title: Cervical carotid and circle of willis arterial anatomy of macaque monkeys: a comparative anatomy study.

text: Macaque monkeys are used in many research applications, including cerebrovascular investigations. However, detailed catalogs of the relevant vascular anatomy are scarce. We present our experience with macaque vessel patterns as determined by digital subtraction angiography of 34 different monkeys. We retrospectively analyzed digital subtraction angiograms obtained during experimental internal carotid artery (ICA) catheterization and subsequent injection of 1-methyl 4-phenyl 1,2,3,6-tetrahydropyridine. Results were catalogued according to vascular distribution and variants observed. Macaque monkeys have a bovine aortic arch. The carotid vessels generally bifurcate, but are occasionally observed to divide into three vessels. The external carotid gives rise primarily to two trunks: an occipital branch and a common vessel that subsequently gives off the lingual, facial, and superior thyroid arteries. The internal maxillary artery may be present as a terminal branch of the external carotid or as a branch of the occipital artery. The ICA is similar in course to that of the human. The anterior circle of Willis was intact in all monkeys in our study. Its primary difference from that of the human is the union of the bilateral anterior cerebral arteries as a single (azygous) median vessel. Macaque cervical carotid and circle of Willis arterial anatomy differs from humans in a couple of specific patterns. Knowledge of these differences and similarities between human and macaque anatomy is important in developing endovascular macaque models of human diseases, such as ischemic stroke.


title: Prevalence of Barrett's esophagus in obese patients undergoing pre-bariatric surgery evaluation: a systematic review and meta-analysis.

text: INTRODUCTION Obesity is a known risk factor for gastroesophageal reflux disease (GERD), Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC). Obese patients routinely undergo preoperative esophagogastroduodenoscopy (EGD) before bariatric procedures. We aimed to assess the prevalence of BE in this patient population. METHODS We conducted a comprehensive literature search ending in March 2019. Search results were imported into covidence.org and screened by two independent reviewers. Heterogeneity was assessed using I 2 and Q statistics and publication bias using funnel plots and the Orwin fail-safe test. Random-effects modeling was used in all analyses. RESULTS : Of 4087 citations, 77 were reviewed in full text and 29 were included in the final analysis based on our predetermined inclusion/exclusion criteria. A total of 13 434 patients underwent pre-bariatric surgery EGD. The pooled prevalence of BE using random-effects modeling was 0.9 % (95 % confidence interval [CI] 0.7 % - 1.3 %); P < 0.001; I 2 = 58 %, Q = 67). In meta-regression analyses, controlling for sex and GERD, we found a positive association between mean body mass index (BMI) and the prevalence of BE (β = 0.15 [95 %CI 0.02 - 0.28]; P = 0.03). A linear relationship between the prevalence of BE and the prevalence of GERD was also noted (β = 3.9 [95 %CI 0.4 - 7.5]; P = 0.03). CONCLUSIONS : Obesity has been postulated as a major risk factor for BE, yet we found that the prevalence of BE in morbidly obese patients undergoing preoperative EGD was very low. Therefore, obesity alone may not be a major risk factor for BE.


title: Molecular Detection and Phylogenetic Characterization of Bat and Human Adenoviruses in Southern China.

text: Several novel adenoviruses (AdVs) have recently been identified in humans and other animal species. In this study, we report the molecular detection of and phylogenetically characterize bat and human AdVs detected in fecal or rectal swab samples collected in southern China. To detect AdVs, a 252-261 bp fragment of the DNA polymerase (DPOL) gene was amplified using nested PCR. A total of 520 rectal swab samples were collected from eight bat species in four geographic regions of southern China (Guangzhou, Yunfu, Huizhou, and Haikou city). Thirty-six (6.9%) samples from the following species tested positive for AdVs: Myotis ricketti, Miniopterus schreibersii, Scotophilus kuhlii, Taphozous melanopogon, Rhinolophus blythi, and Cynopterus sphinx. Eight novel AdVs were detected in 13.3% of the samples from C. sphinx. Of 328 fecal samples from patients with diarrhea, 16 (4.9%) were positive for classical human AdVs. Phylogenetic analysis showed that human AdVs shared low similarity (57.1-69.3%) with bat AdVs in deduced amino acid sequences of the AdV DPOL region. Thus, our study indicated that bat AdVs and human AdVs are species specific. As such, there is no evidence of cross-species transmission of AdV between bats and humans based on current data.


Mission to MERS.


title: Long-Term Outcome of Tubridge Flow Diverter(S) in Treating Large Vertebral Artery Dissecting Aneurysms-A Pilot Study.

text: BACKGROUND AND PURPOSE The experience of flow diverters (FDs) in treating large vertebral artery-dissecting aneurysms (VADAs) is still limited. This study was conducted to present our long-term outcome of VADAs treated with a Tubridge flow diverter (TFD), a new device developed in China. MATERIALS AND METHODS The clinical and angiographic data of six patients harboring large VADAs and treated with TFDs were prospectively collected and analyzed. RESULTS A total of nine TFDs were successfully implanted in six patients. Angiographic follow-up images were available for all patients at a median of 26.0 (18.5, 37.5) months after treatment. Five of the six VADAs were completely occluded, and the last was improved (near complete occlusion). In-stent stenosis was detected in one case and was handled appropriately by angioplasty and stenting. All covered branches and parent arteries remained patent. There were no complications or new neurological deficits observed in any of the patients. At the latest clinical follow-up (36.5 (26.0, 44.5) months), all patients achieved 0 in the modified Rankin scale score. CONCLUSIONS Our preliminary experience suggests that the Tubridge flow diverter might be an alternative treatment for large and recurrent dissecting aneurysms derived from the vertebral artery.


title: Single port access laparoscopic adnexal surgery versus conventional laparoscopic adnexal surgery: a comparison of peri-operative outcomes.

text: OBJECTIVE The objective of the study was to compare the peri-operative outcomes of single port access (SPA) laparoscopic adnexal surgery and conventional laparoscopic adnexal surgery. STUDY DESIGN This is a retrospective case-control study matched by body mass index (BMI; kg/m(2)). A single surgeon (T-JK) performed 17 SPA laparoscopic adnexal surgeries (cases) consecutively between December 2008 and March 2009; 34 conventional laparoscopic adnexal surgeries (controls) were performed by another surgeon who had similar surgical skill at our hospital during the same time period. Data on the SPA laparoscopic adnexal surgery cases were collected prospectively into our data registry after Institutional Review Board (IRB) approval and we reviewed the data on the controls from the electronic medical records with IRB approval. RESULTS In both groups all procedures were performed without failure. Among preoperative baseline characteristics there was no difference between the two groups including preoperative size of ovarian tumor and bilaterality. The pathology findings were similar; a mature cystic teratoma was the most common pathological feature in both groups. The two groups were comparable with regard to operative outcomes according the surgery type. There were no differences between SPA and conventional groups in median operation time (64 min vs. 57.5 min, p=0.252), the number of patients that requested additional parenteral non-steroidal anti-inflammatory drugs (7 patients vs. 19 patients, p=0.597), and the absolute decrease (1.3mg/dl vs. 1.1mg/dl, p=0.640) from preoperative hemoglobin to postoperative day 1 measurements. No patient from either cohort required a blood transfusion. There were no complications in either group including umbilical incision complications in the SPA group. CONCLUSION Our study demonstrated that SPA laparoscopic adnexal surgery had comparable operative outcomes to conventional laparoscopic adnexal surgery. A prospective comparison is needed for confirmation and to define the role of SPA in gynecological adnexal surgery.


title: Protective Humoral Immunity in the Central Nervous System Requires Peripheral CD19-Dependent Germinal Center Formation following Coronavirus Encephalomyelitis.

text: B cell subsets with phenotypes characteristic of naive, non-isotype-switched, memory (Bmem) cells and antibody-secreting cells (ASC) accumulate in various models of central nervous system (CNS) inflammation, including viral encephalomyelitis. During neurotropic coronavirus JHMV infection, infiltration of protective ASC occurs after T cell-mediated viral control and is preceded by accumulation of non-isotype-switched IgD+ and IgM+ B cells. However, the contribution of peripheral activation events in cervical lymph nodes (CLN) to driving humoral immune responses in the infected CNS is poorly defined. CD19, a signaling component of the B cell receptor complex, is one of multiple regulators driving B cell differentiation and germinal center (GC) formation by lowering the threshold of antigen-driven activation. JHMV-infected CD19-/- mice were thus used to determine how CD19 affects CNS recruitment of B cell subsets. Early polyclonal ASC expansion, GC formation, and virus-specific ASC were all significantly impaired in CLN of CD19-/- mice compared to wild-type (WT) mice, consistent with lower and unsustained virus-specific serum antibody (Ab). ASC were also significantly reduced in the CNS, resulting in increased infectious virus during persistence. Nevertheless, CD19 deficiency did not affect early CNS IgD+ B cell accumulation. The results support the notion that CD19-independent factors drive early B cell mobilization and recruitment to the infected CNS, while delayed accumulation of virus-specific, isotype-switched ASC requires CD19-dependent GC formation in CLN. CD19 is thus essential for both sustained serum Ab and protective local Ab within the CNS following JHMV encephalomyelitis.IMPORTANCE CD19 activation is known to promote GC formation and to sustain serum Ab responses following antigen immunization and viral infections. However, the contribution of CD19 in the context of CNS infections has not been evaluated. This study demonstrates that antiviral protective ASC in the CNS are dependent on CD19 activation and peripheral GC formation, while accumulation of early-recruited IgD+ B cells is CD19 independent. This indicates that IgD+ B cells commonly found early in the CNS do not give rise to local ASC differentiation and that only antigen-primed, peripheral GC-derived ASC infiltrate the CNS, thereby limiting potentially harmful nonspecific Ab secretion. Expanding our understanding of activation signals driving CNS migration of distinct B cell subsets during neuroinflammatory insults is critical for preventing and managing acute encephalitic infections, as well as preempting reactivation of persistent viruses during immune-suppressive therapies targeting B cells in multiple sclerosis (MS), such as rituximab and ocrelizumab.


Caution Needed on the Use of Chloroquine and Hydroxychloroquine for Coronavirus Disease 2019.


title: Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review.

text: Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.


SEPAR Guidelines for Nosocomial Pneumonia.


title: Future infectious disease threats to Europe.

text: We examined how different drivers of infectious disease could interact to threaten control efforts in Europe. We considered projected trends through 2020 for 3 broad groups of drivers: globalization and environmental change, social and demographic change, and health system capacity. Eight plausible infectious disease threats with the potential to be significantly more problematic than they are today were identified through an expert consultation: extensively drug-resistant bacteria, vector-borne diseases, sexually transmitted infections, food-borne infections, a resurgence of vaccine-preventable diseases, health care-associated infections, multidrug-resistant tuberculosis, and pandemic influenza. Preemptive measures to be taken by the public health community to counteract these threats were identified.


title: Single-incision laparoscopic adrenalectomy for primary aldosteronism: report of a case.

text: We herein report the first case of a single-incision laparoscopic access (SILA) adrenalectomy in Japan. A 74-year-old woman who was a hepatitis B virus carrier was referred to our hospital because of an abnormal screening result during a routine health checkup. Abdominal computed tomography and an endocrinologic workup revealed a 2-cm left adrenal tumor with primary aldosteronism. We prioritized the safety of the SILA adrenalectomy by choosing a left lower abdominal approach. A SILS port was inserted through a 2.5-cm incision. An ultrasonic coagulator was the main tool used during the surgical procedure. The duration of the surgery was 105 min and the blood loss was 1 ml. This result was comparable to that of a conventional laparoscopic adrenalectomy. Based on our experience, an SILA adrenalectomy is thus considered to be feasible and safe, with better cosmetic results and a greater overall patient satisfaction than that of a conventional laparoscopic adrenalectomy. However, further studies will be necessary before the universal adoption of this new technique can be considered.


title: Decline in acute upper gastrointestinal bleeding during Covid-19 pandemic after lockdown in Austria.

text: Background and study aims COVID-19 disease has rapidly spread all over the world. The Austrian government has implemented a lockdown to contain further spread of this disease on March 16th. We investigated the effects of lockdown on acute upper gastrointestinal (GI) bleeding in Austria. Patients and methods We contacted 98 Austrian hospitals performing emergency endoscopies. The hospitals were asked to report upper GI endoscopies performed because of recent hematemesis, melena, or both and exhibiting endoscopically visible signs of bleeding. Investigated time points included three weeks before and after lockdown. Results 61% of Austrian hospitals and importantly all major state hospitals responded. 575 upper GI bleedings occurred in the three weeks before and 341 after lockdown (40.7% reduction). When comparing the first and last calendar week of investigation we observed an almost 55% decline in nonvariceal bleeding events (calendar week 9 versus 14: 196 versus 89) whereas rates of variceal hemorrhage did not change (calendar week 9 versus 14: 17 versus 15). Conclusions National lockdown resulted in a dramatic decrease in upper gastrointestinal bleeding events.


Acute peritoneal dialysis in COVID-19.


title: Lessons and challenges during a 5-year follow-up of 21 Composix Kugel implantations.

text: INTRODUCTION From its introduction in 2000 until its US recall in December 2005, the Composix Kugel mesh was implanted in an estimated 350,000 patients worldwide. In our patients, minor postoperative complications were followed after a few years by more serious problems (persistent abdominal pain, infections, intestinal perforations). In this study, we take stock after a 5-year follow-up and issue a plea for improved product development strategies and the creation of hernia registries. PATIENTS AND METHODS Between 2003 and 2006, we implanted the Bard(®) Composix(®) Kugel(®) mesh in 21 patients (11 men, 10 women, mean age 63.2 ± 13.7 years) with incisional hernias using the open intraperitoneal onlay mesh technique. The mesh is made on one side of ePTFE and on the other of polypropylene and is expanded by a polyethylene (PET) memory recoil ring. The average follow-up was 45.5 months. All patients had at least one risk factor for hernia recurrence. Explanted prostheses were analyzed by scanning electron microscopy (SEM) and subjected to mechanical strength tests. RESULTS During the postoperative course, six patients suffered a wound healing disorder. Ten patients complained of persistent abdominal wall pain and four experienced recurrence of the hernia. In one patient, the mesh had to be explanted due to chronic infection. In one patient, the PET memory recoil ring broke after 5 years of follow-up with consequent small bowel perforation. The PET memory recoil ring exhibited clear signs of degradation on SEM and unmistakable signs of material fatigue in a materials testing machine. CONCLUSIONS Patients with recalled Composix Kugel meshes face a singular risk for complications that may occur even many years after implantation. The most serious complication is the breakage of its PET memory recoil ring. Since the recall of the Composix Kugel Mesh, we have discontinued its use. It is necessary that future complications are documented in a common post-market surveillance registry. Algorithms need to be developed and promoted to support affected patients and surgeons.


title: Radiofrequency Ablation of Osteoid Osteoma with Use of Intraoperative Three-Dimensional Imaging and Surgical Navigation.

text: Introduction During the performance of radiofrequency ablation of osteoid osteomas, the use of intraoperative cone-beam computed tomography (CT) imaging with surgical navigation lowers radiation exposure while allowing real-time targeting of the nidus. Step 1 Preoperative Planning Review all images to confirm a high level of confidence in the radiographic diagnosis. Step 2 Patient Positioning and Setup Be sure to position and set up properly. Step 3 Placement of Tracking Optical Array Attach the optical array to the target bone. Step 4 O-Arm Setup Initial CT Imaging for Surgical Navigation and Remote Mouse Registration Set up the intraoperative CT (O-Arm) machine and acquire the initial images for surgical navigation. Step 5 CT Data Interpretation and Approach Planning Analyze the initial images, rotated or positioned as necessary, to allow you to proceed with the planned direction and angle of approach to the nidus. Step 6 Surgical Navigation Setup Register the surgical instruments with the surgical navigation unit. Step 7 Nidus Localization and Kirschner Wire Insertion Target the nidus and then insert the Kirschner wire into its center. Step 8 Exchanging Kirschner Wire for a Radiofrequency Probe Once the accuracy of the Kirschner wire placement is confirmed, exchange it for the radiofrequency probe and perform a CT scan to confirm proper probe placement. Step 9 Confirmation of RFA Probe Placement Perform a CT scan to confirm proper placement of the probe within the center of the nidus. Step 10 Activation of the Radiofrequency Probe and Closure Perform the radiofrequency treatment to ablate the cells within the nidus. Results We conducted a study of three different techniques of radiofrequency ablation.IndicationsContraindicationsPitfalls & Challenges.


title: Indocyanine green fluorescence-guided laparoscopic surgery, with omental appendices as fluorescent markers for colorectal cancer resection: a pilot study.

text: BACKGROUND Currently, we lack tools that can reliably guide laparoscopic surgeons to a target anatomical destination for dissection. We aimed to develop and evaluate a fluorescent destination marker (FDM), composed of a resected omental appendix injected with indocyanine green (ICG), for real-time navigation in laparoscopic surgery for colorectal cancer in this pilot study. METHODS This study included ten patients diagnosed with colorectal cancer. To prepare FDMs, we laparoscopically harvested omental appendices attached to the colon we planned to resect. The harvested appendices were injected with diluted ICG, and a gauze tag was attached. The FDMs were placed at target intra-abdominal sites with a ligation clip. RESULTS Patient diagnoses included 1 cecal, 2 ascending colon, 3 transverse colon, 2 sigmoid colon, and 2 rectal cancers. No conversion to open surgery was required and no intraoperative complications occurred. We created 12 sets of FDMs, which were placed at a total of 13 sites in abdominal cavities. FDM fluorescence was successfully detected in all cases. Furthermore, FDMs could be detected earlier than the gauze tags at 12 points, and they were detected at the same time at 1 point. CONCLUSIONS All FDMs facilitated laparoscopic surgery by allowing the surgeon to find the tissue to be dissected, particularly in procedures that required the dissection of lymph nodes around middle colic vessels and mobilization of the splenic flexure. FDMs showed potential for guiding the laparoscopic surgeon to a target anatomical destination. This marker represents a contribution to the evolution of real-time navigation surgery.


title: Resident training in minimally invasive surgery: a survey of Canadian department and division chairs.

text: BACKGROUND This study aimed to seek the opinions of academic surgical chairs on minimally invasive surgery (MIS) education for general surgery residents and to identify perceived gaps and trends in educational strategies. METHODS A national survey on attitudes toward MIS was sent to the chairs of departments of surgery and divisions of general surgery across the 16 Canadian academic centers. The survey contained 34 questions consisting of Likert scales, single answers, and multiple-choice questions. Nonresponders were contacted directly. At the time of the survey, two department chair positions were vacant. RESULTS The response rate was 87% (26/30). The majority of the centers used early operating room exposure to basic MIS cases (92%) and animal labs (85%). Two-thirds of the institutions used early operating room exposure to advanced MIS cases (69%) and didactic lectures (65%). Half of the academic centers used MIS video (54%) and the laparoscopic virtual reality simulator (54%). The least used method was computer software (19%). The surgical division and department chairs believed the most effective teaching method was early operating room exposure to basic MIS cases (100%), followed by the laparoscopic virtual reality simulator (91%) and animal labs (88%). Computer software was considered 42% useful, and the least useful method was didactic lectures (16%). In the next 5 years, 62% of academic centers plan to add laparoscopic virtual reality simulators to their MIS curriculum. CONCLUSION The chairs' opinion on the most effective MIS teaching method for residents is basic MIS cases followed by laparoscopic virtual reality simulators. The majority of academic institutions plan to add laparoscopic virtual reality simulators to the curriculum in the next 5 years.


title: Effect of a Fenestration Between an Intrascleral Lake and Supraciliary Space on Deep Sclerectomy.

text: PURPOSE To evaluate the effects of a scleral fenestration on the surgical outcomes of modified deep sclerectomy (DS). METHODS We retrospectively studied the surgical outcomes of 83 eyes of 83 patients after modified DS for primary open-angle glaucoma (POAG) or ocular hypertension. In 39 eyes, combination of DS, incision of the trabeculo-Descemet's membrane, and iridectomy were performed (DSF-); in 44 eyes, a scleral fenestration between the supraciliary space and lake was added to the DSF- (DSF+). Forty-eight eyes of 48 patients with POAG who underwent trabeculectomy with adjunctive mitomycin C (lect MMC) served as controls. RESULTS The probability of bleb survival was more common in the following order: lect MMC>DSF->DSF+ (P=0.0029). A significantly greater intraocular pressure (IOP) reduction occurred in the lect MMC group compared with the DSF+ (P=0.0015) and DSF- (P=0.0006) groups. So far as the eyes that underwent DS were concerned, bleb formation (P=0.0130) and a scleral bed fenestration (P=0.0315) significantly lowered the IOP by the Cox proportional hazard model. In eyes treated with DSF+, the positive IOP-lowering effect of the fenestration was counterbalanced by inhibited bleb formation and resulted in equivalent IOP reductions in the DSF+ and DSF- groups (P=0.9881). IOP reduction by DSF+ without a bleb was 25.0% at 1 year (P=0.00015) and this reduction increased to 43.2% (P=0.0001) when eyes accompany a bleb and scleral fenestration. CONCLUSIONS Both the scleral fenestration and bleb formation lower IOP, whereas the scleral fenestration suppresses bleb formation in patients treated with DS.


title: Estimation of Severe Middle East Respiratory Syndrome Cases in the Middle East, 2012-2016.

text: Using data from travelers to 4 countries in the Middle East, we estimated 3,250 (95% CI 1,300-6,600) severe cases of Middle East respiratory syndrome occurred in this region during September 2012-January 2016. This number is 2.3-fold higher than the number of laboratory-confirmed cases recorded in these countries.


title: Treatment approach in locally advanced rectal cancer during Coronavirus (COVID-19) pandemic: long course or short course?

text: In this document, we briefly share the strategies and actions for patients with locally advanced rectal cancer to face the challenges of Coronavirus disease 2019 (COVID-19).


title: The Combined Use of Intraluminal and Intrasaccular Flow Diversion for the Treatment of Intracranial Aneurysms: Report of 25 Cases.

text: Purpose The Medina Embolic Device (MED) is a new intrasaccular device with promising early results. Previously we documented our initial experience of this device both alone and in combination with other devices including flow diverter stents (FDS). We sought to determine the effect of the MED + FDS strategy for the treatment of selected aneurysms. Materials and Methods We performed a retrospective analysis of prospectively collected data to identify all patients with aneurysms treated using both the MED and intraluminal FDS. We present our technical success rate, early and mid-term angiographic follow-up, and clinical outcome data. Results We identified 25 non-consecutive patients. The treatment was staged in 9 patients and in a single session 16 patients. The average age was 61±12.8 years (range 40-82). The average fundus height was 11±3.6 mm and average fundus width was 10.1±3.4 mm. In the staged cohort (n=9) at delayed angiography (mean 10 mths) 8 aneurysms (89%) showed complete exclusion (mRRC 1) and in one patient there was a parent vessel occlusion. In the simultaneous cohort delayed angiography (n=10, mean 8.1 months) demonstrated complete occlusion (mRRC 1) in 6 aneurysms (60%), 3 neck remnants (mRRC 2) (30%) and 1 patient (10%) showed persistent aneurysmal filling (mRRC 3a). There were 5 complications with permanent morbidity (mRS >2) in two patients. There were no mortalities. Conclusion The MED can be successfully used in combination with intraluminal FDS and in selected aneurysms this may represent an alternative to FDS and adjunctive coiling.


title: CD117-positive cells of the heart: progenitor cells or mast cells?

text: Human cardiac stem/progenitor cells and their potential for repair of heart injury are a current hot topic of research. CD117 has been used frequently as a marker for identification of stem/progenitor cells in the heart. However, cardiac mast cells, which are also CD117(+), have not been excluded by credible means when selecting putative cardiac progenitors by using CD117 as a marker. We evaluated the relationship between CD117(+) cells and mast cells in the left ventricle of human hearts (n=5 patients, ages 1 week-75 years) with the well-established mast cell markers tryptase, toluidine blue, and thionine. A large number (85-100%) of CD117(+) cells in the human heart were specifically identified as mast cells. In addition, mast cells showed weak or moderate CD45 immunostaining signals. These results indicate that the majority of CD117(+) cells in the heart are mast cells and that these cells are distinctly positive for CD45, although staining was weak or moderate. These results strongly suggest that the newly reported CD117(+)/CD45(dim/moderate) putative cardiac progenitor cells are mast cells. The significance of this observation in stem cell research of the heart is discussed.


title: Nasal priming by a murine coronavirus provides protective immunity against lethal heterologous virus pneumonia.

text: The nasal mucosa is an important component of mucosal immunity. Immunogenic particles in inspired air are known to activate the local nasal mucosal immune system and can lead to sinonasal inflammation; however, little is known about the effect of this activation on the lung immune environment. Here, we showed that nasal inoculation of murine coronavirus (CoV) in the absence of direct lung infection primes the lung immune environment by recruiting activated monocytes (Ly6C+ inflammatory monocytes) and NK cells into the lungs. Unlike infiltration of these cells into directly infected lungs, a process that requires type I IFN signaling, nasally induced infiltration of Ly6C+ inflammatory monocytes into the lungs is IFN-I independent. These activated macrophages ingested antigen and migrated to pulmonary lymph nodes, and enhanced both innate and adaptive immunity after heterologous virus infection. Clinically, such nasal-only inoculation of MHV-1 failed to cause pneumonia but significantly reduced mortality and morbidity of lethal pneumonia caused by severe acute respiratory syndrome CoV (SARS-CoV) or influenza A virus. Together, the data indicate that the nose and upper airway remotely prime the lung immunity to protect the lungs from direct viral infections.


title: The Issue of Survival After Colorectal Liver Metastasis Surgery: Parenchyma Sparing vs. Radicality.

text: BACKGROUND/AIM Nowadays, obtaining optimal surgical margin of the resected metastasis and the parenchyma- sparing surgical technique are a great challenge for hepatic surgeons. The aim of this follow-up study was to investigate the prognostic value of the surgical margin and the parenchyma- sparing liver resection technique. PATIENTS AND METHODS We performed a retrospective analysis of the data of 319 patients [123 (36.6%) female and 196 (61.4%) male] who had colorectal cancer and underwent surgery to treat colorectal liver metastases in our Department between 2005 and 2014. RESULTS The most commonly used resection type was the non-anatomic resection (43%). Multivariate analysis indicated that there was no significant difference in survival (p=0.473) between the microscopically-negative (R0) and microscopically-positive (R1) resections, as well as between the resection types (p=0.257). CONCLUSION Parenchymal-sparing non-anatomic resection and spray diathermy on the resection surface of the liver should be applied not only for hemostasis, but also to destroy the area containing possible tumor cells after an R1 resection and not to have worse survival outcomes.


title: Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia.

text: INTRODUCTION High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes. METHODS Comparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM. RESULTS Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (p = 0.6491) or BMI (p = 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8; p < 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2; p = 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7; p < 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (p = 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3; p = 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5; p = 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p = 0.0170). CONCLUSIONS Using HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.


title: The impact of enhanced recovery on open and laparoscopic liver resections.

text: Enhanced recovery after surgery programs (ERP) have been implemented in many surgical specialties. Their impact in liver surgery is poorly understood and approach-specific ERPs have not yet been assessed. This retrospective study aims to analyse the effect of such programs on liver resection. All patients undergoing liver resection at a tertiary referral centre between January 2009 and April 2019 were identified. Primary outcome was the length of stay (LOS), secondary outcomes were functional recovery, complications and readmission rates. Patients in the ERP with different protocols for open, laparoscopic, major and minor resections were compared to a historical cohort. Of 1056 patients, 644 were treated within the ERP. A comparable duration of hospital stay [7 days (IQR (interquartile range) 6-12) vs 7 days (IQR 5-9) p = 0.047] and faster functional recovery with fewer complications was found in the ERP group [94 (50.5%) vs 103 (35.9%) p < 0.002]. Those advantages were smaller after open minor compared to open major resection. In patients undergoing laparoscopic resection no differences were observed except for a lower readmission rate [21 (9.3%) vs 13 (3.6%) p = 0.005]. Multivariable analysis showed that laparoscopy was associated with a shorter LOS. ERPs offer significant advantages in open liver surgery. Those advantages are less evident after laparoscopic resection.


title: Determination of miRNAs in serum of cancer patients with a label- and enzyme-free voltammetric biosensor in a single 30-min step.

text: The preparation of an integrated biosensor for the easy, fast, and sensitive determination of miRNAs is described based on a direct hybridization format and a label-free voltammetric detection. The biosensor involves a disposable carbon electrode substrate doubly nanostructured with reduced graphene oxide (rGO) and AuNPs modified with pyrene carboxylic acid (PCA) and 6-ferrocenylhexanethiol (Fc-SH), respectively. A synthetic amino terminated DNA capture probe was covalently immobilized on the CO2H moieties of PCA/rGO, while Fc-SH was used as a signaling molecule. Differential pulse voltammetry was employed to record the decrease in the oxidation peak current of Fc after the hybridization due to the hindering of the electron transfer upon the formation of the DNA-RNA duplex on the electrode surface. The stepwise biosensor preparation was characterized by surface and electrochemical techniques showing the role played by each biosensor component as well as the reliability of the target miRNA determination. The determination of the oncogene miRNA-21 synthetic target allowed quantification in the low femtomolar range (LOD of 5 fM) with a high discrimination of single-base mismatched sequences in a single 30-min incubation step. The bioplatform allowed the determination of the target miRNA in a small amount of total RNA extracted from breast cancer (BC) cells or directly in serum samples collected from BC patients without the need for prior extraction, purification, amplification, or reverse transcription of the genetic material and with no matrix effect. Graphical abstract.


title: Tracheal tube biofilm removal through a novel closed-suctioning system: an experimental study.

text: BACKGROUND Tracheal tube biofilm develops during mechanical ventilation. We compared a novel closed-suctioning system vs standard closed-suctioning system in the prevention of tracheal tube biofilm. METHODS Eighteen pigs, on mechanical ventilation for 76 h, with P. aeruginosa pneumonia were randomized to be tracheally suctioned via the KIMVENT* closed-suctioning system (control group) or a novel closed-suctioning system (treatment group), designed to remove tracheal tube biofilm through saline jets and an inflatable balloon. Upon autopsy, two tracheal tube hemi-sections were dissected for confocal and scanning electron microscopy. Biofilm area, maximal and minimal thickness were computed. Biofilm stage was assessed. RESULTS Sixteen animals were included in the final analysis. In the treatment and control group, the mean (sd) pulmonary burden was 3.34 (1.28) and 4.17 (1.09) log cfu gr(-1), respectively (P=0.18). Tracheal tube P. aeruginosa colonization was 5.6 (4.9-6.3) and 6.2 (5.6-6.9) cfu ml(-1) (median and interquartile range) in the treatment and control group, respectively (P=0.23). In the treatment group, median biofilm area was 3.65 (3.22-4.21) log10 μm2 compared with 4.49 (4.27-4.52) log10 μm2 in the control group (P=0.031). In the treatment and control groups, the maximal biofilm thickness was 48.3 (26.7-71.2) µm (median and interquartile range) and 88.8 (43.8-125.7) µm, respectively. The minimal thickness in the treatment and control group was 0.6 (0-4.0) µm and 23.7 (5.3-27.8) µm (P=0.040) (P=0.017). Earlier stages of biofilm development were found in the treatment group (P<0.001). CONCLUSIONS The novel CSS reduces biofilm accumulation within the tracheal tube. A clinical trial is required to confirm these findings and the impact on major outcomes.


title: High neutralizing antibody titer in intensive care unit patients with COVID-19.

text: Coronavirus disease 2019 (COVID-19) has a wide spectrum of disease severity from mild upper respiratory symptoms to respiratory failure. The role of neutralizing antibody (NAb) response in disease progression remains elusive. This study determined the seroprevalence of 733 non-COVID-19 individuals from April 2018 to February 2020 in the Hong Kong Special Administrative Region and compared the neutralizing antibody (NAb) responses of eight COVID-19 patients admitted to the intensive care unit (ICU) with those of 42 patients not admitted to the ICU. We found that NAb against SARS-CoV-2 was not detectable in any of the anonymous serum specimens from the 733 non-COVID-19 individuals. The peak serum geometric mean NAb titer was significantly higher among the eight ICU patients than the 42 non-ICU patients (7280 [95% confidence interval (CI) 1468-36099]) vs 671 [95% CI, 368-1223]). Furthermore, NAb titer increased significantly at earlier infection stages among ICU patients than among non-ICU patients. The median number of days to reach the peak Nab titers after symptoms onset was shorter among the ICU patients (17.6) than that of the non-ICU patients (20.1). Multivariate analysis showed that oxygen requirement and fever during admission were the only clinical factors independently associated with higher NAb titers. Our data suggested that SARS-CoV-2 was unlikely to have silently spread before the COVID-19 emergence in Hong Kong. ICU patients had an accelerated and augmented NAb response compared to non-ICU patients, which was associated with disease severity. Further studies are required to understand the relationship between high NAb response and disease severity.


title: [It's world war at CoViD-19. The first battle on the front of the viral invasion against the exitus for interstitial pneumonia was decisive.]

text: An outbreak of a new coronavirus originating from Wuhan (China), responsible for a severe acute respiratory syndrome (SARS), called SARS-CoV-2, is causing a pandemic disease called CoViD-19 (Coronavirus Disease-19), although strict containment measures and restrictions on individual travel have been taken everywhere to hinder the spread of the virus. The clinical spectrum of this infection includes, in order of lesser to greater severity, asymptomatic viremia, paucisymptomatic forms, clinical conditions characterized by respiratory failure that needs mechanical ventilation and support in an intensive care unit, systemic manifestations of infection, septic shock, and multiple organ dysfunction syndromes. There is currently no vaccine to prevent CoViD-19, but the international scientific community is intensely focused on finding a vaccine that will prevent SARS-CoV-2 transmission. In the meanwhile, to prevent hospitals from risking collapse, it is crucial to stratify patients at high risk of poor lung progression, to find effective monitoring strategies, even at home, for the positive patients and/or those highly at risk of positivity of CoViD-19. Starting from the pathogenetic mechanisms involved in the development of this infection up to the clinical characteristics of the infected patients, in this review we tried to focus on the crucial points of the infection in combination with the appropriateness of the medical intervention. We aim to offer indications of therapeutic intervention that are timely and, as far as possible, effective, targeted to the individual patient in relation to age, clinical condition and comorbidities. An early diagnosis associated with an appropriate therapeutic action in the initial stages of the disease can reduce the progression of CoViD-19 towards interstitial pneumonia, thus interfering with the number of transfers to intensive care and lethality of the pandemic in progress.


title: Respiratory failure alone does not suggest central nervous system invasion by SARS-CoV-2.

text: Many viruses can occasionally gain entry into the human central nervous system (CNS), even if most of the disease they cause does not involve the CNS. In a recent review, Li and colleagues (J Med Virol doi: 10.1002/jmv.25728) propose that SARS coronavirus-2 (SARS-CoV-2) can enter the human CNS, based upon the observation that a number of patients need mechanical ventilation to treat respiratory failure. However, respiratory failure caused by pneumonia is clinically distinct from that caused by brain failure. The published clinical features of COVID-19 do not suggest that involvement of the CNS is common. The possibility of CNS entry by SARS-CoV-2 remains plausible, but unproven. This article is protected by copyright. All rights reserved.


title: Analgesic efficacy of pre-emptive local wound infiltration plus laparoscopic-assisted transversus abdominis plane block versus wound infiltration in patients undergoing laparoscopic colorectal resection: results from a randomized, multicenter, single-blind, non-inferiority trial.

text: BACKGROUND Transversus abdominis plane (TAP) block is considered a reliable locoregional technique for pain control after laparoscopic colorectal surgery. However, no clear benefit of TAP block over wound infiltration has been demonstrated by the current literature. This multicenter randomized clinical trial tested the non-inferiority of wound infiltration (WI) compared to WI plus laparoscopic-assisted TAP block (L-TAP). METHODS All patients with colorectal cancer and diverticular disease scheduled for laparoscopic resection at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, Verona, Italy and at the Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University, Daegu, Korea, between April 2018 and March 2019 were considered for the trial. Patients were randomly allocated to either the WI group or the WI plus L-TAP group in a 1:1 allocation ratio. In total, 108 patients entered the study and 102 patients were analyzed; 50 patients received WI plus L-TAP and 52 patients received WI. The primary end point was the efficacy in pain control at 6 h measured according to Numeric Rating Scale (NRS). Secondary aims evaluated pain control at 12, 24, 48 and 72 h and other short-term results related to pain management. RESULTS Estimation of pain intensity at 6 h was comparable between the two groups (p = 0.16) with a mean (95% CI) difference in pain scores of 0.94 (- 0.13 to 2.02). No differences in pain scores were observed at other interval times or considering analgesic consumption, return of bowel function, postoperative complications and length of hospital stay. CONCLUSION This study suggests that adding TAP block to WI does not affect pain control, amount of analgesics and other short-term outcomes. TRIAL REGISTRATION NCT03376048 ( https://www.clinicaltrials.gov ).


title: Minimal Inter-Fractional Fiducial Migration during Image-Guided Lung Stereotactic Body Radiotherapy Using SuperLock Nitinol Coil Fiducial Markers.

text: OBJECTIVES Stereotactic body radiotherapy (SBRT) is being increasingly used for the treatment of patients with lung cancer or lung metastasis who are medically unfit to undergo resection. In order to improve accuracy and confidence in targeting tumors, many centers rely on fiducial implantation. We evaluated the migration of a novel fiducial marker specifically designed for lung tissue implanted via electromagnetic navigation bronchoscopy (ENB). METHODS We retrospectively quantified the individual and group migrations of SuperLock nitinol coil fiducials for 15 patients receiving lung stereotactic body radiotherapy (SBRT), in order to evaluate the reliability of using these fiducials as a target surrogate for cases where tumors cannot be clearly delineated on cone beam CTs (CBCTs). For each fraction, we compared the individual and group migrations of the fiducials between the planning CT and the acquired CBCT. The group migration was defined as the distance between the centroids of the fiducial group and GTV. RESULTS A total of 16 lung targets were included in our study for these 15 patients (one patient with two targets). Of 55 fiducials placed, we observed a 100% retention rate. The mean individual migration was 1.87 mm (range, 0.63-5.25 mm) with a standard deviation of 1.26 mm. The mean group migration was 1.94 mm (range, 0.03-6.19 mm) with a standard deviation of 1.45 mm. Overall, there was minimal change in the relative locations of the markers with respect to each other, as well as to the target. CONCLUSIONS We found that the SuperLock nitinol coil fiducial marker positions are stable throughout the radiation treatment, and can be used as a reliable surrogate to target, and to avoid geometric misses during gated treatments.


Retooling the uniformed US Public Health Service for the 21st century.


title: Personality traits are directly associated with anti-black prejudice in the United States.

text: Modern psychological theories postulate that individual differences in prejudice are determined by social and ideological attitudes instead of personality. For example, the dual-process motivational (DPM) model argues that personality does not directly associate with prejudice when controlling for the attitudinal variables that capture the authoritarian-conservatism motivation and the dominance motivation. Previous studies testing the DPM model largely relied on convenience samples and/or European samples, and have produced inconsistent results. Here we examined the extent to which anti-black prejudice was associated with the Big Five personality traits and social and ideological attitudes (authoritarianism, social dominance orientation, political party affiliation) in two large probability samples of the general population (N1 = 3,132; N2 = 2,483) from the American National Election Studies (ANES). We performed structural equation modeling (SEM) to test the causal assumptions between the latent variables and used survey weights to generate estimates that were representative of the population. Different from prior theories, across both datasets we found that two personality traits, agreeableness and conscientiousness, were directly associated with anti-black prejudice when controlling for authoritarianism, social dominance orientation, and political party affiliation. We also found that a substantial part of the associations between personality traits and anti-black prejudice were mediated through those social and ideological attitudes, which might serve as candidates for prejudice-reduction interventions in the real world.


title: Comparison of Synthetic and Biologic Mesh in Ventral Hernia Repair Using Components Separation Technique.

text: Ventral hernia repair (VHR) for large abdominal wall defects is challenging. Prior research established that the use of mesh is superior to suture closure alone and that component separation is an effective technique to combat loss of abdominal domain. Studies comparing component separation technique (CST) outcomes utilizing synthetic versus biologic mesh are limited. A retrospective review was conducted of 72 consecutive patients who underwent VHR with CST between 2006 and 2010 at our institution. Surgeon preference and the presence of contamination guided whether synthetic mesh (27 patients) or biologic mesh (45 patients) was used. Mean follow-up interval for all comers was 13.9 months and similar in both groups (P > 0.05). Degree of contamination and severity of premorbid medical conditions were significantly higher in the biologic mesh group, as reflected in the higher Ventral Hernia Working Group (VHWG) score (2.04 versus 2.86). Clinical outcomes, as measured by both minor and major complication rates and recurrence rates, were not significantly different. Minor complication rates were 26% in the synthetic group and 37% in the biologic group and major complication rates 15% in the synthetic group and 22% in the biologic group. There was 1 recurrence (4%) in the synthetic mesh group versus 5 (11%) in the biologic mesh group. Multivariable analysis for major complications revealed no significant difference for either synthetic or biologic mesh while controlling for other variables. Subset analysis of uncontaminated cases revealed recurrence rates of 4% in the synthetic mesh group and 6% in the biologic mesh group. VHR using CST and either synthetic mesh or biologic mesh resulted in low recurrence rates with similar overall complication profiles, despite the higher average VHWG grading score in the biologic mesh group. Our results support the VHWG recommendation for biologic mesh utilization in higher VHWG grade patients. In VHWG grade 2 patients, our clinical outcomes were similar, supporting the use of either type of mesh.


Asymptomatic carotid stenosis: the not-so-silent disease: changing perspectives from thromboembolism to cognition.


title: Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.

text: BACKGROUND Government policies can strongly influence migrants' health. Using a Health in All Policies approach, we systematically reviewed evidence on the impact of public policies outside of the health-care system on migrant health. METHODS We searched the PubMed, Embase, and Web of Science databases from Jan 1, 2000, to Sept 1, 2017, for quantitative studies comparing the health effects of non-health-targeted public policies on migrants with those on a relevant comparison population. We searched for articles written in English, Swedish, Danish, Norwegian, Finnish, French, Spanish, or Portuguese. Qualitative studies and grey literature were excluded. We evaluated policy effects by migration stage (entry, integration, and exit) and by health outcome using narrative synthesis (all included studies) and random-effects meta-analysis (all studies whose results were amenable to statistical pooling). We summarised meta-analysis outcomes as standardised mean difference (SMD, 95% CI) or odds ratio (OR, 95% CI). To assess certainty, we created tables containing a summary of the findings according to the Grading of Recommendations Assessment, Development, and Evaluation. Our study was registered with PROSPERO, number CRD42017076104. FINDINGS We identified 43 243 potentially eligible records. 46 articles were narratively synthesised and 19 contributed to the meta-analysis. All studies were published in high-income countries and examined policies of entry (nine articles) and integration (37 articles). Restrictive entry policies (eg, temporary visa status, detention) were associated with poor mental health (SMD 0·44, 95% CI 0·13-0·75; I2=92·1%). In the integration phase, restrictive policies in general, and specifically regarding welfare eligibility and documentation requirements, were found to increase odds of poor self-rated health (OR 1·67, 95% CI 1·35-1·98; I2=82·0%) and mortality (1·38, 1·10-1·65; I2=98·9%). Restricted eligibility for welfare support decreased the odds of general health-care service use (0·92, 0·85-0·98; I2=0·0%), but did not reduce public health insurance coverage (0·89, 0·71-1·07; I2=99·4%), nor markedly affect proportions of people without health insurance (1·06, 0·90-1·21; I2=54·9%). INTERPRETATION Restrictive entry and integration policies are linked to poor migrant health outcomes in high-income countries. Efforts to improve the health of migrants would benefit from adopting a Health in All Policies perspective. FUNDING Swedish Council for Health, Working Life, and Social Research; UK Medical Research Council; Scottish Government Chief Scientist Office.


Perspective on the COVID-19 Coronavirus Outbreak.


title: The Presence of a Reticulated Trabecula-Like Structure Increases the Risk for the Recurrence of Primary Spontaneous Pneumothorax after Thoracoscopic Bullectomy.

text: INTRODUCTION Deteriorated alveolar structure at the base of blebs and bullae is known as the reticulated trabecula-like structure. Its clinical significance in primary spontaneous pneumothorax (PSP) remains unclear. This study aimed to investigate the impact of the structure on recurrence of PSP after video-assisted thoracoscopic surgery (VATS) bullectomy. METHODS Between April 2010 and March 2014, 80 cases of PSP in 76 patients who underwent VATS bullectomy using endoscopic staplers were included. The staple line was covered with polyglycolic acid sheets and fibrin glue. Cases were assigned to a normal alveolar structure (NAS) group (n = 54) and a reticulated trabecula-like structure (RT) group (n = 26) based on the histological analysis. Factors associated with recurrence were analysed using logistic regression. RESULTS The reticulated trabecula-like structure was significantly related to apical lung blebs. The recurrence rate of PSP was significantly higher in the RT group than in the NAS group (38.5% vs. 3.7%; P <0.001). On multivariate analysis, the reticulated trabecula-like structure was an independent factor for recurrence of PSP after VATS bullectomy. CONCLUSION The change of alveolar structure at the base of apical lung blebs would increase the risk for recurrence of PSP after VATS bullectomy.


title: Incidental CT Findings Suspicious for COVID-19–Associated Pneumonia on Nuclear Medicine Examinations: Recognition and Management Plan

text: Some patients undergoing routine SPECT/CT and PET/CT examinations during the COVID-19 pandemic may incidentally reveal findings of COVID-19–associated pneumonia (C-19AP) on localizing CT. It is critical for nuclear medicine physicians to develop diagnostic skills for timely recognition of typical findings of C-19AP on a localizing CT. Furthermore, it is our responsibility to know the optimal practices for safely isolating and managing such patients while protecting the staff, other patients at the facility, family and/or friend accompanying the patients, and the public in general from risky exposure to COVID-19 sources. We offer several steps following an encounter suspicious of C-19AP.


title: Effect of High-Dose vs Standard-Dose Wintertime Vitamin D Supplementation on Viral Upper Respiratory Tract Infections in Young Healthy Children.

text: Importance Epidemiological studies support a link between low 25-hydroxyvitamin D levels and a higher risk of viral upper respiratory tract infections. However, whether winter supplementation of vitamin D reduces the risk among children is unknown. Objective To determine whether high-dose vs standard-dose vitamin D supplementation reduces the incidence of wintertime upper respiratory tract infections in young children. Design, Setting, and Participants A randomized clinical trial was conducted during the winter months between September 13, 2011, and June 30, 2015, among children aged 1 through 5 years enrolled in TARGet Kids!, a multisite primary care practice-based research network in Toronto, Ontario, Canada. Interventions Three hundred forty-nine participants were randomized to receive 2000 IU/d of vitamin D oral supplementation (high-dose group) vs 354 participants who were randomized to receive 400 IU/d (standard-dose group) for a minimum of 4 months between September and May. Main Outcome Measures The primary outcome was the number of laboratory-confirmed viral upper respiratory tract infections based on parent-collected nasal swabs over the winter months. Secondary outcomes included the number of influenza infections, noninfluenza infections, parent-reported upper respiratory tract illnesses, time to first upper respiratory tract infection, and serum 25-hydroxyvitamin D levels at study termination. Results Among 703 participants who were randomized (mean age, 2.7 years, 57.7% boys), 699 (99.4%) completed the trial. The mean number of laboratory-confirmed upper respiratory tract infections per child was 1.05 (95% CI, 0.91-1.19) for the high-dose group and 1.03 (95% CI, 0.90-1.16) for the standard-dose group, for a between-group difference of 0.02 (95% CI, -0.17 to 0.21) per child. There was no statistically significant difference in number of laboratory-confirmed infections between groups (incidence rate ratio [RR], 0.97; 95% CI, 0.80-1.16). There was also no significant difference in the median time to the first laboratory-confirmed infection: 3.95 months (95% CI, 3.02-5.95 months) for the high-dose group vs 3.29 months (95% CI, 2.66-4.14 months) for the standard-dose group, or number of parent-reported upper respiratory tract illnesses between groups (625 for high-dose vs 600 for standard-dose groups, incidence RR, 1.01; 95% CI, 0.88-1.16). At study termination, serum 25-hydroxyvitamin D levels were 48.7 ng/mL (95% CI, 46.9-50.5 ng/mL) in the high-dose group and 36.8 ng/mL (95% CI, 35.4-38.2 ng/mL) in the standard-dose group. Conclusions and Relevance Among healthy children aged 1 to 5 years, daily administration of 2000 IU compared with 400 IU of vitamin D supplementation did not reduce overall wintertime upper respiratory tract infections. These findings do not support the routine use of high-dose vitamin D supplementation in children for the prevention of viral upper respiratory tract infections. Trial Registration clinicaltrials.gov Identifier: NCT01419262.


SARS-CoV-2 infection associated with spontaneous pneumothorax.


title: Novel approach of laparoscopic and endoscopic cooperative surgery (LECS) for cholecystectomy.

text: BACKGROUND Endoscopic submucosal dissection (ESD) techniques, such as generating an artificial space between digestive tract layers for safer dissection, were thought to be safer for the resection of organs in cholecystectomy. We investigated whether combinations of endoscopic techniques and laparoscopic techniques could be performed more safely and rapidly. MATERIAL AND METHODS Laparoscopic and endoscopic cooperative-cholecystectomy (LEC-chole) and conventional laparoscopic cholecystectomy (Lapa-chole) were performed in six dogs. Operation time was defined as the time from the creation of the first port to the retrieval of the resected gallbladder (GB); and GB bed dissection time was the time from local injection of natural saline to the clipping of the cystic duct. The main roles of the endoscope in LEC-chole were to obtain a sufficient cutting space via local injection of natural saline to the GB bed and to monitor the operative view without laparoscopic camera, thus omitting the umbilical port. RESULTS The operation times were 60 ± 18.3 minutes for LEC-chole and 95 ± 7.0 for Lapa-chole (p = .036). The GB bed dissection times were 31 ± 8.54 minutes in LEC-chole and 50.6 ± 7.37 minutes in Lapa-chole (p = 0.048). There were significant differences in liver damage and bleeding (p = 0.116), but there were no significant differences in one-month survival. CONCLUSIONS The application of LEC-chole may be expanded to cholecystectomy.


title: Development and evaluation of loop-mediated isothermal amplification assay for rapid and inexpensive detection of cytomegalovirus DNA in vitreous specimens from suspected cases of viral retinitis.

text: A loop-mediated isothermal amplification (LAMP) assay for the rapid detection of cytomegalovirus (CMV) was developed and evaluated. The LAMP assay specifically amplified only CMV DNA, and no cross-reactivity with the DNA of herpes simplex virus type 1, varicella-zoster virus, adenovirus, Aspergillus flavus, or Staphylococcus aureus was observed. The sequences of the LAMP assay-positive CMV products were perfectly (100%) matched with the CMV sequence deposited in the GenBank database. The sensitivity of the LAMP assay was found to be 10 copies/microl of CMV DNA. Vitreous samples from 40 patients with suspected retinitis were subjected to LAMP and real-time PCR for the detection of CMV. Of 40 patients with suspected viral retinitis, 10 tested positive for CMV by the real-time PCR and LAMP assays. A 100% concordance was observed between the results of the two methods. The LAMP assay is a rapid, highly specific, and sensitive method for the diagnosis of retinitis caused by CMV.


title: Noninvasive ventilation for acute respiratory failure.

text: Noninvasive ventilation (NIV) for acute respiratory failure has gained much academic and clinical interest. Despite this, NIV is underutilized. The evidence strongly supports its use in patients presenting with an exacerbation of COPD and in patients with acute cardiogenic pulmonary edema. As reviewed in this paper, there is now evidence supporting or not supporting the use of NIV in various other presentations of acute respiratory failure. It is important not only to know when to initiate NIV, but also when this therapy is failing. Whether NIV in the setting of acute respiratory failure can be managed appropriately outside the ICU setting is controversial. Although a variety of interfaces are available, the oronasal mask is the best initial interface in terms of leak prevention and patient comfort. Some critical care ventilators have NIV modes that compensate well for leaks, but as a group the ventilators that are designed specifically for NIV have better leak compensation. NIV should be part of the armamentarium of all clinicians caring from patients with acute respiratory failure.


title: Esophageal reinforcement with an extracellular scaffold during total gastrectomy for gastric cancer.

text: BACKGROUND Esophagojejunal (EJ) anastomotic leaks after total gastrectomy (TG) for malignancy lead to significant morbidity and mortality, thus affecting long-term survival. Preclinical and clinical trials have shown promise in utilizing degradable extracellular matrix (ECM) scaffolds in buttressing anastomoses. We describe our experience buttressing the EJ anastomosis after TG with a ECM scaffold. METHODS From February 2012 to January 2014, a total of 37 consecutive patients underwent TG buttressing of the EJ anastomosis with the degradable ECM scaffold composed of a porcine urinary bladder called MatriStem (ACell Inc.). The scaffold was circumferentially wrapped around the EJ anastomosis. The primary end point was the EJ leak rate, while the secondary end point was the EJ stricture rate. RESULTS The mean ± SD age and body mass index were 59 ± 16 years and 28.1 ± 4.9 kg/m(2), respectively. Most patients were male (51 %), white (78 %), and former smokers (51 %). Over half (59 %) underwent neoadjuvant chemotherapy. A minimally invasive TG was performed in 70 % of patients. Signet ring was the most common tumor type (48 %), and most patients had midstage disease (59 %). The mean number of lymph nodes procured was 36 ± 16. Eighteen patients (49 %) experienced a complication, mostly minor. One patient (2.7 %) developed an EJ leak, while three patients (8 %) developed an EJ stricture. Median follow-up was 7 months (range 2-12 months). There was no operative or in-hospital mortality. DISCUSSION The use of urinary bladder matrix scaffolds may be helpful in decreasing the incidence of EJ anastomotic leak and/or stricture. A prospective phase II trial at our institution is currently under way.


title: Interpretations of responses using the isolated forearm technique in general anaesthesia: a debate.

text: The isolated forearm technique (IFT) enables an otherwise paralysed patient to communicate awareness to the anaesthetist. We present a debate that focuses on how best to interpret IFT responses. On one side, Pandit argues that there is a range of response types from none through to movement initiated by the patient to alert the researcher. He also presents a de novo numerical scale by which IFT responses could be classed. Each response type reflects the underlying mental state (degree of unconsciousness), and he concludes that the effect of general anaesthesia on patients is not binary but heterogeneous. There can be mental states resulting from anaesthesia that produce adequate levels of conscious impairment sufficient for surgery to proceed, but in which a degree of wakefulness, including a capacity for later recall, is retained (a state previously termed 'dysanaesthesia'). A literature review of IFT (31 trials) is presented to support this assertion. In rebuttal, Russell and Wang argue that IFT response types are not so discrete, and that the IFT technique precludes higher levels of response. They argue that overinterpretation of IFT responses might in fact result in a greater risk of accidental awareness; a binary interpretation of the IFT response is the safest option. All authors agree that the IFT has a role in clinical practice and the study of anaesthetic mechanisms.


Psychosocial Stress Contagion in Children and Families During the COVID-19 Pandemic.


title: Perspectives on how to navigate cancer surgery in the breast, head and neck, skin, and soft tissue tumor in limited-resource countries during COVID-19 pandemic.

text: The rapidly spreading coronavirus infection (COVID-19) worldwide has contracted all aspects of health systems. Developing countries that mostly have a weaker healthcare system and insufficient resources are likely to be the most hardly affected by the pandemic. Cancers are frequently diagnosed in late stages with higher case-fatality rates compared to those in high-income countries. Delayed diagnosis, lack of cancer awareness, low adherence to treatment, and inequal or limited access to treatment are among the challenging factors of cancer management in developing countries. Elective cancer surgeries are often considered to be postponed during COVID-19 pandemic to preserve valuable hospital resources such as personal protection equipment, hospital bed, intensive care unit capacity, and manpower to screen and treat the affected individuals. However, specific considerations to defer cancer surgery in developing countries might need to be carefully adjusted to counterbalance between preventing COVID-19 transmission and preserving patients 'long-term life expectancy and quality of life.


title: Management of haemostasis in surgery: sealant and glue applications.

text: Blood loss has always been a sensitive issue in surgery. Traditional techniques, such as suturing and electrocautery, have drastically reduced operatory bleeding. Unfortunately, wound edges and point application devices are frequently characterized by bleeding and infections. Over the past 20 years, haemostatic agents and tissue sealants have been developed and now are currently used, along with classic suture in various surgical specialties. Their fluid nature allows management of blood loss along any point of the wound and tissue repair. This review presents an overview of the most diffused haemostatic sealants, focusing on their main use in surgery and their adverse effects.


title: Diagnostic challenges and treatment options of a suspected pericardial metallic projectile foreign body in a dog.

text: OBJECTIVE To describe a case of a suspected pericardial metallic projectile foreign body in a dog with a history of trauma to the left shoulder and to review the literature regarding the management of cardiac and intracardiac foreign bodies. CASE SUMMARY A 3-year-old male, neutered Brittany spaniel presented with a 10-day history of decreased activity and partial anorexia. Serial thoracic radiographs identified a migrating pericardial metallic projectile foreign body and an echocardiogram diagnosed pericardial effusion and abdominal ultrasound identified the presence of ascites. Concern for a possible effusive-constrictive pericarditis prompted a subphrenic pericardectomy performed via thoracoscopy. The foreign body was not recovered. Six months postsurgery, the dog remained asymptomatic. NEW OR UNIQUE INFORMATION PROVIDED Considering the high rate of complications that develop in human patients where the foreign bodies are not removed, veterinarians should be aware of risks associated with long standing pericardial foreign bodies even when no clinical signs are present. Guidelines from the human literature may be considered for investigation of, and treatment options for, cardiac and intracardiac metallic projectile foreign bodies in dogs.


title: Current management of liver metastases from gastric cancer: what is common practice? New challenge of EORTC and JCOG.

text: The role of multidisciplinary treatment including surgery for liver metastases from gastric cancer (LMGC) is controversial. Studies to answer this clinical question are increasing in number, but all published data thus far are based on retrospective analyses with limited sample sizes. Thus, the European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Tract Cancer Group (GITCG) and the Japan Clinical Oncology Group (JCOG) Stomach Cancer Study Group (SCSG) initiated a collaboration to develop an optimal treatment strategy for LMGC. Before planning a prospective study, a questionnaire was sent out to the network members of both groups in June 2016 to clarify current common practice in each region. Sixty-seven sites from 17 countries in the EORTC network and 55 sites from Japan responded. According to the survey, for patients with resectable LMGC without extrahepatic metastases, preoperative chemotherapy followed by resection of both primary (if still in place) and liver lesions was the preferred option for both the synchronous and the metachronous setting. For patients with unresectable LMGC, most of the sites recommended chemotherapy only. In this article, the detailed results of this survey are reported, shedding light on current community practice, and a joint EORTC-JCOG strategy of investigation is delineated.


title: Practical Aspects of Neuroendoscopic Techniques and Complication Avoidance: A Systematic Review.

text: Although endoscopic techniques have many advantages including improved visualization and magnification, they are also associated with limitations. The objective of this review is to discuss the practical aspects that can reduce complications after endoscopic procedures, and their management. The review is based on the personal experience of more than 2000 neuroendoscopic procedures performed by the senior author. Topic search was made on PubMed using Neuroendoscopy, complications and neuroendoscopy, complication avoidance and neuroendoscopy, endoscopic neurosurgery, and minimally invasive neurosurgery. Relevant articles were selected after analyzing abstracts and/or topics. Endoscopic procedures are also associated with limitations such as obstruction in instruments manipulation, steep learning curve, blind area, difficulty in visualization, disorientation, loss of stereoscopic image and others. Neuroendoscopy is distinct from microsurgery and the surgeon has to learn endoscopic skills in addition to microsurgical techniques. Difficulties in controlling bleeding, working in a limited area, higher complication rate during the initial learning curve and longer operative time are some of the limitations. Attending live workshops, practicing on models, and hands on cadaveric workshops can reduce the learning curve. Proper case selection, multidisciplinary team approach, watching operative video, visiting other departments, observing a skillful endoscopic surgeon, lab training, and simulators can improve results and shorten the learning curve. Limitations of this review are that the search is limited to the English literature and personal experience of a single surgeon that may create some bias. Although neuroendoscopic techniques are associated with improved results in some indications, they have many limitations. Neuroendoscopic skills need to be learned to improve results.


title: Cellular radioprotecting potential of glyzyrrhizic acid, silver nanoparticle and their complex.

text: Silver nanoparticles (SN) of particle size of less than 50nm were redispersed in aqueous solution of Pluronic F127 and complexed with the phytoceutical, glyzyrrhizic acid (GLY). Radioprotecting ability of the obtained nanoparticle-glyzyrrhizic acid complex (SN-GLY) was evaluated in an in vivo model using Swiss albino mice. Oral administration of SN-GLY, SN and GLY one hour prior to radiation exposure reduced the radiation induced damage in peripheral blood leucocytes, bone marrow cells and spleen cells of mice as revealed by comet assay. Exposure of mice to whole body gamma irradiation resulted in formation of micronuclei in blood reticulocytes and chromosomal aberrations in bone marrow cells while SN-GLY, SN or GLY administration resulted in reduction in micronucleus formation and chromosomal aberrations indicating radioprotection. In SN-GLY treated mice the cellular DNA was found protected to a greater extent compared to GLY or SN treated mice. The studies, under in vivo radiation exposure conditions, showed effective radiation protection.


title: Determinants of a short convalescence after laparoscopic transabdominal preperitoneal inguinal hernia repair.

text: BACKGROUND Evidence-based recommendations for the expected duration of convalescence after laparoscopic groin hernia repair are not available, and objective reasons for prolonged convalescence are not clear. Our main aim was to establish the expected duration of convalescence using preoperative recommendations to the patient and to identify the limiting factors for early (postoperative) resumption of normal activities after laparoscopic transabdominal preperitoneal inguinal herniorraphy (TAPP). METHODS This was a single-center prospective study. The intervention (the recommendation to the patient) was 1 day for convalescence. Several predefined factors were investigated for their influence on the duration of convalescence and the risk of early postoperative pain. Predefined, clinically justified reasons for not resuming normal activities within the first 3 postoperative days were also registered. RESULTS Between August 2009 and August 2010, 185 consecutive male patients with groin hernia were enrolled prospectively, and 162 patients were available for analysis. Convalescences from work and leisure activities were a median of 5 days (range, 1-40) and 3 days (range, 1-49), respectively (P = .34). Preoperative expectations of convalescence from work (the number of days) was the only factor to explain prolonged convalescence from work (P < .001). Postoperative, self-registered planned sick leave, and complaints of pain and fatigue were the dominant reasons for not resuming normal activities within the first 3 days after operation. Younger age was the only factor found to explain the intensity of postoperative pain (P < .001). CONCLUSION Postoperative convalescence (return to work or normal activities) was between 3 and 5 days after TAPP in patients who were counseled about a 1-day expected convalescence. The expectation of convalescence from work was an important reason for delayed convalescence beyond 1 day.


title: Acknowledgement to Reviewers of IJERPH in 2016.

text: The editors of IJERPH would like to express their sincere gratitude to the following reviewers for assessing manuscripts in 2016.[...].


title: Gastrojejunal Anastomosis Complications and Their Management after Laparoscopic Roux-en-Y Gastric Bypass.

text: BACKGROUND Complications at the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) are challenging in terms of diagnosis, therapy, and prevention. This study aims at identifying these complications and discussing their management. METHODS Data of 228 patients who underwent a LRYGB between October 2008 and December 2011 were reviewed retrospectively to evaluate the frequency and treatment of complications such as stenoses, marginal ulcers, perforated marginal ulcers, or anastomotic leaks related to the operation. RESULTS Follow-up information was available for 209 patients (91.7%) with a median follow-up of 38 months (range 24-62 months). Of these patients 16 patients (7.7%) experienced complications at the gastrojejunostomy. Four patients (1.9%) had stenoses and 12 patients (5.7%) marginal ulcers, one of them with perforation (0.5%). No anastomotic leaks were reported. One case with perforated ulcer and one with recurrent ulcers required surgical revision. CONCLUSION Gastrojejunal anastomotic complications are frequent and occur within the first few days or up to several years after surgery. Stenoses or marginal ulcers are usually successfully treated nonoperatively. Laparoscopic repair, meanwhile, is an appropriate therapeutic option for perforated ulcers.


title: Which interventions work best in a pandemic?

text: We can exploit randomized controlled trials, compartmental models, and spillovers.


title: Covidien micro vascular plug in congenital heart diseases and vascular anomalies: A new kid on the block for premature babies and older patients.

text: OBJECTIVES To evaluate the safety, feasibility, and efficacy of the MVP™ microvascular plug(Covidien) for closure of vascular anomalies in patients with congenital heart diseases (CHD). BACKGROUND The MVP™ is a novel device with PTFE integrated. The device has been recently introduced in the radiological field and reported exclusively for neurological anomalies. METHODS All CHD patients receiving the device from April 2015 until July 2015 were included in the study and followed up clinically as well as by transthoracic echocardiography. Standard safety and follow-up such as vascular complications, embolization rate, and residual shunting were assessed. RESULTS Twelve patients with a median age of 2.6-years (0.03-12.6 years) and a mean weight of 13 kg (2.8-34.2 kg) were included. Devices were delivered from the femoral artery in 10 and from the femoral vein in 2 patients. Devices were used for closure of patent ductus arteriosus (PDA) closure (n = 5), aorto-pulmonary collaterals or Blalock-Taussig shunt (n = 5), veno-venous fistula (n = 1), and coronary fistula (n = 1). One device was retrieved before release due to inappropriate size estimation (PDA spasm). The PDA was successfully closed using a PDA device (Lifetech, Medtronic). Immediate angiographic evaluation showed minimal or no shunt in 90% (10/11 patients) and 100% occlusion rate after a mean follow-up of 3.2-months. There was no device embolization, hemolysis, or any other complication following closure. CONCLUSIONS The delivery of new MVP™ micro vascular plug system (Covidien) is safe and effective in patients with CHD for closure of a variety of vascular abnormalities. The low profile of the device and the sheathless nature of the procedure make it particularly interesting for PDA closure in premature babies. © 2016 Wiley Periodicals, Inc.


title: Single-incision versus multiport laparoscopic right and hand-assisted left colectomy: a case-matched comparison.

text: BACKGROUND New technology for single-incision laparoscopic colectomy is now commercially available, yet advantages of this approach over multiport laparoscopic colectomy have not been demonstrated. OBJECTIVE This study aimed to compare the outcomes of patients who underwent single-incision vs multiport laparoscopic colectomies. DESIGN Consecutive patients who underwent single-incision laparoscopic colectomies were case matched to patients who underwent multiport laparoscopic colectomies by age, operation, surgeon, diagnosis, and body mass index. Data from a prospective database and the medical records of patients treated were reviewed. SETTINGS This study took place at 2 tertiary care hospitals. PATIENTS Forty-six consecutive patients with a body mass index of 24 underwent single-incision laparoscopic colectomies (24 right, 18 sigmoid, 4 low anterior resection). MAIN OUTCOME MEASURES Perioperative outcomes and cosmesis and body image scores at 90 days were compared. RESULTS The largest incision length was significantly shorter for the single-incision group. Two patients with single incisions were converted to hand-assisted laparoscopic surgery and 4 required placement of a 5-mm trocar. A significantly greater portion of the operation was performed by the attending surgeons in the single-incision group. For right colectomies, operative times were similar. For left colectomies, operative time (149 ± 30 vs 126 ± 21 min) was significantly longer for the single-incision group. Time to flatus and bowel movements were significantly shorter for the single-incision group, but length of stay was similar. Cosmetic score was higher for the single-incision group (P = .03). CONCLUSIONS Single incision is equivalent to multiport laparoscopic colectomy with regard to safety and efficacy with smaller incision size and higher cosmetic scores. Operative times were equivalent, although a greater portion of the operation was performed by the attending surgeons in the single-incision group. Further prospective studies are warranted to evaluate the advantages of single-incision laparoscopic colectomy.


title: First-in-human uPAR PET: Imaging of Cancer Aggressiveness.

text: A first-in-human clinical trial with Positron Emission Tomography (PET) imaging of the urokinase-type plasminogen activator receptor (uPAR) in patients with breast, prostate and bladder cancer, is described. uPAR is expressed in many types of human cancers and the expression is predictive of invasion, metastasis and indicates poor prognosis. uPAR PET imaging therefore holds promise to be a new and innovative method for improved cancer diagnosis, staging and individual risk stratification. The uPAR specific peptide AE105 was conjugated to the macrocyclic chelator DOTA and labeled with (64)Cu for targeted molecular imaging with PET. The safety, pharmacokinetic, biodistribution profile and radiation dosimetry after a single intravenous dose of (64)Cu-DOTA-AE105 were assessed by serial PET and computed tomography (CT) in 4 prostate, 3 breast and 3 bladder cancer patients. Safety assessment with laboratory blood screening tests was performed before and after PET ligand injection. In a subgroup of the patients, the in vivo stability of our targeted PET ligand was determined in collected blood and urine. No adverse or clinically detectable side effects in any of the 10 patients were found. The ligand exhibited good in vivo stability and fast clearance from plasma and tissue compartments by renal excretion. In addition, high uptake in both primary tumor lesions and lymph node metastases was seen and paralleled high uPAR expression in excised tumor tissue. Overall, this first-in-human study therefore provides promising evidence for safe use of (64)Cu-DOTA-AE105 for uPAR PET imaging in cancer patients.


title: Telehealth: Synopsis.

text: The COVID-19 pandemic has changed the Australian medical landscape, especially in relation to how we need to provide clinical care in general practice.


title: A schlieren optical study of the human cough with and without wearing masks for aerosol infection control.

text: Various infectious agents are known to be transmitted naturally via respiratory aerosols produced by infected patients. Such aerosols may be produced during normal activities by breathing, talking, coughing and sneezing. The schlieren optical method, previously applied mostly in engineering and physics, can be effectively used here to visualize airflows around human subjects in such indoor situations, non-intrusively and without the need for either tracer gas or airborne particles. It accomplishes this by rendering visible the optical phase gradients owing to real-time changes in air temperature. In this study, schlieren video records are obtained of human volunteers coughing with and without wearing standard surgical and N95 masks. The object is to characterize the exhaled airflows and evaluate the effect of these commonly used masks on the fluid-dynamic mechanisms that spread infection by coughing. Further, a high-speed schlieren video of a single cough is analysed by a computerized method of tracking individual turbulent eddies, demonstrating the non-intrusive velocimetry of the expelled airflow. Results show that human coughing projects a rapid turbulent jet into the surrounding air, but that wearing a surgical or N95 mask thwarts this natural mechanism of transmitting airborne infection, either by blocking the formation of the jet (N95 mask), or by redirecting it in a less harmful direction (surgical mask).


Authors' reply: Outbreak of COVID-19 - an urgent need for good science to silence our fears?


title: Laparoscopic Organopexy with Non-mesh Genital (LONG) Suspension: A Novel Uterine Preservation Procedure for the Treatment of Apical Prolapse.

text: To assess whether our novel uterus-sparing procedure- laparoscopic organopexy with non-mesh genital(LONG) suspension is an effective, safe, and timesaving surgery for the treatment of apical prolapse. Forty consecutive women with main uterine prolapse stage II or greater defined by the POP quantification(POP-Q) staging system were referred for LONG procedures at our hospitals. Clinical evaluations before and 6 months after surgery included pelvic examination, urodynamic study, and a personal interview to evaluate urinary and sexual symptoms with overactive bladder symptom score(OABSS), the short forms of Urogenital Distress Inventory(UDI-6) and Incontinence Impact Questionnaire(IIQ-7), and the Female Sexual Function Index(FSFI). After follow-up time of 12 to 30 months, anatomical cure rate was 85%(34/40), and the success rates for apical, anterior, and posterior vaginal prolapse were 95%(38/40), 85%(34/40), and 97.5%(39/40), respectively. Six recurrences of anterior vaginal wall all suffered from significant cystocele (stage3; Ba>+1) preoperatively. The average operative time was 73.1 ± 30.8 minutes. One bladder injury occurred and was recognized during surgery. The dyspareunia domain and total FSFI scores of the twelve sexually-active premenopausal women improved postoperatively in a significant manner (P < 0.05). The results of our study suggest that LONG suspension is an effective and safe uterus-sparing surgery for the treatment of apical prolapse.


title: An allosteric inhibitor of substrate recognition by the SCF(Cdc4) ubiquitin ligase.

text: The specificity of SCF ubiquitin ligase-mediated protein degradation is determined by F-box proteins. We identified a biplanar dicarboxylic acid compound, called SCF-I2, as an inhibitor of substrate recognition by the yeast F-box protein Cdc4 using a fluorescence polarization screen to monitor the displacement of a fluorescein-labeled phosphodegron peptide. SCF-I2 inhibits the binding and ubiquitination of full-length phosphorylated substrates by SCF(Cdc4). A co-crystal structure reveals that SCF-I2 inserts itself between the beta-strands of blades 5 and 6 of the WD40 propeller domain of Cdc4 at a site that is 25 A away from the substrate binding site. Long-range transmission of SCF-I2 interactions distorts the substrate binding pocket and impedes recognition of key determinants in the Cdc4 phosphodegron. Mutation of the SCF-I2 binding site abrogates its inhibitory effect and explains specificity in the allosteric inhibition mechanism. Mammalian WD40 domain proteins may exhibit similar allosteric responsiveness and hence represent an extensive class of druggable target.


title: Intranasal delivery of an adjuvanted modified live porcine reproductive and respiratory syndrome virus vaccine reduces ROS production.

text: Reactive oxygen species (ROS) are produced predominantly by phagocytic cells in response to microbial infections. When produced at optimal levels ROS have potent antimicrobial properties. However, excessive production of ROS induces apoptosis/necrosis of infected as well as bystander cells, resulting in inflammatory pathology. Previously we showed that vaccination of pigs with a modified live porcine reproductive and respiratory syndrome virus vaccine (PRRS-MLV) administered intranasally with a potent mucosal adjuvant M. tuberculosis whole-cell lysate (Mtb WCL) induces protective immunity against PRRSV challenge. In this study, using bronchoalveolar lavage fluid cells and peripheral blood mononuclear cells harvested from that study were quantified for the levels of ROS produced. Our results indicated that in vaccinated pigs, levels of ROS were lower compared to unvaccinated PRRSV-challenged pigs. In unvaccinated but PRRSV-challenged pigs, the higher ROS production was associated with increased inflammatory lung pathology. In conclusion, our results suggest that intranasal immunization using PRRS-MLV along with a potent mucosal adjuvant protects pigs against both homologous and virulent heterologous PRRSV challenge, which was associated with reduced ROS production and reduced lung pathology compared to control virus-challenged pigs.


title: Impact of Continuous Capnography in Ventilated Neonates: A Randomized, Multicenter Study.

text: OBJECTIVE To compare the time spent within a predefined safe range of CO2 (30-60 mmHg) during conventional ventilation between infants who were monitored with distal end-tidal CO2 (dETCO2, or capnography) and those who were not. STUDY DESIGN For this randomized, controlled multicenter study, ventilated infants with a double-lumen endotracheal tube were randomized to 1 of 2 groups: the open (monitored) group, in which data from the capnograph were recorded, displayed to the medical team, and used for patient care, and the masked group, in which data from the capnograph were recorded. However, the measurements were masked and not available for patient care. dETCO2 was compared with PaCO2 measurements recorded for patient care. RESULTS Fifty-five infants (25 open, 30 masked) participated in the study (median gestational age, 28.6 weeks; range, 23.5-39.0 weeks). The 2 groups were comparable. dETCO2 was in good correlation (r = 0.73; P < .001) and adequate agreement (mean ± SD of the difference, 3.0 ± 8.5 mmHg) with PaCO2. Compared with infants in the masked group, those in the monitored group had significantly (P = .03) less time with an unsafe dETCO2 level (high: 3.8% vs 8.8% or low: 3.8% vs 8.9%). The prevalence of intraventricular hemorrhage or periventricular leukomalacia rate was lower in the monitored group (P = .02) and was significantly (P < .05) associated with the independent factors dETCO2 monitoring and gestational age. CONCLUSION Continuous dETCO2 monitoring improved control of CO2 levels within a safe range during conventional ventilation in a neonatal intensive care unit. TRIAL REGISTRATION ClinicalTrials.gov: NCT01572272.


title: Sexually transmitted infections among high-risk populations that use treatment as prevention or pre-exposure prophylaxis: a protocol for a systematic review.

text: BACKGROUND Among men who have sex with men, pre-exposure prophylaxis (PrEP) reduces the risk of HIV by 95%. Based on the documented benefits, the Centre for Disease Control and Prevention has recommended PrEP as a prevention method for high-risk groups. Moreover, for those HIV-infected individuals, antiretroviral therapy has been shown to serve as both as a treatment and prevention method for HIV. METHODS AND ANALYSIS This systematic review protocol was reported according to the Preferred Reporting Items for Systematic reviews and Analyses (PRISMA) P framework. Medline (1980-present), Embase (1980-present), CINAHL (1980-present), Cochrane Central Register of Controlled Trials and clinicaltrials.gov will be used to identify relevant articles based on a piloted search strategy. Peer-reviewed observational and experimental studies will be included. A narrative style will be used to describe descriptive data. A meta-analysis will be conducted if heterogeneity is not significant. ETHICS AND DISSEMINATION Recent evidence suggests that there is an increased risk of sexually transmitted infections (STIs) among high-risk persons that use PrEP. Furthermore, there is a paucity of data on the relationship of treatment as prevention and incidence of STIs. The findings of this review will assess this emerging public health phenomenon and serve to inform future public health policy. No formal ethical review is required for this protocol. All findings will be published in a peer reviewed journal. PROTOCOL REGISTRATION NUMBER CRD42019128720.


Removal of percutaneous K-wires used in paediatric fracture stabilisation under IV sedation: a cost-effective and timesaving service delivery in the COVID-19 pandemic setting.


title: Dying in the face of the COVID-19 pandemic: Contextual considerations and clinical recommendations.

text: Dying is a natural part of life; however, death is often a fearful, frightening event. Dying in the midst of the COVID-19 pandemic presents challenges that magnify normative fears and may interfere with a healthy grieving process. To maintain a resilient spirit among those who are at risk of losing a loved one or who have lost a family member to COVID-19, it is important that they be provided with the necessary contextually and culturally appropriate skills and resources to facilitate healing in the face of hardship and uncertainty. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Clopidogrel Resistance in Neurovascular Stenting: Correlations between Light Transmission Aggregometry, VerifyNow, and the Multiplate.

text: BACKGROUND AND PURPOSE Clopidogrel resistance is blamed for thromboembolic complications in neurovascular stent placement. Platelet-function assays are weakly standardized. The aim of this study was to correlate the results of 3 different platelet-inhibition measurements (from light transmission aggregometry, the VerifyNow P2Y12 test, and the Multiplate analyzer) and their relation to periprocedural thromboembolic complications in elective neurovascular stent placement. MATERIALS AND METHODS Clopidogrel resistance was determined on the day of the intervention according to predefined platelet reactivity cutoff values. All 3 tests were performed in 103 consecutive neurovascular stent-placement procedures in 97 patients (extracranial, n = 77; intracranial, n = 26). RESULTS The clopidogrel resistance rates were 47.6% (light transmission aggregometry), 50.5% (VerifyNow), and 35.9% (Multiplate). In 67% of the patients, clopidogrel resistance was present according to at least one method. The correlations of qualitative results that classified a patient as responsive or resistant to clopidogrel were 67.9% for light transmission aggregometry with VerifyNow, 77.7% for light transmission aggregometry with the Multiplate, and 66% for VerifyNow with the Multiplate. Periprocedural thromboembolic complications (n = 9) occurred more frequently in patients who were determined by all 3 methods to be clopidogrel resistant. The difference was most pronounced with light transmission aggregometry (complication rates, 14.4% [clopidogrel-resistant patients] vs 3.7% [clopidogrel-responsive patients]). Sensitivity and specificity rates of clopidogrel resistance in relation to embolic complications were, respectively, 78% and 55% for light transmission aggregometry, 67% and 51% for VerifyNow, and 44% and 67% for the Multiplate. CONCLUSIONS Clopidogrel resistance is a frequent finding in patients who undergo neurovascular stent placement. The correlations among the different testing methods are only modest and differ considerably. Light transmission aggregometry results seem to correlate with thromboembolic complications more accurately than with VerifyNow and Multiplate point-of-care methods.