OBJECTIVE The effect of user experience and inflation technique on endotracheal tube cuff pressure using a feline airway simulator. STUDY DESIGN Prospective, experimental clinical study. METHODS Participants included veterinary students at the beginning (group S1) and end (group S2) of their 2-week anaesthesia rotation and veterinary anaesthetists (group A). The feline airway simulator was designed to simulate an average size feline trachea, intubated with a 4.5 mm low-pressure, high-volume cuffed endotracheal tube, connected to a Bain breathing system with oxygen flow of 2 L minute-1. Participants inflated the on-endotracheal tube cuff by pilot balloon palpation and by instilling the minimum occlusive volume (MOV) required for loss of airway leaks during manual ventilation. Intracuff pressures were measured by manometers obscured to participants and ideally were 20-30 cm H2O. Student t, Fisher exact, and Chi-squared tests were used where appropriate to analyse data (p < 0.05). RESULTS Participants were 12 students and eight anaesthetists. Measured intracuff pressures for palpation and MOV, respectively, were 19 ± 12 and 29 ± 19 cm H2O for group S1, 10 ± 5 and 20 ± 11 cm H2O for group S2 and 13 ± 6 and 29 ± 18 cm H2O for group A. All groups performed poorly at achieving intracuff pressures within the ideal range. There was no significant difference in intracuff pressures between techniques. Students administered lower (p = 0.02) intracuff pressures using palpation after their training. CONCLUSIONS AND CLINICAL RELEVANCE When using palpation and MOV for cuff inflation operators rarely achieved optimal intracuff pressures. Experience had no effect on this skill and, as such, a cuff manometer is recommended.


title: South Korea tackles virus outbreak.

text: Nurses at the Seoul Medical Center in South Korea are testing patients to see whether they have contracted Middle East Respiratory Syndrome Coronavirus (MERS-CoV).


title: A comparison of cardiac computerized tomography and exercise stress electrocardiogram test for the investigation of stable chest pain: the clinical results of the CAPP randomized prospective trial.

text: AIMS To determine the symptomatic and prognostic differences resulting from a novel diagnostic pathway based on cardiac computerized tomography (CT) compared with the traditional exercise stress electrocardiography test (EST) in stable chest pain patients. METHODS AND RESULTS A prospective randomized controlled trial compared selected patient outcomes in EST and cardiac CT coronary angiography groups. Five hundred patients with troponin-negative stable chest pain and without known coronary artery disease were recruited. Patients completed the Seattle Angina Questionnaires (SAQ) at baseline, 3, and 12 months to assess angina symptoms. Patients were also followed for management strategies and clinical events. Over the year 12 patients withdrew, resulting in 245 in the EST cohort and 243 in the CT cohort. There was no significant difference in baseline demographics. The CT arm had a statistical difference in angina stability and quality-of-life domains of the SAQ at 3 and12 months, suggesting less angina compared with the EST arm. In the CT arm, there was more significant disease identified and more revascularizations. Significantly, more inconclusive results were seen in the EST arm with a higher number of additional investigations ordered. There was also a longer mean time to management. There were no differences in major adverse cardiac events between the cohorts. At 1 year in the EST arm, there were more Accident and Emergency (A&E) attendances and cardiac admission. CONCLUSION Cardiac CT as an index investigation for stable chest pain improved angina symptoms and resulted in fewer investigations and re-hospitalizations compared with EST. CLINICAL TRIAL REGISTRATION http://www.controlled-trials.com/ISRCTN52480460.


title: Contribution of common and rare damaging variants in familial forms of bipolar disorder and phenotypic outcome.

text: Genome-wide association studies on bipolar disorders (BD) have revealed an additive polygenic contribution of common single-nucleotide polymorphisms (SNPs). However, these SNPs explain only 25% of the overall genetic variance and suggest a role of rare variants in BD vulnerability. Here, we combined high-throughput genotyping data and whole-exome sequencing in cohorts of individuals with BD as well as in multiplex families with a high density of affected individuals in order to determine the contribution of both common and rare variants to BD genetic vulnerability. Using polygenic risk scores (PRS), we showed a strong contribution of common polymorphisms previously associated with BD and schizophrenia (SZ) and noticed that those specifically associated with SZ contributed more in familial forms of BD than in non-familial ones. The analysis of rare damaging variants shared by affected individuals in multiplex families with BD revealed a single interaction network enriched in neuronal and developmental biological pathways, as well as in the regulation of gene expression. We identified four genes with a higher mutation rate in individuals with BD than in the general population and showed that mutations in two of them were associated with specific clinical manifestations. In addition, we showed a significant negative correlation between PRS and the number of rare damaging variants specifically in unaffected individuals of multiplex families. Altogether, our results suggest that common and rare genetic variants both contribute to the familial aggregation of BD and this genetic architecture may explain the heterogeneity of clinical manifestations in multiplex families.


Social-media companies must flatten the curve of misinformation.


title: Influence of barbed suture on leak pressures after double-layer inverting closure of cystotomy sites in sheep.

text: OBJECTIVE To determine the influence of barbed suture on double-layer inverting closure of cystotomy sites in sheep. STUDY DESIGN Ex vivo study. SAMPLE POPULATION Urinary bladders harvested from ovine (n = 26) cadaveric specimens. METHODS After collection and specimen preparation, a 3-cm-long incision was created on the ventral aspect of the urinary bladder. The cystotomy was repaired with barbed (n = 13) or nonbarbed analogous monofilament absorbable suture (n = 13) in a double-layer inverting suture pattern. Time required for closure in seconds was recorded for each test. Each bladder was connected to a pressure transducer to monitor intraluminal pressure during infusion with dyed Hartmann's solution until leakage occurred. Intraluminal pressure at time of initial leakage and leakage site were also recorded. Two-sample t tests were used to compare initial leakage pressure and closure time between the 2 types of suture (P = .05). RESULTS The mean ( ± SD) leakage pressure of ovine urinary bladder incisions did not differ between closures with barbed sutures (42.3 ± 21.7 mmHg) and nonbarbed closures (32.5 ± 14.4 mmHg, P = .187). Cystorrhaphies were performed faster with barbed suture (307 ± 50 seconds) than with nonbarbed suture (390 ± 62 seconds, P = .001). CONCLUSION The use of barbed suture did not affect mean leakage pressure of ovine urinary bladder incisions but decreased the time required to complete cystorrhaphies in this model. CLINICAL SIGNIFICANCE This study provides evidence to support the use of knotless barbed suture for open ovine cystorrhaphies. Use of such suture for laparoscopic and laparoscopic-assisted procedures in sheep warrants caution until cyclic and in vivo testing is performed with appropriate laparoscopic instrumentation.


Lessons from Queens.


ANNALS EXPRESS: On the Clinical Utility of Cardiac Troponin measurement in COVID-19 Infection.


Apple doesn't fall far from the tree.


Commentary: COVID-19: "There is no education like adversity".


title: Ureteroarterial fistula from ureteral stump: a challenging case.

text: Ureteroarterial fistula (UAF) is a relatively rare condition with about 150 cases reported in the literature. Since it is a potentially life-threatening condition, a prompt diagnosis and treatment are crucial. We present here a rare, challenging case of UAF diagnosed after left nephrectomy, thus involving the ureteral stump. The difficult diagnosis and treatment by contemporary use of endovascular stent placement and ureteral occlusion by mean of metallic coils and Onyx injection are discussed.


title: Rapid diagnostic testing for seasonal influenza: an evidence-based review and comparison with unaided clinical diagnosis.

text: BACKGROUND Worldwide, seasonal influenza imposes a considerable health and economic burden. Clinical diagnosis of influenza-like illness (ILI) is complicated by non-specific symptomatology. Rapid flu tests (RFTs) impact treatment decisions and may improve patient care; yet, recommendations for RFT use are broad, and the performance of unaided clinical diagnosis relative to RFTs is unclear. OBJECTIVES To determine age-stratified, overall sensitivities and specificities of the widely studied RFT, QuickVue® (Quidel Corporation, San Diego, CA), and clinical diagnosis of ILI by meta-analysis and to seek factors associated with poorer clinical diagnostic discrimination. METHODS A systematic literature review was conducted using article selection criteria identifying studies indexed in PubMed/MEDLINE, the Cochrane Library, and other pertinent sources of studies reporting sensitivity, specificity, and effects of RFTs and clinical diagnosis on decision-making for patients with ILI. RESULTS QuickVue's® diagnostic specificity exceeds that of unaided clinical diagnosis by 29-31%. False-positive results occur approximately 8.2 times more frequently by unaided clinical diagnosis than by the RFT alone. These findings were unaffected by seasonal variations in disease prevalence. RFTs reduce diagnostic testing, antibiotic use, and emergency department utilization while increasing antiviral prescription rates. No systematic relationship between the broadness of clinical diagnostic criteria for influenza and diagnostic performance was observed across studies included in this review. CONCLUSIONS Use of RFTs improves seasonal influenza diagnostic specificity above that based on unaided clinical diagnosis irrespective of the broadness of clinical diagnostic criteria, and affects clinical decision-making. These results provide an improved framework upon which to diagnose influenza, design future RFT studies, and modify existing recommendations for improved ILI patient management.


title: Preclinical evaluation of 99mTc(CO)3-aspartic-N-monoacetic acid, a renal radiotracer with pharmacokinetic properties comparable to 131I-o-iodohippurate.

text: UNLABELLED In an ongoing effort to develop a renal tracer with pharmacokinetic properties comparable to p-aminohippurate and superior to those of both (99m)Tc-mercaptoacetyltriglycine and (131)I-o-iodohippurate ((131)I-OIH), we evaluated a new renal tricarbonyl radiotracer based on the aspartic-N-monoacetic acid (ASMA) ligand, (99m)Tc(CO)(3)(ASMA). The ASMA ligand features 2 carboxyl groups and an amine function for the coordination of the {(99m)Tc(CO)(3)}(+) core as well as a dangling carboxylate to facilitate rapid renal clearance. METHODS rac-ASMA and l-ASMA were labeled with a (99m)Tc-tricarbonyl precursor, and radiochemical purity of the labeled products was determined by high-performance liquid chromatography. Using (131)I-OIH as an internal control, we evaluated biodistribution in normal rats with (99m)Tc(CO)(3)(ASMA) isomers and in rats with renal pedicle ligation with (99m)Tc(CO)(3)(rac-ASMA). Clearance studies were conducted in 4 additional rats. In vitro radiotracer stability was determined in phosphate-buffered saline, pH 7.4, and in challenge studies with cysteine and histidine. (99m)Tc(CO)(3)(ASMA) metabolites in urine were analyzed by high-performance liquid chromatography. RESULTS Both (99m)Tc(CO)(3)(ASMA) preparations had greater than 99% radiochemical purity and were stable in phosphate-buffered saline, pH 7.4, for 24 h. Challenge studies on both revealed no significant displacement of the ligand. In normal rats, the percentage injected dose in urine at 10 and 60 min for both preparations averaged, respectively, 103% and 106% that of (131)I-OIH. The renal clearances of (99m)Tc(CO)(3)(rac-ASMA) and (131)I-OIH were comparable (P = 0.48). The tracer was excreted unchanged in the urine, proving its in vivo stability. In pedicle-ligated rats, (99m)Tc(CO)(3)(rac-ASMA) had less excretion into the bowel (P < 0.05) than did (131)I-OIH and was better retained in the blood (P < 0.05). CONCLUSION Both (99m)Tc(CO)(3)(ASMA) complexes have pharmacokinetic properties in rats comparable to or superior to those of (131)I-OIH, and human studies are warranted for their further evaluation.


title: Psychological aspects of employment instability during the COVID-19 pandemic.

text: Psychological aspects that accompany employment instability because of the COVID-19 quarantine (lockdown) policy were investigated. Two hundred ninety-three Israeli participants completed a Brief Illness Perception Questionnaire, a Distress Thermometer, and a Perceived Stress Scale. People placed on furlough (unpaid leave of absence) by their employers demonstrated significantly higher distress (M = 5.34) than those who were unemployed prior to the pandemic (M = 3.79). The implications and coping modes with these results are detailed herein. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Oedipus and the Coronavirus Pandemic.


Covid-19: Africa's case numbers are rising rapidly, WHO warns.


title: Attenuation of Influenza A Virus Disease Severity by Viral Coinfection in a Mouse Model.

text: Influenza viruses and rhinoviruses are responsible for a large number of acute respiratory viral infections in human populations and are detected as copathogens within hosts. Clinical and epidemiological studies suggest that coinfection by rhinovirus and influenza virus may reduce disease severity and that they may also interfere with each other's spread within a host population. To determine how coinfection by these two unrelated respiratory viruses affects pathogenesis, we established a mouse model using a minor serogroup rhinovirus (rhinovirus strain 1B [RV1B]) and mouse-adapted influenza A virus (A/Puerto Rico/8/1934 [PR8]). Infection of mice with RV1B 2 days before PR8 reduced the severity of infection by a low or medium, but not high, dose of PR8. Disease attenuation was associated with an early inflammatory response in the lungs and enhanced clearance of PR8. However, coinfection by RV1B did not reduce PR8 viral loads early in infection or inhibit replication of PR8 within respiratory epithelia or in vitro Inflammation in coinfected mice remained focal compared to diffuse inflammation and damage in the lungs of mice infected by PR8. The timing of RV1B coinfection was a critical determinant of protection, suggesting that sufficient time is needed to induce this response. Finally, disease attenuation was not unique to RV1B: dose-dependent coinfection by a murine coronavirus (mouse hepatitis virus strain 1 [MHV-1]) also reduced the severity of PR8 infection. Unlike RV1B, coinfection with MHV-1 reduced early PR8 replication, which was associated with upregulation of beta interferon (IFN-β) expression. This model is critical for understanding the mechanisms responsible for influenza disease attenuation during coinfection by unrelated respiratory viruses.IMPORTANCE Viral infections in the respiratory tract can cause severe disease and are responsible for a majority of pediatric hospitalizations. Molecular diagnostics have revealed that approximately 20% of these patients are infected by more than one unrelated viral pathogen. To understand how viral coinfection affects disease severity, we inoculated mice with a mild viral pathogen (rhinovirus or murine coronavirus), followed 2 days later by a virulent viral pathogen (influenza A virus). This model demonstrated that rhinovirus can reduce the severity of influenza A virus, which corresponded with an early but controlled inflammatory response in the lungs and early clearance of influenza A virus. We further determined the dose and timing parameters that were important for effective disease attenuation and showed that influenza disease is also reduced by coinfection with a murine coronavirus. These findings demonstrate that coinfecting viruses can alter immune responses and pathogenesis in the respiratory tract.


title: Development and evaluation of a one step reverse transcription-loop mediated isothermal amplification assay (RT-LAMP) for rapid detection of foot and mouth disease virus in India.

text: A simple, rapid and sensitive diagnostic assay for Foot-and-mouth disease (FMD) is required for deployment in the field. In this study, development of Reverse Transcription-Loop Mediated Isothermal Amplification (RT-LAMP) assay based on the 3D polymerase gene for specific and rapid detection FMD virus (FMDV) was carried out. The assay was optimised with viral RNA extracted from serotype O, A and Asia 1 FMDV vaccine strains, which resulted a reliable amplification at 65 °C for 60 min. The amplified RT-LAMP products were identified by agarose gel electrophoresis with ethidium bromide staining or observation by naked eye for the presence of turbidity and colour change following the addition of hydroxyl naphthol blue (HNB). The specificity of the assay was demonstrated by the absence of amplification of genome extracted from other viruses or cellular origin. With respect to analytical sensitivity the developed RT-LAMP assay was found more sensitive than routinely used multiplex PCR (mPCR). Further, the assay was evaluated with RNA extracted from cell cultured isolates (n = 50), tongue epithelial samples (n = 150) and semen samples from infected bulls (n = 13). In conclusion, RT-LAMP with HNB dye was shown to be simple, specific and sensitive assay for rapid diagnosis of FMDV infection. Further, the assay has the potential for field deployment and use for rapid FMDV surveillance in India.


title: Structural and cellular characterization of electrospun recombinant human tropoelastin biomaterials.

text: An off-the-shelf vascular graft biomaterial for vascular bypass surgeries is an unmet clinical need. The vascular biomaterial must support cell growth, be non-thrombogenic, minimize intimal hyperplasia, match the structural properties of native vessels, and allow for regeneration of arterial tissue. Electrospun recombinant human tropoelastin (rTE) as a medial component of a vascular graft scaffold was investigated in this study by evaluating its structural properties, as well as its ability to support primary smooth muscle cell adhesion and growth. rTE solutions of 9, 15, and 20 wt% were electrospun into sheets with average fiber diameters of 167 ± 32, 522 ± 67, and 735 ± 270 nm, and average pore sizes of 0.4 ± 0.1, 5.8 ± 4.3, and 4.9 ± 2.4 µm, respectively. Electrospun rTE fibers were cross-linked with disuccinimidyl suberate to produce an insoluble fibrous polymeric recombinant tropoelastin (prTE) biomaterial. Smooth muscle cells attached via integrin binding to the rTE coatings and proliferated on prTE biomaterials at a comparable rate to growth on prTE coated glass, glass alone, and tissue culture plastic. Electrospun tropoelastin demonstrated the cell compatibility and design flexibility required of a graft biomaterial for vascular applications.


title: Levetiracetam as an adjunct to phenobarbital treatment in cats with suspected idiopathic epilepsy.

text: OBJECTIVE To assess pharmacokinetics, efficacy, and tolerability of oral levetiracetam administered as an adjunct to phenobarbital treatment in cats with poorly controlled suspected idiopathic epilepsy. DESIGN-Open-label, noncomparative clinical trial. ANIMALS 12 cats suspected to have idiopathic epilepsy that was poorly controlled with phenobarbital or that had unacceptable adverse effects when treated with phenobarbital. PROCEDURES Cats were treated with levetiracetam (20 mg/kg [9.1 mg/lb], PO, q 8 h). After a minimum of 1 week of treatment, serum levetiracetam concentrations were measured before and 2, 4, and 6 hours after drug administration, and maximum and minimum serum concentrations and elimination half-life were calculated. Seizure frequencies before and after initiation of levetiracetam treatment were compared, and adverse effects were recorded. RESULTS Median maximum serum levetiracetam concentration was 25.5 microg/mL, median minimum serum levetiracetam concentration was 8.3 microg/mL, and median elimination half-life was 2.9 hours. Median seizure frequency prior to treatment with levetiracetam (2.1 seizures/mo) was significantly higher than median seizure frequency after initiation of levetiracetam treatment (0.42 seizures/mo), and 7 of 10 cats were classified as having responded to levetiracetam treatment (ie, reduction in seizure frequency of >or=50%). Two cats had transient lethargy and inappetence. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that levetiracetam is well tolerated in cats and may be useful as an adjunct to phenobarbital treatment in cats with idiopathic epilepsy.


If the world fails to protect the economy, COVID-19 will damage health not just now but also in the future.


title: Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial.

text: BACKGROUND The IMS III trial did not show a clinical benefit of endovascular treatment compared with intravenous alteplase (recombinant tissue plasminogen activator) alone for moderate or severe ischaemic strokes. Late reperfusion of tissue that was no longer salvageable could be one explanation, as suggested by previous exploratory studies that showed an association between time to reperfusion and good clinical outcome. We sought to validate this association in a preplanned analysis of data from the IMS III trial. METHODS We used data for patients with complete proximal arterial occlusions in the anterior circulation who received endovascular treatment and achieved angiographic reperfusion (score on Thrombolysis in Cerebral Infarction scale of grade 2-3) during the endovascular procedure (within 7 h of symptom onset). We used logistic regression to model good clinical outcome (defined as a modified Rankin Scale score of 0-2 at 3 months) as a function of the time to reperfusion. We prespecified variables to be considered for adjustment, including age, baseline National Institutes of Health Stroke Scale score, sex, and baseline blood glucose concentration. FINDINGS Of 240 patients who were otherwise eligible for inclusion in our analysis, 182 (76%) achieved angiographic reperfusion. Mean time from symptom onset to reperfusion (ie, procedure end) was 325 min (SD 52). Increased time to reperfusion was associated with a decreased likelihood of good clinical outcome (unadjusted relative risk for every 30-min delay 0·85 [95% CI 0·77-0·94]; adjusted relative risk 0·88 [0·80-0·98]). INTERPRETATION Delays in time to angiographic reperfusion lead to a decreased likelihood of good clinical outcome in patients after moderate to severe stroke. Rapid reperfusion could be crucial for the success of future acute endovascular trials. FUNDING US National Institutes of Health and National Institute of Neurological Disorders and Stroke.


Generalized Cowpox Virus Infection in a Patient with HIV, Germany, 2012.


Rural Matters - Coronavirus and the Navajo Nation.


title: Complications of transbrachial arterial access for peripheral endovascular interventions.

text: PURPOSE To prospectively assess current limitations and complication rates of the transbrachial access technique for endovascular treatment of peripheral vascular pathologies. METHODS In total, 150 patients (112 men; mean age 66.3 ± 10.0 years) with arterial occlusive disease underwent endovascular therapy via a transbrachial access. Periprocedure data (sheath size, dose area product, fluoroscopy time, and procedure duration) were analyzed. Postprocedure complications of the puncture sites were categorized as minor (local hematoma, pseudoaneurysm, embolization, dissection, minor bleeding) and major (thrombotic occlusion, hematoma requiring surgery, major bleeding, nerve injury). RESULTS The minor and major complication rates were 14.0% (n = 21) and 2.7% (n = 4). The most frequent major complication was thrombotic occlusion of the brachial artery requiring surgical treatment (3/150, 2%). There was only one temporary palsy of the median nerve and no stroke. Local hematoma (15, 10%), pseudoaneurysm (3, 2%), or a combination of both (3, 2%) dominated the minor complications. The average dose area product and fluoroscopy time were 12,752.1 ± 9524.5 cGy*cm(2) and 24.3 ± 18.4 minutes, respectively, though procedure duration was acceptable (121.8 ± 48.9 minutes). CONCLUSION Complication rates of the transbrachial access for endovascular treatment of peripheral or visceral artery occlusive disease are tolerably low, making it a safe and an important alternative to the transfemoral access in selected cases, though the radiation exposure is rather high.


title: Association of influenza outbreaks with advanced pediatric medical support.

text: Retrospective data evaluated increases in advanced medical support for children with medically attended acute respiratory illness (MAARI) during influenza outbreak periods (IOP). Advanced support included hospitalisation, intensive care unit admission, or mechanical ventilation, for children aged 0-17 years hospitalised in Maryland's 50 acute-care hospitals over 12 influenza seasons. Weekly numbers of positive influenza tests in the Maryland area defined IOP for each season as the fewest consecutive weeks, including the peak week containing at least 85% of positive tests with a 2-week buffer on either side of the IOP. Peak IOP (PIOP) was defined as four consecutive weeks containing the peak week with the most number of positive influenza tests. Off-PIOP was defined as the 'shoulder' weeks during each IOP. Non-influenza season (NIS) was the remaining weeks of that study season. Rate ratios of mean daily MAARI-related admissions resulting in advanced medical support outcomes during PIOP or Off-PIOP were compared with the NIS and were significantly elevated for all 12 study seasons combined. The results suggest that influenza outbreaks are associated with increased advanced medical support utilisation by children with MAARI. We feel that this data may help preparedness for severe influenza epidemics or pandemic.


title: The Coronavirus and the Risks to the Elderly in Long-Term Care.

text: The elderly in long-term care (LTC) and their caregiving staff are at elevated risk from COVID-19. Outbreaks in LTC facilities can threaten the health care system. COVID-19 suppression should focus on testing and infection control at LTC facilities. Policies should also be developed to ensure that LTC facilities remain adequately staffed and that infection control protocols are closely followed. Family will not be able to visit LTC facilities, increasing isolation and vulnerability to abuse and neglect. To protect residents and staff, supervision of LTC facilities should remain a priority during the pandemic.


title: The spike protein of murine coronavirus regulates viral genome transport from the cell surface to the endoplasmic reticulum during infection.

text: We observed that the nonfusogenic mouse hepatitis virus (MHV) strain MHV-2 reached a titer of approximately 2 log10 higher than that of the fusogenic strain A59 in astrocytoma DBT cells. To determine whether the spike protein is responsible for the difference, a recombinant virus, Penn-98-1, that contains the A59 genome with a spike from MHV-2 was used to infect DBT cells. Results showed that Penn-98-1 behaved like MHV-2, thus establishing a role for the spike protein in viral growth. The inverse correlation between viral fusogenicity and growth was further established in four different cell types and with a fusogenic mutant, the S757R mutant, derived from isogenic Penn-98-1. While both A59 and Penn-98-1 entered cells at similar levels, viral RNA and protein syntheses were significantly delayed for A59. Interestingly, when the genomic RNAs were delivered directly into the cells via transfection, the levels of gene expression for these viruses were similar. Furthermore, cell fractionation experiments revealed that significantly more genomic RNAs for the nonfusogenic MHVs were detected in the endoplasmic reticulum (ER) within the first 2 h after infection than for the fusogenic MHVs. Pretreatment of Penn-98-1 with trypsin reversed its properties in syncytium formation, virus production, and genome transport to the ER. These findings identified a novel role for the spike protein in regulating the uncoating and delivery of the viral genome to the ER after internalization.


title: The Role of Interventional Radiologists in the Use of Extracorporeal Membranous Oxygenation in the Catheter-Directed Treatment of Pulmonary Embolism.

text: Patients with pulmonary embolism who are in hemodynamically unstable condition present a special challenge to the interventionalist. When treating such patients, extracorporeal membranous oxygenation (ECMO) can help to stabilize these patients' condition; however, specific criteria for its use do not exist. Two patients are presented here to familiarize the reader with the use of ECMO and to demonstrate its utility for the interventional radiologist.


title: Pandemic (H1N1) 2009 infection in adult solid organ transplant recipients in Singapore.

text: BACKGROUND Influenza can produce significant complications in immunocompromised persons. METHODS We studied the effects of the pandemic (H1N1) 2009 (pH1N1) infection on solid organ transplant recipients in our hospital, with emphasis on clinical information, duration of viral culture positivity, polymerase chain reaction positivity, effects of oseltamivir therapy, and graft status at 6 months of follow-up. RESULTS Twenty-two cases of pH1N1 infection involving 18 renal, two lung, one heart, and one liver transplant recipients were seen from July 14 to September 8, 2009. Their median age was 50.5 years (range 20-70 years); 64% were women, and median time posttransplant was 40 months (range 6-204 months). Common symptoms were fever (86%), cough (77%), sore throat (55%), phlegm (32%), and myalgia (27%). The median duration of symptoms (n=21) and duration of polymerase chain reaction positivity (n=15) were 7 (range 4-13 days) and 8 days (range 4-16 days), respectively. Mean (± SD) duration of symptom resolution (7.4 ± 3.0 vs. 7.8 ± 3.0 days, P=0.76) and viral culture positivity (5.3 ± 2.8 vs. 4.3 ± 3.2 days, P=0.65) did not differ between those who received a 5-day (n=9) or 10-day (n=12) course of oseltamivir. Five patients (22.7%) developed pneumonia with three needing intensive care. Mortality rate was 4.5% (1/22). At 6 months, three graft rejections involving two renal and one lung developed. CONCLUSIONS Our findings indicate that the pH1N1 infection in solid organ transplant recipients is associated with some degree of morbidity and may affect the function of the transplanted organ. In this nonrandomized comparison, patients treated with 5 days of oseltamivir did not fare worse compared with those who received 10 days.


title: Comparative effectiveness of revascularization strategies.

text: BACKGROUND Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG. METHODS We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias. RESULTS Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis. CONCLUSIONS In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI. (Funded by the National Heart, Lung, and Blood Institute.).


title: Differences between COVID-19 and suspected then confirmed SARS-CoV-2-negative pneumonia: a retrospective study from a single center.

text: Coronavirus disease 2019 (COVID-19) broke out in Wuhan, Hubei, China in December 2019. Tens thousands of people have been infected with the disease. Our aim was to distinguish severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients from SARS-CoV-2-negative patients. We retrospectively compared the data of COVID-19 patients with those of suspected and confirmed SARS-CoV-2-negative patients (control patients). There were 78 COVID-19 patients and 26 control patients, whose median ages were significantly different (P=0.001). The percentage of COVID-19 patients admitting exposure to Wuhan was obviously higher than that of control patients (X2 =29.130, P<0.001). Fever and cough appeared more frequently in COVID-19 patients than in the control patients. The routine blood work-up parameters of COVID-19 patients did not change much and their mean counts were in normal range. There were 38.5% of control patients had higher procalcitonin (PCT) levels than 0.5ng/ml, which was significantly higher than that percentage of COVID-19 patients (X2 =22.636, P <0.05), and COVID-19 patients were also more likely to have decreased or normal urea and creatinine levels than control patients (X2 =24.930, 8.480, P <0.05).Younger age, exposure to Wuhan, fever, cough, and slight changes in routine blood work-up parameters, urea and creatinine were important features discriminating COVID-19 from control patients. Slightly increased, but far less than 0.5ng/ml, PCT levels also differentiated COVID-19 patients from control patients This article is protected by copyright. All rights reserved.


title: Beneficial Effects of Ivabradine on Post-Resuscitation Myocardial Dysfunction In A Porcine Model of Cardiac Arrest.

text: BACKGROUND Ivabradine selectively inhibits the If current, reducing the heart rate and protecting against myocardial ischemia/reperfusion injury. We investigated the effects of ivabradine on post-resuscitation myocardial function in a porcine model of cardiopulmonary resuscitation. METHODS AND RESULTS Ventricular fibrillation was induced and untreated for 8 minutes while defibrillation was attempted after 6 minutes of cardiopulmonary resuscitation in anesthetized domestic swine. Then the animals were randomized into ivabradine and placebo groups (n = 5 each). Ivabradine and saline were administered at the same volume 5 minutes after ROSC (Return of Spontaneous Circulation), followed by continuous intravenous infusion at 0.5 mg/kg for 480 minutes. Hemodynamic parameters were continuously recorded. Myocardial function was assessed by echocardiography at baseline and at 60, 120, 240, 480 minutes and 24 hours after resuscitation. The serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin I (cTnI) were measured by commercial enzyme-linked immunosorbent assay kits. Animals were killed 24 hours after resuscitation, and all myocardial tissue was removed for histopathological analysis. The heart rate was significantly reduced from 1 hour after resuscitation in the ivabradine group (all p < 0.05). The post-resuscitation mitral E/A and E/e' velocity ratios and left ventricular ejection fraction were significantly better in the ivabradine than placebo group (p < 0.05). The serum levels of myocardial injury biomarkers (NT-proBNP, cTnI) and the myocardial biopsy scores were significantly lower in the ivabradine than placebo group (p < 0.05). Neurological deficit scores were lower in the IVA group at PR 24 hours (p < 0.05). CONCLUSIONS Ivabradine improved post-resuscitation myocardial dysfunction, myocardial injury and post-resuscitation cerebral function, and also slowed the heart rate in this porcine model.


title: Vaccines for the common cold.

text: BACKGROUND The common cold is a spontaneously remitting infection of the upper respiratory tract, characterised by a runny nose, nasal congestion, sneezing, cough, malaise, sore throat, and fever (usually < 37.8º C). The widespread morbidity caused by the common cold worldwide is related to its ubiquitousness rather than its severity. The development of vaccines for the common cold has been difficult because of antigenic variability of the common cold virus and the indistinguishable multiple other viruses and even bacteria acting as infective agents. There is uncertainty regarding the efficacy and safety of interventions for preventing the common cold in healthy people. This is an update of a Cochrane review first published in 2011 and previously updated in 2013. OBJECTIVES To assess the clinical effectiveness and safety of vaccines for preventing the common cold in healthy people. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (September 2016), MEDLINE (1948 to September 2016), Embase (1974 to September 2016), CINAHL (1981 to September 2016), and LILACS (1982 to September 2016). We also searched three trials registers for ongoing studies and four websites for additional trials (February 2017). We included no language or date restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) of any virus vaccines compared with placebo to prevent the common cold in healthy people. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated methodological quality and extracted trial data. We resolved disagreements by discussion or by consulting a third review author. MAIN RESULTS We found no additional RCTs for inclusion in this update. This review includes one RCT dating from the 1960s with an overall high risk of bias. The RCT included 2307 healthy participants, all of whom were included in analyses. This trial compared the effect of an adenovirus vaccine against placebo. No statistically significant difference in common cold incidence was found: there were 13 (1.14%) events in 1139 participants in the vaccines group and 14 (1.19%) events in 1168 participants in the placebo group (risk ratio 0.95, 95% confidence interval 0.45 to 2.02; P = 0.90). No adverse events related to the live vaccine were reported. The quality of the evidence was low due to limitations in methodological quality and a wide 95% confidence interval. AUTHORS' CONCLUSIONS This Cochrane Review was based on one study with low-quality evidence. We found no conclusive results to support the use of vaccines for preventing the common cold in healthy people compared with placebo. We identified a need for well-designed, adequately powered RCTs to investigate vaccines for the common cold in healthy people. Any future trials on medical treatments for preventing the common cold should assess a variety of virus vaccines for this condition. Outcome measures should include common cold incidence, vaccine safety, and mortality related to the vaccine.


title: Intensity-modulated radiotherapy vs. conventional radiotherapy in the treatment of anal squamous cell carcinoma: a propensity score analysis.

text: BACKGROUND AND PURPOSE Definitive chemoradiation is the standard management for anal squamous cell carcinoma (ASCC); more conformal pelvic radiotherapy using intensity modulated radiotherapy (IMRT) minimizes toxicity but may increase locoregional recurrences (LRR). We compared IMRT and conventional radiotherapy (CRT) outcomes in ASCC patients. MATERIAL AND METHODS We retrospectively reviewed records of 223 ASCC patients treated at Memorial Sloan-Kettering Cancer Center from 1991 to 2010. Forty-five patients received IMRT and 178 CRT. We determined locoregional recurrence-free survival (LRFS), distant metastases-free survival (DMFS), and overall survival (OS) for each radiation modality. A propensity score analysis was performed using potentially confounding variables. Locoregional and distant patterns of failure for CRT and IMRT were compared. RESULTS Patients treated with IMRT had significantly higher N stage (P<.01), and were less likely to be treated with induction chemotherapy (P=.01). The 2-year LRFS, DMFS, and OS were 87%, 86%, and 93%, respectively, for IMRT; and 82%, 88%, 90%, respectively, for CRT; with no significant difference in outcomes by univariate analysis or in a propensity score analysis adjusted for disparity between the groups. CONCLUSIONS This large, single-institution experience of definitive chemoradiation for ASCC using CRT vs. IMRT demonstrates that outcomes are not compromised by more conformal radiotherapy. In the absence of prospective, multi-institutional, randomized trials of IMRT in ASCC, these retrospective data, using methods to minimize bias, can help to establish the role of IMRT in the definitive therapy of ASCC.


title: Bilateral medial displacement of the biceps tendon of origin: repair using polypropylene mesh and staples.

text: A three-year-old male greyhound was presented with acute onset right forelimb lameness because of medial displacement of the biceps tendon of origin. Ultrasonographic examination confirmed the diagnosis, and a concomitant partial tear of the medial glenohumeral ligament was detected during arthroscopy. To stabilise the biceps tendon, polypropylene mesh was fixed across the intertubercular groove to replace the torn transverse humeral retinaculum. Recovery was uneventful and lameness resolved. Fifteen months later, the dog was presented with medial displacement of the biceps tendon of origin of the left shoulder, and was treated successfully using the same technique.


title: Towards Predicting Patient-Specific Flow-Diverter Treatment Outcomes for Bifurcation Aneurysms: From Implantation Rehearsal to Virtual Angiograms.

text: Despite accounting for the majority of all cerebral aneurysm cases, bifurcation aneurysms present many challenges to standard endovascular treatment techniques. This study examines the treatment of bifurcation aneurysms endovascularly with flow-diverting stents and presents an integrative computational modeling suite allowing for rehearsing all aspects of the treatment. Six bifurcation aneurysms are virtually treated with 70% porosity flow-diverters. Substantial reduction (>50%) in aneurysm inflow due to device deployment is predicted in addition to reductions in peak and average aneurysm wall shear stress to values considered physiologically normal. The subsequent impact of flow-diverter deployment on daughter vessels that are jailed by the device is investigated further, with a number of simulations conducted with increased outlet pressure conditions at jailed vessels. Increased outlet pressures at jailed daughter vessels are found to have little effect on device-induced aneurysm inflow reduction, but large variation (13-86%) is seen in the resulting reduction in daughter vessel flow rate. Finally, we propose a potentially powerful approach for validation of such models, by introducing an angiographic contrast model, with contrast transport modeled both before and after virtual treatment. Virtual angiograms and contrast residence curves are created, which offer unique clinical relevance and the potential for future in vivo verification of simulated results.


ESCAIDE 2015: an operational scientific conference on infectious diseases for professionals from Europe and beyond.


title: [Treatment of COVID-19 guided by holistic view of traditional Chinese medicine--therapy aimed at both viral and host].

text: The global outbreak of coronavirus disease 2019(COVID-19) has further spread, and there is an increasing number of confirmed cases in many countries. On February 28, 2020 of Geneva time, the World Health Organization has raised global risk level to the very high level in view of outbreak of COVID-19. Since some patients' condition appeared to deteriorate rapidly after infection of this 2019 novel coronavirus(2019-nCoV), a variety of treatments should be considered. Holistic view and syndrome differentiation are the two characteristics of traditional Chinese medicine(TCM). Therefore, under the guidance of the holistic view, syndrome diffe-rentiation of TCM has achieved good effects in the treatment of COVID-19. This treatment mainly aimed at eliminating pathogens and strengthening overall health, regulating the balance of body and coordinating various of functions of Zangfu organs. In addition, modern medical proposes host-directed therapy(HDT), a strategy aims to interfere with host cell mechanism, enhance immune responses, and reduce exacerbated inflammation. To some extent, the combined application of HDT and antiviral therapy is highly consistent with the therapeutic concept of the holistic view of TCM. Therefore, under the guidance of the holistic view, syndrome differentiation of TCM uses treatments, such as clearing heat, detoxification, relieving asthma, clearing damp and phlegm, together with Lianhua Qingwen Capsules, Maxing Shigan Decoction, and Haoqin Qingdan Decoction under the guidance of these therapeutic methods. These therapeutic methods and prescriptions intervened with both virus and host at the same time in the treatment of COVID-19, which has important implications for the effective clinical treatment of COVID-19.


Intrasternal anastomotic pseudoaneurysm following ascending aortic graft replacement.


title: Noninvasive regional cerebral oxygen saturation for neurological prognostication of patients with out-of-hospital cardiac arrest: a prospective multicenter observational study.

text: AIM To investigate the association between regional brain oxygen saturation (rSO2) at hospital arrival and neurological outcomes at 90 days in patients with out-of-hospital cardiac arrest (OHCA). METHODS The Japan-Prediction of neurological Outcomes in patients post cardiac arrest (J-POP) registry is a prospective, multicenter, cohort study to test whether rSO2 predicts neurological outcomes after OHCA. We measured rSO2 in OHCA patients immediately after hospital arrival using a near-infrared spectrometer placed on the forehead with non-blinded fashion. The primary endpoint was "neurological outcomes" at 90 days after OHCA. RESULTS EMS providers are not permitted to terminate CPR in the field in Japan, and so most patients with OHCA who are treated by EMS personnel are transported to emergency hospitals. Among 1017 OHCA patients, 672 patients including 52 comatose patients with pulses detectable (8%) and 620 cardiac arrest patients (92%) at hospital arrival were enrolled prospectively and consecutively. Twenty-nine patients with good neurological outcome had a significantly higher value of rSO2 at hospital arrival than 643 patients with poor neurological outcome (mean [±SD] 55.6±20.8% vs. 19.7±11.0%, p<0.001). Receiver operating curve analysis indicated an optimal rSO2 cutoff point of >42% for predicting good neurological outcome, with sensitivity 0.79 (95% confidence interval [CI], 0.60-0.92), specificity 0.95 (95% CI, 0.93-0.96), positive predictive value, 0.41 (95% CI, 0.28-0.55), negative predictive value, 0.99 (95% CI, 0.98-1.00), and area under the curve 0.90 (95% CI, 0.88-0.92). CONCLUSION The rSO2 at hospital arrival can predict good neurological outcome at 90 days after OHCA.


title: American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery.

text: The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period.


title: Recorded infection control messages delay inter-professional communication but are not associated with COVID-19 prevalence or mortality: insights from a national switchboard analysis.

text: Appropriate dissemination of information to the general public is a key component of the pandemic response. In 2018, recorded infection control advice messages were affixed to 30% of England's automated hospital switchboards during the seasonal influenza and norovirus outbreaks. As the majority of messages were mandatory for all callers, healthcare professionals using the hospital switchboard - including during time-critical emergencies - had their enquiries significantly delayed by these measures. Importantly, published analyses did not demonstrate an association between these messages and patient outcomes. As of May 2020, 85% of NHS trusts made use of infection control messages; on average, these delayed healthcare professionals by 59.4 seconds per call, but had no clear association with patient outcomes from COVID-19. An ongoing national switchboard quality improvement project seeks to establish a gold standard whereby healthcare professionals with urgent enquiries can press 'X' to skip past infection control messages and have their calls triaged immediately.


title: Novel energy-efficient electrodialysis system for continuous brackish water desalination: Innovative stack configurations and optimal inflow modes.

text: Electrodialysis (ED) is a well-established brackish water (BW) desalination technology that has been commercially applied for decades. However, the energy efficiency of BWED cannot approach optimization because of the low salt concentration of BW. In this study, a novel two hydraulic-stage ED desalination system was presented to enhance mass transfer and reduce energy consumption. In terms of energy-efficient strategies, it involved not only innovative membrane stack configurations (resin-filled electrode cells and asymmetric cell pairs design) but also optimizing inflow modes (electrolytes parallel flow and dilute/concentrate counter flow). Results showed that thin resin-filled (1 mm) electrode cells, asymmetric cell pair design (cell pairs ratio of 1st and 2nd-hydraulic stages, 1.2), and optimizations of general inflow mode were beneficial for savings 10-30% of energy consumption at the same salt removal ratio (SR). The synergistic effects of these strategies indicated that this novel ED system could save ∼40% of the energy consumption at the same SR, compared with conventional two hydraulic-stage ED system (CED). Three stage continuous BWED performance tests, compared with a CED, showed that a 36.9% total energy saving could be achieved using the novel ED system when the BW concentration decreased from 3500 mg/L to the quality requirement of drinking water (∼450 mg/L). It was therefore possible to open the way for saving energy in BWED systems.


title: Evaluation of automated nucleic acid extraction methods for virus detection in a multicenter comparative trial.

text: Five European veterinary laboratories participated in an exercise to compare the performance of nucleic acid extraction robots. Identical sets of coded samples were prepared using serial dilutions of bovine viral diarrhoea virus (BVDV) from serum and cell culture propagated material. Each laboratory extracted nucleic acid from this panel using available robotic equipment (12 separate instruments, comprising 8 different models), after which the processed samples were frozen and sent to a single laboratory for subsequent testing by real-time RT-PCR. In general, there was good concordance between the results obtained for the different automated extraction platforms. In particular, the limit of detection was identical for 9/12 and 8/12 best performing robots (using dilutions of BVDV infected-serum and cell culture material, respectively), which was similar to a manual extraction method used for comparison. The remaining equipment and protocols used were less sensitive, in an extreme case for serum, by a factor of 1000. There was no evidence for cross-contamination of RNA template in any of the negative samples included in these panels. These results are not intended to replace local optimisation and validation, but provide reassurance to laboratories to indicate that the best performing optimised nucleic acid extraction systems can have similar performance.


title: Long-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus the same dose of ICS alone for adults with asthma.

text: BACKGROUND Despite the availability of several evidence-based therapies and non-pharmacological strategies to improve control of symptoms and prevent exacerbations of asthma, patients with asthma continue to be at risk for mortality and morbidity.Previous trials have demonstrated the potentially beneficial effects of the long-acting muscarinic antagonist (LAMA) tiotropium on lung function in patients with asthma; however, a definitive conclusion on the benefit of LAMA in asthma is lacking, as is information on where in the current step-wise management strategy they would be most beneficial. OBJECTIVES To assess the efficacy and safety of a LAMA added to any dose of an inhaled corticosteroid (ICS) compared with the same dose of ICS alone for adults whose asthma is not well controlled. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register (CAGR) from inception to April 2015, and we imposed no restriction on language of publication. We also searched clinicaltrials.gov, the World Health Organization (WHO) trials portal and drug company registries to identify unpublished studies. SELECTION CRITERIA We searched for parallel and cross-over randomised controlled trials in which adults whose asthma was not well controlled by ICS alone were randomly assigned to receive LAMA add-on or placebo (both combined with ICS) for at least 12 weeks. DATA COLLECTION AND ANALYSIS Two review authors independently screened the searches and extracted data from study reports. We used Covidence for duplicate screening, extraction of study characteristics and numerical data and risk of bias ratings. Pre-specified primary outcomes included exacerbations requiring oral corticosteroids, quality of life and all-cause serious adverse events. MAIN RESULTS We identified five studies that met the inclusion criteria. All studies applied a double-blind, double-dummy design, and the population of all studies totalled 2563 adult participants. Study duration ranged from 12 weeks to 52 weeks, and risk of bias across domains in all studies was low. Trials included more women than men (33% to 47% male), and mean age of participants ranged from 41 to 48 years. Participants generally had a long history of asthma, and mean baseline predicted forced expiratory volume in one second (FEV1) was between 72% and 75% in three studies reporting pre-bronchodilator values.The rate of exacerbations requiring oral corticosteroids (OCS) was lower in patients prescribed an LAMA add-on than in those receiving the same dose of ICS alone (odds ratio (OR) 0.65, 95% confidence interval (CI) 0.46 to 0.93; 2277 participants; four studies; I(2) = 0%; high-quality evidence), meaning that 27 fewer people per 1000 would have an exacerbation over 21 weeks requiring OCS with LAMA compared with ICS alone (95% CI 42 fewer to 6 fewer).All-cause serious adverse events (SAEs) and exacerbations requiring hospital admission were rare and the effects too imprecise to permit firm conclusions, but effects suggested that LAMA add-on may be associated with fewer of both compared with ICS alone (SAEs: OR 0.60, 95% CI 0.23 to 1.57; 2532 participants; four studies; low-quality evidence; exacerbations requiring hospital admission: OR 0.42, 95% CI 0.12 to 1.47; 2562 participants; five studies; moderate-quality evidence). Additional therapy with a LAMA showed no clear benefit in terms of quality of life compared with ICS given alone; high-quality evidence showed only a small mean improvement in quality of life as measured on the Asthma Quality of Life Questionnaire (AQLQ), which was not statistically significant. The same was true for asthma control as measured on the Asthma Control Questionnaire (ACQ), which was based on moderate-quality evidence. LAMA combined with ICS showed consistent benefit in a range of lung function measures compared with the same dose of ICS alone, and LAMA was not associated with significantly higher rates of adverse events than were reported with placebo. AUTHORS' CONCLUSIONS For adults taking ICS for asthma without a long-acting beta₂-agonist (LABA), LAMA given as add-on treatment reduces the likelihood of exacerbations requiring treatment with OCS and improves lung function. The benefits of LAMA combined with ICS for hospital admissions, all-cause serious adverse events, quality of life and asthma control remain unknown.Results of this review, along with findings of related reviews conducted to assess the use of LAMA in other clinical scenarios involving asthma, can help to define the role of LAMA in the management of asthma. Trials of longer duration (up to 52 weeks) would provide a better opportunity to observe rare events such as serious adverse events and exacerbations requiring hospital admission.


title: Multivariable fractional polynomial interaction to investigate continuous effect modifiers in a meta-analysis on higher versus lower PEEP for patients with ARDS.

text: OBJECTIVES A recent individual patient data (IPD) meta-analysis suggested that patients with moderate or severe acute respiratory distress syndrome (ARDS) benefit from higher positive end-expiratory pressure (PEEP) ventilation strategies. However, thresholds for continuous variables (eg, hypoxaemia) are often arbitrary and linearity assumptions in regression approaches may not hold; the multivariable fractional polynomial interaction (MFPI) approach can address both problems. The objective of this study was to apply the MFPI approach to investigate interactions between four continuous patient baseline variables and higher versus lower PEEP on clinical outcomes. SETTING Pooled data from three randomised trials in intensive care identified by a systematic review. PARTICIPANTS 2299 patients with acute lung injury requiring mechanical ventilation. INTERVENTIONS Higher (N=1136) versus lower PEEP (N=1163) ventilation strategy. OUTCOME MEASURES Prespecified outcomes included mortality, time to death and time-to-unassisted breathing. We examined the following continuous baseline characteristics as potential effect modifiers using MFPI: PaO2/FiO2 (arterial partial oxygen pressure/ fraction of inspired oxygen), oxygenation index, respiratory system compliance (tidal volume/(inspiratory plateau pressure-PEEP)) and body mass index (BMI). RESULTS We found that for patients with PaO2/FiO2 below 150 mm Hg, but above 100 mm Hg or an oxygenation index above 12 (moderate ARDS), higher PEEP reduces hospital mortality, but the beneficial effect appears to level off for patients with very severe ARDS. Patients with mild ARDS (PaO2/FiO2 above 200 mm Hg or an oxygenation index below 10) do not seem to benefit from higher PEEP and might even be harmed. For patients with a respiratory system compliance above 40 mL/cm H2O or patients with a BMI above 35 kg/m(2), we found a trend towards reduced mortality with higher PEEP, but there is very weak statistical confidence in these findings. CONCLUSIONS MFPI analyses suggest a nonlinear effect modification of higher PEEP ventilation by PaO2/FiO2 and oxygenation index with reduced mortality for some patients suffering from moderate ARDS. STUDY REGISTRATION NUMBER CRD42012003129.


title: COVID-19 Crisis Creates Opportunities for Community-Centered Population Health: Community Health Workers at the Center.

text: Dealing with the COVID-19 coronavirus requires a coordinated transnational effort. We propose a 2-stage state-led effort that utilizes community health workers (CHWs). We spell out what is beginning to occur in states to control and suppress COVID-19. In the second stage, we suggest working with these CHWs as a key element in the next evolution of our health care system: community-centered population health.


title: Composite mesh and gluteal fasciocutaneous rotation flap for perineal hernia repair after abdominoperineal resection: a novel technique.

text: Perineal hernia is an uncommon complication following abdominoperineal rectum resection. Several surgical procedures have been proposed for perineal hernia repair, including perineal, laparoscopic and abdominal approaches. Repair techniques can be classified into primary suture techniques, mesh placements and repairs with autogenous tissue. We report a 68-year-old man with a perineal hernia, who underwent a pelvic floor reconstruction with a transperineal composite mesh and a gluteal fasciocutaneous rotation flap. We conclude that a combined approach with transperineal mesh reconstruction and gluteal fasciocutaneous flap could be an alternative choice in perineal hernia repair after abdominoperineal resection.


title: Long-term clinical and quality of life outcomes after stenting of femoropopliteal artery stenosis: 3-year results from the STROLL study.

text: OBJECTIVES To evaluate the clinical and health status outcomes of patients undergoing superficial femoral artery (SFA) revascularization using the Shape Memory Alloy Recoverable Technology (S.M.A.R.T.®) nitinol self-expanding stent through 3 years of follow-up. BACKGROUND Limited long-term data are available describing the durability of benefits after femoropopliteal revascularization. METHODS In a multicenter, prospective, core-lab adjudicated study, 250 subjects with de novo or restenotic femoropopliteal arterial lesions were treated with the S.M.A.R.T.® stent. The primary endpoint of target vessel patency, a composite of ultrasound-assessed patency and freedom from clinically driven target lesion revascularization (TLR), was evaluated through 3 years. Secondary endpoints included stent fracture and health status. Health status was measured using generic and disease-specific instruments, including the Peripheral Artery Questionnaire (PAQ). RESULTS At 3-year follow-up, Kaplan-Meier estimated target vessel patency was 72.7%, freedom from clinically driven TLR was 78.5%, and the incidence of stent fracture was 3.6%. The PAQ summary score was markedly impaired at baseline (mean 37.3 ± 19.6 points) and improved substantially at 1 month (mean change from baseline of 31.4 points, 95% CI: 28.5-34.3; P < 0.001). Disease-specific health status benefits assessed by the PAQ were largely preserved through 3 years of follow-up (mean change from baseline, 28.0 points, 95% CI: 24.3-31.7; P < 0.0001). CONCLUSIONS In patients undergoing revascularization for moderately complex SFA disease, use of the self-expanding S.M.A.R.T® stent was associated with a high rate of target vessel patency through 3 years and led to substantial and sustained health status benefits.


title: Microwave ablation of liver metastases to overcome the limitations of radiofrequency ablation.

text: PURPOSE The purpose of our study was to evaluate technical success, effectiveness and safety of microwave ablation (MWA) in patients with unresectable liver metastases, where radiofrequency ablation (RFA) presents some limits. MATERIALS AND METHODS Twenty-five patients (17 men, 8 women) with 31 liver metastases >3 cm or located near vessels (>3 mm) were treated in a total of 29 sessions. Tumours were subdivided as follows: colorectal metastases (n=21) and no colorectal metastases (n=10). All procedures were performed percutaneously under ultrasound (US) guidance. Follow-up was performed with computed tomography (CT) scan at 1, 3, 6 and 12 months after treatment; mean follow-up period was 12.04 (range, 3-36) months. Technical success, mean disease-free survival, effectiveness and safety were evaluated. RESULTS Technical success was obtained in all cases. Mean disease-free survival was of 20.5 months. Local recurrence was recorded in 12.9% of metastases treated (4/31). No major complications were recorded. The rate of minor complications was 44.8% (13/29 sessions). Mortality at 30 days was 0%. CONCLUSIONS Percutaneous MWA of liver metastases >3 cm or located near vessels (>3 mm) can be considered a valid and safe option, probably preferable to RFA. Further studies are required to confirm these encouraging initial results.


title: COVID-19 pandemic repercussions on the use and management of plastics.

text: Plastics are essential in society as a widely available and inexpensive material. Mismanagement of personal protective equipment (PPE) during COVID-19 pandemic, with a monthly estimated use of 129 billion face masks and 65 billion gloves globally, is resulting in widespread environmental contamination. This poses a risk to public health as a vector for SARS-CoV-2 virus, which survives up to 3 days on plastics, as well as impacts to ecosystems and organisms more broadly functions. Concerns over the role of reusable plastics as vectors for SARS-CoV-2 virus contributed to the reversal of bans on single-use plastics, highly supported by the plastic industry. While not underestimating the importance of plastics in the prevention of COVID-19 transmission, it is imperative not to undermine recent progress made in the sustainable use of plastics. There is a need to assess alternatives that allow reductions of PPE and reinforce awareness on the proper public use and disposal. Finally, assessment of contamination and impacts of plastics driven by the pandemic will be required once the outbreak ends.


title: Feline ischemic myelopathy and encephalopathy secondary to hyaline arteriopathy in five cats.

text: Five cats presented with acute-onset neurological signs. Magnetic resonance imaging in four cats showed a T2-weighted hyperintense spinal cord lesion that was mildly contrast-enhancing in three cats. Owing to inflammatory cerebrospinal fluid changes three cats were treated with immunosuppression. One cat was treated with antibiotics. All cats improved initially, but were eventually euthanased owing to the recurrence of neurological signs. Histopathology in all cats showed hyaline degeneration of the ventral spinal artery, basilar artery or associated branches with aneurysmal dilation, thrombosis and ischemic degeneration and necrosis of the spinal cord and brain. Two cats also had similar vascular changes in meningeal vessels. Vascular hyaline degeneration resulting in vascular aneurysmal dilation and thrombosis should be a differential diagnosis in cats presenting with acute central nervous system signs.


title: [Suggestions on reforming and improving the prevention and treatment system for major epidemic diseases in China].

text: Based on systematic review of the role of clinical treatment, disease control and scientific research, and combining with the problems exposed by the COVID-19 epidemic, suggestions were proposed to reform and improve the prevention and treatment system for major epidemics diseases in China. In clinical treatment, it is necessary to enhance clinical staff's awareness of law-based reporting, capabilities of syndromic surveillance, the use of infectious diseases reporting systems, and to improve national or local monitoring platforms for emerging infectious diseases detection. In terms of disease control, it is important to provide authorities to disease control departments through laws and regulations, improve the quantity and quality of related human resources, and strengthen the applied research and technical readiness targeted infections disease prevention, control and emergency preparedness. As for scientific research in major epidemic response, it is essential to strengthen research projects guided by national requests, build research institutions that can "make a final decision", establish national and regional key laboratories, and strengthen strategic technical reserve for emergency disease control and treatment.


title: Impact of COVID-19 in Female Urology.

text: This review discusses the impact of COVID-19 in Female Urology, revises the most important disorders in this field and how their diagnosis and treatment may be modified due to the current pandemic. The text also discusses new options such as telemedicine and what clinical situations within Female Urology should be of utmost importance for the urologist to be careful about. We also discuss how surgeries are being postponed are resumed according to the local scenario.


title: Emerging treatments in neurogastroenterology: eluxadoline - a new therapeutic option for diarrhea-predominant IBS.

text: BACKGROUND Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder worldwide. The global prevalence of IBS is estimated to be as high as 15%. For many patients, IBS is a chronic disorder which can significantly reduce quality of life. Just as important as the effects on any one individual, IBS also places a significant impact on the population as a whole with its negative effects on the health care system. Irritable bowel syndrome is categorized into one of three main categories: IBS with diarrhea, IBS with constipation, and IBS with mixed bowel habits. Patients with diarrhea-predominant IBS (IBS-D) comprise a substantial proportion of the overall IBS population. A number of therapeutic options exist to treat the symptoms of abdominal pain, bloating, diarrhea, and fecal urgency, including non-pharmacologic therapies such as dietary changes and probiotics, or pharmacologic therapies such as loperamide and alosetron. However, many patients have persistent symptoms despite these therapies. This unmet need led to the development of eluxadoline, a mu-opioid receptor agonist/delta-opioid receptor antagonist/kappa-receptor agonist. Approved by the FDA in May 2015, this medication shows promise in the treatment of diarrhea-predominant IBS for both men and women. PURPOSE This monograph will briefly review the impact of IBS, discuss current treatments for IBS-D, and then focus on the pharmacology, clinical efficacy and safety of eluxadoline. Potential mechanisms related to rare events of acute pancreatitis or elevated liver tests will be discussed.


title: Abdominal pregnancy during the COVID-19 pandemic.

text: Abdominal pregnancy is a rare type of ectopic pregnancy with an incidence of 1:10 000 to 1:30 000 women. Several different locations have been reported, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen. Most abdominal pregnancies are diagnosed after presenting with various complications; however, in a few cases it may remain asymptomatic and is rarely established before surgery. Institutional Review Board approval was not required for this case report; written informed consent was obtained.


title: Intraureteral and intravenous indocyanine green to facilitate robotic partial nephroureterectomy in a patient with complete ureteral triplication.

text: A patient with a complete right ureteral triplication presented with recurrent pyelonephritis and flank pain that was refractory to medical management. Evaluation showed that the atrophic upper-most renal moiety had been chronically obstructed and was associated with a dilated ureter. Intraureteral and intravenous indocyanine green (ICG) were used as real-time contrast agents intraoperatively to facilitate right robotic partial nephroureterectomy of the diseased system. Intraureteral ICG was used to accurately distinguish the pathologic ureter and associated renal pelvis from its normal counterparts. Intravenous ICG was used to assess perfusion in the right kidney and delineate the margins of diseased renal parenchyma.


title: Introduction of laparoscopic abdominal aortic aneurysm repair.

text: BACKGROUND The aim was to review a consecutive series of patients treated with laparoscopic abdominal aortic aneurysm (AAA) repair. These patients were compared with patients having elective open AAA repair. METHODS Demographic and operative details were collected prospectively and outcomes recorded for all patients undergoing laparoscopic or open AAA repair. RESULTS A total of 316 patients underwent laparoscopic (51), open (53) or endovascular (EVAR; 212) AAA repair between 2007 and 2013. The median age of patients who had laparoscopic or open repair was 72 (i.q.r. 66-75) years, and 92·3 per cent were men. There was no significant difference in sex distribution, age or V-POSSUM physiology score between laparoscopic and open repair. Of the 51 laparoscopic procedures, six were totally laparoscopic, 43 were laparoscopically assisted and two were converted to open repair. Pain scores were similar on days 1 and 3 after laparoscopic and open repair, even though epidurals were used in the open group, and were lower on days 5 and 7 after laparoscopic procedures. Patients who had laparoscopic repair had significantly fewer postoperative cardiorespiratory and renal complications (P = 0·017), and were discharged from hospital sooner (median 5 (i.q.r. 3-7) versus 8 (6-11) days; P = 0 ·001). CONCLUSION Laparoscopic AAA repair was performed safely, and with at least equivalent outcomes to open repair, in patients unfavourable for EVAR.


Subserosal pyomyoma and tubo-ovarian abscess in a diabetic patient.


title: Stentriever Thrombectomy Failure: A Challenge in Stroke Management.

text: BACKGROUND AND OBJECTIVE Stentriever thrombectomy failure in patients with acute ischemic stroke caused by anterior circulation large artery occlusion is not a rare event. The purpose of this study was to investigate whether other procedures (tirofiban, permanent stenting) are able to recanalize the occluded vessel and determine a better outcome without increasing mortality and intracranial hemorrhage rates. METHODS Among 513 patients consecutively admitted with anterior circulation stroke, 109 underwent stentriever thrombectomy. Modified Thrombolysis in Cerebral Ischemia (mTICI) 2b-3 recanalization was achieved in 60 patients (55.0%, group 1). Only 3 of 19 patients (group 2) obtained additional recanalization with intra-arterial infusion of tirofiban. The remaining 46 either underwent permanent stenting (n = 23, group 3) or were left nonrecanalized (n = 23, group 4). The rate of mTICI 2b-3 and clinical outcomes were analyzed in the different groups. RESULTS A successful recanalization (mTICI 2b-3) was achieved in 17 patients of group 3 (73.9%). A significantly better outcome was observed in group 3 (modified Rankin Scale [mRS] score, 0-2) than in group 4 at 3 months (56.5% vs. 17.4%). Symptomatic intracranial hemorrhage rates were not different between group 3 and group 4 (4.3% vs. 4.3%), whereas there was a significantly higher mortality in group 4 than in group 3 (39.1% vs. 4.3%). On multivariate analysis, permanent stenting was the only factor independently associated with favorable outcome and mortality. CONCLUSIONS Permanent stenting might be a feasible solution in patients with acute large artery occlusion after stentriever thrombectomy failure.


title: Glycosylation of mouse DPP4 plays a role in inhibiting Middle East respiratory syndrome coronavirus infection.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) utilizes dipeptidyl peptidase 4 (DPP4) as an entry receptor. Mouse DPP4 (mDPP4) does not support MERS-CoV entry; however, changes at positions 288 and 330 can confer permissivity. Position 330 changes the charge and glycosylation state of mDPP4. We show that glycosylation is a major factor impacting DPP4 receptor function. These results provide insight into DPP4 species-specific differences impacting MERS-CoV host range and may inform MERS-CoV mouse model development.


title: Resumption of activity in gastroenterology departments. Recommendations by SEPD, AEEH, GETECCU and AEG.

text: The set of measures proposed by SEPD, AEEH, GETECCU and AEG are aimed to help departments in their resumption of usual activity. We have prepared a number of practical recommendations regarding patient management and the stepwise resumption of healthcare activity. These recommendations are based on the sparse, changing evidence available, and will be updated in the future according to daily needs and the availability of expendable materials to suit them; in each department they will be implemented depending upon the cumulative incidence of SARS-CoV-2 infection in each region, and the burden the pandemic has represented for each hospital. The general objectives of these recommendations include: • To protect our patients against the risks of infection with SARS-CoV-2 and to provide them with high-quality care. • To protect all healthcare professionals against the risks of infection with SARS-CoV-2. • To resume normal functioning of our departments in a setting of ongoing risk for infection with SARS-CoV-2.


title: Algorithm-Based Pediatric Otolaryngology Management During the COVID-19 Global Pandemic: A Children's Hospital of Philadelphia Clinical Consensus.

text: OBJECTIVE The coronavirus disease 2019 (COVID-19) pandemic requires clinicians to explore alternatives to routine patient management. Otolaryngologists caring for children commonly depend on physical examination, laboratory data, and ambulatory surgical procedures. Limiting patient care, mindful allocation of resources, and concern for safety have challenged all aspects of our health care system. This evidence-based clinical consensus is designed to guide practitioners of pediatric otolaryngology for common scenarios during this time. DATA SOURCES Peer-reviewed literature, published reports, institutional guidelines, and expert consensus. REVIEW METHODS A clinical consensus on 6 common scenarios in pediatric otolaryngology developed with evidence-based strategies. CONCLUSIONS Providers should suspend all in-person nonessential office visits and elective surgical procedures. An emphasis on medical management and caregiver education will provide reasonable approaches to many of the common outpatient concerns. Surgery for chronic otitis media, obstructive sleep apnea, and acute rhinosinusitis should occur only in response to severe complications or failure of medical regimens. The approach to the pediatric neck mass focuses on timely management for oncologic etiologies and cautious surgical intervention for abscess drainage or tissue sampling. Finally, epistaxis and otorrhea must be triaged and addressed without the usual ambulatory procedures. IMPLICATIONS FOR PRACTICE Adaptation of practice patterns during this unprecedented moment for our health care system requires thoughtful planning. The strategies described allow for safe handling of common pediatric otolaryngology diagnoses. Ultimately, otolaryngologists must be stewards of our global health community while advocating for the care of individual pediatric patients.


title: Initial experience with the use of biological implants for soft tissue and chest wall reconstruction in thoracic surgery.

text: BACKGROUND Synthetic materials have traditionally been used for tissue reconstruction in thoracic surgery. New biomaterials have been tested in other areas of surgery with good results. The aim of our study is to evaluate our initial experience using prostheses in extended thoracic surgery. METHODS A review was performed of all patients who underwent extended surgical procedures requiring soft tissue reconstruction with bioprosthetic materials after thoracic surgery from August 2009 to August 2011. A total of 44 consecutive patients were included. Operations involved radical pleurectomy and decortication for mesothelioma (n = 29), extended operations for thoracic malignancies (n = 8), surgery for trauma or perforated organs or complications (n = 6), and for benign infectious causes (n = 1). RESULTS A total of 76 patches were used in 44 patients (median of 2; range 1 to 3 per patient). Median hospital stay was 13 (range 5 to 149) days. Three patients died during the postoperative period (6.8%); pulmonary embolism 5 days after intrapericardial pneumonectomy with chest wall reconstruction, fatal pneumonia 26 days after radical pleurectomy and decortication for mesothelioma, and bronchopleural fistula 11 days after pneumonectomy with diaphragm and atrium excision for lung cancer after initial chemoradiotherapy. No other surgical exploration or removal of patches has been required for infection. CONCLUSIONS Our initial experience of using bioprosthetic patches for soft tissue reconstruction in thoracic surgery has proven satisfactory with overall acceptable results. The infection rates are low even when a proportion of procedures were performed under contaminated environments. Biologic prosthesis should be part of the surgical options to reconstruct soft tissues in thoracic surgery.


title: Subxiphoid thymectomy: single-port, dual-port, and robot-assisted.

text: Currently, surgical techniques that are less invasive than conventional median sternotomy are used for thymectomy in the treatment of myasthenia gravis and anterior mediastinal tumors as no sternal incision is required. We reported on a subxiphoid single-port thymectomy using CO2 insufflation, which has the following advantages: (I) the field of view offered by the camera scope inserted from the midline of the body helps confirm the location of the superior pole of the thymus and bilateral phrenic nerves; (II) there is minimal pain and no intercostal neuropathy occurs as intercostal spaces are not traversed; and (III) cosmetic outcomes are excellent. However, a drawback of this approach is that it requires familiarity with the single-port surgical procedure. Various surgical modifications have been suggested for the subxiphoid approach, which we currently use for thymectomy. These include subxiphoid single-port thymectomy; subxiphoid dual-port thymectomy (DPT) wherein an additional lateral thoracic intercostal port is added, which is used for more complicated surgeries; and subxiphoid robotic thymectomy using the da Vinci Surgical System. Here we report on these techniques. A subxiphoid approach in thymectomy is advantageous to patients as it minimizes or avoids the occurrence of intercostal neuropathy. Moreover, a subxiphoid approach provides the surgeon with a good field of view of the cervical region and helps confirm the location of the bilateral phrenic nerves. Therefore, thymectomy using a subxiphoid approach should be considered an option for a minimally invasive surgery.


title: Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures.

text: BACKGROUND Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading. METHODS Nineteen bovine Achilles tendons were repaired using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weight-bearing, before being loaded to failure. RESULTS Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. CONCLUSION The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.


Segmental upper mid-basilar artery sacrifice in a child using a Micro Vascular Plug device for treatment of a basilar arteriovenous fistula compressing the brainstem.


title: In vivo MRI visualization of parastomal mesh in a porcine model.

text: INTRODUCTION After two-dimensional plane MRI-visible mesh implants could be successfully visualized in phantom and small animal model, the aim of the underlying study was to explore the feasibility of an MRI visualization of complex three-dimensional mesh geometry in close contact to the intestine. We therefore used a MR-visible three-dimensional intra-peritoneal stoma (IPST) mesh in a porcine model. MATERIALS AND METHODS Laparoscopic terminal sigmoid colostomy has been done with implantation of a prophylactic MRI-visible IPST mesh in two animals. MRI investigations were done after 1 week, 6 months and in case of clinical impairment. These findings were compared to endoscopy and makroscopical and histological investigation of the preparation. RESULTS The first animal has to be killed because of an ileus 4 weeks after operation. The second animal has to be killed after 7 weeks because of recurrent obstipation. In all cases MRI investigation could identify the IPST mesh and could clearly separate between mesh and intestine. MRI revealed a big bowl ileus due to a funnel dislocation in the first animal. In the second animal, MR diagnostic explored a functional stenosis because of a too small diameter of the central funnel in combination with sticky feces and distension of the terminal sigmoid before discharging into the funnel. Endoscopy, makroscopical and histological investigation of the preparation supported MRI findings. CONCLUSION Although complicate clinical course was a diagnostic challenge exploring 3D implants such as IPST, visualization of this new MRI-visible IPST mesh could be proved and turned out as an effective diagnostic possibility. Further studies are necessary to analyze long-time effects such as shrinkage, mesh migration and tissue integration using MRI scanning.


title: [Pharmacotherapeutic about the new coronavirus pneumonia].

text: 本文结合作者的实践经验与临床信息，对新型冠状病毒病常用药物做出评价。建议预防用抗菌药物要严格限制；肾上腺皮质激素只应用于已出现肺损伤的患者，并且要注意用量与疗程的个体差异；抗病毒药的试用要慎重，并尽早得出已推荐药物要不要继续试用下去的结论，以避免不必要的药物损伤。.


title: A brief history of medical uniforms: from ancient history to the COVID-19 time.

text: Medical Uniforms date back from medieval times. Nursing uniforms were based on nuns clothes whereas doctors used the famous "plague costumes" and black "frock" coats from about 15th to early 19th century. In latter half 19th century medical uniforms started to change. Nursing uniforms gradually lost their similarities to religious outfits. Doctors started to use white clothing. With great emphasis on hygiene and sanitation, the idea of personal protective equipment (PPE) started to evolve with William Stewart Halsted introducing the use of rubber gloves in 1889. In the 1960s-1970s it became more usual to wear green and blue `scrubs in order to look for a greater contrast in clothing with the all-white hospital environment. In contemporary times, some specialties even stopped using specific uniforms, while others still use them. At the same time, PPE became more and more important, up to nowadays "plague costume" in the combat of the COVID-19 epidemics.


title: A longitudinal single-center cohort study on the prevalence and risk of accessory saphenous vein reflux after radiofrequency segmental thermal ablation of great saphenous veins.

text: OBJECTIVE Endothermal ablation has become a commonly used technology for occlusion of refluxing great saphenous veins (GSVs). However, the risk for primarily untreated accessory saphenous veins (ASVs) to develop reflux during follow-up has not yet been defined. Here, the prevalence and risk of ASV reflux is explored. METHODS During a prospective multicenter cohort study on radiofrequency segmental thermal ablation of refluxing GSVs, the presence and reflux status of ASVs were monitored in 93 legs in a single center. Control examinations were performed after 1 week and at 12, 24, 36, and 48 months. Life-table and multiple regression analyses were used to describe frequency and risk factors for presence of reflux in untreated ASVs. RESULTS Of 93 legs, 82 (88%) were available for 4-year follow-up. At baseline, 43 legs (46%) had an anterior ASV detectable by duplex ultrasound, with only two legs (2%) presenting with reflux. During 4 years of follow-up, according to life-table analysis, the proportion of legs with a detectable anterior ASV increased to 71% (n = 65); 32% of all legs and 55% of legs with a detectable anterior ASV exhibited refluxing anterior ASVs. Remarkably, in 35% of all legs with an anterior ASV, this reflux presented as a source of axial reflux, suggesting hemodynamic relevance. Posterior ASVs were detected in only 10 legs during 4-year follow-up, exhibiting reflux in only two cases. CONCLUSIONS Whereas posterior ASVs were meaningless, refluxing anterior ASVs occurred in a significant proportion of legs after thermal ablation of GSVs. Whether nonrefluxing anterior ASVs should be treated at the time of GSV ablation needs further examination.


title: Variation of Mass Effect After Using a Flow Diverter With Adjunctive Coil Embolization for Symptomatic Unruptured Large and Giant Intracranial Aneurysms.

text: Background: Mass effect associated with large or giant aneurysms is an intractable problem for traditional endovascular treatments. Preventing recurrence of aneurysms requires dense coiling, which may aggravate the mass effect. However, the flow diverter (FD) is a new device that avoids the need for dense coiling. This study was performed to investigate whether use of FDs with adjunctive coil embolization can relieve the aneurysmal mass effect and to explore the factors that affect the variation of compressional symptoms. Methods: We retrospectively evaluated patients with compressional symptoms caused by unruptured aneurysms who underwent endovascular treatment with an FD with adjunctive coil embolization at our center from January 2015 to December 2017. Imaging follow-up included digital subtraction angiography (DSA) ranging from 11 to 14 months and magnetic resonance imaging (MRI) ranging from 24 to 30 months; the former was used to evaluate the intracavitary volume, and the latter was used to measure the variation of the mass effect. Follow-up physical examinations were performed to observe variations of symptoms. Results: In total, 22 patients with 22 aneurysms were treated by an FD combined with coil embolization. All 22 patients underwent the last clinical follow-up. Regarding compressional symptoms, 12 (54.54%) patients showed improvement, 6 (27.27%) were fully recovered, and 6 (27.27%) showed improvement but with incomplete cranial palsy. However, five (22.72%) patients showed no change, four (18.18%) showed worsening symptoms compared with their preoperative state, and one (4.55%) died of delayed rupture. Seventeen of the 22 patients underwent MRI. Of these 17 patients, the aneurysm shrank in 13 (76.47%) and no significant change occurred in 4 (23.53%). In the multivariate analysis, a short duration from symptom occurrence to treatment (p = 0.03) and younger patient age (p = 0.038) were statistically significant factors benefiting symptom improvement, and shrinkage of the aneurysm was associated with favorable clinical outcomes (p = 0.006). Conclusions: Use of the FD with adjunctive loose coil embolization might help to alleviate the compressional symptoms caused by intracranial aneurysms. Shrinkage of the aneurysm, a short duration of symptoms, and younger patient age might contribute to favorable outcomes of mass effect-related symptoms.


title: Intra-Aortic Balloon Counterpulsation Timing: A New Numerical Model for Programming and Training in the Clinical Environment.

text: BACKGROUND AND OBJECTIVE: : The intra-aortic balloon pump (IABP) is the most widely available device for short-term mechanical circulatory support, often used to wean off cardiopulmonary bypass or combined with extra-corporeal membrane oxygenation support or as a bridge to a left ventricular assist device. Although based on a relatively simple principle, its complex interaction with the cardiovascular system remains challenging and open to debate. The aim of this work was focused on the development of a new numerical model of IABP. METHODS: : The new module was implemented in CARDIOSIM©, which is a modular software simulator of the cardiovascular system used in research and e-learning environment. The IABP is inserted into the systemic bed divided in aortic, thoracic and two abdominal tracts modelled with resistances inertances and compliances. The effect induced by the balloon is reproduced in each tract of the aorta by the presence of compliances connected to P(IABP) generator and resistances. P(IABP) generator reproduces the balloon pressure with the option to change IABP timing.We have used literature data to validate the potential of this new numerical model. RESULTS: : The results have shown that our simulation reproduced the typical effects induced during IABP assistance. We have also simulated the effects induced by the device on the hemodynamic variables when the IABP ratio was set to 1:1, 1:2, 1:4 and 1:8. The outcome of these simulations is in accordance with literature data measured in the clinical environment. CONCLUSIONS: : The new IABP module is easy to manage and can be used as a training tool in a clinical setting. Although based on literature data, the outcome of the simulations is encouraging. Additional work is ongoing with a view to further validate its features. The configuration of CARDIOSIM© presented in this work allows to simulate the effects induced by mechanical ventilatory assistance. This facility may have significant importance in the management of patients affected by COVID-19 when they require mechanical circulatory support devices.