title: Seasonality of infection rates after total joint arthroplasty.

text: The correlation between season (fall, winter, spring, and summer) and infection rate in surgical patients is well defined in many specialties. To the authors' knowledge, there are no data in the literature on this phenomenon in patients undergoing total joint arthroplasty. They hypothesized that there would be an increased infection rate in the summer months in patients undergoing elective total joint arthroplasty. They retrospectively reviewed consecutive patients undergoing elective total hip or knee arthroplasty at a single institution during 1 year by a single surgeon. Wound infections were defined as any patient requiring oral antibiotics for cellulitis, readmission for intravenous antibiotics, a return to the operating room for irrigation and debridement, or excisional arthroplasty and placement of a cement spacer within 90 days of the initial procedure. Seventeen of 750 patients developed an infection, for an overall incidence of 2.2%. There was a statistically significant difference in infection rate according to season: 3 (1.5%) infections occurred in winter, 1 (0.5%) in spring, 9 (4.7%) in summer, and 4 (2.4%) in fall. The incidence was highest during July (4.5%), August (5.4%), and September (4.3%). There was a statistically significant difference in infection rate between summer/fall (3.6%) vs winter/spring (1.0%). There is an increase in the incidence of infection during summer months for patients undergoing total joint arthroplasty. The authors recommend increased surveillance and more thorough preoperative sterilization procedures during these warmer months.


title: Open Versus Endoscopic Approach for Sinonasal Melanoma: A Systematic Review and Meta-analysis.

text: BACKGROUND Open resection (OR) of sinonasal mucosal melanoma (SNM) traditionally has been the gold standard for treatment. However, endoscopic resection (ER) has recently become a surgical alternative. The aim of this study was to compare survival outcomes between OR and ER of SNM. METHODS A literature search encompassing PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrials.gov, and Google Scholar was performed. Two reviewers independently screened for original studies comparing survival outcomes between OR and ER for SNM. Data were systematically collected on study design, patient demographics, outcomes, and level of evidence. Quality assessment was performed using the Newcastle-Ottawa scale (NOS). Meta-analysis of overall survival and disease-free survival was performed using random-effects models. RESULTS The initial search yielded 2078 abstracts, of which 9 cohort studies were included for a total of 510 patients from 6 different countries. The average quality of all included studies using the NOS was 7.7 stars. Six out of 7 studies reported no differences in the stages of SNM between patients receiving ER versus OR. Overall survival was longer in the ER group versus OR group (hazard ratio [HR]: 0.68, 95% confidence interval [CI]: 0.49-0.95). There was no significant difference in disease-free survival between groups (HR: 0.59, 95% CI: 0.28-1.25). CONCLUSION Based on the available literature, an endoscopic approach for SNM resection has survival outcomes that are similar or greater compared to an open approach.


Infections in child-care facilities and schools.


Correspondence regarding research letter to the editor by Mathian et al, 'Clinical course of coronavirus disease 2019 (COVID-19) in a series of 17 patients with systemic lupus under long-term treatment with hydroxychloroquine'.


title: Use of energy-based coagulative fusion technology and lung sealants during anatomic lung resection.

text: OBJECTIVES Energy-based tissue fusion technology is being increasingly used for vascular division in numerous intra-abdominal applications. Very few data, however, are available regarding the application of this technology in the chest during anatomic lung resection. In the present review, we evaluated the use of energy-based fusion and lung sealants during anatomic lung resection. METHODS We performed a review of case series and published studies to evaluate the use of energy-based coagulative fusion technology and lung sealants during anatomic lung resection. We then used energy-based coagulative fusion technology during anatomic lung resection (segmentectomy or lobectomy) in 316 cases from 2008 to 2011. Two energy applications were applied to the arterial and venous branches before vessel division. RESULTS In the first 12 cases, we used a device with a small curved jaw (range, 3.3-4.7 mm). Two partial venous dehiscences were noted and controlled intraoperatively. For the remaining cases, we used a larger jaw (6 mm × 22 mm) with no arterial or venous dehiscence occurring (vessels ranged from 0.4 to 1.2 cm). Autologous or synthetic tissue sealants applied to the parenchymal staple lines might reduce the severity and duration of perioperative air leaks. Suture line buttressing with pericardial or absorbable biosynthetic polyester strips might reduce the severity of air leaks in patients with severe emphysema undergoing anatomic lung resection or lung volume reduction surgery. CONCLUSIONS The bipolar tissue fusion system provides a safe and effective technique for the division of the pulmonary arterial and venous branches during anatomic lung resection. Surgical sealants and buttressing adjuncts might reduce perioperative air leak potential.


title: Retroperitoneoscopic renal biopsy: still a good indication!

text: The histological evaluation of the renal parenchyma is often essential in cases of several renal diseases and provides useful information in determining the prognosis and guiding treatment. In patients with contraindications to percutaneous kidney biopsy, retroperitoneal laparoendoscopic single-site surgery (LESS) is to be preferred as a minimally invasive technique. However, there are cases in which the LESS technique is difficult to perform, especially given that the learning curve is not optimal. We present a case of a Jehovah's Witness patient with severe obesity, in whom conventional retroperitoneal laparoscopic renal biopsy was preferred to the LESS technique.


title: Statistical models for fever forecasting based on advanced body temperature monitoring.

text: Body temperature monitoring provides health carers with key clinical information about the physiological status of patients. Temperature readings are taken periodically to detect febrile episodes and consequently implement the appropriate medical countermeasures. However, fever is often difficult to assess at early stages, or remains undetected until the next reading, probably a few hours later. The objective of this article is to develop a statistical model to forecast fever before a temperature threshold is exceeded to improve the therapeutic approach to the subjects involved. To this end, temperature series of 9 patients admitted to a general internal medicine ward were obtained with a continuous monitoring Holter device, collecting measurements of peripheral and core temperature once per minute. These series were used to develop different statistical models that could quantify the probability of having a fever spike in the following 60 minutes. A validation series was collected to assess the accuracy of the models. Finally, the results were compared with the analysis of some series by experienced clinicians. Two different models were developed: a logistic regression model and a linear discrimination analysis model. Both of them exhibited a fever peak forecasting accuracy greater than 84%. When compared with experts' assessment, both models identified 35 (97.2%) of 36 fever spikes. The models proposed are highly accurate in forecasting the appearance of fever spikes within a short period in patients with suspected or confirmed febrile-related illnesses.


title: [Recommendations for the regulation of medical practices of burn treatment during the outbreak of the coronavirus disease 2019].

text: 2019 novel coronavirus (2019-nCoV) is one of the beta coronaviruses and was identified as the pathogen of the severe "coronavirus disease 2019 (COVID-19)" in 2019. China has formally included the 2019-nCoV in the statutory notification and control system for infectious diseases according to the Law of the People's Republic of China on the Prevention and Treatment of Infectious Diseases. Currently, the national defending actions on the 2019-nCoV in China is in a critical period. Burn Department is also confronted with risk of infection by the 2019-nCoV. According to the guidelines on the diagnosis and treatment of COVID-19 (6(th) trial edition), the latest relative literature at home and abroad, the features of the COVID-19, recommendations for the COVID-19 prevention and control issued by the National Health Commission of China, and management experience of diagnosis and treatment in the related disciplines, we put forward recommendations for the medical practices of burn treatment during the outbreak of the COVID-19 in outpatient and emergency treatment, inpatient treatment, operation and ward management, etc. We hope these recommendations could benefit the professionals of the same occupation as us and related hospital managers, improve the treatment of burn during the outbreak of the COVID-19, and avoid or reduce the risk of infection of medical staff .


title: [The biological and pharmacological activity of essential oils in the treatment and prevention of infectious diseases].

text: Despite the large progress in medicine and pharmacy in the last few decades, traditional treatment of bacterial or viral diseases is frequently ineffective and is connected with some side effects. Currently, there is observed an increasing interest in natural plant-derived substances as a potential and promising group of medicines in prevention and treatment of several infectious diseases. Terpenes and their derivatives are a large class of natural organic components of essential oils and are widespread in the plant kingdom. Numerous experimental studies have shown that essential oils exhibit a large spectrum of biological and pharmacological activities in vitro. Herbal essential oils have been proved to possess antimicrobial, antiviral, antifungal and antiparasitic properties. They have also been reported to exhibit anti-inflammatory and immunostimulatory activities. Based on the wide spectrum of various biological activities, essential oils and terpenes commonly found in fruit, vegetables, herbs etc. have been suggested to constitute a novel group of preventive and therapeutic agents. Further experiments are necessary to confirm their pharmacological effectiveness, to determine potential toxic effects and the mechanism of their activity in in vivo models. This article describes the biological and pharmacological properties of herbal essential oils and some of their components, and summarizes the future prospects of potential application of essential oils in the prevention and treatment of infectious human diseases. In this review also possible mechanisms of their biological action are presented.


title: COVID-19 among Health Workers in Germany and Malaysia.

text: We report on the suspected case reports filed for SARS-CoV-2 infections and COVID-19 illnesses among health and social welfare workers in Germany. In addition, we report about COVID-19 in health workers in Malaysia. Claims for occupational diseases caused by SARS-CoV-2 are recorded separately in a database of the Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW). This database is analyzed according to its content as of May 22, 2020. In addition, the notifiable cases of SARS-CoV-2 infections from personnel in medical institutions (e.g., clinics and doctor's office) and social welfare institutions (e.g., nursing homes, shelters and refugee camps) following the German Infection Protection Act are analyzed. The report from Malaysia is based on personal experience and publications of the government. In Germany at present, 4398 suspected case reports for the diagnosis of SARS-CoV-2 infections among health and social workers have been filed. This figure is four times the number of all reported infections normally received per year. The majority of claims, regardless of being a confirmed infection, concerned nurses (n = 6927, 63.9%). The mortality rate for workers infected with SARS-CoV-2 is 0.2% to 0.5%. Doctors are affected by severe illness more frequently than other occupational groups (8.1% vs. 4.1%). In Malaysia, work-related infection of health workers (HW) occurred mainly when COVID-19 was not suspected in patients and no adequate personal protective equipment (PPE) was worn. Although knowledge on the spread of SARS-CoV-2 infections among workers remains limited, the impact appears to be substantial. This is supported by the mortality rate among infected workers. Occupational health check-ups carried out at the present time should be systematically analyzed in order to gain more information on the epidemiology of COVID-19 among HW. Since the supply and use of PPE improved, the infection risk of HW in Malaysia seems to have decreased.


title: Rubicon Modulates Antiviral Type I Interferon (IFN) Signaling by Targeting IFN Regulatory Factor 3 Dimerization.

text: Rubicon is part of a Beclin-1-Vps34-containing autophagy complex. Rubicon induces antimicrobial responses upon Toll-like receptor (TLR) stimulation and functions as a feedback inhibitor to prevent unbalanced proinflammatory responses depending on dectin-1 signaling. However, the role played by Rubicon during antiviral immune responses, particularly the type I interferon (IFN) responses, remains largely unknown. Here, we report that Rubicon acts as a negative regulator for virus-triggered IFN signaling. Knockdown of Rubicon promoted type I interferon signaling and inhibited virus replication, while overexpression of Rubicon had the opposite effect. Rubicon specifically interacts with the interferon regulatory factor (IRF) association domain (IAD) of IRF3, and this interaction leads to inhibition of the dimerization of IRF3, which negatively regulates IFN-mediated antiviral response. Thus, our findings suggest the novel additional role of Rubicon as a negative regulator that inhibits the IFN signaling and cellular antiviral responses, providing a novel cellular mechanism of IRF3 inhibition.IMPORTANCE The type I IFN system is a critical innate immune response that protects organisms against virus infection. However, type I IFN signaling must be tightly regulated to avoid excessive production of IFNs. Hence, negative regulatory mechanisms for type I IFN signaling are important, and to date, several related molecules have been identified. Here, we show that Rubicon is a major negative regulator of type I IFN signaling, and unlike previous reports of cellular molecules that inhibit IRF3 activation via proteasomal degradation or dephosphorylation of IRF3, we show that Rubicon interacts with IRF3 and that ultimately this interaction leads to inhibition of the dimerization of IRF3. Thus, we identified a novel negative regulator of type I IFN signaling pathways and a novel cellular mechanism of IRF3 inhibition. The results of this study will increase our understanding of the role of negative-feedback mechanisms that regulate type I IFN signaling and maintain immune homeostasis.


title: Long-term voice outcome after thyroidectomy using energy based devices.

text: OBJECTIVE Voice dysfunction is frequently reported after thyroidectomy even in absence of vocal fold paralysis. The energy-based devices such as Harmonic scalpel (HS) or LigaSure (LS) are commonly used in conventional thyroidectomy. The objective of this study was to investigate the long-term voice outcome after total thyroidectomy using energy based devices. METHODS Patients who underwent total thyroidectomy with or without central neck dissection for papillary thyroid carcinoma using HS or LS from April 2012 to March 2013 were involved. The videolaryngostroboscopy, acoustic analysis, voice range profile, voice perceptual evaluation, and voice handicap index-30 were obtained preoperatively, 1 week, 1 month, 3 months, 6 months, and 1year after thyroidectomy. RESULTS Total 92 patients (HS group: 58 cases; LS group: 34 cases) were enrolled in this study. Demographics, tumor stage, and extent of operation were not significantly different between the HS and LS group. None of the patients evidenced any abnormalities at the pre- or postoperative videolaryngostroboscopic examination. The voice range profile (highest frequency), voice perceptual evaluation (grade, rough, and breathy), and voice handicap index-30 (total, functional, physical, and emotional) showed significantly worse scores in early postoperative period (<1month), but gradually returned to preoperative values. The all parameters of acoustic analysis, voice range profile, voice perceptual evaluation, and voice handicap index-30 were not significantly different between the HS and LS group. CONCLUSION The long-term voice change after thyroidectomy shows similar results regardless of the type of energy-based devices.


title: Delayed Endovascular Coil Extrusion following Internal Carotid Artery Embolization.

text: Internal carotid artery injury is a rare and devastating complication of endoscopic sinus and skull base surgery that has an associated mortality rate of 15%. This case describes a patient who developed massive epistaxis following routine sinus surgery and was eventually diagnosed with a pseudoaneurysm of the cavernous internal carotid artery. Endovascular coiling and Onyx (Covidien, Irvine, California, United States) liquid embolization were ultimately used to completely occlude the internal carotid artery with resolution of bleeding; however, the patient had an unexpected late complication of coil extrusion through the pseudoaneurysm sac into the sphenoid sinus and nasal cavity. The endoscopic skull base team safely excised the coils endoscopically without recurrent bleeding. We describe the multidisciplinary operative management of this case of endovascular coil extrusion to increase awareness of this potentially life-threatening complication.


title: Results of More Than 11,800 Sleeve Gastrectomies: Data Analysis of the German Bariatric Surgery Registry.

text: BACKGROUND Laparoscopic sleeve gastrectomy (SG) is an upcoming procedure in bariatric surgery and is currently performed worldwide. Staple line leakage, as the most frequent and most feared complication, is still a major concern. METHODS Since 2005 data from patients undergoing bariatric procedures in Germany have been prospectively registered in an online database and analyzed. All patients who had undergone primary SG within a 7-year period were considered for analysis. RESULTS Using the German Bariatric Surgery Registry, data from more than 11,800 SGs were collected between January 1, 2005, and December 31, 2013. Staple line leak rate decreased from 6.5% to 1.4%. Male sex, higher body mass index, concomitant sleep apnea, conversion to laparotomy, longer operation time, a combination of buttresses and oversewing, and the occurrence of intraoperative complications were associated with a significantly higher leakage rate compared with when using either buttresses or oversewing alone. On multivariable analysis, operation time and year of procedure only had a significant impact on staple line leakage rate. CONCLUSIONS Owing to the growing experience a constant decrease in the leakage rate after SG has been observed. Staple line disruption may still lead to sepsis, multiorgan dysfunction, and increased mortality. The results of the current study demonstrated that there are factors that increase the risk of leakage and which would enable surgeons to define risk groups, select patients more carefully, and offer closer follow-up during the postoperative course with early recognition and adequate treatment.


title: Variable ventilation improves ventilation and lung compliance in preterm lambs.

text: PURPOSE In adult animals, ventilation with variable tidal volume and rate improves lung mechanics, arterial oxygenation and ventilation compared to a monotonously controlled ventilation pattern. We assessed the physiological consequences of variable ventilation in the immature lung. METHODS Lambs delivered at 129 days (term = 150 days) were euthanised (n = 9) or anaesthetised, tracheostomised and suctioned prior to prophylactic intra-tracheal surfactant instillation (Curosurf(®), 100 mg/kg) and commencement of controlled ventilation (50 breaths/min, tidal volume 7.7 ± 0.8 mL/kg). Volume history was standardised at 20 min with two sustained (3 s) inflations to 30 cmH(2)O followed immediately by measurement of baseline dynamic lung mechanics (FlexiVent, Scireq, Canada). Ventilation was continued according to prior randomisation (variable or conventional ventilation). For variable ventilation (n = 9), breath-to-breath tidal volume and respiratory rate varied but intra-breath minute volume (MV) and average tidal volume were equivalent to the conventional ventilation group with fixed tidal volume and rate (n = 7). Lung mechanics and gas exchange were measured at intervals. Lambs were euthanised at 2 h. Inflammatory cell counts and protein from bronchoalveolar lavage fluid and lung tissue cytokine mRNA were quantified. RESULTS At study completion, PaCO(2) (p = 0.026) and mean airway pressure (p = 0.002) were lower and pH (p = 0.047), ventilation efficiency index (p = 0.021) and dynamic compliance were higher (p = 0.003) in lambs on variable rather than conventional ventilation. However, oxygenation indices and post-mortem static compliances were not different between groups. CONCLUSION Variable ventilation improves ventilation efficiency and in vivo lung compliance in the preterm lung, but unlike adult models, had no effect on arterial oxygenation.


title: Single-access laparoscopic cholecystectomy with routine intraoperative cholangiogram.

text: BACKGROUND While laparoscopy is now the standard for cholecystectomy, recent papers have focused on single-incision approaches. Intraoperative cholangiography remains an integral part of laparoscopic cholecystectomy but has not yet been well described within the single-access literature. We discuss our method of single-incision laparoscopic cholecystectomy with routine intraoperative cholangiograms. METHODS A retrospective review of our surgical database was completed. One hundred twenty-three patients undergoing laparoscopic cholecystectomy were identified (83 standard laparoscopy, 40 single-incision laparoscopy). Patient demographics including age and body mass index (BMI), and indications for surgery, operative time, intra- and postoperative complications, and ability to complete cholangiography were analyzed. RESULTS All patients with standard laparoscopy had successful cholangiograms. Two patients did not undergo cholangiography based on a preoperative decision (pregnancy). In the 40 patients who underwent single-incision cholecystectomy, 38 cholangiograms were completed (95%). One patient with acute cholecystitis had a small cystic duct which could not be cannulated. The second had a cystic duct through which the cholangiocatheter could not be advanced. Comparative analysis of patient demographics showed a significant difference in patient age between the two groups, as well as a significantly greater number of patients undergoing single-incision cholecystectomy for symptomatic cholelithiasis as opposed to acute cholecystitis. DISCUSSION Completion of intraoperative cholangiography is an important aspect of cholecystectomy in order to identify choledocholithiasis and verify anatomy. With the advent of single-access laparoscopy, standard operative principles should not be compromised. Cholangiography may provide a safer approach to cholecystectomy when adopting a new technique. We present our technique of single-incision cholecystectomy and routine cholangiography with a 95% success rate. The ability to perform single-incision intraoperative cholangiograms will allow a safe, more minimally invasive approach to cholecystectomy with suspected choledocholithiasis and obviate the need to convert to standard multiport laparoscopy for the sole reason of completing cholangiograms.


title: There might be blood: a scoping review on women's responses to contraceptive-induced menstrual bleeding changes.

text: INTRODUCTION Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women's responses to CIMBCs has not been mapped or summarized in a systematic scoping review. METHODS We conducted a systematic scoping review of data on women's responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers. RESULTS We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women's responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women's responses to menstrual suppression; and other emergent themes. Women's preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of "dirty" or "blocked" blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or menstruation) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains. CONCLUSIONS Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women's lives. Women's responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely - and potentially substantial - impacts on contraceptive discontinuation and unmet need for modern contraception.


title: Adolescent Girls' Perceptions of Physical Activity: A Systematic Review of Qualitative Studies.

text: OBJECTIVE To synthesize evidence from qualitative studies relating to adolescent girls' perceptions of physical activity participation. The protocol for this review is registered with PROSPERO (ID no. CRD42017054944). DATA SOURCE PubMed, Sports Discus, Academic Search Complete, and Education Resources Information Centre. INCLUSION AND EXCLUSION CRITERIA Studies reporting qualitative data that explored the views/opinions/perceptions of adolescent girls (>12 and <18 years old) published between 2001 and 2016 were included. Studies not in English, those focusing on school physical education or specific sports, and those including special populations were excluded. EXTRACTION Study characteristics and results were extracted to a form developed by the authors and managed using NVivo 10 (QSR International's NVivo 10 software). Data were extracted by 1 reviewer, and a sample (25%) was checked by a second reviewer. SYNTHESIS Data were synthesized using a thematic network and managed using NVivo 10. The validity of the included studies was assessed using the "Critical Appraisal Skills Programme (2018)" checklist. The ENTREQ and PRISMA statement was followed when reporting this qualitative synthesis. RESULTS Of the 1818 studies identified in the search strategy, 24 met the inclusion criteria and were included in the analysis. Global themes were identified using a thematic network. These themes were "Gender Bias in Sport," "Motivation and Perceived Competence," "Competing Priorities during Adolescence," and "Meeting Societal Expectations." CONCLUSIONS The results of this review provide insights into adolescent girls' views on physical activity. Future research is needed to investigate the potential impact of alternative activity programs on adolescent girls with appropriate follow-up. Researchers and individuals working with young girls must consider the role of perceived motor competence in participation and how this can impact their perceptions.


Where in the World Did You Get That Rash?


title: Totally stapled gastrojejunal anastomosis using hybrid NOTES: single 12-mm trocar approach in a porcine model.

text: BACKGROUND The aim of this study was to evaluate the feasibility of a totally stapled gastrojejunal anastomosis performed using one transabdominal 12-mm trocar and a gastroscope in a porcine model. METHODS The procedure was carried out on six domestic pigs weighing 45 kg using a hybrid technique with a gastroscope and a 12-mm Hasson trocar, positioned in the left hypochondrium. At the end of the procedure a mechanical circular 21-mm gastrojejunal anastomosis was performed by inserting the stapler through a small gastrotomy after enlarging the trocar incision. RESULTS In all six cases the procedure was completed through a single 3 cm abdominal incision and without complications. The mean operating time was 2 h, and endoscopic investigation showed that the anastomoses were intact, patent, and airtight. CONCLUSIONS Totally stapled gastrojejunal anastomosis using a hybrid NOTES-single 12-mm trocar approach is a feasible procedure in the porcine model. Further survival studies are warranted, particularly to evaluate the functional results of this procedure.


Clare Gerada: Doctors on the covid-19 front line also need to protect themselves and their colleagues.


Noninvasive hemodynamic monitoring: no high heels on the farm; no clogs to the opera.


title: Single-port versus conventional laparoscopic total extra-peritoneal inguinal hernia repair: a prospective, randomized, controlled clinical trial.

text: BACKGROUND The advantage of single-port total extra-peritoneal (TEP) inguinal hernia repair over the conventional technique is still debatable. Our objective was to compare the outcomes of TEP inguinal hernia repair using either a single-port or conventional surgical technique, in two blind randomized groups of patients. METHODS In this prospective, randomized, double-blind, controlled clinical trial, 100 patients undergoing surgery for unilateral inguinal hernia were randomized into two groups: One group underwent conventional laparoscopic TEP inguinal hernia repair, while the other was selected for single-port TEP repair. Primary endpoint is postoperative pain (VAS), while secondary endpoints are recurrence, chronic pain and complications. RESULTS From 100 patients, 49 underwent single-port hernia TEP repair, 50 had conventional three-port TEP hernia repair, and one patient declined to participate after randomization. The two groups were comparable in terms of patient demographics and operative findings. Mean operative time was 49.1(±13.8) min in the conventional group and 54.1(±14.4) min in the single-port group (p = 0.08). Mean hospital stay was 19.7(±5.8) h in the conventional group and 20.5(±6.4) h in the single-port group (p = 0.489). No major complications and no recurrence reported at 11-month follow-up. No statistically significant difference noted in postoperative pain between the two groups at regular intervals. CONCLUSIONS The outcomes after laparoscopic TEP inguinal hernia repair with a single-port device are similar but not superior to the conventional technique.


title: Laparoscopy-assisted subtotal gastrectomy with very small remnant stomach: a novel surgical procedure for selected early gastric cancer in the upper stomach.

text: Total gastrectomy or proximal gastrectomy is usually performed either as an open procedure or laparoscopically for the treatment of early gastric cancer (EGC) in the upper stomach. However, quality of life after either total or proximal gastrectomy is not so satisfactory. The authors report a novel surgical procedure, laparoscopy-assisted subtotal gastrectomy (LAsTG), by which a very small remnant stomach is preserved, for the surgery of selected EGCs in the upper stomach. Twenty-three patients with EGC in the upper stomach underwent LAsTG. After lymph node dissection and mobilization of the stomach, the stomach was transected about 2 cm proximal to the tumor and a very small remnant stomach was preserved. An anvil was inserted transorally into the remnant stomach by using the OrVil system. The reconstruction method was Roux-en-Y, and hemidouble-stapling gastrojejunostomy with a circular stapler was performed intracorporeally. There were no intraoperative complications or conversions to open surgery. Mean operation time and blood loss were 266.7 min and 54.6 ml, respectively. The overall incidence of early postoperative complications was 17.4%, and two patients underwent reoperation because of duodenal stump leakage and stenosis of the Y-anastomosis, respectively. During the follow-up period, two patients experienced gastrojejunostomy stenosis and both were treated successfully by endoscopic balloon dilation. LAsTG may be performed in selected patients with EGC in the upper stomach. With the described method, a very small remnant stomach can be preserved.


title: Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage.

text: IMPORTANCE Although use of oral anticoagulants (OACs) is increasing, there is a substantial lack of data on how to treat OAC-associated intracerebral hemorrhage (ICH). OBJECTIVE To assess the association of anticoagulation reversal and blood pressure (BP) with hematoma enlargement and the effects of OAC resumption. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at 19 German tertiary care centers (2006-2012) including 1176 individuals for analysis of long-term functional outcome, 853 for analysis of hematoma enlargement, and 719 for analysis of OAC resumption. EXPOSURES Reversal of anticoagulation during acute phase, systolic BP at 4 hours, and reinitiation of OAC for long-term treatment. MAIN OUTCOMES AND MEASURES Frequency of hematoma enlargement in relation to international normalized ratio (INR) and BP. Incidence analysis of ischemic and hemorrhagic events with or without OAC resumption. Factors associated with favorable (modified Rankin Scale score, 0-3) vs unfavorable functional outcome. RESULTS Hemorrhage enlargement occurred in 307 of 853 patients (36.0%). Reduced rates of hematoma enlargement were associated with reversal of INR levels <1.3 within 4 hours after admission (43/217 [19.8%]) vs INR of ≥1.3 (264/636 [41.5%]; P < .001) and systolic BP <160 mm Hg at 4 hours (167/504 [33.1%]) vs ≥160 mm Hg (98/187 [52.4%]; P < .001). The combination of INR reversal <1.3 within 4 hours and systolic BP of <160 mm Hg at 4 hours was associated with lower rates of hematoma enlargement (35/193 [18.1%] vs 220/498 [44.2%] not achieving these values; OR, 0.28; 95% CI, 0.19-0.42; P < .001) and lower rates of in-hospital mortality (26/193 [13.5%] vs 103/498 [20.7%]; OR, 0.60; 95% CI, 0.37-0.95; P = .03). OAC was resumed in 172 of 719 survivors (23.9%). OAC resumption showed fewer ischemic complications (OAC: 9/172 [5.2%] vs no OAC: 82/547 [15.0%]; P < .001) and not significantly different hemorrhagic complications (OAC: 14/172 [8.1%] vs no OAC: 36/547 [6.6%]; P = .48). Propensity-matched survival analysis in patients with atrial fibrillation who restarted OAC showed a decreased HR of 0.258 (95% CI, 0.125-0.534; P < .001) for long-term mortality. Functional long-term outcome was unfavorable in 786 of 1083 patients (72.6%). CONCLUSIONS AND RELEVANCE Among patients with OAC-associated ICH, reversal of INR <1.3 within 4 hours and systolic BP <160 mm Hg at 4 hours were associated with lower rates of hematoma enlargement, and resumption of OAC therapy was associated with lower risk of ischemic events. These findings require replication and assessment in prospective studies. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01829581.


title: Computed tomography manifestations in super early stage 2019 novel coronavirus pneumonia.

text: BACKGROUND The recent outbreak of pneumonia cases in Wuhan, PR China, was caused by a novel beta coronavirus, the 2019 novel coronavirus (COVID-19). PURPOSE To summarize chest computed tomography (CT) manifestations of the early stage of COVID-19 infection and provide a piece of reliable imaging evidence for initial screening and diagnosis. MATERIAL AND METHODS From 10 January 2020 to 10 February 2020, we continuously observed chest CT imaging of 14 patients with clinically suspected new coronavirus infection in the two weeks after onset of symptoms. Ground-glass opacity (GGO), consolidation, reticular pattern, and ground-glass mimic nodules in each patient's chest CT image were recorded. RESULTS We enrolled 14 patients, of which nine patients had the infection confirmed by reverse transcription polymerase chain reaction (RT-PCR). Five patients were highly suspected of infection. All cases had epidemiological evidence. GGO was a dominant imaging manifestation in the initial days of infection. GGO performance accounts for 40% in 1- 2 days, 90% in 3- 6 days, and 85% in 7- 10 days. With disease progression, consolidation appeared on follow-up CT. Consolidation performance accounts for 0% in 1- 2 days, 40% in 3- 6 days, and 71% in 7- 10 days. The lesions are mostly near the pleura. The number of lesions and the extent of the lesions increased as the disease progressed. CONCLUSION Patients with novel coronavirus pneumonia have characteristic CT features in the initial stage of infection, which can be used as an essential supplement for nucleic acid examination.


Severe respiratory failure in the course of COVID-19, treated with extracorporeal membrane oxygenation (ECMO).


title: Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch.

text: BACKGROUND Bariatric surgery is widely performed to induce weight loss. OBJECTIVE The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. DESIGN A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. RESULTS Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). CONCLUSIONS Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912.


title: Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore.

text: Importance Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, in December 2019 and has spread globally with sustained human-to-human transmission outside China. Objective To report the initial experience in Singapore with the epidemiologic investigation of this outbreak, clinical features, and management. Design, Setting, and Participants Descriptive case series of the first 18 patients diagnosed with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection at 4 hospitals in Singapore from January 23 to February 3, 2020; final follow-up date was February 25, 2020. Exposures Confirmed SARS-CoV-2 infection. Main Outcomes and Measures Clinical, laboratory, and radiologic data were collected, including PCR cycle threshold values from nasopharyngeal swabs and viral shedding in blood, urine, and stool. Clinical course was summarized, including requirement for supplemental oxygen and intensive care and use of empirical treatment with lopinavir-ritonavir. Results Among the 18 hospitalized patients with PCR-confirmed SARS-CoV-2 infection (median age, 47 years; 9 [50%] women), clinical presentation was an upper respiratory tract infection in 12 (67%), and viral shedding from the nasopharynx was prolonged for 7 days or longer among 15 (83%). Six individuals (33%) required supplemental oxygen; of these, 2 required intensive care. There were no deaths. Virus was detectable in the stool (4/8 [50%]) and blood (1/12 [8%]) by PCR but not in urine. Five individuals requiring supplemental oxygen were treated with lopinavir-ritonavir. For 3 of the 5 patients, fever resolved and supplemental oxygen requirement was reduced within 3 days, whereas 2 deteriorated with progressive respiratory failure. Four of the 5 patients treated with lopinavir-ritonavir developed nausea, vomiting, and/or diarrhea, and 3 developed abnormal liver function test results. Conclusions and Relevance Among the first 18 patients diagnosed with SARS-CoV-2 infection in Singapore, clinical presentation was frequently a mild respiratory tract infection. Some patients required supplemental oxygen and had variable clinical outcomes following treatment with an antiretroviral agent.


title: Benzimidazoles Promote Anti-TNF Mediated Induction of Regulatory Macrophages and Enhance Therapeutic Efficacy in a Murine Model.

text: Background and Aims Regulatory macrophages play a critical role in tissue repair, and we have previously shown that anti-tumour necrosis factor [TNF] antibodies induce these macrophages in vitro and in vivo in IBD patients. The induction of regulatory macrophages can be potentiated using the combination of anti-TNF and thiopurines, consistent with the enhanced efficacy of this combination therapy described in clinical trials. As thiopurines are unfortunately associated with significant side effects, we here aimed to identify alternatives for combination therapy with anti-TNF, using the macrophage induction model as a screening tool. Methods Mixed lymphocyte reactions were treated with anti-TNF and a library of 1600 drug compounds. Induction of CD14+CD206+ macrophages was analysed by flow cytometry. Positive hits were validated in vitro and in the T cell transfer model of colitis. Results Among the 98 compounds potentiating the induction of regulatory macrophages by anti-TNF were six benzimidazoles, including albendazole. Albendazole treatment in the presence of anti-TNF resulted in alterations in the tubulin skeleton and signalling though AMPK, which was required for the enhanced induction. Combination therapy also increased expression levels of the immunoregulatory cytokine IL-10. In vivo, albendazole plus anti-TNF combination therapy was superior to monotherapy in a model of colitis, in terms of both induction of regulatory macrophages and improvement of clinical symptoms. Conclusions Albendazole enhances the induction of regulatory macrophages by anti-TNF and potentiates clinical efficacy in murine colitis. Given its favourable safety profile, these data indicate that the repurposing of albendazole may be a novel option for anti-TNF combination therapy in IBD.


title: Recombinant Ag85B vaccine by taking advantage of characteristics of human parainfluenza type 2 virus vector showed Mycobacteria-specific immune responses by intranasal immunization.

text: Viral vectors are promising vaccine candidates for eliciting suitable Ag-specific immune response. Since Mycobacterium tuberculosis (Mtb) normally enters hosts via the mucosal surface of the lung, the best defense against Mtb is mucosal vaccines that are capable of inducing both systemic and mucosal immunity. Although Mycobacterium bovis bacille Calmette-Guérin is the only licensed tuberculosis (TB) vaccine, its efficacy against adult pulmonary forms of TB is variable. In this study, we assessed the effectiveness of a novel mucosal TB vaccine using recombinant human parainfluenza type 2 virus (rhPIV2) as a vaccine vector in BALB/c mice. Replication-incompetent rhPIV2 (M gene-eliminated) expressing Ag85B (rhPIV2-Ag85B) was constructed by reverse genetics technology. Intranasal administration of rhPIV2-Ag85B induced Mtb-specific immune responses, and the vaccinated mice showed a substantial reduction in the number of CFU of Mtb in lungs and spleens. Unlike other viral vaccine vectors, the immune responses against Ag85B induced by rhPIV2-Ag85B immunization had an advantage over that against the viral vector. In addition, it was revealed that rhPIV2-Ag85B in itself has an adjuvant activity through the retinoic acid-inducible gene I receptor. These findings provide further evidence for the possibility of rhPIV2-Ag85B as a novel TB vaccine.


title: Emergency department 'outbreak rostering' to meet challenges of COVID-19.

text: The COVID-19 outbreak has posed unique challenges to the emergency department rostering. Additional infection control, the possibility of quarantine of staff and minimising contact among staff have significant impact on the work of doctors in the emergency department. Infection of a single healthcare worker may require quarantine of close contacts at work. This may thus affect a potentially large number of staff. As such, we developed an Outbreak Response Roster. This Outbreak Response Roster had fixed teams of doctors working in rotation, each team that staff the emergency department in turn. Members within teams remained constant and were near equally balanced in terms of manpower and seniority of doctors. Each team worked fixed 12 hours shifts with as no overlapping of staff or staggering of shifts. Handovers between shifts were kept as brief as possible. All these were measures to limit interactions among healthcare workers. With the implementation of the roster, measures were also taken to bolster the psychological wellness of healthcare workers. With face-to-face contact limited, we also had to maintain clear, open channels for communication through technology and continue educating residents through innovative means.


A27 Using whole genome sequence data and minority variant profiles to elucidate transmission patterns during RSV household outbreaks.


title: High mannose-binding lectin with preference for the cluster of alpha1-2-mannose from the green alga Boodlea coacta is a potent entry inhibitor of HIV-1 and influenza viruses.

text: The complete amino acid sequence of a lectin from the green alga Boodlea coacta (BCA), which was determined by a combination of Edman degradation of its peptide fragments and cDNA cloning, revealed the following: 1) B. coacta used a noncanonical genetic code (where TAA and TAG codons encode glutamine rather than a translation termination), and 2) BCA consisted of three internal tandem-repeated domains, each of which contains the sequence motif similar to the carbohydrate-binding site of Galanthus nivalis agglutinin-related lectins. Carbohydrate binding specificity of BCA was examined by a centrifugal ultrafiltration-HPLC assay using 42 pyridylaminated oligosaccharides. BCA bound to high mannose-type N-glycans but not to the complex-type, hybrid-type core structure of N-glycans or oligosaccharides from glycolipids. This lectin had exclusive specificity for α1-2-linked mannose at the nonreducing terminus. The binding activity was enhanced as the number of terminal α1-2-linked mannose substitutions increased. Mannobiose, mannotriose, and mannopentaose were incapable of binding to BCA. Thus, BCA preferentially recognized the nonreducing terminal α1-2-mannose cluster as a primary target. As predicted from carbohydrate-binding propensity, this lectin inhibited the HIV-1 entry into the host cells at a half-maximal effective concentration of 8.2 nm. A high association constant (3.71 × 10(8) M(-1)) of BCA with the HIV envelope glycoprotein gp120 was demonstrated by surface plasmon resonance analysis. Moreover, BCA showed the potent anti-influenza activity by directly binding to viral envelope hemagglutinin against various strains, including a clinical isolate of pandemic H1N1-2009 virus, revealing its potential as an antiviral reagent.


EuroHeartCare 2017.


title: Prospective randomized controlled trial comparing 2 versions of laparoscopic ileal interposition associated with sleeve gastrectomy for patients with type 2 diabetes with BMI 21-34 kg/m(2).

text: BACKGROUND The objective of the present study was to prospectively evaluate the results of 2 versions of laparoscopic ileal interposition (II) and sleeve gastrectomy (SG) for the treatment of patients with type 2 diabetes mellitus and body mass index of 21-34 kg/m(2). METHODS The laparoscopic procedures were prospectively and randomly performed in 38 patients. Of the 38 patients, 18 underwent the first version (II-SG) and 20 underwent the second version in which a diversion of the second portion of the duodenum was applied (II-DSG) and a segment of ileum was interposed into the proximal duodenum. The groups were comparable regarding age (56 and 50 years); gender (13 men and 5 women and 14 men and 6 women); weight (78 and 86 kg); mean BMI (27 and 29 kg/m(2)); duration of type 2 diabetes mellitus (10.1 and 9.2 years); the presence of dyslipidemia (12 and 8 patients), micro- and macroalbuminuria (9 and 9 patients), hypertension (8 and 15 patients), and retinopathy (5 and 8 patients); and the use of antidiabetic medications and the hemoglobin A1c level (8.6% and 8.4%). All patients were followed up for >or=2 years. RESULTS The mean hospital stay was 3.4 days for the II-SG and 3.5 days for the II-DSG group. No patient required reoperation. All patients in both groups achieved lower levels of hemoglobin A1c. In the II-SG group, the mean hemoglobin A1c level was 6.35% (range 4.9-8.1). In the II-DSG group, the mean hemoglobin A1c level was 5.39% (range 4.2-6.5%). The mean BMI decreased in both groups to 22.2 kg/m(2) in the II-SG group and 22.7 kg/m(2) in the II-DSG group. Normal cholesterol levels (<200 mg/dL) were observed in 95% of the II-SG group and 100% of the II-DSG group. The triglycerides were lower than 150 mg/dL in 73% of the II-SG group and 90% of the II-DSG group after 24 months. CONCLUSION Laparoscopic II-SG and II-DSG were safe and effective operations for controlling type 2 diabetes mellitus in a nonobese (BMI 21-34 kg/m(2)) population.


Can hydroxychloroquine protect patients with rheumatic diseases from COVID-19? Response to: 'Does hydroxychloroquine prevent the transmission of COVID-19?' by Heldwein and Calado and 'SLE, hydroxychloroquine and no SLE patients with COVID-19: a comment' by Joob and Wiwanitkit.


title: A pilot study on the applicability of thromboelastometry in detecting brain tumour-induced hypercoagulation.

text: Patients with intracranial tumours have an increased risk of venous thromboembolism, particularly during the first month after neurosurgery. A proposed explanation for this increased risk, are procoagulant tumour-derived substances, such as tissue factor, usually measured in peripheral blood. The aim of the present study is to investigate whether a rotational thromboelastometry (ROTEM) can measure the procoagulative activity of tumour tissue. The study included 21 patients who were undergoing a craniotomy and complete tumour resection after written consent and ethical approval were obtained. Tumour tissue was biopsied during surgery and used for in vitro spiking of patients own citrated whole blood. Blood samples with or without spiking were analyzed with ROTEM using different activating reagents. ROTEM clotting time significantly decreased (p < .001), indicating a hypercoagulative response on clot initiation that was strongest for glioma tumours. However, ROTEM clot formation time was significantly prolonged (p < .001), which was an opposite response that indicated poor initial clot propagation. ROTEM maximum lysis was increased in the tumour tissue-spiked samples (p < .001), indicating a strong fibrinolytic activity in brain tumour tissue. Tissue extracts from intracranial tumours have both procoagulant and fibrinolytic effects that are detectable with ROTEM. Glioma tumours had the strongest hypercoagulative response in our in vitro model. Larger studies are necessary to test the clinical relevance and accuracy of tumour extract spiked viscoelastic tests to predict the individual patient risk for developing a thrombotic complication.


title: Transanal access for rectal tumors: the simultaneous use of a flexible endoscope and SILS.

text: The authors report that TEM with a single-incision laparoscopic surgery (SILS) port can be facilitated by the use of a colonoscope instead of a conventional laparoscopic camera. The colonoscope can be inserted through one of the SILS channels and has the added benefit of flexibility, insufflation, irrigation, suction, and an operative port.


Sleep medicine durable medical equipment management during COVID-19 pandemic: our center's initial experience.


Covid-19: Doctors challenge legality of government's PPE guidance.


title: Quality of life and defecative function 10 years or longer after posterior sagittal anorectoplasty and laparoscopic-assisted anorectal pull-through for anorectal malformation.

text: PURPOSE In our center, patients with anorectal malformation, including males with recto-vesical (RV)/recto-bladder neck (RBN)/recto-prostatic urethral (RU) fistulas, and females with recto-vaginal (RV) fistulas have been treated by posterior sagittal anorectoplasty (PSARP) before 2000, and by laparoscopic-assisted anorectal pull-through (LAARP) thereafter. We would like to compare the quality of life (QOL) and long-term defecative function between these two groups of patients 10 years after reconstructive surgery. METHODS Patients who underwent LAARP between 2001 and 2005 were compared with historical controls treated with PSARP between 1996 and 2000. Degrees of continence were graded by the Krickenbeck classification and Kelly's score. QOL was assessed by Hirschsprung's disease/Anorectal Malformation Quality of Life (HAQL) questionnaire. Results were compared using Chi-square test and t test. RESULTS There were 14 LAARP and 7 PSARP patients. All attained voluntary bowel movements. Moderate to severe soiling (Krickenbeck Grade 2 and 3) was found in 3/14 LAARP (21.4%) and 1/7 PSARP (14.3%) patients, p = 1.00. Constipation requiring use of laxatives was present in 3/14 LAARP (28.6%) and 1/7 PSARP (14.3%) patients, p = 0.62. Mean Kelly's scores were 3.79 ± 0.98 (LAARP) and 4.71 ± 1.25 (PSARP), p = 0.12. No patient required Malone antegrade continence enema (MACE). The QOL scores based on the HAQL questionnaire were comparable between the two groups in all areas except social functioning, in which the LAARP patients attained a significantly lower mean score (26.4 vs 71.7, p = 0.0001). CONCLUSION The 10-year outcome between LAARP and PSARP patients in terms of QOL and defecative function is comparable. Impairment in social functioning in these patients is reflected by the self-reported lower level of functioning.


title: Chlorhexidine gluconate or polyhexamethylene biguanide disc dressing to reduce the incidence of central-line-associated bloodstream infection: a feasibility randomized controlled trial (the CLABSI trial).

text: BACKGROUND A number of antimicrobial-impregnated discs to prevent central-line-associated bloodstream infection (CLABSI) are marketed but it is unclear which disc is most effective. AIM To investigate the feasibility and safety of comparing two antimicrobial-impregnated discs to prevent CLABSI. METHODS A single-centre, parallel group, randomized controlled trial was conducted in a 929-bed tertiary referral hospital. Hospital inpatients requiring a peripherally inserted central catheter were randomized to chlorhexidine gluconate (CHG) or polyhexamethylene biguanide (PHMB) disc dressing group. Dressings were replaced every seven days, or earlier, if clinically required. Participants were followed until device removal or hospital discharge. Feasibility outcomes included: proportion of potentially eligible participants who were enrolled; proportion of protocol violations; and proportion of patients lost to follow-up. Clinical outcomes were: CLABSI incidence, diagnosed by a blinded infection control practitioner; all-cause bloodstream infection (BSI); and product-related adverse events. FINDINGS Of 143 patients screened, 101 (71%) were eligible. Five (3.5%) declined participation. There was one post-randomization exclusion. Two (2%) protocol violations occurred in the CHG group. No patients were lost to follow-up. Three (3%) BSIs occurred; two (2%) were confirmed CLABSIs (one in each group) and one a mucosal barrier injury-related BSI. A total of 1217 device-days were studied, resulting in 1.64 CLABSIs per 1000 catheter-days. One (1%) disc-related adverse event occurred in the CHG group. CONCLUSION Disc dressings containing PHMB are safe to use for infection prevention at catheter insertion sites. An adequately powered trial to compare PHMB and CHG discs is feasible.


title: Prosthetic graft reconstruction after portal vein resection in pancreaticoduodenectomy: a multicenter analysis.

text: BACKGROUND Use of prosthetic grafts for reconstruction after portal vein (PV) resection during pancreaticoduodenectomy is controversial. We examined outcomes in patients who underwent vein reconstruction using polytetrafluoroethylene (PTFE). STUDY DESIGN Review of prospectively maintained databases at 3 centers identified all patients who underwent pancreaticoduodenectomy (PD) with vein resection and reconstruction using PTFE grafts between 1994 and 2009. Patient, operative, and outcomes variables were studied. Graft patency and survival were assessed using the Kaplan-Meier technique. RESULTS Thirty-three patients underwent segmental vein resection with interposition PTFE graft reconstruction. Median age was 67 years; median Eastern Cooperative Oncology Group score was 1. Most operations were performed for pancreatic adenocarcinoma (n = 28, 85%); 96% were T3 lesions or greater. Standard PD was performed in 12 (36%) patients, pylorus-preservation in 17 (52%), and total pancreatectomy in 4 (12%). Combined resection of portal and superior mesenteric veins (SMV) was required in 49%, with resection isolated to PV in 12% and SMV in 39%. Splenic vein ligation was necessary in 30%. Median graft diameter was 12 mm (range 8 to 20 mm), with the majority being ring-enforced (73%). Median operative and vascular clamp times were 463 and 41 minutes, respectively, with median blood loss of 1,500 mL. The negative margin rate was 64%. Overall morbidity rate was 46%, and 30-day mortality was 6%. No patients developed irreversible hepatic necrosis or graft infection. Pancreatic fistulas occurred in 3 (9.1%). With mean follow-up of 14 months, overall graft patency was 76%. Estimated median duration of graft patency was 21 months. Median survival was 12 months for pancreatic adenocarcinoma. CONCLUSIONS With careful patient selection, PTFE graft reconstruction of resected PV/SMV during pancreaticoduodenectomy is possible with minimal risk of hepatic necrosis or graft infection. Comparison studies to primary anastomosis and autologous vein reconstruction are necessary.


title: Off-label prescribing in the midst of a pandemic: The case of hydroxychloroquine.

text: There is currently no robust evidence to support prescribing hydroxychloroquine as a treatment or prophylaxis for COVID-19.


title: Recombinant protein-based viral disease diagnostics in veterinary medicine.

text: Identification of pathogens or antibody response to pathogens in human and animals modulates the treatment strategies for naive population and subsequent infections. Diseases can be controlled and even eradicated based on the epidemiology and effective prophylaxis, which often depends on development of efficient diagnostics. In addition, combating newly emerging diseases in human as well as animal healthcare is challenging and is dependent on developing safe and efficient diagnostics. Detection of antibodies directed against specific antigens has been the method of choice for documenting prior infection. Other than zoonosis, development of inexpensive vaccines and diagnostics is a unique problem in animal healthcare. The advent of recombinant DNA technology and its application in the biotechnology industry has revolutionized animal healthcare. The use of recombinant DNA technology in animal disease diagnosis has improved the rapidity, specificity and sensitivity of various diagnostic assays. This is because of the absence of host cellular proteins in the recombinant derived antigen preparations that dramatically decrease the rate of false-positive reactions. Various recombinant products are used for disease diagnosis in veterinary medicine and this article discusses recombinant-based viral disease diagnostics currently used for detection of pathogens in livestock and poultry.


title: Yemen field epidemiology training programme: a tool for strengthening the public health workforce.

text: Background The shortage of skilled public health workers, especially epidemiologists, remains an important challenge for building effective public health systems in many low-income countries, including Yemen. To address this need, in 2011 the Ministry of Public Health and Population established the Yemen Field Epidemiology Training Programme (Y-FETP). Aims To describe the Y-FETP and its strengths and challenges in addressing Yemen's National Health System (NHS) needs. Methods We describe the structure and functions of the Y-FETPs and analyse the achievements and challenges of the first 7 years of programme implementation as they relate to the NHS. Results The Y-FETP is a postgraduate competency-based training with the objective of strengthening capacity in field epidemiology so that events of public health importance can be detected and investigated in a timely and effective manner. Since its establishment, the Y-FETP has successfully trained 30 health professionals in advanced field epidemiology. Furthermore, trainees investigated over 100 outbreaks, analysed and evaluated 95 surveillance systems, conducted 30 planned studies and presented 70 oral and poster presentations at national and international conferences. The main challenges are low retention of graduates by the NHS and financial unsustainability. Conclusions The Y-FETP has strengthened the capacity of the Yemen health workforce and has been instrumental in supporting the NHS, especially during the war and the current crisis and health emergency as the security situation deteriorated and access to outside experts becomes limited. The programme provides a practical example of health systems strengthening through health workforce capacity development that can be replicated in countries with similar health workforce capacity challenges.


title: Protective Efficacy of Recombinant Modified Vaccinia Virus Ankara Delivering Middle East Respiratory Syndrome Coronavirus Spike Glycoprotein.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) causes severe respiratory disease in humans. We tested a recombinant modified vaccinia virus Ankara (MVA) vaccine expressing full-length MERS-CoV spike (S) glycoprotein by immunizing BALB/c mice with either intramuscular or subcutaneous regimens. In all cases, MVA-MERS-S induced MERS-CoV-specific CD8(+) T cells and virus-neutralizing antibodies. Vaccinated mice were protected against MERS-CoV challenge infection after transduction with the human dipeptidyl peptidase 4 receptor. This MERS-CoV infection model demonstrates the safety and efficacy of the candidate vaccine.


title: Biodiversity, bioactive natural products and biotechnological potential of plant-associated endophytic actinobacteria.

text: Endophytic actinobacteria, which exist in the inner tissues of living plants, have attracted increasing attention among taxonomists, ecologists, agronomists, chemists and evolutionary biologists. Numerous studies have indicated that these prolific actinobacteria appear to have a capacity to produce an impressive array of secondary metabolites exhibiting a wide variety of biological activity, such as antibiotics, antitumor and anti-infection agents, plant growth promoters and enzymes, and may contribute to their host plants by promoting growth and enhancing their ability of withstanding the environmental stresses. These microorganisms may represent an underexplored reservoir of novel species of potential interest in the discovery of novel lead compounds and for exploitation in pharmaceutical, agriculture and industry. This review focuses on new findings in the isolation methods, bio- and chemical diversity of endophytic actinobacteria and reveals the potential biotechnological application. The facing problems and strategies for biodiversity research and bioactive natural products producing are also discussed.


title: Nanofibrillar cellulose-alginate hydrogel coated surgical sutures as cell-carrier systems.

text: Hydrogel nanomaterials, especially those that are of non-human and non-animal origins, have great potential in biomedical and pharmaceutical sciences due to their versatility and inherent soft-tissue like properties. With the ability to simulate native tissue function, hydrogels are potentially well suited for cellular therapy applications. In this study, we have fabricated nanofibrillar cellulose-alginate (NFCA) suture coatings as biomedical devices to help overcome some of the limitations related to cellular therapy, such as low cell survivability and distribution out of target tissue. The addition of sodium alginate 8% (w/v) increased the NFCA hydrogel viscosity, storage and loss moduli by slightly under one order of magnitude, thus contributing significantly to coating strength. Confocal microscopy showed nearly 100% cell viability throughout the 2-week incubation period within and on the surface of the coating. Additionally, typical morphologies in the dual cell culture of spheroid forming HepG2 and monolayer type SK-HEP-1 were observed. Twelve out of 14 NFCA coated surgical sutures remained intact during the suturing operation with various mice and rat tissue; however, partial peeling off was observed in 2 of the coated sutures. We conclude that NFCA suture coatings could perform as cell-carrier systems for cellular based therapy and post-surgical treatment.


title: Modified Robert Jones bandage can not reduce invisible blood loss after total knee arthroplasty: a randomized-controlled trial.

text: INTRODUCTION To compare the efficacy and safety of modified Robert Jones bandage (MRJB) and non-compressive dressing (NCD) on reducing invisible blood loss (IBL) after total knee arthroplasty (TKA). MATERIALS AND METHODS Eighty patients who underwent unilateral TKA were randomly assigned into two groups: MRJB and NCD groups. Pre- and post-operative hematocrit levels, amount of drained blood and transfused blood were measured and calculated into IBL. Pain score, amount of morphine usage, range of motion (ROM) at discharge, blood transfusion rate, and complications were also recorded and compared between both groups. RESULTS There was no significant difference in the mean IBL between MRJB (221.2 ± 233.3 ml) and NCD groups (158.5 ± 186.7 ml) (p = 0.219). Post-operative pain score at rest and during ambulation, amount of morphine usage, ROM at discharge, blood transfusion rate, and complications were also similar between two groups. CONCLUSIONS This study cannot determine the benefit of MRJB over NCD. The use of MRJB may not be necessary after primary TKA.


title: Cerebral oxygen saturation monitoring in preeclamptic pregnant women undergoing cesarean section with spinal anesthesia: a prospective, observational study.

text: It has been suggested that cerebral oximetry can detect acute and chronic changes in cerebral oxygen saturation due to pregnancy related complications. Furthermore, regional cerebral oxygenation saturation (rcSO2) decreases were obtained during spinal anesthesia for cesarean section. The aim of this prospective observational study is to compare the effects of spinal anesthesia on rcSO2 in preeclamptic and normotensive pregnant women. Preeclamptic (Group P, n = 24) and normotensive (Group N, n = 25) women with gestational week 32 and above, and scheduled for cesarean section under spinal anesthesia were included in this study. In addition to routine monitoring, rcSO2 values obtained with right and left frontal cerebral sensors (rcSO2right and rcSO2left) were recorded before (baseline) spinal injection and during the surgery. The baseline rcSO2 values were similar in both groups. In Group P, rcSO2left values were higher than Group N only 3 and 5 min after spinal injection. In Group N, rcSO2 values decreased from baseline 1, 3, 5, and 10 min after spinal injection. In Group P, rcSO2 values decreased from baseline 1, 3, 5, 10, 30 and 35 min after spinal injection and at the end of the operation. There was no difference between the number of declines and the patients with rScO2 below the cerebral hypoxic threshold. There was a positive correlation between rcSO2 and blood pressure only 5 min after spinal injection, but no correlation with peripheral oxygen saturation was detected during the operation. There is decrease in rcSO2 values after spinal anesthesia correlating with hypotension in preeclamptic women. However, the decrease is less than that of normotensive pregnant women, especially the first 5 min after spinal injection when the blood pressure is lowest. The clinical impact of these results and the relationship between cerebral desaturation and neurological complications remain to be determined.


Reassessing advance care planning in the light of covid-19.


title: ASSOCIATION OF INITIAL VIRAL LOAD IN SARS-CoV-2 PATIENTS WITH OUTCOME AND SYMPTOMS.

text: The dynamics of viral load (VL) of the 2019 novel coronavirus (SARS-CoV-2) and its association with different clinical parameters remain poorly characterized in the United States patient population. Herein we investigate associations between VL and parameters such as severity of symptoms, disposition (admission vs direct discharge), length of hospitalization, and admission to the intensive care unit, length of need for oxygen support and overall survival in a cohort of 205 patients from a tertiary care center in New York City. VL was determined using q-PCR and Log10 transformed for normalization. Univariate and multivariate regression models were used to test these associations. We found that diagnostic viral load is significantly lower in hospitalized patients than in patients not hospitalized (log10 VL = 3.3 vs.4.0; p=0.018) after adjusting for age, sex, race, BMI, and comorbidities. Higher VL was associated with shorter duration of the symptoms in all patients and hospitalized patients only and shorter hospital stay (coefficient =-2.02,-2.61, -2.18; p<0.001, p=0.002, p=0.013, respectively). No significant association was noted between VL, admission to ICU, length of oxygen support, and overall survival. Our findings suggest a higher shedding risk in less symptomatic patients; an important consideration for containment strategies in SARS-CoV-2. Furthermore, we identify a novel association between viral load and history of cancer. Larger studies are warranted to validate our findings.


title: The Chinese import ban and its impact on global plastic waste trade.

text: The rapid growth of the use and disposal of plastic materials has proved to be a challenge for solid waste management systems with impacts on our environment and ocean. While recycling and the circular economy have been touted as potential solutions, upward of half of the plastic waste intended for recycling has been exported to hundreds of countries around the world. China, which has imported a cumulative 45% of plastic waste since 1992, recently implemented a new policy banning the importation of most plastic waste, begging the question of where the plastic waste will go now. We use commodity trade data for mass and value, region, and income level to illustrate that higher-income countries in the Organization for Economic Cooperation have been exporting plastic waste (70% in 2016) to lower-income countries in the East Asia and Pacific for decades. An estimated 111 million metric tons of plastic waste will be displaced with the new Chinese policy by 2030. As 89% of historical exports consist of polymer groups often used in single-use plastic food packaging (polyethylene, polypropylene, and polyethylene terephthalate), bold global ideas and actions for reducing quantities of nonrecyclable materials, redesigning products, and funding domestic plastic waste management are needed.


Covid-19: medical students to be employed by NHS as part of epidemic response.


title: Health systems preparedness for COVID-19 pandemic.

text: Some nations in the world and some states in India have had more success in containing this pandemic. Recent efforts in strengthening the health sector have focused largely on reforms in modes of financing, but as the pandemic brings home to us, the main challenge in India remains the challenge of the organization of public services using a health systems understanding. A close to community comprehensive primary health care, quality assurance, and planned excess capacity in public health systems, a more robust disease surveillance systems that can integrate data on new outbreaks and the indigenous technological capacity to scale up innovation and manufacture of essential health commodities are some of our most important requirements for both epidemic preparedness and response.


How Cyberpsychology and Virtual Reality Can Help Us to Overcome the Psychological Burden of Coronavirus.


title: The role of angiotensin-converting enzyme 2 in the pathogenesis of COVID-19: the villain or the hero?

text: Angiotensin-converting enzyme 2 (ACE 2) is the entry receptor for the novel coronavirus SARS-CoV-2, the aetiological agent of COVID-19. At the same time, ACE 2 expression decreases during COVID-19. Two seemingly contradictory relationships between the expression of ACE 2 and COVID-19 have been reported. Increased level of expression of ACE 2 may be a risk factor for the development of COVID-19 infection, while reduced ACE 2 expression during COVID-19 leads to acute respiratory distress syndrome. This article provides a comprehensive overview of available scientific knowledge about the role of ACE 2 in the pathogenesis of COVID-19, which is available up to current day. Also, it discusses unknown factors that we will have to reveal in order to understand the whole role of ACE 2 in the pathogenesis of COVID-19.


title: Wildlife diseases in New Zealand: recent findings and future challenges.

text: Our knowledge of diseases in New Zealand wildlife has expanded rapidly in the last two decades. Much of this is due to a greater awareness of disease as a cause of mortality in some of our highly threatened species or as a limiting factor to the successful captive rearing of intensely managed species such as hihi (Notiomystis cincta), kiwi (Apteryx spp.) and kakapo (Strigops habroptilus). An important factor contributing to the increase of our knowledge has been the development of new diagnostic techniques in the fields of molecular biology and immunohistochemistry, particularly for the diagnosis and epidemiology of viral and protozoan diseases. Although New Zealand remains free of serious exotic viruses there has been much work on understanding the taxonomy and epidemiology of local strains of avipox virus and circoviruses. Bacterial diseases such as salmonellosis, erysipelas and tuberculosis have also been closely investigated in wildlife and opportunist mycotic infections such as aspergillosis remain a major problem in many species. Nutritional diseases such as hyperplastic goitre due to iodine deficiency and metabolic bone disease due to Ca:P imbalance have made significant impacts on some captive reared birds, while lead poisoning is a problem in some localities. The increasing use of wildlife translocations to avoid the extinction of threatened species has highlighted the need for improved methods to assess the disease risks inherent in these operations and other intensive conservation management strategies such as creching young animals. We have also become more aware of the likelihood of inbreeding suppression as populations of many species decrease or pass through a genetic bottleneck. Climate change and habitat loss, however, remain the greatest threats to biodiversity and wildlife health worldwide. Temperature changes will affect our wildlife habitats, alter the distribution of disease vectors and wildlife predators, or directly harm threatened species in vulnerable localities.


title: Umbilical hernias: the cost of waiting.

text: BACKGROUND Umbilical hernias are well described in the literature, but its impact on health care is less understood. The purpose of this study was to investigate the effect of non-operative management of umbilical hernias on cost, work absenteeism, and resource utilization. METHODS The Truven Health Database, consisting of 279 employers and over 3000 hospitals, was reviewed for all umbilical hernia patients, aged 18-64 who were enrolled in health plans for 12 months prior to surgery and 12 months after surgery. Patients were excluded if they had a recurrence or had been offered a "no surgery" approach within 1 year of the index date. The remaining patients were separated into surgery (open or laparoscopic repair) or no surgery (NS). Post-cost analysis at 90 and 365 days and estimated days off from work were reviewed for each group. RESULTS The non-surgery cohort had a higher proportion of females and comorbidity index. Adjusted analysis showed significantly higher 90 and 365 costs for the surgery group (p < 0.0001), though the cost difference did decrease over time. NS group had significantly higher estimated days of health-care utilization at both the 90 (1.99 vs. 3.58 p < 0.0001) and 365 (8.69 vs. 11.04 p < 0.0001) day post-index mark. A subgroup analysis demonstrated laparoscopic repair had higher costs compared to open primarily due to higher index procedure costs (p < 0.05). CONCLUSIONS Though the financial costs were found to be higher in the surgery group, the majority of these were due to the surgery itself. Significantly higher days of health-care utilization and estimated days off work were experienced in the NS group. It is our belief that early operative intervention will lead to decreased costs and resource utilization.


title: Prognostic Value of Novel Liquid Biomarkers in Patients with Metastatic Castration-Resistant Prostate Cancer Treated with Enzalutamide: A Prospective Observational Study.

text: BACKGROUND Several treatment options were recently added for metastatic castration-resistant prostate cancer (mCRPC). However, response to therapy is variable, and biomarkers that can guide treatment selection and response evaluation are lacking. Circulating RNAs are a promising source of biomarkers. We explored messenger RNAs (mRNAs), microRNAs (miRNAs), and long noncoding RNAs (lncRNAs) as potential biomarkers in liquid biopsies of patients with mCRPC treated with enzalutamide. METHODS Forty patients were included in this prospective multicenter observational study. Whole blood was drawn at baseline and 1, 3, and 6 months after start of therapy. Four mRNAs, 6 miRNAs, and 5 lncRNAs were analyzed by quantitative PCR. RNA levels in 30 healthy individuals were used as controls. RNA expression data were analyzed by Kaplan-Meier and Cox regression analyses, and the primary end point was progression-free survival. Clinical factors were included in the multivariable Cox regression analysis. RESULTS Levels of 2 miRNAs, miR-375 and miR-3687, and 1 lncRNA, N-acetylated alpha-linked acidic dipeptidase like 2 antisense RNA 2 (NAALADL2-AS2), were more than 2-fold higher in patients with mCRPC compared with healthy volunteers. Patients with higher levels of miR-375 or miR-3687 showed a shorter time to progression. Patients with higher levels of NAALADL2-AS2 showed a longer time to progression. In the multivariable Cox regression analysis, higher miR-375, miR-3687 and serum prostate-specific antigen concentrations were shown to be independent predictors for shorter time to progression. CONCLUSIONS We identified miR-3687 as a novel prognostic marker for response in patients with CRPC treated with enzalutamide, and we confirmed the prognostic value of miR-375.


Neurologic complications of coronavirus infections.


title: Longitudinal Change of Medial and Lateral Patellar Stiffness After Reconstruction of the Medial Patellofemoral Ligament for Patients with Recurrent Patellar Dislocation.

text: BACKGROUND Longitudinal changes in patellar stiffness following reconstruction of the medial patellofemoral ligament for recurrent patellar dislocation at full extension are unknown. METHODS Fifteen consecutive patients (three men and twelve women, with a mean age of twenty-two years) with seventeen knees were matched by sex and age to thirty-two reference subjects in this prospective study. The follow-up period was a minimum of twenty-four months. The medial patellofemoral ligament reconstruction used an autograft semitendinosus tendon and an interference screw system with or without lateral release under 10 N of laterally directed force. The medial patellar stiffness and lateral patellar stiffness were measured in 0° of knee extension using the Patella Stability Tester preoperatively; postoperatively at three, six, twelve, and eighteen months; and at the time of the latest follow-up. Before and after the surgical procedure, patients were evaluated for apprehension and Kujala and Lysholm scores; radiographic examinations were performed to evaluate changes, including osteoarthritic changes. RESULTS The medial stiffness of the affected side before the surgical procedure was significantly lower than the lateral stiffness (p = 0.004) and the stiffness for healthy reference knees (p = 0.004). Medial stiffness three months after the surgical procedure was significantly elevated compared with lateral values (p = 0.027), preoperative values (p < 0.001), and reference group values (p = 0.002); reached the reference level by six months; and was maintained for up to two years. Furthermore, medial stiffness and lateral stiffness were well balanced after six months and this balance was sustained for up to two years postoperatively. No recurrent dislocation occurred during the follow-up period; one patient experienced apprehension. Postoperative radiographic findings and clinical scores were significantly improved at the time of the latest follow-up (p < 0.05). One knee progressed to patellofemoral osteoarthritis. CONCLUSIONS The value for medial stiffness was significantly improved three months after medial patellofemoral ligament reconstruction compared with the preoperative and lateral values and returned to the reference level by six months. Medial stiffness and lateral stiffness of the patella were well balanced by six months and retained that balance for up to two years, with good clinical results. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.


RCVS council vote an opportunity for change.


title: Onyx versus nBCA and coils in the treatment of intracranial dural arteriovenous fistulas.

text: BACKGROUND AND PURPOSE Intracranial dural arteriovenous fistulas (DAVFs) with cortical venous drainage have significant morbidity and mortality. Complete closure of these lesions is necessary to reduce these risks. The purpose of our study was to compare the outcome of DAVFs treated with Onyx versus those treated with n-Butyl Cyanoacrylate (nBCA) and coil embolization in a case-control study. Compared with nBCA and coil embolization, we hypothesized that Onyx embolization for DAVF is safer and has a higher chance of complete obliteration, with no need for post-embolization surgery for the DAVF. MATERIALS AND METHODS From 1998 to 2015, 29 patients who had DAVFs were treated with endovascular embolization. Of these, 24 patients had imaging available for analysis. Successful closure rates, complications, and procedure time were compared between the embolization techniques. RESULTS The chance of not requiring post-embolization surgery with Onyx (81.8%) was significantly higher (p = 0.005) than with nBCA (22.22%). The complication rate with Onyx (9.1%) tended to be lower compared with that of nBCA (22.22%; p = 0.37). Procedural time was not significantly different between Onyx (mean 267 minutes) and nBCA (mean 288 minutes) (p = 0.59). The odds ratio of a DAVF being treated with Onyx and then requiring no follow-up surgery was 17.5 (95% CI 1.97-155.4). CONCLUSION Our case-control study suggests that Onyx embolization is superior to nBCA and coil embolization in completely obliterating DAVFs, with higher odds of no post-embolization surgery. We also found that Onyx is safe for embolization of DAVFs, with no associated neurological mortality and morbidity.


title: Assessing the impact of budget controls on the prescribing behaviours of physicians treating dialysis-dependent patients.

text: OBJECTIVES This study examined whether outpatient haemodialysis providers changed their treatment practices with the establishment of an outpatient dialysis global budget (ODGB) through analysing the outpatient visits and medication received by those patients. METHODS A sample of 4668 observations (patient year) of 1350 haemodialysis with hypertension (HH) patients and 4668 observations of 1436 non-HH (NHH) patients were drawn from the National Health Insurance Research Database over the years from 1999 to 2005. The impact of ODGB on hypertension-related outpatient utilization of HH was estimated using the difference in difference (DID) method and examined in three stages: (1) the fee for service stage, the pre-ODGB (2000), (2) the phase-in stage (2001-2002) and (3) the post-ODGB stage (2003-2005). RESULTS ODGB implementation did not affect the number of dialysis visits for HH patients. However, it did lead to a reduction in fees for antihypertension drugs used by haemodialysis facilities. There was an increase of 4.06 visits per patient per year (P < 0.001) in the number of non-dialysis outpatient with antihypertensive drugs visits for HH patients compared with the control group. The total fees for antihypertensive drugs for HH patients increased by New Taiwan Dollars (NT$)13 008 (P < 0.001) per patient per year relative to the control group after the implementation of ODGB. CONCLUSIONS As ODGB was implemented, HH patients received fewer antihypertensive drugs during their dialysis visit. In addition, there was an increase in the number of non-dialysis outpatient visits by HH patients as well as increased payment in the drugs associated with their non-dialysis outpatient visits compared with the control group.


title: First-in-man use of a novel embolic protection device for patients undergoing transcatheter aortic valve implantation.

text: AIMS We describe the first-in-human experience with a novel cerebral embolic protection device used during transcatheter aortic valve implantation (TAVI). One current challenge of TAVI is the reduction of procedural stroke. Procedural mobilisation of debris is a known source of cerebral embolisation. Mechanical protection by transient filtration of cerebral blood flow might reduce the embolic burden during TAVI. We aimed to evaluate the feasibility and safety of the Claret CE Pro™ cerebral protection device in patients undergoing TAVI. METHODS AND RESULTS Patients scheduled for TAVI were prospectively enrolled at three centres. The Claret CE Pro™ (Claret Medical, Inc. Santa Rosa, CA, USA) cerebral protection device was placed via the right radial/brachial artery prior to TAVI and was removed after the procedure. The primary endpoint was technical success rate. Secondary endpoints encompassed procedural and 30-day stroke rates, as well as device-related complications. Deployment of the Claret CE Pro™ cerebral protection device was intended for use in 40 patients, 35 devices were implanted into the aortic arch. Technical success rate with delivery of the proximal and distal filter was 60% for the first generation device and 87% for the second-generation device. Delivery times for the first-generation device were 12.4±12.1 minutes and 4.4 ± 2.5 minutes for the second-generation device (p<0.05). The quantity of contrast used related to the Claret CE Pro System was 19.6 ± 3.8 ml. Captured debris was documented in at least 19 of 35 implanted devices (54.3%). No procedural transient ischaemic attacks, minor strokes or major strokes occurred. Thirty-day follow-up showed one minor stroke occurring 30 days after the procedure, and two major strokes both occurring well after the patient had completed TAVI. CONCLUSIONS The use of the Claret CE Pro™ system is feasible and safe. Capture of debris in more than half of the patients provides evidence for the potential to reduce the procedural cerebral embolic burden utilising this dedicated filter system during TAVI.


COVID-19 pandemic: what can pharmaceutical formulation and drug delivery experts offer?


title: Improving the trajectory of transpedicular transdiscal lumbar screw fixation with a computer-assisted 3D-printed custom drill guide.

text: Transpedicular transdiscal screw fixation is an alternative technique used in lumbar spine fixation; however, it requires an accurate screw trajectory. The aim of this study is to design a novel 3D-printed custom drill guide and investigate its accuracy to guide the trajectory of transpedicular transdiscal (TPTD) lumbar screw fixation. Dicom images of thirty lumbar functional segment units (FSU, two segments) of L1-L4 were acquired from the PACS system in our hospital (patients who underwent a CT scan for other abdomen diseases and had normal spine anatomy) and imported into reverse design software for three-dimensional reconstructions. Images were used to print the 3D lumbar models and were imported into CAD software to design an optimal TPTD screw trajectory and a matched custom drill guide. After both the 3D printed FSU models and 3D-printed custom drill guide were prepared, the TPTD screws will be guided with a 3D-printed custom drill guide and introduced into the 3D printed FSU models. No significant statistical difference in screw trajectory angles was observed between the digital model and the 3D-printed model (P > 0.05). Our present study found that, with the help of CAD software, it is feasible to design a TPTD screw custom drill guide that could guide the accurate TPTD screw trajectory on 3D-printed lumbar models.


title: Assessment of basic laparoscopic skills on virtual reality simulator or box trainer.

text: INTRODUCTION We investigated whether the peg transfer task is interchangeable between a VR simulator and a box trainer. Our research questions: (1) Are scores of the box trainer interchangeable with the virtual equivalent of the exercise; (2) does training on the box affect performance on the VR simulator and vice versa; and (3) which system is preferred? METHODS Experienced laparoscopists and medical interns were randomly assigned to one of two groups (V or B). They performed eight repetitions of the peg transfer task (4 on each simulator system) following a crossover study design. Group B started on the box trainer and group V started on the VR simulator. Opinion of participants was evaluated by a questionnaire. RESULTS A significant correlation was found between time to complete the task on the box and the VR simulator. The comparison of the performances per system showed that group B (N = 14) performed the peg transfer task on the VR simulator in significantly less time than group V (N = 14; p = 0.014). Overall, the box was preferred over the VR simulator. CONCLUSIONS Although performances on the box trainer and VR simulator were correlated, they were not interchangeable. The results also imply that assessment on the VR simulator after pretraining on the box is acceptable, whereas VR simulator training alone might not suffice to pass an assessment on a box trainer. More research is needed to validate the use of the VR simulator as a FLS and PLUS assessment instrument.


title: Mechanisms for Env glycoprotein acquisition by retroviruses.

text: A mandatory step in the formation of an infectious retroviral particle is the acquisition of its envelope glycoprotein (Env). This step invariably occurs by Env positioning itself in the host membrane at the location of viral budding and being incorporated along with the host membrane into the viral particle. In some ways, this step of the viral life cycle would appear to be imprecise. There is no specific sequence in Env or in the retroviral structural protein, Gag, that is inherently required for the production of an infectious Env-containing particle. Additionally, Env-defective proviruses can efficiently produce infectious particles with any of a number of foreign retroviral Env glycoproteins or even glycoproteins from unrelated viral families, a process termed pseudotyping. However, mounting evidence suggests that Env incorporation is neither passive nor random. Rather, several redundant mechanisms appear to contribute to the carefully controlled process of Env acquisition, many of which are apparently used by a wide variety of enveloped viruses. This review presents and discusses the evidence for these different mechanisms contributing to incorporation.


title: A Wrist-Worn Strap with an Array of Electrodes for Robust Physiological Sensing.

text: Robust sensing is one of the main challenges for wearable physiological monitoring because of the high dependency on the placement of electrodes on the body, retaining suitable contact between electrodes and skin, and the effect of motion artifacts. In this paper, we present a wrist-worn strap that includes a 2-D array of 48 miniature electrodes covering the bottom side of the wrist with good contact with the skin. Good skin contact directly impacts the sensing robustness. The array provides local measurements between adjacent electrodes that span the whole bottom side of the wrist with an area of 6.25×4.60 cm for robust sensing. The array allows for the automatic selection of the correct electrodes at the right location regardless of changes in the device placement on the wrist. In addition, using a large number of electrodes over a large area on the wrist ensures continuous contact of some electrodes with the skin during motion since all of the electrodes will not lose contact with the skin at the same time. We measured the electrode-skin impedance of the fabricated electrodes versus frequency and compared to other types of electrodes. We demonstrated good contact between all electrodes of the array and the skin by measuring electrode-skin impedance less than 10 k$\Omega$ at 16 kHz for all locations on the wrist strap. We also conducted measurements of impedance while the wearer was bending the wrist to validate the continuous contact of at least a subset of electrodes with the skin during such movements.


title: Absence of coronaviruses, paramyxoviruses, and influenza A viruses in seabirds in the southwestern Indian Ocean.

text: We investigated circulation of coronaviruses, paramyxoviruses, and influenza A viruses in eight seabird species of the southwestern Indian Ocean. Viruses were not detected by real-time polymerase chain reactions in the 338 tested cloacal swab samples, supporting that they did not circulate in the studied colonies at the time of sampling.


title: Lipomatosis of the trigeminal nerve causing trigeminal neuralgia: case report and literature review.

text: UNLABELLED Cerebellopontine angle lipomas are rare and attempts at surgical excision are associated with significant morbidity. Lipomatosis of nerve, the fatty infiltration of nerves, is a distinct entity. We present a case of intractible trigeminal neuralgia caused by lipomatosis of the trigeminal nerve. CLINICAL CASE A 25-year-old male presented with severe right-sided trigeminal neuralgia. Imaging showed a lesion involving the trigeminal nerve with signal characteristics of fat. At surgery the lesion was found to be a fatty infiltration of the nerve itself. Surgery was therefore limited to arachnoid adhesiolysis. The patient remains symptom-free and neurologically intact to date. Correctly identifying these lesions as lipomatosis of nerve rather than lipoma of the cerebellopontine angle make it clear that even partial surgical excision will inevitably result in neurological deficit and should not be attempted. However, in the case of intractable trigeminal neuralgia we demonstrate that surgery can still play a role.