title: MIRD pamphlet No. 20: the effect of model assumptions on kidney dosimetry and response--implications for radionuclide therapy.

text: UNLABELLED Renal toxicity associated with small-molecule radionuclide therapy has been shown to be dose-limiting for many clinical studies. Strategies for maximizing dose to the target tissues while sparing normal critical organs based on absorbed dose and biologic response parameters are commonly used in external-beam therapy. However, radiopharmaceuticals passing though the kidneys result in a differential dose rate to suborgan elements, presenting a significant challenge in assessing an accurate dose-response relationship that is predictive of toxicity in future patients. We have modeled the multiregional internal dosimetry of the kidneys combined with the biologic response parameters based on experience with brachytherapy and external-beam radiation therapy to provide an approach for predicting radiation toxicity to the kidneys. METHODS The multiregion kidney dosimetry model of MIRD pamphlet no. 19 has been used to calculate absorbed dose to regional structures based on preclinical and clinical data. Using the linear quadratic model for radiobiologic response, we computed regionally based surviving fractions for the kidney cortex and medulla in terms of their concentration ratios for several examples of radiopharmaceutical uptake and clearance. We used past experience to illustrate the relationship between absorbed dose and calculated biologically effective dose (BED) with radionuclide-induced nephrotoxicity. RESULTS Parametric analysis for the examples showed that high dose rates associated with regions of high activity concentration resulted in the greatest decrease in tissue survival. Higher dose rates from short-lived radionuclides or increased localization of radiopharmaceuticals in radiosensitive kidney subregions can potentially lead to greater whole-organ toxicity. This finding is consistent with reports of kidney toxicity associated with early peptide receptor radionuclide therapy and (166)Ho-phosphonate clinical investigations. CONCLUSION Radionuclide therapy dose-response data, when expressed in terms of biologically effective dose, have been found to be consistent with external-beam experience for predicting kidney toxicity. Model predictions using both the multiregion kidney and linear quadratic models may serve to guide the investigator in planning and optimizing future clinical trials of radionuclide therapy.


title: Quantifying the bias due to observed individual confounders in causal treatment effect estimates.

text: It is often of interest to use observational data to estimate the causal effect of a target exposure or treatment on an outcome. When estimating the treatment effect, it is essential to appropriately adjust for selection bias due to observed confounders using, for example, propensity score weighting. Selection bias due to confounders occurs when individuals who are treated are substantially different from those who are untreated with respect to covariates that are also associated with the outcome. A comparison of the unadjusted, naive treatment effect estimate with the propensity score adjusted treatment effect estimate provides an estimate of the selection bias due to these observed confounders. In this article, we propose methods to identify the observed covariate that explains the largest proportion of the estimated selection bias. Identification of the most influential observed covariate or covariates is important in resource-sensitive settings where the number of covariates obtained from individuals needs to be minimized due to cost and/or patient burden and in settings where this covariate can provide actionable information to healthcare agencies, providers, and stakeholders. We propose straightforward parametric and nonparametric procedures to examine the role of observed covariates and quantify the proportion of the observed selection bias explained by each covariate. We demonstrate good finite sample performance of our proposed estimates using a simulation study and use our procedures to identify the most influential covariates that explain the observed selection bias in estimating the causal effect of alcohol use on progression of Huntington's disease, a rare neurological disease.


title: The use of acellular dermal matrices in chest wall reconstruction.

text: Surgeons are faced with increasingly complex and larger chest wall defects as a result of a variety of pathologies, the majority of which are oncologic. Skeletal reconstruction of these resulting defects and subsequent soft-tissue coverage remain a challenge for thoracic and plastic and reconstructive surgeons. A variety of techniques and grafts have been utilized to support the thoracic cage. This review focuses on the use of acellular dermal matrices in thoracic skeletal reconstruction, with a focus on the indications, published data, and surgical techniques for utilizing acellular dermal matrices in chest wall reconstruction.


The 4th Biennial Congress of ECTA, Eurasian Colorectal Technologies Association, Moscow, 24-26 May 2015.


title: Multimedia article. Natural orifice transluminal endoscopic surgery applied to sigmoidectomy in survival animal models: using paired magnetic intra-luminal device.

text: BACKGROUND The clinical application of natural orifice transluminal endoscopic surgery (NOTES) for sigmoidectomy is associated with several difficulties that need to be overcome before wider clinical application of the procedure. The purpose of this study was to evaluate the technical feasibility and safety of transgastric sigmoidectomy in a survival animal model, as well as to evaluate the safety and usability of a custom paired magnetic intraluminal device, which we developed for the NOTES procedure. METHODS Survival experiments were conducted on 24-33-kg dogs. After anesthesia, a gastrotomy was created using double-channel endoscope, and peritoneoscopy was performed. The sigmoid colon was retracted laterally using paired magnetic intraluminal device, the mesocolon was dissected, and the branch vessel was sealed. The anvil was placed into the descending colon through anus. A proximal and distal colonic transection was then performed. The circular stapler was passed through the anus and performed end-to-end anastomosis. Afterwards the specimen was removed through gastrotomy, and the gastric incision was closed. Postoperatively, all dogs were recovered and monitored for well-being during convalescence. Reexploration was practiced under anesthesia 2 weeks after surgery for evaluation of intra-abdominal complications, and intra-peritoneal cultures for microorganism. RESULTS The mean operative time was 141 (range, 122-157) min. There were no complications or physical evidence of sepsis or bowel obstruction during the observation period. Only one dog exhibited decreased body weight, decreasing to 20.4 kg from 22.4 kg after surgery; all of the other dogs exhibited increased body weight. We observed no evidence of peritonitis, intra-abdominal abscess, bleeding, or organ injury on reexploration conducted on day 14 after surgery. CONCLUSIONS Transgastric NOTES sigmoidectomy is a safe operation technique as evaluated in a dog model. The paired magnetic intraluminal device that was used in this study was useful to avoid an abdominal incision for retracting the sigmoid colon.


The national public health institutes of the world--update.


title: Development and Validation of a Prognostic Nomogram Based on Clinical and CT Features for Adverse Outcome Prediction in Patients with COVID-19.

text: OBJECTIVE The purpose of our study was to investigate the predictive abilities of clinical and computed tomography (CT) features for outcome prediction in patients with coronavirus disease (COVID-19). MATERIALS AND METHODS The clinical and CT data of 238 patients with laboratory-confirmed COVID-19 in our two hospitals were retrospectively analyzed. One hundred sixty-six patients (103 males; age 43.8 ± 12.3 years) were allocated in the training cohort and 72 patients (38 males; age 45.1 ± 15.8 years) from another independent hospital were assigned in the validation cohort. The primary composite endpoint was admission to an intensive care unit, use of mechanical ventilation, or death. Univariate and multivariate Cox proportional hazard analyses were performed to identify independent predictors. A nomogram was constructed based on the combination of clinical and CT features, and its prognostic performance was externally tested in the validation group. The predictive value of the combined model was compared with models built on the clinical and radiological attributes alone. RESULTS Overall, 35 infected patients (21.1%) in the training cohort and 10 patients (13.9%) in the validation cohort experienced adverse outcomes. Underlying comorbidity (hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.67-6.71; p < 0.001), lymphocyte count (HR, 0.12; 95% CI, 0.04-0.38; p < 0.001) and crazy-paving sign (HR, 2.15; 95% CI, 1.03-4.48; p = 0.042) were the independent factors. The nomogram displayed a concordance index (C-index) of 0.82 (95% CI, 0.76-0.88), and its prognostic value was confirmed in the validation cohort with a C-index of 0.89 (95% CI, 0.82-0.96). The combined model provided the best performance over the clinical or radiological model (p < 0.050). CONCLUSION Underlying comorbidity, lymphocyte count and crazy-paving sign were independent predictors of adverse outcomes. The prognostic nomogram based on the combination of clinical and CT features could be a useful tool for predicting adverse outcomes of patients with COVID-19.


title: Public Health and Cost Benefits of Successful Reperfusion After Thrombectomy for Stroke.

text: Background and Purpose- The benefit that endovascular thrombectomy offers to patients with stroke with large vessel occlusions depends strongly on reperfusion grade as defined by the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Our aim was to determine the lifetime health and cost consequences of the quality of reperfusion for patients, healthcare systems, and society. Methods- A Markov model estimated lifetime quality-adjusted life years (QALY) and lifetime costs of endovascular thrombectomy-treated patients with stroke based on eTICI grades. The analysis was performed over a lifetime horizon in a United States setting, adopting healthcare and societal perspectives. The reference case analysis was conducted for stroke at 65 years of age. National health and cost consequences of improved eTICI 2c/3 reperfusion rates were estimated. Input parameters were based on best available evidence. Results- Lifetime QALYs increased for every grade of improved reperfusion (median QALYs for eTICI 0/1: 2.62; eTICI 2a: 3.46; eTICI 2b: 5.42; eTICI 2c: 5.99; eTICI 3: 6.73). Achieving eTICI 3 over eTICI 2b reperfusion resulted on average in 1.31 incremental QALYs as well as healthcare and societal cost savings of $10 327 and $20 224 per patient. A 10% increase in the eTICI 2c/3 reperfusion rate of all annually endovascular thrombectomy-treated patients with stroke in the United States is estimated to yield additional 3656 QALYs and save $21.0 million and $36.8 million for the healthcare system and society, respectively. Conclusions- Improved reperfusion grants patients with stroke additional QALYs and leads to long-term cost savings. Procedural strategies to achieve complete reperfusion should be assessed for safety and feasibility, even when initial reperfusion seems to be adequate.


title: Single-incision laparoscopic stoma creation: experience with 31 consecutive cases.

text: INTRODUCTION Fecal diversion may be performed using various techniques. Each technique has advantages that affect patient selection. In this report, we report our experience with 31 patients who underwent single-incision laparoscopic stoma creation using only a pre-selected stoma site as the point of port access. METHODS A 2.5-cm skin incision was made at a previously marked stoma site, and two 5-mm trocars were placed into the abdomen through the stoma site. An optional third trocar was inserted at the stoma site only if the bowel needed to be mobilized or if adhesions needed to be divided. After full intra-abdominal exploration, a selected intestinal loop was brought up to the stoma site, and the ostomy was then matured using standard techniques. RESULTS Between April 2009 and March 2012, 31 patients (19 men) with a mean age of 68 years (range, 46-87 years) underwent single-incision laparoscopic stoma creation. Fecal diversion included ileostomy (n = 18) and colostomy (n = 13). There were no intraoperative complications. Two patients (6.5%) required additional port placement in the midline suprapubic area. Conversion to open laparotomy was required in two patients (6.5%) because of the presence of extensive adhesions. Postoperative complications were observed in two patients and included peristomal ileus and dehydration due to high ileostomy output. CONCLUSIONS Single-incision laparoscopic stoma creation is an effective technique that allows full intra-abdominal visualization and bowel mobilization, while reducing the need for additional skin incisions beyond that of the stoma site.


Association of COVID-19 With Intimate Partner Violence.


title: Role of evolved host breadth in the initial emergence of an RNA virus.

text: Understanding how evolution promotes pathogen emergence would aid disease management, and prediction of future host shifts. Increased pathogen infectiousness of different hosts may occur through direct selection, or fortuitously via indirect selection. However, it is unclear which type of selection tends to produce host breadth promoting pathogen emergence. We predicted that direct selection for host breadth should foster emergence by causing higher population growth on new hosts, lower among-population variance in growth on new hosts, and lower population variance in growth across new hosts. We tested the predictions using experimentally evolved vesicular stomatitis virus populations, containing groups of host-use specialists, directly selected generalists, and indirectly selected generalists. In novel-host challenges, viruses directly selected for generalism showed relatively higher or equivalent host growth, lower among-population variance in host growth, and lower population variance in growth across hosts. Thus, two of three outcomes supported our prediction that directly selected host breadth should favor host colonization. Also, we observed that indirectly selected generalists were advantaged over specialist viruses, indicating that fortuitous changes in host breadth may also promote emergence. We discuss evolution of phenotypic plasticity versus environmental robustness in viruses, virus avoidance of extinction, and surveillance of pathogen niche breadth to predict future likelihood of emergence.


Correction: Vol. 18, No. 2.


title: Laparoscopic Radiofrequency Ablation for Large Subcapsular Hepatic Hemangiomas: Technical and Clinical Outcomes.

text: OBJECTIVES The aim of this study was to evaluate the technical and clinical outcomes of using laparoscopic radiofrequency (RF) ablation for treating large subcapsular hepatic hemangiomas. METHODS We retrospectively reviewed our sequential experience of treating 124 large subcapsular hepatic hemangiomas in 121 patients with laparoscopic RF ablation. RESULTS The mean diameter of the 124 hemangiomas was 9.1 ± 3.2 cm (5.0-16.0 cm). RF ablation was performed successfully in all patients. There were 55 complications related to the ablation in 26 patients, including 5 of 69 (7.3%) patients with hemangioma <10 cm and 21 of 52 (40.4%) patients with hemangiomas ≥10 cm (P < 0.001). No injuries to abdominal viscera occurred in all the 121 patients. According to the Dindo-Clavien classification, all the complications were minor in 26 patients (Grade I). Out of 124 hepatic hemangiomas, 118 (95.2%) were completely ablated, including 70 of 72 (97.2%) lesions < 10 cm and 48 of 52 (92.3%) lesions ≥ 10 cm (P = 0.236). CONCLUSION Laparoscopic RF ablation therapy is a safe, feasible and effective procedure for large subcapsular hepatic hemangiomas, even in the hepatic hemangiomas ≥ 10 cm. Its use avoids thermal injury to the abdominal viscera.


title: Laparoscopic resection of periadrenal paraganglioma mimicking an isolated adrenal hydatid cyst.

text: We present the case of a 64-year-old female with a periadrenal paraganglioma. The mass was diagnosed during abdominal ultrasonography performed to investigate right flank pain. Magnetic resonance imaging showed a lesion 48mm in diameter with an irregular hyperintense central margin, thickened septa, centrally located cystic component, and contrast enhancing peripheral portions. These findings made us think it was an isolated adrenal hydatid cyst. The mass was excised via laparoscopy without complications. Histopathological examination was consistent with periadrenal paraganglioma. We believe that the paraganglioma can mimic the radiological appearance of an isolated adrenal hydatid cyst, which should be taken into consideration during diagnosis.


title: Neuropsychiatric adverse events of chloroquine: a real-world pharmacovigilance study using the FDA Adverse Event Reporting System (FAERS) database.

text: In late March and early April 2020, the antimalarial drug, chloroquine, has been approved as an emergency treatment for the coronavirus disease 2019 (COVID-19) in the United States and in Europe. Although infrequent, neuropsychiatric symptoms have been reported in patients who received chloroquine for the treatment of malaria or autoimmune diseases. In this study, aiming to investigate these adverse events (AEs) using a large self-reporting database, we conducted a disproportionality analysis for the detection of neuropsychiatric AE signals associated with the use of chloroquine (or hydroxychloroquine), reported to FDA Adverse Event Reporting System (FAERS) database between the fourth quarter of 2012 and the fourth quarter of 2019. We included 2,389,474 AE cases, among which 520 cases developed neuropsychiatric AE following the use of chloroquine. Adjusted reporting odds ratio (ROR) for the development of each of the neuropsychiatric AEs following the use of chloroquine was calculated using a multilevel model: exposure to chloroquine was associated with a statistically significant high reporting of amnesia, delirium, hallucinations, depression, and loss of consciousness, (lower 95% confidence interval of the adjusted ROR > 1), although the degree of increase in their ROR was limited. There was no statistically significant high reporting of any other neuropsychiatric AE, including suicide, psychosis, confusion, and agitation. Current pharmacovigilance study results did not suggest any potential link between the use of chloroquine and an increased risk of suicide, psychosis, confusion, and agitation, which would be informative during the emergency use of chloroquine for the treatment of COVID-19.


title: Importance of conserved cysteine residues in the coronavirus envelope protein.

text: Coronavirus envelope (E) proteins play an important, not fully understood role(s) in the virus life cycle. All E proteins have conserved cysteine residues located on the carboxy side of the long hydrophobic domain, suggesting functional significance. In this study, we confirmed that mouse hepatitis coronavirus A59 E protein is palmitoylated. To understand the role of the conserved residues and the necessity of palmitoylation, three cysteines at positions 40, 44, and 47 were changed singly and in various combinations to alanine. Double- and triple-mutant E proteins resulted in decreased virus-like particle output when coexpressed with the membrane (M) protein. Mutant E proteins were also studied in the context of a full-length infectious clone. Single-substitution viruses exhibited growth characteristics virtually identical to those of the wild-type virus, while the double-substitution mutations gave rise to viruses with less robust growth phenotypes indicated by smaller plaques and decreased virus yields. In contrast, replacement of all three cysteines resulted in crippled virus with significantly reduced yields. Triple-mutant viruses did not exhibit impairment in entry. Mutant E proteins localized properly in infected cells. A comparison of intracellular and extracellular virus yields suggested that release is only slightly impaired. E protein lacking all three cysteines exhibited an increased rate of degradation compared to that of the wild-type protein, suggesting that palmitoylation is important for the stability of the protein. Altogether, the results indicate that the conserved cysteines and presumably palmitoylation are functionally important for virus production.


title: Genetic cluster analysis of SARS-CoV-2 and the identification of those responsible for the major outbreaks in various countries.

text: A newly emerged coronavirus, SARS-CoV-2, caused severe pneumonia outbreaks in China in December 2019 and has since spread to various countries around the world. To trace the evolution route and probe the transmission dynamics of this virus, we performed phylodynamic analysis of 247 high quality genomic sequences available in the GISAID platform as of 5 March 2020. Among them, four genetic clusters, defined as super-spreaders (SSs), could be identified and were found to be responsible for the major outbreaks that subsequently occurred in various countries. SS1 was widely disseminated in Asia and the US, and mainly responsible for outbreaks in the states of Washington and California as well as South Korea, whereas SS4 contributed to the pandemic in Europe. Using the signature mutations of each SS as markers, we further analysed 1539 genome sequences reported after 29 February 2020 and found that 90% of these genomes belonged to SSs, with SS4 being the most dominant. The relative degree of contribution of each SS to the pandemic in different continents was also depicted. Identification of these super-spreaders greatly facilitates development of new strategies to control the transmission of SARS-CoV-2.


Care home reforms should prioritise quality of life.


title: Initial management of primary spontaneous pneumothorax with video-assisted thoracoscopic surgery: a 10-year experience.

text: OBJECTIVES First-line conservative treatment of primary spontaneous pneumothorax (PSP) may be challenged by recurrence rates and complications associated with different treatment options. The aim of this study was to evaluate the use of a standardized surgical treatment as 'first-line' treatment. METHODS In a 10-year period, 185 patients with PSP were treated with a standardized video-assisted thoracic surgery (VATS) approach including wedge resection and parietal pleurectomy. Data were evaluated retrospectively. All patients with a first event of PSP were included in the study. In addition, follow-up was done by a questionnaire. RESULTS Mean follow-up period was 70.8 months (±33.5 months). Sub-pleural emphysematous changes were found in every histopathological specimen. In addition, 70.8% had fibrosis of visceral pleura. Recurrence occurred in 4 patients (2.2%). Ten-year freedom from recurrence was 96.2%. Procedure-related morbidity rate was 7.6%. Approximately 85.7% of patients were satisfied with the procedure and the cosmetic result. Three patients died during follow-up (1.6%). CONCLUSIONS Treatment of first episode of PSP by VATS is a safe procedure, with a very low rate of recurrence and a high patient satisfaction. This management of first episode of PSP is based on the underlying pathology. We recommend the use of VATS as the treatment of first choice for patients with PSP.


title: Information Support for Health Management in Regional Sri Lanka: Health Managers' Perspectives.

text: Good management, supported by accurate, timely and reliable health information, is vital for increasing the effectiveness of Health Information Systems (HIS). When it comes to managing the under-resourced health systems of developing countries, information-based decision making is particularly important. This paper reports findings of a self-report survey that investigated perceptions of local health managers (HMs) of their own regional HIS in Sri Lanka. Data were collected through a validated, pre-tested postal questionnaire, and distributed among a selected group of HMs to elicit their perceptions of the current HIS in relation to information generation, acquisition and use, required reforms to the information system and application of information and communication technology (ICT). Results based on descriptive statistics indicated that the regional HIS was poorly organised and in need of reform; that management support for the system was unsatisfactory in terms of relevance, accuracy, timeliness and accessibility; that political pressure and community and donor requests took precedence over vital health information when management decisions were made; and use of ICT was unsatisfactory. HIS strengths included user-friendly paper formats, a centralised planning system and an efficient disease notification system; weaknesses were lack of comprehensiveness, inaccuracy, and lack of a feedback system. Responses of participants indicated that HIS would be improved by adopting an internationally accepted framework and introducing ICT applications. Perceived barriers to such improvements were high initial cost of educating staff to improve computer literacy, introduction of ICTS, and HIS restructure. We concluded that the regional HIS of Central Province, Sri Lanka had failed to provide much-needed information support to HMS. These findings are consistent with similar research in other developing countries and reinforce the need for further research to verify causes of poor performance and to design strategic reforms to improve HIS in regional Sri Lanka.


title: Laminar and turbulent surgical plume characteristics generated from curved- and straight-blade laparoscopic ultrasonic dissectors.

text: OBJECTIVE To characterize laparoscopic ultrasonic dissector surgical plume emission (laminar or turbulent) and investigate plume settlement time between curved and straight blades. MATERIALS AND METHODS A straight and a curved blade laparoscopic ultrasonic dissector were activated on tissue and in a liquid environment to evaluate plume emission. Plume emission was characterized as either laminar or turbulent and the plume settlement times were compared. Devices were then placed in liquid to observed consistency in the fluid disruption. RESULTS Two types of plume emission were identified generating different directions of plume: laminar flow causes minimal visual obstruction by directing the aerosol downwards, while turbulent flow directs plume erratically across the cavity. Laminar plume dissipates immediately while turbulent plume reaches a second maximum obstruction approximately 0.3 s after activation and clears after 2 s. Turbulent plume was observed with the straight blade in 10 % of activations, and from the curved blade in 47 % of activations. The straight blade emitted less obstructive plume. CONCLUSION Turbulent flow is disruptive to laparoscopic visibility with greater field obstruction and requires longer settling than laminar plume. Ultrasonic dissectors with straight blades have more consistent oscillations and generate more laminar flow compared with curved blades. Surgeons may avoid laparoscope smearing from maximum plume generation depending on blade geometry.


title: Nebraska biocontainment unit design and operations.

text: Planning and design of a unique biocontainment unit specifically for care of patients with rare and highly infectious diseases presented an opportunity for nurse leaders to engage staff in crucial groundbreaking decisions. The Magnet® philosophy and framework were used to structure committees with key stakeholders and staff to ensure best and safe practices. Members of the biocontainment unit are engaged in active research and outreach training.


title: Impact of Subnormothermic Machine Perfusion Preservation in Severely Steatotic Rat Livers: A Detailed Assessment in an Isolated Setting.

text: The current drastic shortage of donor organs has led to acceptance of extended-criteria donors for transplantation, despite higher risk of primary nonfunction. Here, we report the impact of subnormothermic machine perfusion (SMP) preservation on the protection of >50% macrosteatotic livers. Dietary hepatic steatosis was induced in Wistar rats via 2-day fasting and subsequent 3-day re-feeding with a fat-free, carbohydrate-rich diet. This protocol induces 50-60% macrovesicular steatosis, which should be discarded when preserved via cold storage (CS). The fatty livers were retrieved and preserved for 4 h using either CS in histidine-tryptophan-ketoglutarate or SMP in polysol solution. Graft functional integrity was evaluated via oxygenated ex vivo reperfusion for 2 h at 37°C. SMP resulted in significant reductions in not only parenchymal alanine aminotransferase (p < 0.001), but also mitochondrial glutamate dehydrogenase (p < 0.001) enzyme release. Moreover, portal venous pressure (p = 0.047), tissue adenosine triphosphate (p = 0.001), bile production (p < 0.001), high-mobility group box protein-1 (p < 0.001), lipid peroxidation, and tissue glutathione were all significantly improved by SMP. Electron microscopy revealed that SMP alleviated deleterious alterations of sinusoidal microvasculature and hepatocellular mitochondria, both of which are characteristic disadvantages associated with steatosis. SMP could protect 50-60% macrosteatotic livers from preservation/reperfusion injury, and may thus represent a new means for expanding available donor pools.


title: Cost Analysis and Surgical Site Infection Rates in Total Knee Arthroplasty Comparing Traditional vs. Single-Use Instrumentation.

text: Surgical site infections (SSIs) are a significant complications in total knee arthroplasty (TKA). The purpose of this study was to evaluate if traditional vs. single-use instrumentation had an effect on SSI's. We compared SSI rates and costs of TKAs performed with single-use (449) and traditional (169) TKA instrumentation trays. Total OR Time was, on average, 30 min less when single-use instrumentation was used. SSIs decreased in the single-use group (n=1) compared to the traditional group (n=5) (P=0.006). Single-use instrumentation added $490 in initial costs; however it saved between $480 and $600. Single-use instrumentation may provide a benefit to the patient by potentially decreasing the risk of infection and reducing the overall hospital costs.


title: Identifying specific surgical tools and methods for laparoscopic colorectal operations in obese patients.

text: OBJECTIVE Laparoscopic operations for obese patients remain challenging due to technical difficulties at operation as well as higher comorbidities and high risk of postoperative complications. The aim of this study is to identify specific surgical tools and methods for laparoscopic colorectal operations for obese patients, applying knowledge of previous literature as well as our expertise in both laparoscopic and bariatric operations. CONCLUSIONS Current knowledge of bariatric surgery is invaluable in establishing a "customized" approach for laparoscopic colorectal operations in obese patients. The instruments routinely used during surgery on patients with normal body mass index (BMI) should often be modified and substituted according to the patient's BMI. We believe such an approach will prove beneficial to surgeons performing laparoscopic operations on obese patients.


Supporting the Health Care Workforce During the COVID-19 Global Epidemic.


title: Healthcare workers' perceptions of the duty to work during an influenza pandemic.

text: Healthcare workers (HCWs) are often assumed to have a duty to work, even if faced with personal risk. This is particularly so for professionals (doctors and nurses). However, the health service also depends on non-professionals, such as porters, cooks and cleaners. The duty to work is currently under scrutiny because of the ongoing challenge of responding to pandemic influenza, where an effective response depends on most uninfected HCWs continuing to work, despite personal risk. This paper reports findings of a survey of HCWs (n = 1032) conducted across three National Health Service trusts in the West Midlands, UK, to establish whether HCWs' likelihood of working during a pandemic is associated with views about the duty to work. The sense that HCWs felt that they had a duty to work despite personal risk emerged strongly regardless of professional status. Besides a strong sense that everyone should pull together, all kinds of HCWs recognised a duty to work even in difficult circumstances, which correlated strongly with their stated likelihood of working. This suggests that HCWs' decisions about whether or not they are prepared to work during a pandemic are closely linked to their sense of duty. However, respondents' sense of the duty to work may conflict with their sense of duty to family, as well as other factors such as a perceived lack of reciprocity from their employers. Interestingly, nearly 25% of doctors did not consider that they had a duty to work where doing so would pose risks to themselves or their families.


title: Characterization of Russian rabies virus vaccine strain RV-97.

text: The RV-97 rabies virus vaccine strain is widely used in Russia as a component of the live attenuated oral anti-rabies vaccine "Sinrab". This vaccine has also been used in some other countries, such as Kazakhstan, Belarus, and Ukraine. Entire genome sequencing is an effective tool for studying the genetic properties of virus strains. In this study, a simple technique for obtaining the entire genome sequence of the rabies virus was used. The entire genome sequence and the deduced amino acid sequences of the major viral proteins were compared with those of other rabies vaccine virus strains. The RV-97 strain forms a separate phylogenetic branch and seems to be phylogenetically more related to the group of Japanese vaccine strains. It also contains several unique amino acid changes in known immunodominant sites of G and P proteins.


title: Coil embolization of the false lumen in complicated type B aortic dissection.

text: A patent false lumen with persistent flow after endovascular repair of type B aortic dissection (TBAD) is associated with an ongoing risk of aortic dilation and rupture. We describe the case of a 64-year-old man who initially underwent thoracic endovascular aortic repair for acute complicated TBAD, but continued to have symptomatic retrograde aneurysm filling and dilatation because of a patent false lumen. Coil embolization of the patent false lumen successfully excluded the aneurysmal thoracic aorta from further perfusion, and led to a decease in aneurysm size on follow-up. Our case report is followed by a discussion on this management strategy and a review of literature.


title: Rescue microsurgery with bypass and stent removal following Pipeline treatment of a giant internal carotid artery terminus aneurysm.

text: We report the microsurgical rescue and removal of a Pipeline stent embolization of a giant internal carotid artery terminus aneurysm. After the initial placement of a Pipeline Embolization Device (PED), it migrated proximally to the cavernous carotid with the distal end free in the middle of the aneurysm, resulting in only partial aneurysm neck coverage. The patient underwent microsurgical rescue with trapping, bypass, and opening of the aneurysm with PED removal. The vessel remained patent in the proximal segment previously covered by the Pipeline stent. Microsurgical rescue for definitive aneurysm treatment with PED removal can be safe and effective for aneurysms unsuccessfully treated with PED.


title: Immunity to respiratory viruses.

text: The respiratory tract is characterized by an extensive surface area that is in direct contact with the environment, posing a significant problem for effective immune surveillance. Yet most respiratory pathogens are quickly recognized and controlled by a coordinated response involving the innate and adaptive arms of the immune system. The investigation of pulmonary immunity to respiratory viruses during a primary infection has demonstrated that multiple innate and adaptive immune mechanisms are necessary for efficient antiviral responses, and the inhibition of any single mechanism can have disastrous consequences for the host. Furthermore, the investigation of recall responses in the lung has shown that protection from a secondary challenge infection is a complex and elegant process that occurs in distinct stages. In this review, we discuss recent advances that describe the roles of individual components during primary and secondary responses to respiratory virus infections and how these discoveries have added to our understanding of antiviral immunity in the lung.


title: Three-Year Outcomes of Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes Mellitus Treatment: A Randomized Clinical Trial.

text: IMPORTANCE Questions remain about the role and durability of bariatric surgery for type 2 diabetes mellitus (T2DM). OBJECTIVE To compare the remission of T2DM following surgical and nonsurgical treatments. DESIGN, SETTING, AND PARTICIPANTS In this 3-arm randomized clinical trial conducted at the University of Pittsburgh Medical Center from October 1, 2009, to June 26, 2014, in Pittsburgh, Pennsylvania, outcomes were assessed 3 years after treating 61 obese participants aged 25 to 55 years with T2DM. Analysis was conducted with an intent-to-treat population. INTERVENTIONS Participants were randomized to either an intensive lifestyle weight loss intervention for 1 year followed by a low-level lifestyle intervention for 2 years or surgical treatments (Roux-en-Y gastric bypass [RYGB] or laparoscopic adjustable gastric banding [LAGB]) followed by low-level lifestyle intervention in years 2 and 3. MAIN OUTCOMES AND MEASURES Primary end points were partial and complete T2DM remission and secondary end points included diabetes medications and weight change. RESULTS Body mass index (calculated as weight in kilograms divided by height in meters squared) was less than 35 for 26 participants (43%), 50 (82%) were women, and 13 (21%) were African American. Mean (SD) values were 100.5 (13.7) kg for weight, 47.3 (6.6) years for age, 7.8% (1.9%) for hemoglobin A1c level, and 171.3 (72.5) mg/dL for fasting plasma glucose level. Partial or complete T2DM remission was achieved by 40% (n = 8) of RYGB, 29% (n = 6) of LAGB, and no intensive lifestyle weight loss intervention participants (P = .004). The use of diabetes medications was reduced more in the surgical groups than the lifestyle intervention-alone group, with 65% of RYGB, 33% of LAGB, and none of the intensive lifestyle weight loss intervention participants going from using insulin or oral medication at baseline to no medication at year 3 (P < .001). Mean (SE) reductions in percentage of body weight at 3 years were the greatest after RYGB at 25.0% (2.0%), followed by LAGB at 15.0% (2.0%) and lifestyle treatment at 5.7% (2.4%) (P < .01). CONCLUSIONS AND RELEVANCE Among obese participants with T2DM, bariatric surgery with 2 years of an adjunctive low-level lifestyle intervention resulted in more disease remission than did lifestyle intervention alone. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01047735.


title: Glucovigilance in COVID-19.

text: The coronavirus disease (COVID-19) pandemic has influenced clinical care in unprecedented ways. There is an urgent need to share best practice in providing diabetes care services in areas affected by COVID. This is a brief review for clinicians managing diabetes in low-income countries based on currently available data. The data is rapidly evolving; however, people with diabetes and its related comorbidities have increased risk for severe disease, and prolonged recovery and mortality. This review is also informed by data from severe acute respiratory syndrome (SARS) caused by SARS coronavirus (SARS-CoV) and Middle East respiratory syndrome (MERS), caused by MERS coronavirus (MERS-CoV). These two viruses share similarities with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus with causes COVID-19. SARS-CoV-2 was also known as 2019-nCOV. We discuss glucovigilance in COVID-19, the challenges and the opportunities. We put a spotlight on investigational new drugs for treatment of COVID medications and virtual care. Diabetologists and clinicians handling high-volume diabetes clinics are at increased risk for contracting COVID-19.


title: End-Tidal Carbon Dioxide as a Prognostic Feature in Pulmonary Arterial Hypertension.

text: RATIONALE Pulmonary arterial hypertension (PAH) is characterized in part by increased dead space ventilation, which can be estimated noninvasively at the bedside by measurement of end-tidal CO2 (ETco2). OBJECTIVES Prior work has demonstrated that ETco2 is lower in patients with PAH than in control patients, but whether ETco2 has prognostic value is unknown. We hypothesized that lower measurements of ETco2 in patients with PAH correlate with worse long-term outcomes. METHODS Patients with PAH seen in our referral clinic were prospectively recruited for ETco2 measurement between September 2009 and February 2010. Vital status as of July 2015 was documented using medical records and the Social Security Death Index. RESULTS Eighty-two patients were followed for a median of 60 months. Twenty-six patients died, and two were lost to follow-up. Patients who died were more likely to be older (58.5 ± 14.9 vs. 47.6 ± 12.2 yr; P < 0.05) and to have shorter 6-minute walk distance (296 ± 127 vs. 401 ± 92 m; P < 0.05). Mean ETco2 in survivors was 30.5 ± 4.8 mm Hg, whereas mean ETco2 in patients who died was 27.1 ± 4.2 mm Hg (P = 0.004). After stratification by median baseline ETco2 of 29 mm Hg, survival in each group was analyzed. Patients with lower ETco2 had shorter survival (P = 0.006). Cox regression analysis with ETco2 as a continuous variable revealed the hazard ratio to be 0.88 (95% confidence interval, 0.80-0.97; P = 0.006). In 52 patients with more than one measurement a median of 17 months apart, ETco2 was unchanged. CONCLUSIONS Our single-center data suggest that lower ETco2 is associated with shorter survival and that ETco2 is stable over time in patients with PAH.


title: Diabetes and COVID-19: Risks, Management, and Learnings From Other National Disasters.

text: Evidence relating to the impact of COVID-19 in people with diabetes (PWD) is limited but continuing to emerge. PWD appear to be at increased risk of more severe COVID-19 infection, though evidence quantifying the risk is highly uncertain. The extent to which clinical and demographic factors moderate this relationship is unclear, though signals are emerging that link higher BMI and higher HbA1c to worse outcomes in PWD with COVID-19. As well as posing direct immediate risks to PWD, COVID-19 also risks contributing to worse diabetes outcomes due to disruptions caused by the pandemic, including stress and changes to routine care, diet, and physical activity. Countries have used various strategies to support PWD during this pandemic. There is a high potential for COVID-19 to exacerbate existing health disparities, and research and practice guidelines need to take this into account. Evidence on the management of long-term conditions during national emergencies suggests various ways to mitigate the risks presented by these events.


title: Interpretation of the Traditional Chinese Medicine portion of the diagnosis and treatment protocol for corona virus disease 2019 (Trial Version 7).

text: The TCM protocol in the Diagnosis and Treatment Protocol for corona virus disease 2019 (COVID-19) (Trial Version 7) has been updated from previous versions. The protocol was formulated under the direct leadership of the National Administration of Traditional Chinese Medicine, based on the experience of a panel of experts, supported by evidence from fever clinics and from the outcomes of emergency (EM) observation rooms and inpatients throughout China (especially in Wuhan, Hubei Province) in combination with the latest scientific research results and data. The present interpretation of the TCM protocol is based on an overall understanding of the revised content, and aims to guide and standardize its clinical application to provide a reference for clinicians.


title: Glycemic Characteristics and Clinical Outcomes of COVID-19 Patients Hospitalized in the United States.

text: INTRODUCTION Diabetes has emerged as an important risk factor for severe illness and death from COVID-19. There is a paucity of information on glycemic control among hospitalized COVID-19 patients with diabetes and acute hyperglycemia. METHODS This retrospective observational study of laboratory-confirmed COVID-19 adults evaluated glycemic and clinical outcomes in patients with and without diabetes and/or acutely uncontrolled hyperglycemia hospitalized March 1 to April 6, 2020. Diabetes was defined as A1C ≥6.5%. Uncontrolled hyperglycemia was defined as ≥2 blood glucoses (BGs) > 180 mg/dL within any 24-hour period. Data were abstracted from Glytec's data warehouse. RESULTS Among 1122 patients in 88 U.S. hospitals, 451 patients with diabetes and/or uncontrolled hyperglycemia spent 37.8% of patient days having a mean BG > 180 mg/dL. Among 570 patients who died or were discharged, the mortality rate was 28.8% in 184 diabetes and/or uncontrolled hyperglycemia patients, compared with 6.2% of 386 patients without diabetes or hyperglycemia (P < .001). Among the 184 patients with diabetes and/or hyperglycemia who died or were discharged, 40 of 96 uncontrolled hyperglycemia patients (41.7%) died compared with 13 of 88 patients with diabetes (14.8%, P < .001). Among 493 discharged survivors, median length of stay (LOS) was longer in 184 patients with diabetes and/or uncontrolled hyperglycemia compared with 386 patients without diabetes or hyperglycemia (5.7 vs 4.3 days, P < .001). CONCLUSION Among hospitalized patients with COVID-19, diabetes and/or uncontrolled hyperglycemia occurred frequently. These COVID-19 patients with diabetes and/or uncontrolled hyperglycemia had a longer LOS and markedly higher mortality than patients without diabetes or uncontrolled hyperglycemia. Patients with uncontrolled hyperglycemia had a particularly high mortality rate. We recommend health systems which ensure that inpatient hyperglycemia is safely and effectively treated.


title: Dynamic Chest CT Evaluation in Three Cases of 2019 Novel Coronavirus Pneumonia.

text: A recent outbreak of pneumonia in Wuhan, China, was caused by the 2019 novel coronavirus (2019-nCoV). There have been some reports of imaging findings regarding the disease's characteristic features. Here, we report three cases of coronavirus disease 2019 (COVID-19) with dynamic pulmonary CT evaluation. The CT scan showed multiple regions of ground-glass opacities and patchy consolidation in COVID-19 patients and the CT scan was useful in tracking the progression or regression of COVID-19.


title: In Memoriam: A Memoir for Our Fallen "Heroes".

text: Even though neurosurgeons exercise these enormous and versatile skills, the COVID-19 pandemic has shaken the fabrics of the global neurosurgical family, jeopardizing human lives, and forcing the entire world to be locked down. We stand on the shoulders of the giants and will not forget their examples and their teachings. We will work to the best of our ability to honor their memory. Professor Harvey Cushing said: "When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted enucleation of a pathologically favorable tumor to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session-all these require surgical judgment which is a matter of long experience." It is up to us, therefore, to keep on the noble path that we have decided to undertake, to accumulate the surgical experience that these icons have shown us, the fruit of sacrifice and obstinacy. Our tribute goes to them; we will always remember their excellent work and their brilliant careers that will continue to enlighten all of us.


title: Patient Reported Outcome Measures of Sleep Quality in Fibromyalgia: A COSMIN Systematic Review.

text: Poor sleep quality is a common concern and a troublesome symptom among patients suffering from fibromyalgia. The purpose of this review was to identify and describe the available patient reported outcome measures (PROMs) of sleep quality validated in adult people diagnosed with fibromyalgia. The COSMIN and PRISMA recommendations were followed. An electronic systematized search in the electronic databases PubMed, Scopus, CINAHL Plus, PsycINFO, and ISI Web of Science was carried out. Validation studies of PROMs of sleep quality in fibromyalgia published in English or Spanish were included. The selection of the studies was developed through a peer review process through the online software "COVIDENCE". The quality of the studies was assessed using the COSMIN Risk of Bias checklist. A total of 5 PROMs were found validated in patients with fibromyalgia: (1) Pittsburgh Sleep Quality Index (PSQI), (2) Jenkins Sleep Scale (JSS), (3) Sleep Quality Numeric Rating Scale (SQ-NRS), (4) Medical Outcomes Study-Sleep Scale (MOS-SS), and (5) Fibromyalgia Sleep Diary (FSD). The quality of the evidence was very good and the quality of the results ranged from moderate to high. All the included PROMs, except for the FSD, showed adequate psychometric properties and, therefore, are valid and reliable tools for assessing sleep quality in the context of FM. However, none of the studies analyzed all the psychometric properties of the included PROMs as established in the COSMIN guidelines, highlighting that this is a potential field of research for future investigations.


title: Positive predictive value for polyps detected at screening CT colonography.

text: PURPOSE To determine the positive predictive value (PPV) for polyps detected at CT colonography (CTC). METHODS Assessment of 739 colorectal lesions >or=6 mm detected prospectively at CTC screening in 479 patients was performed. By-polyp PPV was analyzed according to small (6-9 mm) versus large (>or=10 mm) size; morphology (sessile/pedunculated/flat); diagnostic confidence level (3 = most confident, 1 = least confident); and histology. By-patient PPV was analyzed at various polyp size thresholds. RESULTS By-polyp PPV for CTC-detected lesions >or=6 mm, 6-9 mm, and >or=10 mm was 91.6% (677/739), 90.1% (410/451), and 92.7% (267/288), respectively (p = 0.4). By-polyp PPV according to sessile, pedunculated, flat, and mass-like morphology was 92.5% (441/477), 96.5% (139/144), 77.7% (73/94), and 97.6% (40/41), respectively (p < 0.0001 for flat versus polypoid morphology). By-polyp PPV according to diagnostic confidence level was 94.7% (554/585) for highest (= level 3), 83.5% (106/127) for intermediate (= level 2), and 63.0% (17/27) for lowest (= level 1) confidence (p < 0.0001 for levels-2/3 versus level-1). By-patient PPV at 6-mm, 8-mm, 10-mm, and 30-mm polyp size thresholds was 92.3% (442/479), 93.0% (306/329), 93.1% (228/245), and 97.4% (38/39), respectively. CONCLUSION The overall per-polyp and per-patient PPV for lesions >or=6 mm was 92% for CTC screening. Increased diagnostic confidence and polypoid (non-flat) morphology correlated with a higher PPV, whereas small versus large polyp size had very little effect.


title: Mild encephalopathy with reversible splenial lesion in a patient with influenza A infection--first report in an adult patient in the USA.

text: We present a case of a 51-year-old man with panhypopituarism who developed clinically mild encephalopathy with a lesion in the splenium of the corpus callosum, in the setting of acute influenza A infection. The patient's initial presentation included hypernatraemia due to pre-existing iatrogenic central diabetes insipidus. Despite adequate treatment of hypernatraemia, his course was complicated by otherwise unexplained mild encephalopathy. Brain MRI revealed a diffusion restricted lesion in the splenium of the corpus callosum. This presentation was consistent with mild encephalopathy with reversible splenial lesion (MERS). The patient subsequently tested positive for influenza A. This is the first reported case of MERS syndrome due to influenza A infection in an adult patient in the USA. Mild encephalopathy associated with influenza A infection and a reversible splenial lesion of the corpus callosum has a favourable prognosis and resolves spontaneously.


title: Critical appraisal of paclitaxel balloon angioplasty for femoral-popliteal arterial disease.

text: Peripheral arterial disease, particularly critical limb ischemia, is an area with urgent need for optimized therapies because, to date, vascular interventions often have limited life spans. In spite of initial encouraging technical success after femoropopliteal percutaneous transluminal angioplasty or stenting, postprocedural restenosis remains the major problem. The challenging idea behind the drug-coated balloon (DCB) concept is the biological modification of the injury response after balloon dilatation. Antiproliferative drugs administered via DCBs or drug-eluting stents are able to suppress neointimal hyperplasia, the main cause of restenosis. This article reviews the results of DCB treatments of femoropopliteal and infrapopliteal lesions in comparison to standard angioplasty with uncoated balloons. A systematic literature search was performed in 1) medical journals (ie, MEDLINE), 2) international registers for clinical studies (ie, www.clinicaltrials.gov), and 3) abstracts of scientific sessions. Several controlled randomized trials with follow-up periods of up to 5 years demonstrated the efficacy of paclitaxel -DCB technology. However, calcified lesions seem to affect the efficacy of DCB. Combinations of preconditioning methods with DCBs showed promising results. Although the mechanical abrasion of calcium via atherectomy or laser ablation showed favorable periprocedural results, the long-term impact on restenosis and clinical outcome has to be demonstrated. Major advantages of the DCBs are the rapid delivery of drug at uniform concentrations with a single dose, their efficacy in areas wherein stents have been contraindicated until now (ie, bifurcation, ostial lesions), and in leaving no stent scaffold behind. Reinterventions are easier to perform because DCBs leave no metal behind. Various combinations of DCBs with other treatment modalities may prove to be viable options in future. The follow-up results of clinical studies will evaluate the long-term impact of DCBs.


title: COVID-19: Closing the Psychological Treatment Gap during the Pandemic, a Protocol for Implementation and Evaluation of Text4Hope (a Supportive Text Message Program).

text: BACKGROUND Coronavirus disease 2019 (COVID-19) has spread globally with far-reaching, significant and unprecedented impacts on health and way of life. Threats to mental health, psychological safety and well being are now emerging, increasing the impact of this virus on world health. Providing support for these challenges is difficult because of very high numbers of people requiring support in the context of a need to maintain physical distancing. This protocol describes use of text messaging (Text4Hope) as a convenient, cost-effective, and accessible population-level mental health intervention. This program is evidence-based, with prior research supporting good outcomes and high user satisfaction. OBJECTIVE The project goal is to implement a program of daily supportive text messaging (Text4Hope) to reduce distress related to the COVID-19 crisis initially amongst Canadians. Prevalence of stress, anxiety and depressive symptoms, demographic correlates of the same, and the outcomes of the Text4Hope intervention in mitigating distress will be evaluated. METHODS Self-administered, anonymous, online questionnaires will be used to assess stress (Perceived Stress Scale), anxiety (GAD-7), and depressive symptoms (PHQ-9). Data will be collected at baseline (onset of text messaging), at program midpoint (6-weeks), and end (12-weeks). RESULTS Data analysis will include parametric and non-parametric techniques, focusing on primary outcomes (i.e., stress, anxiety, depressive symptoms) and metrics of use, including number of subscribers and user satisfaction. Given the large size of the data set, machine learning and data-mining methods will also be used. CONCLUSIONS This COVID-19 project will provide key information regarding prevalence rates of stress, anxiety, and depressive symptoms during the pandemic, demographic correlates of distress, and outcome data related to this scalable population-level intervention. Information from this study will be valuable for practitioners, as useful for informing policy and decision-making regarding psychological interventions during the pandemic. CLINICALTRIAL


title: Cost-effectiveness of mechanical thrombectomy using stent retriever after intravenous tissue plasminogen activator compared with intravenous tissue plasminogen activator alone in the treatment of acute ischaemic stroke due to large vessel occlusion in Spain.

text: Introduction To assess the cost-effectiveness of stent-retriever mechanical thrombectomy and intravenous tissue plasminogen activator compared with intravenous tissue plasminogen activator alone in patients with acute ischaemic stroke due to large vessel occlusions in Spain. Materials and methods Clinical data were taken from the SWIFT PRIME clinical trial. A lifetime Markov state transition model defined by the modified Rankin Scale score was developed to estimate costs and health outcomes (life years gained and quality adjusted life years). A Spanish National Health System perspective (direct medical costs) was considered. Resource utilisation and utilities were obtained from available published data and endorsed by an expert panel. Costs (€, 2016) were obtained from various Spanish sources. Deterministic and probabilistic sensitivity analyses were performed. Results Stent-retriever thrombectomy after intravenous tissue plasminogen activator was associated with better outcomes (1.17 life years gained and 2.51 quality adjusted life years) and savings of €44,378, resulting in a dominant therapy over intravenous tissue plasminogen activator alone. A net monetary benefit of €119,744 was obtained considering a willingness-to-pay threshold of €30,000/quality adjusted life year gained. The combined therapy was also dominant in all sensitivity analyses, deterministic and probabilistic. Discussion The results were consistent with a previously published cost-effectiveness analysis and reinforce the likeliness of the selection of stent-retriever mechanical thrombectomy plus intravenous tissue plasminogen activator over intravenous tissue plasminogen activator alone. Conclusion Stent-retriever thrombectomy after intravenous tissue plasminogen activator is a dominant alternative over intravenous tissue plasminogen activator alone (more effective and less costly) for the treatment of acute ischaemic stroke patients with large vessel occlusions in the Spanish setting.


title: Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas.

text: OBJECTIVE Craniopharyngiomas can be difficult to remove completely based on their intimate relationship with surrounding visual and endocrine structures. Reoperations are not uncommon but have been associated with higher rates of complications and lower extents of resection. So radiation is often offered as an alternative to reoperation. The endonasal endoscopic transsphenoidal approach has been used in recent years for craniopharyngiomas previously removed with craniotomy. The impact of this approach on reoperations has not been widely investigated. METHODS The authors reviewed a prospectively acquired database of endonasal endoscopic resections of craniopharyngiomas over 11 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, performed by the senior authors. Reoperations were separated from first operations. Pre- and postoperative visual and endocrine function, tumor size, body mass index (BMI), quality of life (QOL), extent of resection (EOR), impact of prior radiation, and complications were compared between groups. EOR was divided into gross-total resection (GTR, 100%), near-total resection (NTR, > 95%), and subtotal resection (STR, < 95%). Univariate and multivariate analyses were performed. RESULTS Of the total 57 endonasal surgical procedures, 22 (39%) were reoperations. First-time operations and reoperations did not differ in tumor volume, radiological configuration, or patients' BMI. Hypopituitarism and diabetes insipidus (DI) were more common before reoperations (82% and 55%, respectively) compared with first operations (60% and 8.6%, respectively; p < 0.001). For the 46 patients in whom GTR was intended, rates of GTR and GTR+NTR were not significantly different between first operations (90% and 97%, respectively) and reoperations (80% and 100%, respectively). For reoperations, prior radiation and larger tumor volume had lower rates of GTR. Vision improved equally in first operations (80%) compared with reoperations (73%). New anterior pituitary deficits were more common in first operations compared with reoperations (51% vs 23%, respectively; p = 0.08), while new DI was more common in reoperations compared with first-time operations (80% vs 47%, respectively; p = 0.08). Nonendocrine complications occurred in 2 (3.6%) first-time operations and no reoperations. Tumor regrowth occurred in 6 patients (11%) over a median follow-up of 46 months and was not different between first versus reoperations, but was associated with STR (33%) compared with GTR+NTR (4%; p = 0.02) and with not receiving radiation after STR (67% vs 22%; p = 0.08). The overall BMI increased significantly from 28.7 to 34.8 kg/m2 over 10 years. Six months after surgery, there was a significant improvement in QOL, which was similar between first-time operations and reoperations, and negatively correlated with STR. CONCLUSIONS Endonasal endoscopic transsphenoidal reoperation results in similar EOR, visual outcome, and improvement in QOL as first-time operations, with no significant increase in complications. EOR is more impacted by tumor volume and prior radiation. Reoperations should be offered to patients with recurrent craniopharyngiomas and may be preferable to radiation in patients in whom GTR or NTR can be achieved.


title: Exportations of Symptomatic Cases of MERS-CoV Infection to Countries outside the Middle East

text: In 2012, an outbreak of infection with Middle East respiratory syndrome coronavirus (MERS-CoV), was detected in the Arabian Peninsula. Modeling can produce estimates of the expected annual number of symptomatic cases of MERS-CoV infection exported and the likelihood of exportation from source countries in the Middle East to countries outside the region.


title: Tracheostomy Management during the COVID-19 Pandemic.

text: The ongoing coronavirus disease 2019 pandemic has led to unprecedented demands on the modern health care system, and the highly contagious nature of the virus has led to particular concerns of infection among health care workers and transmission within health care facilities. While strong data regarding the transmissibility of the infection are not yet widely available, preliminary information suggests risk of transmission among asymptomatic individuals, including those within health care facilities. We believe that the presence of a tracheostomy or laryngectomy stoma poses a unique risk of droplet and aerosol spread particularly among patients with unsuspected infection. At our institution, guidelines for the care of open airways were developed by a multidisciplinary open airway working group, and here we review those recommendations to provide practical guidance to other institutions.


title: Gaps in Guideline-Concordant Use of Diagnostic Tests Among Lung Cancer Patients.

text: BACKGROUND Practice guidelines recommend routine use of pulmonary function tests (PFTs), computed tomography (CT), and positron emission tomography (PET) for the workup of resectable lung cancer patients. Little is known about the frequency of guideline concordance in routine practice. METHODS A cohort study (2007 to 2013) of 15,951 lung cancer patients undergoing lobectomy or pneumonectomy was conducted with MarketScan, a claims database of individuals with employer-provided health insurance. Guideline concordance was defined by claims for PFT within 180 days of resection and for CT and PET within 90 days of resection. Generalized linear models were used to evaluate temporal trends, patient characteristics, and costs associated with guideline-concordant care. RESULTS Overall, 61% of patients received guideline-concordant care, increasing from 57% in 2007 to 66% in 2013 (p < 0.001). Compared with patients who received guideline-discordant care, patients with guideline-concordant care more frequently underwent repeat testing (PFT: 21% versus 12%, p < 0.001; CT: 46% versus 22%, p < 0.001; PET: 2.3% versus 1.1%, p < 0.001). Health plan-adjusted mean total test-related costs were higher among guideline-concordant patients who underwent repeat testing than patients who did not ($4,304 versus $3,454, p < 0.001). CONCLUSIONS Forty percent of lung cancer patients treated with surgical procedures did not receive recommended noninvasive cancer staging and physiologic assessment before resection. Guideline concordance was associated with repeat testing, and repeat testing was associated with higher costs. These findings support the need for quality improvement interventions that can increase guideline concordance while curbing potential excess use of diagnostic tests.


title: The Enigma ML FluAB-RSV assay: a fully automated molecular test for the rapid detection of influenza A, B and respiratory syncytial viruses in respiratory specimens.

text: The Enigma(®) ML FluAB-RSV assay (Enigma Diagnostics, Porton Down, Salisbury, UK) is a CE-IVD marked multiplex molecular panel for the detection of influenza A, B and respiratory syncytial viruses in nasopharyngeal swabs. The assay runs on the fully automated Enigma ML platform without further specimen manipulation and provides a sample-to-answer result within 95 min. The reported sensitivity and specificity for influenza A are 100% (95% CI: 98.2-100) and 98.3% (95% CI: 95.5-99.4), respectively, for influenza B are 100% (95% CI: 98.2-100) and 98.7% (95% CI: 96-99.6), respectively, and for respiratory syncytial virus are 100% (95% CI: 98.2-100) and 99.4% (95% CI: 97.2-99.9), respectively.


title: Design, synthesis and molecular docking of novel triazole derivatives as potential CoV helicase inhibitors.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) had emerged and spread because of the worldwide travel and inefficient healthcare provided for the infected patients in several countries. Herein we investigated the anti-MERS-CoV activity of newly synthesized sixteen halogenated triazole compounds through the inhibition of helicase activity using the FRET assay. All new compounds underwent justification for their target structures via microanalytical and spectral data. SAR studies were performed. Biological results revealed that the most potent compounds were 4-(cyclopent-1-en-3-ylamino)-5-(2-(4-iodophenyl)hydrazinyl)-4H-1,2,4-triazole-3-thiol (16) and 4-(cyclopent-1-en-3-ylamino)-5-[2-(4-chlorophenyl)hydrazinyl]-4H-1,2,4-triazole-3-thiol (12). In silico molecular docking of the most potent compounds was performed to the active binding site of MERS-CoV helicase nsp13. Molecular docking results are in agreement with experimental findings.


title: Successful Outcomes in Robot-Assisted Laparoscopic Pyeloplasty Using a Unidirectional Barbed Suture.

text: INTRODUCTION Intracorporeal suturing is considered to be the most challenging aspect of laparoscopic and robotic surgery. To overcome this problem, barbed self-retaining sutures have been effectively employed in various minimally invasive endourologic surgeries. However, the use of this suture has been recently cautioned for pyeloplasty due to a high failure rate. Our objective was to report our experience using barbed suture during robotic pyeloplasty. METHODS We retrospectively identified 13 consecutive patients who underwent robotic pyeloplasty with a barbed monofilament (4-0 V-Loc™) suture for the ureteropelvic anastomosis from 2011 to 2014. We compared these patients to 12 consecutive patients who underwent robotic pyeloplasty with a 4-0 nonbarbed suture from 2007 to 2011. We evaluated patient demographics, operative times, preoperative and postoperative symptoms, renal function, and diuretic renograms (DRG). Successful repair was defined as resolution of preoperative symptoms and/or T½ improvement on DRG to less than 20 minutes. RESULTS The median age was 26 (interquartile range [IQR] 20.7-38) years and 35 (IQR 18.3-44) years for the barbed and nonbarbed suture groups, respectively. In the barbed suture group, preoperative DRG revealed ureteropelvic junction obstruction (UPJO) in 11 patients, equivocal UPJO (T½ 10-20 minutes) in one patient, and no obstruction in one patient. In the nonbarbed group, preoperative DRG revealed UPJO in 10 patients, equivocal UPJO in one patient, and no obstruction in one patient. In the barbed suture group, postoperative DRG was obtained in 11 patients, which showed no obstruction in 10/11 patients with 92% of patients experiencing symptom resolution. Similarly, postoperative DRG was obtained in 11 patients in the nonbarbed group, which showed no obstruction in 10/11 patients with 100% postoperative symptom resolution. CONCLUSIONS In the largest series reporting use of V-Loc suture for robotic pyeloplasty, the V-Loc suture was safely and effectively used for robotic pyeloplasty repair.


title: How science will help shape future clinical applications of probiotics.

text: The recent increased interest in probiotics among clinicians has many causes, primarily the concern about the limitations of the current armamentarium of pharmaceutical agents. Although probiotics have been used mostly in dietary supplements and foods to maintain health, scientific and clinical studies are recognizing the potential of some probiotics to be therapeutic in function. Scientific breakthroughs in understanding the source and composition of the human microbiota, the key nutritional factors that influence these microbes, and their immunomodulatory effects; the creation of disease-targeted recombinant strains; the isolation and characterization of signaling molecules that can modulate microbial biofilms and infectious processes; and advances in biomedical engineering that will provide new delivery systems for probiotics will shape the future of clinical applications of probiotics. In time and with rigorous documentation, some probiotics will likely find an important place in medical practice.


title: Endovascular treatment of traumatic carotid pseudoaneurysm with Tubridge flow diverter: A case report.

text: Traumatic pseudoaneurysm is a rare lesion with a high risk of rupture, and represents one of the most difficult lesions to treat, either surgically or endovascularly. Herein, we describe the case of a 32-year-old man with a traumatic pseudoaneurysm of the internal carotid artery, which was treated by overlapped flow diverters (Tubridge). The patient recovered well, and the follow-up angiography at four months showed complete occlusion of the pseudoaneurysm and patency of the internal carotid artery and the ophthalmic artery.


title: Progressive edematous lesions in subacute phase after neuroendovascular therapy.

text: Background The appearance of edematous lesions in the subacute phase is a rare complication following neuroendovascular therapy. Effective management of these lesions remains unclear. In this report, a case with progressive edematous lesions in the subacute phase after neuroendovascular therapy was described, and the clinical features and therapeutic strategies were discussed. Case Description A 54-year-old female with a large, right cavernous internal carotid artery aneurysm was treated with a flow diverter. Left hemiparesis developed 15 days after the procedure, and multiple edematous lesions in areas of prior catheter procedures were revealed on radiological findings. Steroid pulse therapy was employed, and the lesions were gradually reduced without any additional neurological deficits. No recurrence was recognized in the follow-up study. Conclusion In some reports, pathological findings indicate that these lesions result from the presence of foreign bodies, and emboli could be caused by cotton fibers or hydrophilic polymers used as surface coatings on endovascular catheters. In this case, the edematous lesions were most likely caused by hydrophilic polymer emboli. Steroid pulse therapy had a beneficial effect on the lesions. It is important to effectively manage prescribed periods after the procedure to avoid such a rare complication.


title: Flow changes in the posterior communicating artery related to flow-diverter stents in carotid siphon aneurysms.

text: BACKGROUND Flow-diverter stent (FDS) placement for treatment of intracranial aneurysms can cause flow changes in the covered branches. OBJECTIVE To assess the impact of the treatment of carotid siphon aneurysms with FDS on the posterior communicating artery (PComA) flow. MATERIALS AND METHODS Between February 2011 and January 2015, 125 carotid siphon aneurysms were treated with FDS. We retrospectively analyzed all cases with PComA ostial coverage. The circle of Willis anatomy was also studied as the flow changes in PComA postoperatively and during angiographic follow-up. Data from neurological examination were also collected. RESULTS Eighteen aneurysms of the carotid siphon in 17 patients were treated with FDS covering the ostium of the PComA. Based on the initial angiography, patients were divided into two groups: the first with a P1/PComA size ratio >1 (10 cases) and the second with a ratio ≤1 (8 cases). Follow-up angiography (mean time of 10 months) showed 90% of PComA flow changes in group 1 but only 12.5% in group 2. There was a significant difference between the two groups (p=0.002). Nevertheless, no patient had new symptoms related to these flow changes during the follow-up period. CONCLUSIONS In our experience, covering the PComA by FDS when treating carotid siphon aneurysms appeared safe and the P1/PComA ratio is a good predictor of flow changes in PComA.


title: Polyethylene Terephthalate and Polycarbonate Microplastics in Pet Food and Feces from the United States.

text: Human exposure to microplastics has been a topic of interest, but measurements of exposure are limited. Pet animals are sentinels of human exposure, as they share a common living environment with humans. In this study, 58 pet (cat and dog) foods and 78 pet feces samples were collected from Albany, New York, USA, for the analysis of polyethylene terephthalate (PET) and polycarbonate (PC) by alkali-assisted thermal depolymerization and liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) methods. PET was detected at concentrations in the range of <1,500 ng/g to 12,000 ng/g (median: <1,500 ng/g) and <1,500 to 4,600 ng/g (median: <1500 ng/g) in cat and dog foods, respectively. The concentrations of PET in cat (<2,300-340,000 ng/g, median: 61,000 ng/g) and dog (7700-190,000 ng/g, median: 30,000 ng/g) feces were one to two orders of magnitude higher than those in food samples. A significant positive correlation was found between the concentrations of the monomers (i.e., TPA and BPA) and the corresponding MPs in cat feces. The calculated mean estimated daily intake of PET and PC (calculated from pet food) was lower than that of the mean cumulative daily intake (calculated from pet feces), which suggested that diet is a minor source of pet exposure to PET and PC.


title: Discussing substance use with clients during the COVID-19 pandemic: A motivational interviewing approach.

text: During the COVID-19 pandemic, trauma-exposed individuals may have heightened risk for substance use. Using substances to cope may contribute to the development of problematic substance use over time. It is imperative to initiate conversations about substance use with clients during this time and motivational interviewing offers an ideal framework for doing so. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Brief review: Pulmonary artery aneurysms and pseudoaneurysms.

text: The purpose of this review article is to provide a brief overview of pulmonary artery aneurysms and pseudoaneurysms, to discuss the classifications of these conditions, review the role of imaging and discuss management in affected patients.


title: Laparoendoscopic single site surgery in pediatric urology: does it require specialized tools?

text: PURPOSE To describe our experience utilizing Laparoendoscopic single site (LESS) surgery in pediatric urology. MATERIALS AND METHODS Retrospective chart review was performed on LESS urologic procedures from November 2009 through March 2013. A total of 44 patients underwent 54 procedures including: nephrectomy (23), orchiopexy (14), varicocelectomy (9), orchiectomy (2), urachal cyst excision (3), and antegrade continence enema (3) (ACE). RESULTS Median patient age was 6.9 years old. Estimated blood loss (EBL), ranged from less than 5cc to 47cc for a bilateral nephrectomy. Operative time varied from 56 mins for varicocelectomy to a median of 360 minutes for a bilateral nephroureterectomy. Incision length ranged between 2 and 2.5cm. In our initial experience we used a commercial port. However, as we progressed, we were able to perform the majority of our procedures via adjacent fascial punctures for instrumentation at the single incision site. One patient did require conversion to an open procedure as a result of bleeding. Three complications were noted (6.8%), with two Clavien Grade 3b complications. Two patients required additional procedures at 1-year follow-up. CONCLUSIONS The use of LESS applies to many pediatric urologic procedures, ideally for ablative procedures or simple reconstructive efforts. The use of adjacent fascial puncture sites for instrumentation can obviate the need for a commercial port or multiple trocars.


Northern Ireland disease surveillance, April to June 2012.


title: Stents and Stent Mimickers in Endovascular Management of Wide-neck Intracranial Aneurysms.

text: Subarachnoid hemorrhage due to a ruptured cerebral aneurysm is a disastrous event accounting for approximately 5%-15% of all stroke cases and has a high mortality rate. One of the major goals in the management of these patients is to prevent rebleeding by securing the aneurysm either surgically or by endovascular means. Endovascular treatment is considered the first line of treatment for intracranial aneurysms; however, wide-neck aneurysms (WNAs) are specifically difficult to treat by endovascular means due to the difficulty in achieving a stable coil mass inside the aneurysm sac. To overcome this problem, assisted endovascular treatment techniques and devices have evolved over the years. Amongst these, stent-assisted coiling (SAC) techniques provide a scaffold for coil embolization. The concept of the stent-assisted technique inspired creative pioneers to invent new tools like the PulseRider (Pulsar Vascular, Inc. CA, USA) and the pCONUS (Phenox GmbH, Germany), which are a great help in managing wide-neck and bifurcation aneurysms. The concept of stent within stents and its related hemodynamic effect has led to the novel development of flow diverters for reconstructing the arterial wall and correcting the hemodynamic disturbances. In this article, we review the stents and stent-like devices currently in practice for the endovascular management of wide-neck and branch intracranial aneurysms.


title: Visualizing coronavirus RNA synthesis in time by using click chemistry.

text: Coronaviruses induce in infected cells the formation of replicative structures, consisting of double-membrane vesicles (DMVs) and convoluted membranes, where viral RNA synthesis supposedly takes place and to which the nonstructural proteins (nsp's) localize. Double-stranded RNA (dsRNA), the presumed intermediate in RNA synthesis, is localized to the DMV interior. However, as pores connecting the DMV interior with the cytoplasm have not been detected, it is unclear whether RNA synthesis occurs at these same sites. Here, we studied coronavirus RNA synthesis by feeding cells with a uridine analogue, after which nascent RNAs were detected using click chemistry. Early in infection, nascent viral RNA and nsp's colocalized with or occurred adjacent to dsRNA foci. Late in infection, the correlation between dsRNA dots, then found dispersed throughout the cytoplasm, and nsp's and nascent RNAs was less obvious. However, foci of nascent RNAs were always found to colocalize with the nsp12-encoded RNA-dependent RNA polymerase. These results demonstrate the feasibility of detecting viral RNA synthesis by using click chemistry and indicate that dsRNA dots do not necessarily correspond with sites of active viral RNA synthesis. Rather, late in infection many DMVs may harbor dsRNA molecules that are no longer functioning as intermediates in RNA synthesis.


title: Weight Loss and Dietary Interventions for Hidradenitis Suppurativa: A Systematic Review.

text: Hidradenitis suppurativa (HS) is a common inflammatory disorder characterized by recurrent, painful, and malodorous abscesses and nodules predominantly in skin folds. HS is associated with substantial morbidity and poor quality of life. There are no curative therapies, and the only approved biologic drug has variable efficacy and requires high doses, making adjunct treatments crucial. An important risk factor for disease severity is obesity. Our primary objective was to conduct a systematic review examining weight loss and dietary interventions, in HS. Our secondary objective was to examine nutritional supplements in HS.A systematic literature search was conducted using Medline, EMBASE, and the Cochrane Database. We included all study types in adults (>18 years), with a minimum sample size of 5, examining the effects of any dietary or weight loss intervention on HS severity. Two authors screened n = 1279 articles of which 9 met inclusion criteria. All included studies were observational and all interventions were associated with various measures of decreased HS severity. Patient-controlled weight loss and bariatric surgery were associated with HS regression, though a subset of patients with significant increase in panniculi experienced exacerbations and required excision of excess skin. Diets demonstrating benefit eliminated dairy and brewer's yeast. Nutritional supplements including zinc gluconate, vitamin D, and riboflavin had a suppressive, rather than curative, effect on HS lesions in single studies. Overall, the reviewed interventions show promise as potential adjunct treatments in a HS management plan. Prospective randomized controlled trials should validate these findings.


title: Intra-procedural pain score in a randomised controlled trial comparing mechanochemical ablation to radiofrequency ablation: The Multicentre Venefit™ versus ClariVein® for varicose veins trial.

text: OBJECTIVE Endovenous techniques are, at present, the recommended choice for truncal vein treatment. However, the thermal techniques require tumescent anaesthesia, which can be uncomfortable during administration. Non-tumescent, non-thermal techniques would, therefore, have potential benefits. This randomised controlled trial is being carried out to compare the degree of pain that patients experience while receiving mechanochemical ablation or radiofrequency ablation. The early results of this randomised controlled trial are reported here. METHODS Patients attending for the treatment of primary varicose veins were randomised to receive mechanochemical ablation (ClariVein®) or radiofrequency ablation (Covidien® Venefit™). The most symptomatic limb was randomised. The primary outcome measure was intra-procedural pain using a validated visual analogue scale. The secondary outcome measures were change in quality of life and clinical scores, time to return to normal activities and work as well as the occlusion rate. RESULTS One-hundred and nineteen patients have been randomised (60 in the mechanochemical ablation group). Baseline characteristics were similar. Maximum pain score was significantly lower in the mechanochemical ablation group (19.3 mm, standard deviation ±19 mm) compared to the radiofrequency ablation group (34.5 mm ± 23 mm; p < 0.001). Average pain score was also significantly lower in the mechanochemical ablation group (13.4 mm ± 16 mm) compared to the radiofrequency ablation group (24.4 mm ± 18 mm; p = 0.001). Sixty-six percent attended follow-up at one month, and the complete or proximal occlusion rates were 92% for both groups. At one month, the clinical and quality of life scores for both groups had similar improvements. CONCLUSION Early results show that the mechanochemical ablation is less painful than the radiofrequency ablation procedure. Clinical and quality of life scores were similarly improved at one month. The long-term data including occlusion rates at six months and quality of life scores are being collected.


title: RNA interference protects horse cells in vitro from infection with Equine Arteritis Virus.

text: Equine Arteritis Virus (EAV) belongs to the Arteriviridae and causes viral arteritis in horses. In an attempt to develop novel and save therapies against the infection it was tested whether EAV is susceptible to RNA interference (RNAi) in an equine in vitro system. Horse cells were transfected with chemically synthesized small interfering RNA oligonucleotides (siRNAs) and challenged with EAV. Application of these siRNAs led to a significant protection of the cells, and virus titers decreased drastically. siRNAs derived from DNA plasmids expressing small hairpin RNAs (shRNAs) were also effective. The protection was most pronounced with two siRNAs targeting the open reading frame 1 (coding for non-structural proteins), whereas siRNAs targeting sequences for several structural proteins had less or no effect. In addition, it was investigated whether RNAi could be used to treat cells with an already established viral infection. Only application of the siRNAs shortly after viral challenge led to significant survival rates of the cells, whereas transfection at later time points caused much less benefit for the cells. These findings are discussed in a perspective of using RNAi as a therapeutic approach to combat EAV.


title: The HeartShield device reduces the risk for right ventricular damage in patients with deep sternal wound infection.

text: OBJECTIVE Right ventricular rupture, resulting in serious bleeding, is a life-threatening complication associated with negative-pressure wound therapy (NPWT) in cardiac surgery. The use of a rigid barrier between the heart and the sharp sternal edges has been successfully tested on pigs. In the present article, we demonstrate increased safety in NPWT through the use of the HeartShield device. METHODS Six patients were treated with a specially designed device in combination with NPWT. The device consists of a horizontally placed disk covered in foam. The back of the T-shaped device sticks up between the sternal edges and up above skin level. This part of the device is also covered in foam. Drainage is performed through two holes at the top of the device. The device and foam are changed every second to third day, and -120 mm Hg of continuous therapy is used. Six patients were treated with traditional NPWT, serving as control group. RESULTS No signs of calluslike formation were seen on the right ventricle in the group treated with the HeartShield device. In the conventional NPWT control group, all six patients had calluslike formation (>1 × 2 cm2) on the anterior part of the right ventricle. All patients in the HeartShield group had grade 1 epicardial petechial bleeding (<0.5 cm2) on the right ventricle. In the control group, one patient had grade 1 (<0.5 cm2), three patients had grade 2 (0.5-2.0 cm2), and two patients had grade 3 (>2.0 cm2) epicardial petechial bleeding on the right ventricle. No major bleeding or mortality was observed in either group during the course of the study. CONCLUSIONS The use of the HeartShield device significantly minimizes the contact between the right ventricle and the sternal edges, thereby decreasing the risk for life-threatening complications due to bleeding.


title: Role of three-phase bone scintigraphy in paediatric osteoid osteoma eligible for radiofrequency ablation.

text: OBJECTIVE The objective of the study was to underline the importance of three-phase bone scintigraphy at the time of diagnosis in children with suspected osteoid osteoma (OO) who are eligible for radiofrequency ablation. METHODS Fifty-three patients (13 girls; mean age 7.2 years, 20% younger than 10 years of age) who underwent bone scintigraphy for suspected OO between 2005 and 2010 were included in the study, of whom 46 underwent a radiography at diagnosis. Computed tomography-guided biopsy was performed in all patients after bone scintigraphy, and radiofrequency ablation was performed following biopsy in patients with OO; ablation efficacy was confirmed by MRI at 1, 3, 12 and 18 months. RESULTS The radiographic results were negative in 27/46 patients and was unclear in 19. Bone scintigraphy showed lesions in 53/53 patients, of whom 51 patients had a typical pattern of osteoma and nine patients required an additional scan with a pinhole collimator. Histological examination showed OO in 51/53 patients (3/51 intramedullary), Ewing's sarcoma in 1/53 patients, and chronic osteomyelitis in 1/53 patients. CONCLUSION Any child with recurrent nocturnal pain and/or limb swelling should undergo radiography of the involved skeletal segment, which is the first-choice diagnostic method in the clinical suspicion of OO. In the event of ambiguous or negative radiographic results, bone scintigraphy is needed to exclude other pathologic conditions and to confirm the diagnosis. In children with recurrent but not well-localized bone pain in which OO is strongly suspected for signs and symptoms, a bone scan can help detect the lesion. The diagnostic accuracy of the bone scan, particularly for the appendicular skeleton, can be improved by pinhole collimator acquisition.


title: ELEVATED MONOCYTE DISTRIBUTION WIDTH IN COVID-19 PATIENTS: THE CONTRIBUTION OF THE NOVEL SEPSIS INDICATOR.

text: INTRODUCTION Interesting results regarding the contribution of MDW (Monocyte Distribution Width) in the Infectious Disease Unit have been reported. An observational study is ongoing at San Donato Hospital with the aim to evaluate the contribution of MDW in the diagnostic pathway in adult patients entering in the ED setting and tested for SARS-CoV-2. MATERIAL AND METHOD COVID-19 symptomatic and paucisymptomatic patients presenting to ED (Emergency Department), have been enrolled consecutively. Whole blood venous samples have been collected on K2 EDTA for MDW determination, at the same time a nasopharyngeal swab for SARS-CoV-2 RNA detection have been collected. RESULTS One hundred six patients were negative for SARS-CoV-2 with MDW mean value of 20.3 ± 3.3, while forty-one were positive for SARS-CoV-2 with higher MDW mean value of 27.3 ± 4.9 (P <0.005). The ROC curve analysis has been evaluated showing MDW AUC of 0.91. Finally twenty-three patients hospitalized in high-intensity care unit showed an MDW value higher than the eighteen patients presenting few symptoms [28.8 ± 5.3 vs 25.4 ± 3.6 respectively, P<0.05]. DISCUSSION Monocytic population, in Covid19 disease, are the first elements of innate immunity to be involved, these changes are the basis of the modification of the MDW, with evident efficacy in term of sensitivity, particularly in the studied Covid19 patients. Moreover the patients hospitalized in high-intensity care unit showed significantly elevated MDW respects to middle or low symptomatic one, suggest including this parameter as prognostic marker or of therapy efficacy, integrated with other laboratory findings.


title: Evolution and diversity of the human hepatitis d virus genome.

text: Human hepatitis delta virus (HDV) is the smallest RNA virus in genome. HDV genome is divided into a viroid-like sequence and a protein-coding sequence which could have originated from different resources and the HDV genome was eventually constituted through RNA recombination. The genome subsequently diversified through accumulation of mutations selected by interactions between the mutated RNA and proteins with host factors to successfully form the infectious virions. Therefore, we propose that the conservation of HDV nucleotide sequence is highly related with its functionality. Genome analysis of known HDV isolates shows that the C-terminal coding sequences of large delta antigen (LDAg) are the highest diversity than other regions of protein-coding sequences but they still retain biological functionality to interact with the heavy chain of clathrin can be selected and maintained. Since viruses interact with many host factors, including escaping the host immune response, how to design a program to predict RNA genome evolution is a great challenging work.


title: Feasibility and safety of laparoscopic adrenalectomy for large tumours.

text: OBJECTIVE To verify the feasibility and safety of laparoscopic adrenalectomy for large tumours, as since it was described, the laparoscopic approach for adrenalectomy has become the 'gold standard' for small tumours and for large and non-malignant adrenal tumours many studies have reported acceptable results. PATIENTS AND METHODS This is a retrospective study from a general surgery department from January 2006 to December 2013 including 45 patients (56 laparoscopic adrenalectomies). We divided patients into two groups according to tumour size: <5 or ⩾5 cm, we compared demographic data and peri- and postoperative outcomes. RESULTS There was no statistical difference between the two groups for conversion rate (3.7% vs 11.7% P = 0.32), postoperative complications (14% vs 12%, P = 0.4), postoperative length of hospital stay (5 vs 6 days P = 0.43) or mortality (3.5% vs 0% P = 0.99). The only statistical difference was the operating time, at a mean (SD) 155 (60) vs 247 (71) min (P < 0.001). CONCLUSION Laparoscopic adrenalectomy for large tumours needs more time but appears to be safe and feasible when performed by experienced surgeons.


Educating future doctors for uncertainty and complexity.


title: Pancreaticoduodenectomy in portal annular pancreas: report of a case.

text: Portal annular pancreas (PAP) is a rare anatomical anomaly in which the pancreatic parenchyma surrounds the superior mesenteric vein and portal vein (PV) annularly. This anomaly requires careful consideration in pancreatic resection. A case is presented and the technical issues are discussed. A 61-year-old female was referred to the hospital for suspected papilla Vater adenocarcinoma. Preoperative computed tomography showed that the PV was annularly surrounded by pancreatic parenchyma. Surgery revealed the uncinate process extended extensively behind the PV and fused with the pancreatic body. The pancreas was first divided above the PV, and it was divided again in the body after liberating the PV from pancreatic annulation. The postoperative course was uneventful without pancreatic fistula. It is safer to divide the pancreatic body on the left of the fusion between the uncinate process and the pancreatic body to reduce the risk of pancreatic fistula in pancreaticoduodenectomy for PAP.


How to shape research to advance global health.


Double-edged sword of limiting healthcare provision for children in times of COVID-19: the hidden price we pay.


title: Carotid angiographic characteristics in the CREST trial were major contributors to periprocedural stroke and death differences between carotid artery stenting and carotid endarterectomy.

text: OBJECTIVE The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated a higher periprocedural stroke and death (S+D) rate among patients randomized to carotid artery stenting (CAS) than to carotid endarterectomy (CEA). Herein, we seek factors that affect the CAS-CEA treatment differences and potentially to identify a subgroup of patients for whom CAS and CEA have equivalent periprocedural S+D risk. METHODS Patient and arterial characteristics were assessed as effect modifiers of the CAS-CEA treatment difference in 2502 patients by the addition of factor-by-treatment interaction terms to a logistic regression model. RESULTS Lesion length and lesions that were contiguous or were sequential and noncontiguous extending remote from the bulb were identified as influencing the CAS-to-CEA S+D treatment difference. For those with longer lesion length (≥12.85 mm), the risk of CAS was higher than that of CEA (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.19-9.78). Among patients with sequential or remote lesions extending beyond the bulb, the risk for S+D was higher for CAS relative to CEA (OR, 9.01; 95% CI, 1.20-67.8). For the 37% of patients with lesions that were both short and contiguous, the odds of S+D in those treated with CAS was nonsignificantly 28% lower than for CEA (OR, 0.72; 95% CI, 0.21-2.46). CONCLUSIONS The higher S+D risk for those treated with CAS appears to be largely isolated to those with longer lesion length and/or those with sequential and remote lesions. In the absence of those lesion characteristics, CAS appears to be as safe as CEA with regard to periprocedural risk of S+D.