity, which is thought to have a direct impact on immunobiology, epidemiology, diagnosis, and vaccine efficacy. One of the causes of this genetic diversity is recombination among strains. This study provides evidence that recombinant PRRSV isolates are common in most of the countries with significant swine production, especially PRRSV genotype 1. This observation has implications in the proper characterization of PRRSV strains, in the future development of phylogenetic studies, and in the development of new PRRSV control strategies. Moreover, the present paper emphasizes the need for a deeper understanding of the mechanisms and circumstances involved in the generation of genetic diversity of PRRSV.


title: Association of Opioids and Sedatives with Increased Risk of In-Hospital Cardiopulmonary Arrest from an Administrative Database.

text: BACKGROUND While opioid use confers a known risk for respiratory depression, the incremental risk of in-hospital cardiopulmonary arrest, respiratory arrest, or cardiopulmonary resuscitation (CPRA) has not been studied. Our aim was to investigate the prevalence, outcomes, and risk profile of in-hospital CPRA for patients receiving opioids and medications with central nervous system sedating side effects (sedatives). METHODS A retrospective analysis of adult inpatient discharges from 2008-2012 reported in the Premier Database. Patients were grouped into four mutually exclusive categories: (1) opioids and sedatives, (2) opioids only, (3) sedatives only, and (4) neither opioids nor sedatives. RESULTS Among 21,276,691 inpatient discharges, 53% received opioids with or without sedatives. A total of 96,554 patients suffered CPRA (0.92 per 1000 hospital bed-days). Patients who received opioids and sedatives had an adjusted odds ratio for CPRA of 3.47 (95% CI: 3.40-3.54; p<0.0001) compared with patients not receiving opioids or sedatives. Opioids alone and sedatives alone were associated with a 1.81-fold and a 1.82-fold (p<0.0001 for both) increase in the odds of CPRA, respectively. In opioid patients, locations of CPRA were intensive care (54%), general care floor (25%), and stepdown units (15%). Only 42% of patients survived CPRA and only 22% were discharged home. Opioid patients with CPRA had mean increased hospital lengths of stay of 7.57 days and mean increased total hospital costs of $27,569. CONCLUSIONS Opioids and sedatives are independent and additive risk factors for in-hospital CPRA. The impact of opioid sparing analgesia, reduced sedative use, and better monitoring on CPRA incidence deserves further study.


title: Benefits of laparoscopic fellowship training: a survey of former fellows.

text: OBJECTIVE The objective of this study was to assess the impact of minimally invasive surgery (MIS) fellowship training on the fellows' clinical practice as well as former fellows' perception of their fellowship experience. METHODS A survey composed of 50 multiple-choice questions was e-mailed to 268 former MIS fellows who began a fellowship in the United States between 2000 and 2005. E-mail addresses were obtained from Covidien, an industry sponsor of MIS fellowships. RESULTS The response rate was 30%. The most frequent reason for choosing an MIS fellowship was to enhance laparoscopic skills (34%). A total of 85% believed that an MIS fellowship provided an edge on referral of advanced laparoscopic procedures. In all, 75% indicated that their fellowship was extremely beneficial, and 86% would recommend their former fellowship to future applicants. CONCLUSION The majority of respondents felt that their MIS fellowship experience was beneficial and had a positive impact on their laparoscopic knowledge base, skills, referrals, and career.


title: Two-year outcomes on bone density and fracture incidence in patients with T2DM randomized to bariatric surgery versus intensive medical therapy.

text: OBJECTIVE To determine the 2-year outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) vs. intensive medical therapy (IMT) on lean body mass, total bone mass, and bone mineral density (BMD) measures from the STAMPEDE trial. METHODS 54 subjects (BMI: 36 ± 1 kg/m(2) , age: 48 ± 4 years) with type 2 diabetes (T2DM) (HbA1c : 9.7 ± 2%) were randomized to IMT, RYGB, or SG and underwent DXA at baseline and at 1 and 2 years. RESULTS At 2 years, the reduction in BMI was similar after RYGB and SG and was greater than IMT (P < 0.001). Lean mass was reduced by ∼10%, total bone mineral content reduced by ∼8%, and hip BMD reduced by ∼9% in both surgical groups and was significantly greater than IMT despite increases in vitamin D intake in all groups. The change in hip BMD correlated with weight loss (r = 0.84, P < 0.0001) and changes in lean mass (r = 0.74, P < 0.0001) and leptin (r = 0.53, P < 0.0001). Peripheral fractures were self-reported in RYGB (4/18 patients), SG (2/19 patients), and IMT (4/16 patients). CONCLUSIONS Surgically induced weight loss is associated with modest reductions in lean mass, bone mineral content, and BMD, despite calcium and vitamin D supplementation in patients with T2DM. Awareness for bone loss is indicated for patients undergoing bariatric procedures.


title: Mechanical evaluation of articulating instruments and cross-handed manipulation in laparoendoscopic single-site surgery.

text: BACKGROUND Laparoendoscopic single-site surgery (LESS) is limited by loss of triangulation and internal instruments conflict. To overcome these difficulties, some concepts have been introduced, namely, articulating instruments and cross-handed manipulation, which causes the right hand to control the left instrument tip and vice versa. The aim of this study was to compare task performance with different approaches based on a mechanical evaluation platform. METHODS A LESS mechanical evaluation platform was set up to investigate the performance of 2 tasks (suture pass-through rings and clip-cut) with 3 different settings: uncrossed manipulation with straight instruments (group A, the control group), uncrossed manipulation with articulating instruments (group B), and cross-handed manipulation with articulating instruments (group C). The operation time and average load required for accomplishment of the standard tasks were measured. RESULTS Group A presented significantly better time scores than group B, and group C consumed the longest time to accomplish the 2 tasks (P < .05). Comparing of average load required to perform the suture pass-through rings task, it differed significantly between dominant and nondominant hand in all groups (P < .01) and was less in group A and group B than group C in dominant hand (P < .01), while it was almost the same in all groups in the nondominant hand. In terms of average load requirement to accomplish clip-cut task, it was almost equal not only between group A and B but also between dominant and nondominant hand while the increase reached statistical significance when comparing group C with other groups (P < .05). CONCLUSIONS Compared with conventional devices and maneuvering techniques, articulating instruments and cross-handed manipulation are associated with longer operation time and higher workload. Instruments with better maneuverability should be developed in the future for LESS.


Decreasing False Alarms by Obtaining the Best Signal and Minimizing Artifact from Physiological Sensors.


title: Extensive cerebral microbleeds predict parenchymal haemorrhage and poor outcome after intravenous thrombolysis.

text: PURPOSE Thrombolysis-related haemorrhagic transformation (HT) subtypes may have different prognostic implications. We aimed to analyse the impact of cerebral microbleeds (CMBs) burden on HT subtypes and outcome after intravenous thrombolysis. METHODS We retrospectively examined clinical and radiological data from 333 consecutive patients with acute ischaemic stroke who underwent susceptibility-weighted imaging before intravenous thrombolysis. Logistic regression analysis was used to determine the impact of CMBs on HT subtypes and neurological outcome. RESULTS We observed 596 CMBs in 119 (39.7%) patients on initial gradient-recalled echo scans. HT occurred in 88 (29.3%) patients, among which 62 were haemorrhagic infarction and 26 were parenchymal haemorrhage (PH). Logistic regression analysis indicated that the presence of extensive (≥ 3) CMBs was independently associated with PH (OR 6.704; 95% CI 2.054 to 21.883; p = 0.002) and poor clinical outcome (OR 2.281; 95% CI 1.022 to 5.093; p = 0.044). CONCLUSIONS The presence of extensive (≥ 3) CMBs increased the risk of PH 24 h after intravenous thrombolysis, and predicted poor clinical outcome independently.


title: Isolation, characterization, and functional analysis of ferret lymphatic endothelial cells.

text: The lymphatic endothelium (LE) serves as a conduit for transport of immune cells and soluble antigens from peripheral tissues to draining lymph nodes (LNs), contributing to development of host immune responses and possibly dissemination of microbes. Lymphatic endothelial cells (LECs) are major constituents of the lymphatic endothelium. These specialized cells could play important roles in initiation of host innate immune responses through sensing of pathogen-associated molecular patterns (PAMPs) by pattern recognition receptors (PRRs), including toll-like receptors (TLRs). LECs secrete pro-inflammatory cytokines and chemokines to create local inflammatory conditions for recruitment of naïve antigen presenting cells (APCs) such as dendritic cells (DCs) to sites of infection and/or vaccine administration. In this study, we examined the innate immune potential of primary LEC populations derived from multiple tissues of an animal model for human infectious diseases - the ferret. We generated a total of six primary LEC populations from lung, tracheal, and mesenteric LN tissues from three different ferrets. Standard RT-PCR characterization of these primary LECs showed that they varied in their expression of LEC markers. The ferret LECs were examined for their ability to respond to poly I:C (TLR3 and RIG-I ligand) and other known TLR ligands as measured by production of proinflammatory cytokine (IFNα, IL6, IL10, Mx1, and TNFα) and chemokine (CCL5, CCL20, and CXCL10) mRNAs using real time RT-PCR. Poly I:C exposure induced robust proinflammatory responses by all of the primary ferret LECs. Chemotaxis was performed to determine the functional activity of CCL20 produced by the primary lung LECs and showed that the LEC-derived CCL20 was abundant and functional. Taken together, our results continue to reveal the innate immune potential of primary LECs during pathogen-host interactions and expand our understanding of the roles LECs might play in health and disease in animal models.


title: Distinct severe acute respiratory syndrome coronavirus-induced acute lung injury pathways in two different nonhuman primate species.

text: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), caused by influenza A virus H5N1 and severe acute respiratory syndrome coronavirus (SARS-CoV), supposedly depend on activation of the oxidative-stress machinery that is coupled with innate immunity, resulting in a strong proinflammatory host response. Inflammatory cytokines, such as interleukin 1β (IL-1β), IL-8, and IL-6, play a major role in mediating and amplifying ALI/ARDS by stimulating chemotaxis and activation of neutrophils. To obtain further insight into the pathogenesis of SARS-CoV-associated ALI, we compared SARS-CoV infections in two different nonhuman primate species, cynomolgus macaques and African green monkeys. Viral titers in the upper and lower respiratory tract were not significantly different in SARS-CoV-infected macaques and African green monkeys. Inflammatory cytokines that play a major role in mediating and amplifying ALI/ARDS or have neutrophil chemoattractant activity, such as IL-6, IL-8, CXCL1, and CXCL2, were, however, induced only in macaques. In contrast, other proinflammatory cytokines and chemokines, including osteopontin and CCL3, were upregulated in the lungs of African green monkeys to a significantly greater extent than in macaques. Because African green monkeys developed more severe ALI than macaques, with hyaline membrane formation, some of these differentially expressed proinflammatory genes may be critically involved in development of the observed pathological changes. Induction of distinct proinflammatory genes after SARS-CoV infection in different nonhuman primate species needs to be taken into account when analyzing outcomes of intervention strategies in these species.


title: Kallikrein-related peptidases in lung diseases.

text: Human tissue kallikreins (KLKs) are 15 members of the serine protease family and are present in various healthy human tissues including airway tissues. Multiple studies have revealed their crucial role in the pathophysiology of a number of chronic, infectious and tumour lung diseases. KLK1, 3 and 14 are involved in asthma pathogenesis, and KLK1 could be also associated with the exacerbation of this inflammatory disease caused by rhinovirus. KLK5 was demonstrated as an influenza virus activating protease in humans, and KLK1 and 12 could also be involved in the activation and spread of these viruses. KLKs are associated with lung cancer, with up- or downregulation of expression depending on the KLK, cancer subtype, stage of tumour and also the microenvironment. Functional studies showed that KLK12 is a potent pro-angiogenic factor. Moreover, KLK6 promotes malignant-cell proliferation and KLK13 invasiveness. In contrast, KLK8 and KLK10 reduce proliferation and invasion of malignant cells. Considering the involvement of KLKs in various physiological and pathological processes, KLKs appear to be potential biomarkers and therapeutic targets for lung diseases.


title: Design strategies and applications of tissue bioadhesives.

text: In the past two decades tissue adhesives and sealants have revolutionized bleeding control and wound healing. This paper focuses on existing tissue adhesive design, their structure, functioning mechanism, and their pros and cons in wound management. It also includes the latest advances in the development of new tissue adhesives as well as the emerging applications in regenerative medicine. We expect that this paper will provide insightful discussion on tissue bioadhesive design and lead to innovations for the development of the next generation of tissue bioadhesives and their related biomedical applications.


After COVID-19, green investment must deliver jobs to get political traction.