title: Pituitary germinomas: a multi-institutional study analyzing patient demographics and management patterns.

text: PURPOSE Intracranial germinomas are exceedingly rare tumors found in the pineal and suprasellar regions. The extremely low incidence of pituitary germinoma has resulted in a significant gap in knowledge regarding its demographics, management, and treatment outcomes. We present the largest multicenter analysis of pituitary germinomas to date, focused on analyzing demographic and management patterns. METHODS This study utilizes the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program (2004-2016) to study patients with a primary intracranial germinoma of the pituitary gland. We analyzed demographic information and management strategies among adult and pediatric populations and conducted a 20-year overall survival analysis using Kaplan-Meier curve for a descriptive evaluation of survival outcomes between age groups and treatment groups. RESULTS 92 patients were included in the study, consisting of 58% pediatric patients and 42% adults, with overall 60% males. 82% patients received radiation as part of the treatment, with no significant difference between pediatric and adult groups. Chemotherapy was used significantly more in pediatrics (p = 0.0002) while surgery was significantly more common in adults (p = 0.0117). The most common treatment in pediatrics was radiation + chemotherapy (47%), while the most common treatment in adults was radiation + gross total resection + chemotherapy (23%) followed by radiation + gross total resection (19%). Younger age, radiotherapy, and chemotherapy were associated with increased 20-year survival on Kaplan-Meier curves. CONCLUSIONS There exist significant differences in the management of pediatric and adult populations with pituitary germinomas. The low incidence of these tumors makes them challenging to study, but also highlights the importance of national cancer registries in amassing sufficient patient data from which to draw evidence-based conclusions.


title: Postoperative pubic symphysis osteomyelitis after laparoscopic two-team sling with anterior and posterior colporrhaphy.

text: A 53 year-old woman, who previously had a Burch colposuspension, developed osteomyelitis of the pubic symphysis about 1 month after undergoing a laparoscopic 2-team sling with anterior and posterior colporrhaphy. The diagnosis was made on the basis of computed tomography-guided aspiration of the pubic symphysis, which was positive for group B Streptococcus sp. To our knowledge, this is the first case report of osteomyelitis after a laparoscopic retropubic sling procedure. Osteomyelitis is a rare postoperative complication in female pelvic reconstructive surgery but has been reported in cases where the pubic bone is used for anchoring. It is especially unusual in this case because the pubic symphysis was not used for securing the sling.


title: Congenital bronchial artery to pulmonary artery fistula presenting as hemoptysis.

text: A 51-year-old male presented with 2 weeks of hemoptysis. Pulmonary angiography was performed and identified a bronchial artery to pulmonary artery fistula of the right upper lobe. Despite angioembolization, the hemoptysis recurred 1 year later. It was hypothesized that the recurrence occurred due to retrograde filling from the pulmonary arterial side of the abnormality. Right upper lobectomy was performed and resulted in resolution of hemoptysis. We present a case report of a rare, congenital bronchial artery to pulmonary artery fistula.


title: Biodegradable esophageal stent placement does not prevent high-grade stricture formation after circumferential mucosal resection in a porcine model.

text: BACKGROUND Advanced esophageal dysplasia and early cancers have been treated traditionally with esophagectomy. Endoscopic esophageal mucosectomy (EEM) offers less-invasive therapy, but high-degree stricture formation limits its applicability. We hypothesized that placement of a biodegradable stent (BD-stent) immediately after circumferential EEM would prevent stricturing. METHODS Ten pigs (five unstented controls, five BD-stent) were utilized. Under anesthesia, a flexible endoscope with a band ligator and snare was used to incise the mucosa approximately 20 cm proximal to the lower esophageal sphincter. A 10-cm, circumferential, mucosal segment was dissected and excised by using snare electrocautery. In the stented group, an 18-×120-mm, self-expanding, woven polydioxanone stent (ELLA-CS, Hradec-Kralove) was deployed. Weekly esophagograms evaluated for percent reduction in esophageal diameter, stricture length, and proximal esophageal dilation. Animals were euthanized when the stricture exceeded 80% and were unable to gain weight (despite high-calorie liquid diet) or at 14 weeks. RESULTS The control group rapidly developed esophageal strictures; no animal survived beyond the third week of evaluation. At 2 weeks post-EEM, the BD-stent group had a significant reduction in esophageal diameter (77.7 vs. 26.6%, p < 0.001) and degree of proximal dilation (175 vs. 131%, p = 0.04) compared with controls. Survival in the BD-stent group was significantly longer than in the control group (9.2 vs. 2.4 weeks, p = 0.01). However, all BD-stent animals ultimately developed clinically significant strictures (range, 4-14 weeks). Comparison between the maximum reduction in esophageal diameter and stricture length (immediately before euthanasia) demonstrated no differences between the groups. CONCLUSIONS Circumferential EEM results in severe stricture formation and clinical deterioration within 3 weeks. BD-stent placement significantly delays the time of clinical deterioration from 2.4 to 9.2 weeks, but does not affect the maximum reduction in esophageal diameter or proximal esophageal dilatation. The timing of stricture formation in the BD-stent group correlated with the loss radial force and stent disintegration.


title: Intermediate results of a prospective randomized controlled trial of traditional four-port laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy.

text: BACKGROUND Minimally invasive techniques have become an integral part of general surgery, with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents a prospective, randomized, multicenter, single-blind trial of SILC compared with four-port cholecystectomy (4PLC) with the goal of assessing safety, feasibility, and factors predicting outcomes. METHODS Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC or 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Pain, cosmesis, and quality-of-life scores were documented. Patients were followed for 12 months. RESULTS Two hundred patients were randomized to SILC (n = 117) or 4PLC (n = 80) (3 patients chose not to participate after randomization). Patients were similar except for body mass index (BMI), which was lower in the SILC patients (28.9 vs. 31.0, p = 0.011). One SILC patient required conversion to 4PLC. Operative time was longer for SILC (57 vs. 45 min, p < 0.0001), but outcomes, including total adverse events, were similar (34% vs. 38%, p = 0.55). Cosmesis scores favored SILC (p < 0.002), but pain scores were lower for 4PLC (1 point difference in 10-point scale, p < 0.028) despite equal analgesia use. Wound complications were greater after SILC (10% vs. 3%, p = 0.047), but hernia recurrence was equivalent for both procedures (1.3% vs. 3.4%, p = 0.65). Univariate analysis showed female gender, SILC, and younger age to be predictors for increased pain scores, while SILC was associated with improved cosmesis scores. CONCLUSIONS In this multicenter randomized controlled trial of SILC versus 4PLC, SILC appears to be safe with a similar biliary complication profile. Pain scores and wound complication rates are higher for SILC; however, cosmesis scores favored SILC. For patients preferring a better cosmetic outcome and willing to accept possible increased postoperative pain, SILC offers a safe alternative to the standard 4PLC. Further follow-up is needed to detail the long-term risk of wound morbidities, including hernia recurrence.


title: Ocular Surface Expression of SARS-CoV-2 Receptors.

text: PURPOSE The spike proteins of SARS-CoV-2 interact with ACE2 or basigin/CD147 receptors, regulating human-to-human transmissions of COVID-19 together with serine protease TMPRSS2. The expression of these receptors on the ocular surface is unknown. MATERIAL AND METHODS Gene expression of SARS-CoV-2 receptors was investigated in conjunctival epithelial cell samples and in ex-vivo cornea samples using microarray or transcriptome sequencing. RESULTS ACE2 is expressed in conjunctival samples at a low level, while BSG and TMPRSS2 are expressed at intermediate levels in both conjunctiva and cornea. Other receptors such as ANPEP, AGTR2 are expressed at low level in the conjunctiva. Two RNA editing enzymes involved in antiviral responses, APOBEC3A, and ADAR-1 were also highly expressed. CONCLUSIONS The ocular surface may represent an entry point for the SARS-CoV-2 in the human body. The conjunctiva and the cornea can adopt antiviral countermeasures which may explain the low prevalence of eye involvement.


title: The extended nasoseptal flap for coverage of large cranial base defects.

text: BACKGROUND The nasoseptal flap (NSF) is commonly used to repair skull base defects via a transnasal endoscopic approach. The original description of the technique includes 2 parallel incisions that follow the sagittal plane of the septum. We describe a novel modification to the traditional NSF that allows coverage along the posterior wall of the frontal sinus. METHODS In addition to the 2 sagittal incisions, a third incision is made between these coursing along the maxillary crest from the posterior edge to the midportion of the flap. This provides an extension that can be rotated further anteriorly. We report 4 adult patients with skull base defects too large and anterior to cover with a traditional NSF, on whom we successfully reconstructed with the extended flap. We also performed the technique on six cadaver heads (11 flaps) to provide average measurements of the extension. RESULTS Our patients were successfully repaired with maintained flap survival. We were able to achieve an average of 1.9 cm, or 26.8%, of additional length on the cadaveric study. CONCLUSION The relaxing incision described here creates a flap that allows for reconstruction of a larger range of skull base defects.


title: Efficiency and safety of bipolar vessel and tissue sealing in visceral surgery.

text: BACKGROUND The aim of this study was to analyze the efficiency and safety of the bipolar tissue/vessel sealing and cutting device EnSeal(™) in comparison to the conventional clamp and ligation technique in visceral surgery. MATERIAL AND METHODS In an acute animal model, a part of the small bowel, a part of the colon and the kidneys were resected either with the conventional clamp and ligation technique or with EnSeal(™). Operation time, blood loss and blood parameters as well as the lateral thermal spread were evaluated. RESULTS Small bowel, colon and kidney resection time with the EnSeal(™) device was shorter compared to the conventional clamp and ligation technique (small bowel: EnSeal(™): 4.7 ± 1.0 min vs. con: 35.1 ± 2.3 min; colon: EnSeal(™): 7.0 ± 1.4 min vs. con: 16.3 ± 1.5 min, kidney: EnSeal(™): 5.7 ± 1.3 min vs. con: 16.7 ± 3.7 min, p < 0.05) and blood loss was significantly lower. Blood analysis demonstrated no differences in both groups. The lateral thermal spread was not more than 1 mm with EnSeal(™). CONCLUSION The bipolar sealing in visceral surgery with EnSeal(™) can be performed more efficiently in a shorter time, with significantly less blood loss, minimal thermal damage and without changes of blood parameters, indicating biological safety and integrity.


title: Video. Modified single-incision laparoscopic adjustable gastric band.

text: INTRODUCTION This video describes a modified single-incision laparoscopic approach for adjustable gastric band placement. METHOD The patient was a 28-year-old female with a BMI of 48.75 with no prior surgery but with numerous comorbidities. With the patient placed in a split-leg position and in steep reverse Trendelenburg, a 12-mm optical trocar is placed 12 cm distal to the xiphoid process in the left paramedian location. A Nathanson liver retractor is placed through a midepigastric 5-mm incision. Two 5-mm low-profile trocars are placed next to the 12-mm trocar through separate incisions (this maintains stability of each cannula) and a 5-mm 45 ° laparoscope is used. Using an automated suturing device, a stay suture is placed high on the fundus and externalized for retraction. An articulating band passer dissects the phrenogastric attachments at the angle of His. The 12-mm port is removed and the gastric band is inserted. The GE junction fat pad is excised and the Pars Flaccida membrane is divided using conventional instruments. A second traction suture is placed to retract the lesser curve fat and right crus fat pad. A peritoneal bite is also taken in the left lateral subcostal area such that when this suture is externalized, it acts as a pulley. An articulating 5-mm grasper is used to develop the retrogastric tunnel. Then the band is fed into position and its buckle is locked. Three interrupted sutures are placed to create an anterior gastric plication and a fourth antislippage suture is placed below the band along the lesser curve. The band tubing is externalized and the port is implanted by joining the three working trocar incisions into a single 4.5-cm incision. RESULTS The patient did well postoperatively with no complications. CONCLUSIONS A modified single incision approach for laparoscopic gastric band placement is feasible and provides patients with improved cosmesis.


title: Characterization of Bafinivirus main protease autoprocessing activities.

text: The production of functional nidovirus replication-transcription complexes involves extensive proteolytic processing by virus-encoded proteases. In this study, we characterized the viral main protease (M(pro)) of the type species, White bream virus (WBV), of the newly established genus Bafinivirus (order Nidovirales, family Coronaviridae, subfamily Torovirinae). Comparative sequence analysis and mutagenesis data confirmed that the WBV M(pro) is a picornavirus 3C-like serine protease that uses a Ser-His-Asp catalytic triad embedded in a predicted two-β-barrel fold, which is extended by a third domain at its C terminus. Bacterially expressed WBV M(pro) autocatalytically released itself from flanking sequences and was able to mediate proteolytic processing in trans. Using N-terminal sequencing of autoproteolytic processing products we tentatively identified Gln↓(Ala, Thr) as a substrate consensus sequence. Mutagenesis data provided evidence to suggest that two conserved His and Thr residues are part of the S1 subsite of the enzyme's substrate-binding pocket. Interestingly, we observed two N-proximal and two C-proximal autoprocessing sites in the bacterial expression system. The detection of two major forms of M(pro), resulting from processing at two different N-proximal and one C-proximal site, in WBV-infected epithelioma papulosum cyprini cells confirmed the biological relevance of the biochemical data obtained in heterologous expression systems. To our knowledge, the use of alternative M(pro) autoprocessing sites has not been described previously for other nidovirus M(pro) domains. The data presented in this study lend further support to our previous conclusion that bafiniviruses represent a distinct group of viruses that significantly diverged from other phylogenetic clusters of the order Nidovirales.


title: Comparison of short-term outcomes following minimally invasive versus open Sweet esophagectomy for Siewert type II adenocarcinoma of the esophagogastric junction.

text: BACKGROUND Surgical resection is still the main treatment option for patients with resectable Siewert type II adenocarcinoma of the esophagogastric junction (AEG). This retrospective study evaluated the significance of minimally invasive Sweet esophagectomy (MISE) for the treatment of Siewert type II AEG. METHODS We retrospectively evaluated 174 patients with Siewert type II AEG who received a Sweet esophagectomy in our center between October 2013 and September 2017. Of these patients, 73 underwent MISE and 101 underwent open Sweet esophagectomy (OSE). The clinicopathologic factors, operational factors and postoperative complications were compared. RESULTS The two groups were similar in terms of age, sex, American Society of Anesthesiologists grade, preoperative staging and incidence of comorbidities (P > 0.05). Relative to the OSE approach, the MISE approach was associated with a significant decrease in surgical blood loss (P < 0.001), chest tube duration (P = 0.003) and postoperative admission duration (P = 0.002). The minimally invasive approach was associated with significantly less total morbidity and fewer respiratory complications than the open approach (P = 0.015 and P = 0.016, respectively). Relative to the open approach, the MISE approach was associated with a significant increase in the number of total lymph nodes removed and the locations of the total lymph nodes removed (P < 0.001 and P < 0.001, respectively). CONCLUSIONS Our MISE technique can be safely and effectively performed for intrathoracic anastomosis with favorable early outcomes.


title: A systematic review of the barriers and facilitators to the provision and use of low-tech and unaided AAC systems for people with complex communication needs and their families.

text: PURPOSE Speech-language pathologists may introduce augmentative or alternative communication (AAC) systems to people who are unable to use speech for everyday communication. Despite the benefits of AAC systems, they are significantly underutilized by the people with complex communication needs. The current review aimed to synthesize the barriers and facilitators to the provision and use of low-tech and unaided AAC systems. Materials and methods: Relevant literature was identified via a systematic search strategy. Included articles (n = 43) were evaluated using the Critical Appraisal Skills Programme. Qualitative framework analysis was then completed with reference to the International Classification of Functioning, Disability, and Health (ICF). Results and conclusion: Most barriers and facilitators were coded as contextual factors within the ICF. Of most prominence were environmental factors, including attitudes of and supports provided by professionals, family members, and the society at large. Themes were also identified which related to the personal factors, including the user's own attitude, socioeconomic status, and culture. Beyond these contextual factors, the remaining codes related to body functions such as cognition and movement. There are numerous barriers to the provision and use of low-tech and unaided AAC systems, which may contribute to the inadequate use of these systems by people with complex communication needs. Suggestions for reducing these barriers are presented with regards to the person with complex communication needs, their family, and the professionals involved in their care. Implications for Rehabilitation AAC systems can reduce participation restrictions for people with complex communication needs. The provision and use of AAC systems is influenced by environmental factors, personal factors, and features of a person's body function. SLPs may need to collaborate with a large multidisciplinary team to successfully introduce AAC systems. SLP, teaching, and nursing students require theoretical and practical experience in AAC throughout their training to enable the provision and use of these systems.


title: Utility of computed tomography fusion imaging for the evaluation of the ablative margin of radiofrequency ablation for hepatocellular carcinoma and the correlation to local tumor progression.

text: AIM To demonstrate the usefulness of the computed tomography (CT) fusion imaging for the evaluation of treatment effect of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). METHODS Eighty-five patients with 94 HCC with complete ablation judged on conventional side-by-side interpretation of pre-RFA and post-RFA CT at the time of RFA were included in this retrospective study. CT data was retrospectively used to create fusion images of pre-RFA and post-RFA CT using automatic rigid registration and manual correction referring to intrahepatic structures and hepatic contours around a tumor. Clinical factors including a minimal ablative margin (MAM) measured on fusion images were examined to prove risk factors for local tumor progression (LTP). RESULTS LTP was observed in 13 (13.8%) tumors with a median follow up of 21.0 months (range, 2-75). The mean MAM on the fusion image was 1.4 ± 3.1 mm and 23 tumors (24.5%) were judged to be protruding from the ablation zone. Multivariate analysis revealed that protruding from the ablation zone was the only significant factor for LTP (hazard ratio, 7.09; 95% confidential interval, 2.26-22.3; P < 0.001). CONCLUSION Some HCC were assessed as incomplete ablation on the CT fusion images, although considered completely ablated on side-by-side images at the time of treatment, and incomplete ablation was revealed to be the only independent risk factor for LTP. The CT fusion imaging enables quantitative and accurate evaluation of treatment effect of RFA.


title: Inhibitory concentration of propofol in combination with dexmedetomidine during microelectrode recording for deep brain stimulator insertion surgeries under general anesthesia.

text: BACKGROUND Microelectrode recording (MER) for target refinement is widely used in deep brain stimulator insertion for Parkinson disease. Signals may be influenced by anesthetics when patients receive general anesthesia (GA). This study determined the inhibitory concentration of propofol on MER signals when it was coadministered with dexmedetomidine. METHODS Patients were anesthetized with dexmedetomidine (0.5 µg·kg loading, followed by infusion at 0.4 µg·kg·h) and propofol through target-controlled infusion for general anesthesia with tracheal intubation. The surgeon conducted the online scoring of the background signals, spiking frequency, amplitude, and pattern of single-unit activities by using a 0-10 verbal numerical rating scale (NRS; 0, maximal suppression; 10, minimal suppression), and responses were grouped into suppression (NRS ≤ 6) and nonsuppression (NRS > 6). The median inhibitory concentration (IC50) of propofol (as target effect-site concentrations: Ceprop) was determined using modified Dixon's up-and-down method (UDM). Probit regression analysis was further used to obtain the dose-response relationship, and IC05 and IC95 were calculated. RESULTS Twenty-three adult patients participated in this study. Under the concomitant infusion of dexmedetomidine, the predicted IC50 value (95% confidence interval; CI) of Ceprop for neuronal suppression during MER was 1.29 (1.24-1.34) µg·mL as calculated using modified Dixon's UDM. Using probit analysis, the estimated IC05, IC50, and IC95 values (95% CIs) were 1.17 (0.87-1.23), 1.28 (1.21-1.34), and 1.40 (1.33-1.85) µg·mL, respectively. CONCLUSION Our data provided reference values of propofol for dosage adjustment to avoid interference on MER under GA when anesthetics have to be continuously infused during recording.


title: Current perspectives on Coronavirus 2019 (COVID-19) and cardiovascular disease: A white paper by the JAHA editors.

text: Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has infected more than 3.0 million people worldwide and killed more than 200,000 as of April 27, 2020, making it the most lethal pandemic since the Spanish flu of 1918.1, 2 COVID-19 may preferentially infect individuals with cardiovascular conditions, is more severe in subjects with cardiovascular comorbidities, may directly or indirectly affect the heart and may interact with cardiovascular medications.3 In addition, the widespread effects of the pandemic on the global healthcare system affects the routine and emergency cardiac care for patients who are, may be, or are not infected with COVID-19.


title: Management of Fournier's gangrene non-healing wounds by autologous skin micrograft biotechnology: a new technique.

text: Fournier's gangrene is an acute bacterial infection producing necrosis of the perineum and external genitalia that generally affects elderly men. Although skin grafts and flaps are the standard procedure for reconstruction, sometimes wounds can become chronic. Rigenera Protocol is a new technique based on autologous skin micrografts that reactivates and supports wound healing. A 40-year-old male with Fournier's gangrene, due to a rectal microperforation following diarrhoea, was treated with surgical debridement, negative pressure wound therapy and subsequently coverage with skin grafts. He developed non-healing wounds treated by Rigenera protocol after two months of advanced wound dressings. This technique is based on skin micrografts obtained by mechanical dermal disgregation to provide mesenchymal stem cells and extracellular matrix to the wound. The suspension injected into the wound triggers reactivation of healing without significant residual scarring on both donor site and treated area. Non-healing wounds were reduced by 15% at day 7 and by 50% after 30 days. Wounds completely healed after seventy days. The regenerated tissue appeared closer to skin graft than to scar tissue. This report shows how the use of skin micrografts through Rigenera protocol can be a useful method to reactivate wound healing resulting from Fournier's gangrene, with no discomfort for patient in a practical, safe and easy way.


title: Trend of urban-rural disparities in hospital admissions and medical expenditure in China from 2003 to 2011.

text: OBJECTIVES To assess the trend of urban-rural disparities in hospital admissions and medical expenditure between 2003 and 2011 in the context of Chinese health-care system reform. METHODS The data were from three different national surveys: the Third National Health Services Survey in 2003, the Fourth National Health Services Survey in 2008 and the national health-care reform phased assessment survey in 2011. There were 151421, 143380 and 48356 respondents aged 15 years or older in 2003, 2008 and 2011, respectively. RESULTS The health insurance coverage expanded considerably from 27.7% in 2003 to 96.4% in 2011 among respondents aged 15 years or older. Hospitalization rate increased rapidly from 4.1% in 2003 to 9.6% in 2011. Urban respondents had higher hospital admissions than rural respondents, and the RR (95% CI) of hospitalization was 1.23 (1.17-1.30), 1.06 (1.02-1.10) and 1.16 (1.10-1.23) in 2003, 2008 and 2011, respectively. The urban-rural disparity in hospital admissions significantly narrowed over time. Urban respondents had a higher admission rate if insured and a lower admission if not insured than their rural counterparts. Of the six medical expenditure measures, the disparities in reimbursement rate and the proportion of hospitalization direct cost to the total consumer spending significantly narrowed. CONCLUSIONS The health insurance coverage has been continually expanding and health service utilization has been substantially improved. Urban-rural disparities have been narrowed but still exist. Therefore, policy-makers should focus on increasing investment and reimbursement levels, developing a uniform standard health insurance system for urban and rural residents and improving the medical assistance system.


Peripheral Blood Smear Findings in COVID-19.


title: An authentic animal model of the very preterm infant on nasal continuous positive airway pressure.

text: BACKGROUND The surge in uptake of nasal continuous positive airway pressure (CPAP) for respiratory support in preterm infants has occurred in the absence of an authentic animal model. Such a model would allow investigation of research questions of physiological and therapeutic importance. We therefore aimed to develop a preterm lamb model of the non-intubated very preterm infant on CPAP. METHODS After staged exteriorisation and instrumentation, preterm lambs were delivered from anaesthetised ewes at 131 to 133 days gestation. Via a single nasal prong (4-mm internal diameter, 6- to 7-cm depth), positive pressure was delivered from the outset, with nasal intermittent positive pressure ventilation (NIPPV) used until transition to nasal CPAP was attempted, and periodically thereafter for hypoventilation. Caffeine and doxapram were used as respiratory stimulants. Gastric distension was prevented with an oesophageal balloon. Cardiorespiratory parameters and results of arterial blood gas analyses were monitored throughout the study period, which continued for 150 min after first transition to CPAP. RESULTS Ten preterm lambs were studied, at gestation 132 ± 1 days (mean ± SD) and birth weight 3.6 ± 0.45 kg. After stabilisation on NIPPV, transition to nasal CPAP was first attempted at 28 ± 11 min. There was transient respiratory acidosis, with gradual resolution as spontaneous respiratory activity increased. In the final hour, 79% ± 33% of time was spent on CPAP alone, with typical respiratory rates around 60 breaths per minute. PaCO2 at end-experiment was 58 ± 36 mmHg. CONCLUSIONS Non-intubated preterm lambs can be effectively transitioned to nasal CPAP soon after birth. This animal model will be valuable for further research.


title: COVID-19 as an Acute Inflammatory Disease.

text: The 2019 coronavirus disease (COVID-19) pandemic caused by the virus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has created an unprecedented global crisis for the infrastructure sectors, including economic, political, healthcare, education, and research systems. Although over 90% of infected individuals are asymptomatic or manifest noncritical symptoms and will recover from the infection, those individuals presenting with critical symptoms are in urgent need of effective treatment options. Emerging data related to mechanism of severity and potential therapies for patients presenting with severe symptoms are scattered and therefore require a comprehensive analysis to focus research on developing effective therapeutics. A critical literature review suggests that the severity of SARS-CoV-2 infection is associated with dysregulation of inflammatory immune responses, which in turn inhibits the development of protective immunity to the infection. Therefore, the use of therapeutics that modulate inflammation without compromising the adaptive immune response could be the most effective therapeutic strategy.


title: Gastric emptying and intestinal appearance of nonabsorbable drugs phenol red and paromomycin in human subjects: A multi-compartment stomach approach.

text: The goal of this study was to create a mass transport model (MTM) model for gastric emptying and upper gastrointestinal (GI) appearance that can capture the in vivo concentration-time profiles of the nonabsorbable drug phenol red in solution in the stomach and upper small intestine by direct luminal measurement while simultaneously recording the contractile activity (motility) via manometry. We advanced from a one-compartmental design of the stomach to a much more appropriate, multi-compartmental 'mixing tank' gastric model that reflects drug distribution along the different regions of the stomach as a consequence of randomly dosing relative to the different contractile phases of the migrating motor complex (MMC). To capture the intraluminal phenol red concentrations in the different segments of the GI tract both in fasted and fed state conditions, it was essential to include a bypass flow compartment ('magenstrasse') to facilitate the transport of the phenol red solution directly to the duodenum (fasted state) or antrum (fed state). The fasted and fed state models were validated with external reference data from an independent aspiration study using another nonabsorbable marker (paromomycin). These results will be essential for the development and optimization of computational programs for GI simulation and absorption prediction, providing a realistic gastric physiologically-based pharmacokinetic (PBPK) model based on direct measurement of gastric concentrations of the drug in the stomach.


Crowdsourcing drug discovery for pandemics.


title: The LVIS Jr. microstent to assist coil embolization of wide-neck intracranial aneurysms: clinical study to assess safety and efficacy.

text: INTRODUCTION This study was aimed to assess clinical safety and efficacy of the LVIS Jr. microstent in stent-assisted coil embolization of wide-neck intracranial aneurysms. METHODS IRB approved single-center interventional clinical study in 22 patients (10 females, 12 males, mean age 55, age range 33-74 years) for the endovascular treatment of wide-neck aneurysms. After obtaining informed consent, patients were included according to the following criteria: aneurysm fundus-to-neck ratio < 2 or neck diameter > 4 mm, and a parent vessel diameter of ≤3.5 mm. Primary end point for clinical safety was absence of death, absence of major or minor stroke, and absence of transient ischemic attack. Primary end point for treatment efficacy was complete angiographic occlusion according to the Raymond-Roy Occlusion Classification (RROC) immediately after the procedure and at follow-up after 3 and 6 months on magnetic resonance imaging (MRI). RESULTS In 20/22 (91 %) of patients, the primary end point of safety was reached; in the two remaining patients, transient ischemic attack, but no permanent deficit was observed; in 16/22 (73 %), efficient occlusion (RROC1) was reached, and in 6/22 (27 %), a residual neck remained (RROC2). Single [seven with antegrade, two in crossover configuration, and four with "first-balloon-then-stent" (FBTS) technique] or double-stent (eight patients with Y configuration and one patient with X configuration) deployment was technically successful in all cases. CONCLUSION Deployment of the LVIS Jr. microstent in various single- or double-stent configurations is safe and effective to assist the treatment of intracranial wide-neck aneurysms.


title: Shotgun Lipidomic Profiling of the NCI60 Cell Line Panel Using Rapid Evaporative Ionization Mass Spectrometry.

text: Rapid evaporative ionization mass spectrometry (REIMS) was used for the rapid mass spectrometric profiling of cancer cell lines. Spectral reproducibility was assessed for three different cell lines, and the extent of interclass differences and intraclass variance was found to allow the identification of these cell lines based on the REIMS data. Subsequently, the NCI60 cell line panel was subjected to REIMS analysis, and the resulting data set was investigated for its distinction of individual cell lines and different tissue types of origin. Information content of REIMS spectral profiles of cell lines were found to be similar to those obtained from mammalian tissues although pronounced differences in relative lipid intensity were observed. Ultimately, REIMS was shown to detect changes in lipid content of cell lines due to mycoplasma infection. The data show that REIMS is an attractive means to study cell lines involving minimal sample preparation and analysis times in the range of seconds.


title: Deleterious effects of viral pneumonia on cardiovascular system.

text: Viral pneumonia has a significant effect on the cardiovascular system through various mechanisms; even though it is traditionally regarded as a pulmonary disease characterized by dyspnoea and hypoxaemia. Recent research works have shown that cardiovascular events outweigh all other causes of death in various influenza pandemics. Therefore, the exploration of the effects of viral pneumonia on cardiovascular system becomes increasingly essential. The objective of this review is three-fold: first, to summarize the knowledge about the epidemiological characteristics and clinical manifestations of viral infections that are the recent causes of global pandemics; second, to explore the cardiovascular response to these infections; and third, to attempt in identifying the possible coping strategies of the Wuhan epidemic and the future viral infection pandemics.


Recent Advances in Molecular diagnosis curbing the COVID-19.


title: Muscle Activation During Pilates Exercises in Participants With Chronic Nonspecific Low Back Pain: A Cross-Sectional Case-Control Study.

text: OBJECTIVE To determine the amplitude of the electromyographic activity of trunk muscles during Pilates exercises in women with and without chronic low back pain (LBP). DESIGN Case-control study. SETTING University physical therapy clinic. PARTICIPANTS Women (N=60) divided into an LBP group and a control group. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Amplitude of the electromyographic activity (root mean square values) of the gluteus maximus and external oblique muscles collected during 3 Pilates exercises: Shoulder Bridge performed on the mat, and Hip Roll and Breathing performed in equipment. Pain intensity was assessed in the LBP group. RESULTS The amplitude of the electromyographic activity was similar between groups (P≥.05). For both groups, the amplitude of the gluteus maximus was higher in the Shoulder Bridge exercise compared with the Hip Roll with 2 springs (control group: mean difference [MD]=.18; 95% confidence interval [CI], .05-.41; LBP group: MD=.29; 95% CI, .16-.31) and the Breathing exercise (control group: MD=-.40; 95% CI, -.55 to -.26; LBP group: MD=-.36; 95% CI, -.52 to -.20). The amplitude of the external oblique muscle was higher in the Shoulder Bridge compared with the Hip Roll with 2 springs (control group: MD=.13; 95% CI, .05-.21; LBP group: MD=.18; 95% CI, .03-.33). Pain intensity increased after exercises, but this increase was lower for the mat exercises. CONCLUSIONS Similar muscle activation between groups was found. The findings suggest that mat exercises caused less pain and a greater difference in the amplitude of muscle activation compared with the equipment-based exercises.


title: Self-stabilizing colonic capsule endoscopy: pilot study of acute canine models.

text: Video capsule endoscopy (VCE) is a noninvasive method for examining the gastrointestinal tract which has been successful in small intestine studies. Recently, VCE has been attempted in the colon. However, the capsule often tumbles in the wider colonic lumen, resulting in missed regions. Self-stabilizing VCE is a novel method to visualize the colon without tumbling. The aim of the present study was to comparatively quantify the effect of stabilization of a commercially available nonmodified capsule endoscope (CE) MiroCam and its modified self-stabilizing version in acute canine experiments. Two customized MiroCam CEs were reduced in volume at the nonimaging back-end to allow the attachment of a self-expanding, biocompatible stabilizing device. Four mongrel dogs underwent laparotomy and exteriorization of a 15-cm segment of the proximal descending colon. A single CE, either self-stabilizing or nonmodified was inserted through an incision into the lumen of the colon followed by pharmacologically induced colonic peristalsis. The inserted capsule was propelled distally through the colon and expelled naturally through the anus. Novel signal processing method was developed to quantify the video stabilization based on camera tracking a predetermined target point (locale). The average locale trajectory, the average radius movement of the locale, and the maximum rate of change of the locale for sequential images were significantly lower for the stabilized capsules compared to the nonstabilized ones . The feasibility of self-stabilized capsule endoscopy has been demonstrated in acute canine experiments.


title: Cardiac Rehabilitation During COVID-19 Pandemic: Highlighting the Value of Home-Based Programs.

text: Cardiac rehabilitation (CR) is a class I treatment for cardiovascular disease, however, underutilization of these services remains. Home-based CR (HBCR) models have been implemented as a potential solution to addressing access barriers to CR services. Home-based models have been shown to be effective, however, there continues to be large variation of protocols and minimal evidence of effectiveness in higher risk populations. In addition, lack of reimbursement models has discouraged the widespread adoption of HBCR. During the coronavirus 2019 (COVID-19) pandemic, an even greater gap in CR care has been present due to decreased availability of on-site services. The COVID-19 pandemic presents a time to highlight the value and experiences of home-based models as clinicians search for ways to continue to provide care. Continued review and standardization of HBCR models are essential to provide care for a wider range of patients and circumstances.


title: Jet or intensive care unit ventilator during simulated percutaneous transtracheal ventilation: a lung model study.

text: BACKGROUND Percutaneous transtracheal ventilation (PTV) via a jet ventilator (PTJV) is considered a rescue technique in difficult airway management. However, whether a conventional ventilator can generate adequate ventilation via PTV is not known. Our goal was to evaluate the tidal volume (V(T)) generated by a conventional ventilator during simulated PTV compared with PTJV in a lung model. METHODS A lung model simulating an adult lung was used. A catheter was inserted through the artificial trachea and connected to either a jet ventilator or a conventional ventilator. The direction of catheter insertion was perpendicular to the trachea, pointing towards the lung and away from the lung. The jet ventilator was operated at 344.7 kPa. The conventional ventilator was operated in the pressure mode at peak inspiratory pressures of 40-90 cm H(2)O. RESULTS The jet ventilator generated larger V(T) [817 (336) ml] when the catheter was pointing towards the lung than when pointing away from the lung or perpendicular to the trachea [121 (41) and 69 (24) ml, respectively, P<0.01]. With the conventional ventilator, changes in V(T) at different direction of catheter insertion were much less [222 (81) ml catheter pointing towards the lung, 229 (121) ml perpendicular to the trachea, and 187 (97) ml away from the lung]. CONCLUSIONS Our result demonstrated that PTJV was effective only when the catheter was pointing towards the lung and requires high operating pressure. A conventional ventilator can generate reasonable minute ventilation through the transtracheal catheter less dependent on directions of catheter insertion and should be considered during emergent PTV.


title: The use of smart technologies in enabling construction components reuse: A viable method or a problem creating solution?

text: The exploitation of Radio Frequency Identification (RFID) for tracking and archiving the properties of structural construction components could be a potentially innovative disruption for the construction sector. This is because RFID can stimulate the reuse of construction components and reduce their wastage, hence addressing sustainability issues in the construction sector. To test the plausibility of that idea, this study explores the potential pre-conditions for RFID to facilitate construction components reuse, and develops a guidance for promoting their redistribution back to the supply chain. It also looks at how integrating RFID with Building Information Modelling (BIM) can possibly be a valuable extension of its capabilities, providing the opportunity for tracked components to be incorporated into new structures in an informed, sound way. A preliminary assessment of the strengths, weaknesses, opportunities and threats of the RFID technology is presented in order to depict its current and future potential in promoting construction components' sustainable lifecycle management, while emphasis has been laid on capturing their technical, environmental, economic and social value. Findings suggest that the collection of the right amount of information at the design-construction-deconstruction-reuse-disposal stage is crucial for RFID to become a successful innovation in the construction sector. Although a number of limitations related to the technical operability and recycling of RFID tags seem to currently hinder its uptake for structural components' lifecycle management, future technological innovations could provide solutions that would enable it to become a mainstream practice. Taken together these proposals advocate that the use of RFID and its integration with BIM can create the right environment for the development of new business models focused on sustainable resource management. These models may then unlock multiple values that are otherwise dissipated in the system. If the rapid technological development of RFID capability can be allied to policy interventions that control and manage its uptake along the supply chain, the sustainable lifecycle management of construction components could be radically enhanced.


title: Laparoscopic transabdominal preperitoneal (TAPP) groin hernia repair using n-butyl-2-cyanoacrylate (Liquiband®Fix8™) for mesh fixation and peritoneal closure: learning experience during introduction into clinical practice.

text: INTRODUCTION In a single centre evaluation of a novel hernia repair device, 200 consecutive patients underwent 247 laparoscopic (TAPP) groin hernia repairs (47 bilateral) using n-butyl-2-cyanoacrylate (Liquiband®Fix8™) for mesh fixation and peritoneal closure over a 2-year period by a single experienced laparoscopic surgeon. PATIENTS AND METHODS All groin hernia patients requiring TAPP repair were included in the study: Inguinal 142, Femoral 14, Spigelian 4, and Inguinal disruption 40. A retrospective review of the data was performed. There were 161 males and 39 females, mean age 55 years (range 20-89 years). Mesh fixation was successful in all 247 TAPP repairs, and 90% of patients had a successful peritoneal closure using the device (20 patients required the use of conventional tacks to complete closure). FOLLOW-UP Patients were followed up with an out-patient visit at 6 weeks post-op, followed by a Patient Initiated Follow Up programme, and a final Telephone follow-up. To date all patients have completed 1 year of follow-up, and 70% of patients 2 years of follow-up (median 29 months, range 14 to 40 months). RESULTS There were very few procedure-related adverse events: groin seromas 6 (2.4%), port site bleeding 2 (0.3%), port site hernia 2 (0.3%), and only 1 groin hernia recurrence (0.4%). Prospective surgeon scoring of satisfaction for mesh fixation, peritoneal closure, and device clogging was favourable and increased following the initial learning phase. Changes in the device design during the study period improved the efficacy of the device significantly. CONCLUSION This retrospective study shows that mesh fixation and peritoneal closure using the Liquiband®Fix8™ device is feasible, safe, practical, and is easy to learn.


title: Isolation and Characterization of a Novel Bat Coronavirus Closely Related to the Direct Progenitor of Severe Acute Respiratory Syndrome Coronavirus.

text: We report the isolation and characterization of a novel bat coronavirus which is much closer to the severe acute respiratory syndrome coronavirus (SARS-CoV) in genomic sequence than others previously reported, particularly in its S gene. Cell entry and susceptibility studies indicated that this virus can use ACE2 as a receptor and infect animal and human cell lines. Our results provide further evidence of the bat origin of the SARS-CoV and highlight the likelihood of future bat coronavirus emergence in humans.


title: Reduction of chronic post-herniotomy pain and recurrence rate. Use of the anatomical self-gripping ProGrip laparoscopic mesh in TAPP hernia repair. Preliminary results of a prospective study.

text: INTRODUCTION The role of fixation of the mesh is especially important in the endoscopic technique. The fixation of mesh through penetrating techniques using staples, clips or screws is associated with a significantly increased risk of developing a post-herniotomy pain syndrome. AIM To demonstrate the safety and efficacy of the self-fixating anatomical Parietex ProGrip laparoscopic mesh (Sofradim Production, Trévoux France) used with laparoscopic transabdominal preperitoneal hernia repair. The incidence of chronic post-herniotomy pain and recurrence rate in the follow-up after 12 months were evaluated. MATERIAL AND METHODS Data analysis included all patients who underwent inguinal hernia surgery at our Surgical Department within the period from 1.05.2013 to 31.12.2014, who fulfilled the inclusion criteria. Standard surgical technique was used. Data were prospectively entered and subsequently analyzed on the Herniamed platform. Herniamed is an internet-based register in German and English language and includes all data of patients who underwent surgery for some types of hernia. RESULTS There were 95 patients enrolled in the group and there were in total 156 inguinal hernias repaired. The mean follow-up was 15.52 months. At the assessment at 1 year mild discomfort in the groin was reported in 2 patients (3.51%) (1-3 VAS). No recurrence or chronic postoperative pain was reported. CONCLUSIONS Laparoscopic inguinal hernia repair using the transabdominal preperitoneal technique with implantation of the ProGrip laparoscopic mesh is a fast, effective and reliable method in experienced hands, which according to our results reduces the occurrence of chronic post-operative inguinal pain with simultaneously a low recurrence rate.


title: Clinical Sequencing Uncovers Origins and Evolution of Lassa Virus.

text: The 2013-2015 West African epidemic of Ebola virus disease (EVD) reminds us of how little is known about biosafety level 4 viruses. Like Ebola virus, Lassa virus (LASV) can cause hemorrhagic fever with high case fatality rates. We generated a genomic catalog of almost 200 LASV sequences from clinical and rodent reservoir samples. We show that whereas the 2013-2015 EVD epidemic is fueled by human-to-human transmissions, LASV infections mainly result from reservoir-to-human infections. We elucidated the spread of LASV across West Africa and show that this migration was accompanied by changes in LASV genome abundance, fatality rates, codon adaptation, and translational efficiency. By investigating intrahost evolution, we found that mutations accumulate in epitopes of viral surface proteins, suggesting selection for immune escape. This catalog will serve as a foundation for the development of vaccines and diagnostics. VIDEO ABSTRACT.


title: Management of High Hepatopulmonary Shunting in Patients Undergoing Hepatic Radioembolization.

text: PURPOSE To review the safety of hepatic radioembolization (RE) in patients with high (≥ 10%) hepatopulmonary shunt fraction (HPSF) using various prophylactic techniques. MATERIALS AND METHODS A review was conducted of 409 patients who underwent technetium 99m-labeled macroaggregated albumin scintigraphy before planned RE. Estimated pulmonary absorbed radiation doses based on scintigraphy and hepatic administered activity were calculated. Outcomes from dose reductions and adjunctive catheter-based prophylactic techniques used to reduce lung exposure were assessed. RESULTS There were 80 patients with HPSF ≥ 10% who received RE treatment (41 resin microspheres for metastases, 39 glass microspheres for hepatocellular carcinoma). Resin microspheres were used in 17 patients according to consensus guideline-recommended dose reduction; 38 patients received no dose reduction because the expected lung dose was < 30 Gy. Prophylactic techniques were used in 25 patients (with expected lung dose ≤ 74 Gy), including hepatic vein balloon occlusion, variceal embolization, or bland arterial embolization before, during, or after RE delivery. Repeated scintigraphy after prophylactic techniques to reduce HPSF in seven patients demonstrated a median change of -40% (range, +32 to -69%). Delayed pneumonitis developed in two patients, possibly related to radiation recall after chemoembolization. Response was lower in patients treated with resin spheres with dose reduction, with an objective response rate of 13% and disease control rate of 47% compared with 56% and 94%, respectively, without dose reduction (P = .023, P = .006). CONCLUSIONS Dose reduction recommendations for HPSF may compromise efficacy. Excessive shunting can be reduced by prophylactic catheter-based techniques, which may improve the safety of performing RE in patients with high HPSF.


title: Infusion of Reconstituted High-Density Lipoprotein, CSL112, in Patients With Atherosclerosis: Safety and Pharmacokinetic Results From a Phase 2a Randomized Clinical Trial.

text: BACKGROUND CSL112 is a new formulation of human apolipoprotein A-I (apoA-I) being developed to reduce cardiovascular events following acute coronary syndrome. This phase 2a, randomized, double-blind, multicenter, dose-ranging trial represents the first clinical investigation to assess the safety and pharmacokinetics/pharmacodynamics of a CSL112 infusion among patients with stable atherosclerotic disease. METHODS AND RESULTS Patients were randomized to single ascending doses of CSL112 (1.7, 3.4, or 6.8 g) or placebo, administered over a 2-hour period. Primary safety assessments consisted of alanine aminotransferase or aspartate aminotransferase elevations >3× upper limits of normal and study drug-related adverse events. Pharmacokinetic/pharmacodynamic assessments included apoA-I plasma concentration and measures of the ability of serum to promote cholesterol efflux from cells ex vivo. Of 45 patients randomized, 7, 12, and 14 received 1.7-, 3.4-, and 6.8-g CSL112, respectively, and 11 received placebo. There were no clinically significant elevations (>3× upper limit of normal) in alanine aminotransferase or aspartate aminotransferase. Adverse events were nonserious and mild and occurred in 5 (71%), 5 (41%), and 6 (43%) patients in the CSL112 1.7-, 3.4-, and 6.8-g groups, respectively, compared with 3 (27%) placebo patients. The imbalance in adverse events was attributable to vessel puncture/infusion-site bruising. CSL112 resulted in rapid (T(max)≈2 hours) and dose-dependent increases in apoA-I (145% increase in the 6.8-g group) and total cholesterol efflux (up to 3.1-fold higher than placebo) (P<0.001). CONCLUSIONS CSL112 infusion was well tolerated in patients with stable atherosclerotic disease. CSL112 immediately raised apoA-I levels and caused a rapid and marked increase in the capacity of serum to efflux cholesterol. This potential novel approach for the treatment of atherosclerosis warrants further investigation. CLINICAL TRIAL REGISTRATION URL: http://www.ClinicalTrials.gov. Unique identifier: NCT01499420.


Roles and challenges of traditional Chinese medicine in COVID-19 in Hong Kong.


Helen Salisbury: Who is vulnerable?


title: The impact of social amplification and attenuation of risk and the public reaction to mad cow disease in Canada.

text: Following the detection of bovine spongiform encephalopathy (BSE) in Canada, and subsequently in the United States, confidence in the safety of beef products remained high. Consumers actually increased their consumption of beef slightly after the news of an increased risk from mad cow disease, which has been interpreted as public support for beef farmers and confidence in government regulators. The Canadian public showed a markedly different reaction to the news of domestic BSE than the furious and panicked responses observed in the United Kingdom, Germany, and Japan. Using the social amplification of risk framework, we show that, while other countries displayed social amplification of risk, Canada experienced a social attenuation of risk. The attenuated reaction in Canada toward mad cow disease and increased human health risks from variant Creutzfeldt-Jakob disease (vCJD) was due to the social context at the time when BSE was discovered domestically. Mortality, morbidity, and psychosocial impacts resulting from other major events such as severe acute respiratory syndrome (SARS), West Nile virus (WNV), and the U.S.-Iraq war made the theoretical risks of BSE and vCJD a lower priority, reducing its concern as a risk issue.


title: Case of COVID-19 presenting with gastrointestinal symptoms.

text: Patients with coronavirus disease 2019 (COVID-19) predominantly present with the pulmonary symptoms such as fever, cough, and shortness of breath. We present a case of an 83 years old patient with COVID-19 who presented with only gastrointestinal symptoms without respiratory complaints. Our case raises the concern regarding our current lack of understanding of extrapulmonary manifestations of COVID-19. Given genetic homology between 2019 severe acute respiratory syndrome coronavirus (SARS-CoV) 2 and SARS-CoV, our case underscores the urgent need for further studies to understand the role of the gastrointestinal system in 2019 SARS-CoV-2 transmission and COVID-19 pathogenesis.


Personal protective equipment during COVID-19 outbreak at the First Affiliated Hospital of Wenzhou Medical University, China.


Preventing COVID-19 in Assisted Living Facilities-A Balancing Act.


Human infection with Eurasian avian-like influenza A(H1N1) virus, China.


title: Cervical carotid artery stenosis: latest update on diagnosis and management.

text: Carotid atherosclerotic disease is implicated in 15% to 30% of all ischemic strokes. Carotid endarterectomy has been the standard treatment for carotid artery atherosclerosis, but carotid angioplasty and stenting have emerged as a less-invasive treatment alternative. In this article, we review the recent literature on the epidemiology, pathophysiology, investigations, and treatment for atherosclerotic carotid artery disease, focusing on the role of carotid endarterectomy and carotid angioplasty and stenting in the treatment of symptomatic and asymptomatic carotid lesions.


title: Natural orifice proctectomy using a transanal endoscopic microsurgical technique in a porcine model.

text: BACKGROUND Transanal endoscopic microsurgery (TEM) has been used for several decades for excision of neoplastic lesions in the rectum. With the development of natural orifice translumenal endoscopic surgery (NOTES) techniques, the authors describe a new method of proctectomy using a combination of TEM and NOTES principles. METHODS In a porcine model, a circumferential rectal sleeve resection was performed using TEM with flexible endoscopic assistance. The rectum was delivered through the anus, resected, and an end-to-end stapled anastomosis was performed. RESULTS The specimen was approximately 10 cm in length. No adjacent organ injuries or evidence of hemorrhage from the vascular pedicle or in the pelvis was observed at necropsy. Procedure time was 3 hours. CONCLUSION This technique may increase the complexity of lesions accessible by TEM and may ultimately lead to the performance of total mesorectal excision using transanal techniques, reducing the morbidity of the abdominal approach.


title: The Era of COVID-19 and the Rise of Science Collectivism in Cancer Research.

text: The coronavirus SARS-CoV-2 has created a global pandemic that has killed more than a quarter million people since December 2019, halted commerce, and disrupted our ability to research cancer in the laboratory and clinic and care for our patients. A return toward a functioning society can be facilitated by the active participation of cancer researchers to diagnose and treat SARS-CoV-2 infected patients, and the direct and indirect benefits of our involvement cannot be overstated.


title: Extensive toxic epidermal necrolysis versus acute graft versus host disease after allogenic hematopoietic stem-cell transplantation: challenges in diagnosis and management.

text: Toxic epidermal necrolysis (TEN) is a rare complication after allogeneic hematopoietic stem-cell transplantation and carries high mortality rates. Graft-vs-host disease (GVHD) is also a life-threatening complication, and potentially indistinguishable from TEN because of similar clinical symptoms. However, current therapeutic recommendations differ between these two conditions, thereby posing a diagnostic dilemma. The authors, herein, present a complicated postoperative course after bone marrow transplantation with concurrent gastrointestinal and hepatic GVHD, and extensive epidermolytic disease compatible with both severe cutaneous GVHD and TEN. An early consult to a specialized burn service, and prompt transfer to a burn intensive care unit with extensive supportive care and nursing are of paramount importance in the management of immunosuppressed patients with TEN. Better understanding of the pathogenesis of TEN and GVHD after hematopoietic stem-cell transplantation, further treatment strategies, and more advanced diagnostic techniques are still needed to achieve acceptable mortality rates.


title: Management of sternal wounds by limited debridement and partial bilateral pectoralis major myocutaneous advancement flaps in 25 patients: a less invasive approach.

text: PURPOSE Because sternal wound complications after sternotomy can be life threatening and often occur in very sick patients, optimal management of these complications remains an important topic. To decrease postoperative morbidity and shorten the recovery period, the senior author (J.A.A.) sought a less invasive approach to sternal debridement and flap closure in carefully selected patients. The purpose of this study was to evaluate the effectiveness of this approach by obtaining specific outcomes data from a series of patients treated with this less invasive method. MATERIALS AND METHODS Of the most recent 174 sternal wounds treated by the senior author, 25 underwent limited debridement and partial bilateral pectoralis major advancement flaps. The charts of these 25 patients were reviewed and analyzed. RESULTS In the 25 patients who underwent limited debridement, there were no mortalities intraoperatively or during the 30-day postoperative period. Six patients (24%) experienced complications after debridement, including 1 recurrent sternal wound infection, 1 partial wound dehiscence, 1 seroma, 1 hematoma, and 1 wound edge necrosis requiring revision. Mean length of hospitalization after the procedure was 10 days, compared with 30 days (P = 0.0001) as previously reported with full debridement (Plast Reconstr Surg 2004; 114:676). Mean estimated intraoperative blood loss was reduced from 331 mL during full debridement to 93 mL (P < 0.0001) with limited debridement (Plast Reconstr Surg 2004; 114:676). There was no increase in postoperative morbidity (24 % vs 13 %, P = 0.2117). CONCLUSIONS The authors advocate limited sternal debridement and partial bilateral pectoralis major myocutaneous advancement flaps in patients with limited wounds and partially or fully healed sternums. We demonstrate that the procedure is effective but less invasive than complete debridement, reduces operative time and blood loss, and shortens length of hospitalization.


title: Uniportal video-assisted thoracoscopic right upper lobectomy with systematic lymphadenectomy.

text: Over the past decade, uniportal video-assisted thoracic surgery (VATS) has been reported to be a promising, less invasive alternative with potentially better cosmesis and less postoperative pain and paraesthesia. Although uniportal VATS has now evolved into a sophisticated technique capable of performing some of the most complex thoracic procedures, this approach to lobectomy is not standardized, and the surgical procedure still varies between surgeons. Here, we describe our uniportal VATS procedure during right upper lobectomy in a patient with a nodule in the right upper lobe. Subsequent mediastinal lymphadenectomy was performed to remove lymph nodes from the 2(nd), 3(rd), 4(th), 7(th), 8(th), and 9(th) groups. Although there are some details that are different compared to the conventional VATS approach, as experience with uniportal VATS has grown, this approach is a viable alternative approach for lobectomy in selected patients.


title: Single-incision laparoscopic rectopexy (Wells) with simultaneous sigmoidectomy in a case of complete rectal prolapse and a sigmoid tumor: report of a case.

text: Recently, the technique of single-incision laparoscopic surgery for colorectal disease has rapidly disseminated in association with improvements in instrumentation and procedures, offering a less invasive procedure and excellent cosmetic results. We herein present the case of a 74-year-old female who suffered complete rectal prolapse with a pedunculated polyp (20 mm) in the sigmoid colon; the stalk of the polyp was too thick to perform endoscopic mucosal resection, which is associated with a high risk of bleeding. The patient was successfully managed using single-incision laparoscopic rectopexy (Wells) with simultaneous sigmoidectomy, a procedure that has not been reported in the literature to date. There were no perioperative complications. The patient's constipation caused by the rectal prolapse improved, and no recurrence was observed for 2 months after the operation. This case emphasizes that complete rectal prolapse is a benign disease occurring in elderly patients that is well suited to treatment with minimally invasive single-incision laparoscopic surgery.


title: A comparison of electronic and paper-based clinical skills assessment: Systematic review.

text: Introduction: The aim of this systematic review was to compare the effectiveness of electronic recording with paper-based recording of clinical skills assessments for entry-level health professional students. Methods: A comprehensive database search was undertaken using AMED, CINAHL, CENTRAL, EMBASE, Medline, PsycINFO, Scopus, and Web of Science on 12-16 June 2017, and updated 9 April 2018. Studies investigating electronic and paper-based recordings of clinical skills assessments of students in entry-level health professional programs were eligible for inclusion. Two independent researchers completed screening of studies for inclusion, quality assessments, and data extraction, with discrepancies resolved by consensus. Quality assessment was performed using the Critical Appraisal Skills Program Diagnostic checklist. Results: From 2264 studies identified, five observational cohort studies were included. Published between 2006 and 2016, included studies investigated electronic and paper examinations of clinical skills assessments of students from medical, dentistry, and physical therapy programs. Electronic assessments were reported to be more time efficient than paper-based assessments with an added advantage of no missing data. Quality and quantity of quantitative and qualitative student feedback increased with electronic assessment compared to paper-based assessments. Conclusions: Electronic assessments were used successfully across a range of health professional programs, take significantly less time to complete and provide higher quality feedback to students. Future studies are needed with more robust psychometric testing and cost-effective analysis to inform the increasing uptake of electronic assessment tools in health professional training.


Swivel-HEPA-ETT (SHE) bougie and HEPA-ETT (HE) methods for safe intubation while managing patients with COVID-19.


title: Detection and characterization of human pathogenic viruses circulating in community wastewater using multi target microarrays and polymerase chain reaction.

text: Sewage pollution remains the most significant source of human waterborne pathogens. This study describes the detection and characterization of human enteric viruses in community wastewaters using cell culture coupled with multiple target microarrays (with a total of 780 unique probes targeting 27 different groups of both DNA and RNA viruses) and polymerase chain reaction (PCR) assays. Over a 13-month sampling period, RNA viruses (astroviruses and enteroviruses) were more frequently detected compared to DNA viruses (adenoviruses, particularly type 41 and BK polyomavirus). Overall, many more viruses were shed during the winter months (December-February) compared to the summer months. Exploration of the multiple types of enteric viruses particularly in winter months identified much more significant prevalence of key viral pathogens associated with sewage pollution of the water environment than previously realized and seasonal disinfection used in some parts of the world may lead to a seeding of ambient waters. Molecular characterization of pathogenic viruses in community wastewater will improve the understanding of the potential risk of waterborne disease transmission of viral pathogens.


title: Telemedicine Versus Face-to-Face Evaluations by Respiratory Therapists of Mechanically Ventilated Neonates and Children: A Pilot Study.

text: BACKGROUND Mechanical ventilation is one of the most important therapeutic interventions in neonatal and pediatric ICUs. Telemedicine has been shown to reliably extend pediatric intensivist expertise to facilities where expertise is limited. If reliable, telemedicine may extend the reach of pediatric respiratory therapists (RTs) to facilities where expertise does not exist or free up existing RT resources for important face-to-face activities in facilities where expertise is limited. The aim of this study was to determine how well respiratory assessments for ventilated neonates and children correlated when performed simultaneously by 2 RTs face-to-face and via telemedicine. METHODS We conducted a pilot study including 40 assessments by 16 RTs on 11 subjects (5 neonatal ICU; 6 pediatric ICU). Anonymously completed intake forms by 2 different RTs concurrently assessing 14 ventilator-derived and patient-based respiratory variables were used to determine correlations. RESULTS Forty paired assessments were performed. Median telemedicine assessment time was 8 min. The Pearson correlation coefficient (r) was used to determine agreement between continuous data, and the Cohen kappa statistics were used for binary variables. Pressure control, PEEP, breathing frequency, and FIO2 perfectly correlated (r = 1, all P < .001) as did the presence of a CO2 monitor and need for increased ventilatory support (kappa = 1). The Pearson correlation coefficient for VT, minute ventilation, mean airway pressure, and oxygen saturation ranged from 0.84 to 0.97 (all P < .001). kappa = 0.41 (95% CI 0.02-0.80) for patient-triggered breaths, and kappa = 0.57 (95% CI 0.19-0.94) for breathing frequency higher than set frequency. kappa = -0.25 (95% CI -0.46 to -0.04) for need for suctioning. CONCLUSIONS Telemedicine technology was acceptable to RTs. Telemedicine evaluations highly correlated with face-to-face for 10 of 14 aspects of standard bedside respiratory assessment. Poor correlation was noted for more complex, patient-generated parameters, highlighting the importance of further investigation incorporating a virtual stethoscope.


title: Comparative Cost of Stockpiling Various Types of Respiratory Protective Devices to Protect the Health Care Workforce During an Influenza Pandemic.

text: Specific guidance on the size and composition of respiratory protective device (RPD) stockpiles for use during a pandemic is lacking. We explore the economic aspects of stockpiling various types and combinations of RPDs by adapting a pandemic model that estimates the impact of a severe pandemic on a defined population, the number of potential interactions between patients and health care personnel, and the potential number of health care personnel needed to fulfill those needs. Our model calculates the number of the different types of RPDs that should be stockpiled and the consequent cost of purchase and storage, prorating this cost over the shelf life of the inventory. Compared with disposable N95 or powered air-purifying respirators, we show that stockpiling reusable elastomeric half-face respirators is the least costly approach. Disposable N95 respirators take up significantly more storage space, which increases relative costs. Reusing or extending the usable period of disposable devices may diminish some of these costs. We conclude that stockpiling a combination of disposable N95 and reusable half-face RPDs is the best approach to preparedness for most health care organizations. We recommend against stockpiling powered air-purifying respirators as they are much more costly than alternative approaches.


title: Minimal invasive surgery: NOSE and NOTES in ulcerative colitis.

text: BACKGROUND In patients with ulcerative colitis (UC), laparoscopic pelvic dissection for IPAA is not always straightforward: often, a hand-assistance incision is used to complete the proctectomy, lengthening operative times. Hybrid NOSE and NOTES are emerging as an alternative approach to conventional laparoscopy. We believe that UC patients could benefit from this new hybrid approach in three ways: by easing the proctectomy as performed down to up, avoiding additional incisions and decreasing surgical times. We present the short-term outcomes of our series. METHODS All patients with UC who required IPAA were enrolled in a single-arm prospective study (July 2011 to March 2014). A three-step procedure was performed. The first step: laparoscopic colectomy (with transanal removal of the colon) and temporary ileostomy. The second step: "down-to-up" proctectomy (with transanal removal of the rectum) and IPAA with a covering ileostomy. We combined simultaneously transanal and laparoscopic approach. The third step: ileostomy closure. Functional outcomes were assessed 3 months after third step. RESULTS Eighteen patients were enrolled. Two patients are waiting to complete the second stage, and 16 underwent all surgical steps. Twelve have been evaluated with functional scores. For the first step, the mean operative time was 162.2 min (SD 40.5) and 170 min (SD 50.1) for the second one. The median hospital stay was 6 days (IQR 5-14.75) for the first step and 5.5 (IQR 5-9.75) for the second one. No major complications occurred. Twenty-four-hour defecation frequency was 5.5 per day (SD 1.7), 0.5 per night. Seventy-five percentage of patients may retain stools for more than 30 min; the mean value of Oresland score was 4.7 and Wexner score 1.4. CONCLUSIONS This is a safe and feasible technique to treat UC patients with good short-term outcomes. Long-term outcomes and controlled trials are needed.


SnapShot: Viral and eukaryotic protein fusogens.


title: Coexistence of different genotypes in the same bat and serological characterization of Rousettus bat coronavirus HKU9 belonging to a novel Betacoronavirus subgroup.

text: Rousettus bat coronavirus HKU9 (Ro-BatCoV HKU9), a recently identified coronavirus of novel Betacoronavirus subgroup D, from Leschenault's rousette, was previously found to display marked sequence polymorphism among genomes of four strains. Among 10 bats with complete RNA-dependent RNA polymerase (RdRp), spike (S), and nucleocapsid (N) genes sequenced, three and two sequence clades for all three genes were codetected in two and five bats, respectively, suggesting the coexistence of two or three distinct genotypes of Ro-BatCoV HKU9 in the same bat. Complete genome sequencing of the distinct genotypes from two bats, using degenerate/genome-specific primers with overlapping sequences confirmed by specific PCR, supported the coexistence of at least two distinct genomes in each bat. Recombination analysis using eight Ro-BatCoV HKU9 genomes showed possible recombination events between strains from different bat individuals, which may have allowed for the generation of different genotypes. Western blot assays using recombinant N proteins of Ro-BatCoV HKU9, Betacoronavirus subgroup A (HCoV-HKU1), subgroup B (SARSr-Rh-BatCoV), and subgroup C (Ty-BatCoV HKU4 and Pi-BatCoV HKU5) coronaviruses were subgroup specific, supporting their classification as separate subgroups under Betacoronavirus. Antibodies were detected in 75 (43%) of 175 and 224 (64%) of 350 tested serum samples from Leschenault's rousette bats by Ro-BatCoV HKU9 N-protein-based Western blot and enzyme immunoassays, respectively. This is the first report describing coinfection of different coronavirus genotypes in bats and coronavirus genotypes of diverse nucleotide variation in the same host. Such unique phenomena, and the unusual instability of ORF7a, are likely due to recombination which may have been facilitated by the dense roosting behavior and long foraging range of Leschenault's rousette.


title: Safety of iodinated intravenous contrast medium administration in sickle cell disease.

text: BACKGROUND Increased sickling of erythrocytes following intravenous iodinated contrast has been described in patients with sickle cell disease. In vitro, the effect is correlated with the tonicity, viscosity, acidity, and ionic nature of contrast media. Less erythrocyte sickling is observed in vitro with second-generation low- and iso-osmolar contrast agents. Clinical impact of these newer intravenous contrast agents has not been investigated. PURPOSE To review adverse outcomes following contrast administration in a cohort of patients with sickle cell disease. METHODS Inpatients with sickle cell disease who received iodinated intravenous were identified. Medical records were reviewed for evidence of worsening crisis and occurrence of adverse events within 48 hours of contrast administration. Data points were further analyzed with the goal of identifying predictors of adverse outcome. RESULTS There were 132 imaging studies that met inclusion criteria in 79 patients, mostly with homozygous hemoglobin S. The low-osmolar contrast Optiray (Coviden Imaging Inc., Hazelwood, Mo) was used in 45%. Administration of fluids, Mucomyst (Bristol-Myers Squibb, New York, NY), oxygen, or blood transfusion preceded 58% of studies. Minor adverse events followed 16% of studies, with new or worsening pain being most common (12%). Contrast-induced nephropathy occurred in 1.5%, resolving in all cases. Prehydration was associated with a decreased incidence of adverse events (P=.02). CONCLUSION Adverse events related to intravenous contrast occur in sickle cell disease patients at a rate similar to the general population, without an increase in contrast-induced nephropathy. Subjective reports of new or worsening pain crisis do not translate to objective findings. Beneficial diagnostic imaging can be performed without increased risk of serious complication in this population.


title: Prevention of venous thromboembolism amongst patients in an acute tertiary referral teaching public hospital: a best practice implementation project.

text: BACKGROUND Deep vein thrombosis and pulmonary embolism are known collectively as venous thromboembolism (VTE). These conditions are possible complications in hospitalized patients that can extend hospital stay, result in unplanned readmission, and are associated with long-term disability and death. Despite strong evidence, many patients do not receive optimal thromboprophylaxis. VTE prevention is a top priority in healthcare systems worldwide. AIM The aim of the project was to establish a standardized hospital-wide VTE prevention program and to improve awareness of, and compliance with, best practice standards in the prevention of VTE. METHODS A multidisciplinary team utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System program to facilitate the collection of pre and post implementation audit data. The Getting Research into Practice program was also used to conduct a situational analysis to identify barriers, enablers, and implementation strategies while taking into account the context in which the changes were to occur. Hospital-acquired VTE data were collected to monitor the impact, if any, on patient outcomes. The project was conducted in three different phases over a 2.5-year period in an acute care public hospital. RESULTS A comprehensive suite of professionally crafted guidelines, tools, and resources were developed to facilitate clinician acceptance of evidence-based practices. Comparison of compliance results showed variable improvements with four audit criteria. Formalized patient risk assessment improved to 7.5% with the introduction of a new form. High-risk patients receiving appropriate prophylaxis improved to 81% in medical and 83% in surgical patients, on an existing high background compliance rate. A total of 59% of staff attended a VTE update education in-service. No patients received information about adverse VTE events prior to discharge. The hospital-acquired VTE rate decreased slightly from 0.65 to 0.52 events per 1000 overnight bed days. CONCLUSION Overall the project achieved improvements in compliance with best practice standards. A number of delays and barriers contributed to some of the planned interventions not being fully implemented at the time of the follow-up audit. Contributing factors included the lack of electronic capabilities, some processes not being fully embedded into routine clinical workflows, lack of staff time, and identification of an additional organizational barrier relating to practical issues in providing patient education at discharge. A second action cycle is recommended in an attempt to further improve compliance, ensure intervention fidelity, and embed practices into routine daily workflows to positively impact patient and organizational outcomes.


title: Infection of bat and human intestinal organoids by SARS-CoV-2.

text: A novel coronavirus-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-emerged in humans in Wuhan, China, in December 2019 and has since disseminated globally1,2. As of April 16, 2020, the confirmed case count of coronavirus disease 2019 (COVID-19) had surpassed 2 million. Based on full-genome sequence analysis, SARS-CoV-2 shows high homology to SARS-related coronaviruses identified in horseshoe bats1,2. Here we show the establishment and characterization of expandable intestinal organoids derived from horseshoe bats of the Rhinolophus sinicus species that can recapitulate bat intestinal epithelium. These bat enteroids are fully susceptible to SARS-CoV-2 infection and sustain robust viral replication. Development of gastrointestinal symptoms in some patients with COVID-19 and detection of viral RNA in fecal specimens suggest that SARS-CoV-2 might cause enteric, in addition to respiratory, infection3,4. Here we demonstrate active replication of SARS-CoV-2 in human intestinal organoids and isolation of infectious virus from the stool specimen of a patient with diarrheal COVID-19. Collectively, we established the first expandable organoid culture system of bat intestinal epithelium and present evidence that SARS-CoV-2 can infect bat intestinal cells. The robust SARS-CoV-2 replication in human intestinal organoids suggests that the human intestinal tract might be a transmission route of SARS-CoV-2.


title: Association of meteorological factors with childhood viral acute respiratory infections in subtropical China: an analysis over 11 years.

text: The objective of this study was to obtain a better understanding of the effects of meteorological factors on the prevalence and seasonality of common respiratory viruses in China, which has a subtropical climate. A retrospective study was conducted by identifying children admitted to a hospital with acute respiratory infections due to seven common viruses between January 2001 and December 2011. A total of 42,104 nasopharyngeal samples were tested for respiratory syncytial virus (RSV), influenza A and B viruses (IV-A and IV-B), parainfluenza viruses 1-3 (PIV-1, PIV-2, PIV-3), and adenovirus (ADV) by direct immunofluorescence assay. Meteorological data were obtained from Suzhou Weather Bureau. Correlations of viral prevalence with meteorological factors were evaluated using Spearman rank correlation and partial correlation. Multivariate time-series analysis including an autoregressive integrated moving average (ARIMA) model and generalized linear Poisson models was conducted to study the effect of meteorological factors on the prevalence of respiratory virus infection. RSV and IV-A activity showed distinctive winter peak, whereas PIV-3 and ADV peaked in the summer. Incidence of RSV was correlated with low environmental temperature, and PIV-3 only with high temperature. IV-A activity was correlated with both low temperature and high relative humidity. ADV activity was correlated with high total rainfall. In the ARIMA model, RSV-associated hospitalizations were predictable, and the monthly number of RSV cases decreased by 11.25 % (95 % CI: 5.34 % to 16.79 %) for every 1 °C increase in the average temperature. Seasonality of certain respiratory virus may be explained by meteorological influences. The impact of meteorological factors on the prevalence of RSV may be useful for predicting the activity of this virus.


title: Real-time tracking of self-reported symptoms to predict potential COVID-19.

text: A total of 2,618,862 participants reported their potential symptoms of COVID-19 on a smartphone-based app. Among the 18,401 who had undergone a SARS-CoV-2 test, the proportion of participants who reported loss of smell and taste was higher in those with a positive test result (4,668 of 7,178 individuals; 65.03%) than in those with a negative test result (2,436 of 11,223 participants; 21.71%) (odds ratio = 6.74; 95% confidence interval = 6.31-7.21). A model combining symptoms to predict probable infection was applied to the data from all app users who reported symptoms (805,753) and predicted that 140,312 (17.42%) participants are likely to have COVID-19.


title: Laparoscopic surgery for rectal cancer: preoperative radiochemotherapy versus surgery alone.

text: BACKGROUND A few studies have suggested advantages of laparoscopic surgery for rectal cancer. However, the role of laparoscopy has not been clearly defined specifically in cases after neoadjuvant radiochemotherapy. This study aimed to assess the impact of preoperative radiotherapy on the feasibility of laparoscopic rectal excision with sphincter preservation for rectal cancer. METHODS From 1999 to 2010, the authors considered all patients treated by laparoscopic rectal excision with sphincter preservation for rectal cancer. Patients treated by long-course preoperative radiochemotherapy (45 Gy during 5 weeks) were compared with those treated by surgery alone. The end points of the study were mortality, conversion, and overall and surgical morbidity. RESULTS Among 422 patients treated by laparoscopic conservative rectal excision, 292 received preoperative radiotherapy, and 130 had surgery alone. The two groups were similar in sex, age, body mass index, and American Society of Anesthesiologists (ASA) score. The mortality rate was 0.3% in the radiotherapy group and 0.8% in the surgical group (P = 0.52). The two groups did not differ in terms of conversion (19 vs. 15%; P = 0.39), overall morbidity (37 vs. 29%; P = 0.14), surgical morbidity (20 vs. 18%; P = 0.60), or anastomotic leakage (13 vs. 11%; P = 0.54). Multivariate analysis showed male gender and synchronous metastasis as independent factors of surgical morbidity. The independent factors of conversion were male gender, obesity, tumor stage, and type of anastomosis. Preoperative radiotherapy influenced neither conversion nor surgical morbidity. CONCLUSION Long-course radiochemotherapy does not have an impact on the feasibility or short-term outcome of laparoscopic conservative rectal excision for rectal cancer.


Inhaled budesonide does not prevent acute mountain sickness after rapid ascent to 4559 m.


title: Ultrasound-guided laparoscopic liver resections.

text: BACKGROUND Intraoperative liver ultrasound has an established role in liver surgery to complete staging and to guide resection. The same performances should be expected by laparoscopic ultrasound (LUS). METHODS LUS is first performed to identify relationships between tumor and vasculo-biliary pedicles. The planes where the main vascular structures run are marked on the liver surface. Parenchymal transection is performed and each vessel recognized during LUS exploration is divided. RESULTS From 01/2009 to 10/2013, in 61 out of 742 liver resections (8.2 %), a laparoscopic approach was attempted. The conversion rate was 9.8 % (six patients). No conversion was related to bleeding or intraoperative complications. The remnant 55 patients were affected by benign lesions in 11 cases and malignant tumors in 44. The resections included 3 left hepatectomies, 14 bisegmentectomies Sg2-3, 5 segmentectomies, and 38 wedge resections. Associated procedures were performed in eight patients (14.5 %), including four colorectal resections. Median duration of surgery was 150 min (60-345 min). Median operative blood loss was 100 mL (0-500 mL). Median size of resected tumor was 2.5 cm (0.9-8 cm). Median surgical margin in oncological resections was 7 mm (0-50 mm). Postoperative complications occurred in four patients (7.2 %), all grade 2 according to Dindo classification. No liver-related morbidity occurred. Median length of hospital stay was 5 days (3-9 days). CONCLUSIONS Ultrasound-guided liver resections can be performed by laparoscopic approach with the same accuracy than open surgery.


Guest editorial: special focus on the pathology of biological select agents and toxins in animals and research challenges in biological defense.


title: Safety and Efficacy of Bivalirudin in Patients With Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: From the REPLACE-2, ACUITY and HORIZONS-AMI Trials.

text: Optimal antithrombotic pharmacotherapy in patients affected by diabetes mellitus (DM) undergoing percutaneous coronary intervention is unclear. We sought to evaluate the safety and efficacy of bivalirudin compared with heparin plus a glycoprotein IIb/IIIa inhibitor (GPI) in patients with DM undergoing percutaneous coronary intervention. We pooled patient-level data from the Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events-2, Acute Catheterization and Urgent Intervention Triage strategy, and Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trials. The primary efficacy end point was the incidence of major adverse cardiac events, defined as the composite of death, myocardial infarction, or unplanned revascularization at 30 days. The primary safety end point was the incidence of 30-day non-coronary artery bypass graft-related major bleeding. All-cause mortality was reported at 30 days and 1 year. Of the 14,737 patients included in the pooled database, 3,641 (24.7%) had DM. Patients with DM had higher rates of 30-day major bleeding and 30-day and 1-year all-cause mortality. There were no differences in 30-day major adverse cardiac events between bivalirudin versus heparin plus GPI in patients with DM (6.9% vs 7.8%; relative risk [RR] 0.89, 95% CI 0.71 to 1.12) or without DM (7.5% vs 6.7%; RR 1.11, 95% CI 0.97 to 1.27; pinteraction = 0.10). Bivalirudin treatment was associated with reduced risk of major bleeding in similar magnitude in patients with DM (4.3% vs 6.6% RR 0.68, 95% CI 0.51 to 0.89) or without DM (3.2% vs 6.1%; RR 0.51, 95% CI 0.43 to 0.61; pinteraction = 0.15). The hemorrhagic benefit of bivalirudin was noted for both access site- and non-access site-related bleeding. Overall, bivalirudin treatment was associated with a significant 1-year mortality benefit (2.7% vs 3.3%; RR 0.82, 95% CI 0.68 to 0.98; p = 0.03), which was consistent between patients with or without DM (pinteraction = 0.30). In conclusion, compared with heparin plus GPI, bivalirudin was associated with similar 30-day antithrombotic efficacy and better 30-day freedom from bleeding and 1-year mortality, irrespective of diabetic status.


title: Pulmonary infarction complicating thoracoscopic removal of congenital foregut cyst.

text: A 42-year old woman presented with rheumatoid arthritis, dyspnoea and a congenital foregut cyst referred by a rheumatologist for thoracic surgery. The cyst was removed by video-assisted thoracoscopic surgery. The patient developed acute haemoptysis in the immediate postoperative period, which necessitated pulmonary resection due to infracted right lower lobe. This case report highlights the complication related to an unusual anatomy of a congenital foregut cyst.


title: Registries Offer Insights on COVID-19-Cancer Connection.

text: Findings from CCC19 and TERAVOLT suggest that patients with cancer may be more likely to die from COVID-19 than people in the general population. Additional mortality risk factors may include age, performance status, treatment with chemotherapy, and exposure to hydroxychloroquine plus azithromycin.


title: The longitudinal assessment of osteomyelitis development by molecular imaging in a rabbit model.

text: INTRODUCTION Osteomyelitis is a severe orthopaedic complication which is difficult to diagnose and treat. Previous experimental studies mainly focussed on evaluating osteomyelitis in the presence of an implant or used a sclerosing agent to promote infection onset. In contrast, we focused on the longitudinal assessment of a nonimplant related osteomyelitis. METHODS An intramedullary tibial infection with S. aureus was established in NZW rabbits. Clinical and haematological infection status was evaluated weekly, combined with X-ray radiographs, biweekly injections of calcium binding fluorophores, and postmortem micro-CT. The development of the infection was assessed by micro-PET at consecutive time points using 18F-FDG as an infection tracer. RESULTS The intramedullary contamination of the rabbit tibia resulted in an osteomyelitis. Haematological parameters confirmed infection in mainly the first postoperative weeks (CRP at the first 5 postoperative weeks, leucocyte differentiation at the second and sixth postoperative weeks, and ESR on the second postoperative week only), while micro-PET was able to detect the infection from the first post-operative week onward until the end of the study. CONCLUSIONS This study shows that osteomyelitis in the rabbit can be induced without use of an implant or sclerosing agent. The sequential follow-up indicates that the diagnostic value of each infection parameter is time point dependant. Furthermore, from all parameters used, the diagnostic value of 18F-FDG micro-PET is the most versatile to assess the presence of an orthopaedic infection in this model.


title: Design of the stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis trial.

text: BACKGROUND Patients with recent transient ischemic attack (TIA) or stroke caused by 70% to 99% stenosis of a major intracranial artery are at high risk of recurrent stroke on usual medical management, suggesting the need for alternative therapies for this disease. METHODS The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial is an ongoing, randomized, multicenter, 2-arm trial that will determine whether intracranial angioplasty and stenting adds benefit to aggressive medical management alone for preventing the primary endpoint (any stroke or death within 30 days after enrollment or after any revascularization procedure of the qualifying lesion during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days) during a mean follow-up of 2 years in patients with recent TIA or stroke caused by 70% to 99% stenosis of a major intracranial artery. Aggressive medical management in both arms consists of aspirin 325 mg per day, clopidogrel 75 mg per day for 90 days after enrollment, intensive risk factor management primarily targeting systolic blood pressure <140 mm Hg (<130 mm Hg in diabetics) and low density cholesterol <70 mg/dL, and a lifestyle modification program. The sample size required to detect a 35% reduction in the rate of the primary endpoint from angioplasty and stenting based on the log-rank test with an alpha of 0.05, 80% power, and adjusting for a 2% loss to follow-up and 5% crossover from the medical to the stenting arm is 382 patients per group. RESULTS Enrollment began in November 2008 and 451 patients have been enrolled as of March 31, 2011. CONCLUSIONS This is the first randomized stroke prevention trial to compare angioplasty and stenting with medical therapy in patients with intracranial arterial stenosis and to incorporate intensive management of multiple risk factors and a lifestyle modification program in the study design. Hopefully, the results of the trial will lead to more effective therapy for this high-risk disease.


title: CEA a thrombus CAM: CEACAM2, a twin of CEACAM1?

text: In this issue of Blood, Alshahrani et al demonstrate that carcinoembryonic antigen-related cell adhesion molecule 2 (CEACAM2) is expressed on platelets and negatively regulates the collagen receptor glycoprotein (GP)VI-FcRγ chain and C-type lectin-like receptor 2 (CLEC-2)-mediated platelet activation.