title: Hemodialysis catheter tip design: observations on fluid flow and recirculation.

text: PURPOSE To observe fluid flow patterns and measure recirculation rates of tunneled hemodialysis catheters using a mechanical model that simulates hemodialysis treatment. MATERIALS AND METHODS Nine tunneled hemodialysis catheters were evaluated using a mechanical model that simulated catheter conditions during a routine hemodialysis treatment. Objective and subjective determinants of catheter performance were measured and compared. Catheters were evaluated with blood lines connected in standard and reversed configurations using a fluid flow rate of 425 ml/min. RESULTS With blood lines in standard configuration the Split Cath® was the only catheter to exhibit an atypical fluid flow pattern and significant tip movement. When the blood lines were reversed, three split-tip catheters had significant tip movement. The three step-tip catheters and two symmetric tip catheters had stable fluid flow patterns and no significant tip movement with blood lines connected in standard and reverse configurations.The nine catheters had no recirculation when connected in standard configuration. When the blood lines were reversed the percentage of recirculating fluid for symmetric tip, step-tip, and split-tip catheters was 0%, 15% to 20%, and 20% to 30%, respectively. The Equistream®, Palindrome™, and Symetrex catheters had no recirculation with blood lines connected in standard or reversed configurations. CONCLUSIONS Eight of the nine catheters evaluated in this study performed well with blood lines connected in standard configuration. When blood lines were reversed, symmetric tip and step-tip designs had more stable fluid flow patterns, less tip movement and lower recirculation rates when compared to split-tip designs.


title: Improving the Use of Simulation in Nursing Education: Protocol for a Realist Review.

text: BACKGROUND Nursing education has evolved in line with societal needs, and simulation-based learning (SBL) is increasingly being used to bridge the gap between practice and education. Previous literature reviews have demonstrated the effectiveness of using SBL in nursing education. However, there is a need to explore how and why it works to expand the theoretical foundation of SBL. Realist reviews are a theory-based approach to synthesizing existing evidence on how complex programs work in particular contexts or settings. OBJECTIVE This review aims to understand how, why, and in what circumstances the use of simulation affects learning as part of the bachelor's program in nursing. METHODS A realist review will be conducted in accordance with the realist template for a systematic review. In particular, we will identify and explore the underlying assumption of how SBL is supposed to work, that is, identify and explore program theories of SBL. The review will be carried out as an iterative process of searching, appraising, and synthesizing the evidence to uncover theoretical concepts that explain the causal effects of SBL. In the final section of the review, we will involve stakeholders in the Norwegian community in a web-based Delphi survey to ensure that the emerging theoretical framework derived from the published literature aligns with stakeholders' experience in practice. RESULTS The Norwegian Centre for Research Data (project number 60415) has approved the study. We have performed an initial literature search, whereas quality appraisal and data extraction are ongoing processes. CONCLUSIONS The final outcome of the review is anticipated to extend the theoretical foundation for using simulation as an integrated component of the bachelor's program in nursing. Furthermore, the findings will be used to produce a briefing document containing guidance for national stakeholders in the community of simulation-based nursing education. Finally, the review findings will be disseminated in a peer-reviewed journal as well as national and international conferences. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/16363.


title: Retrieval of Distally Migrated Coils with Detachable Intracranial Stent during Coil Embolization of Cerebral Aneurysm.

text: Migration of coils during endovascular procedures is a rare, but well-known complication. We are reporting two cases of successfully retrieving migrated coil using detachable intracranial stent. In both of our cases there was distal migration of coil during the intracranial aneurysm coiling procedure. The Solitaire® AB stent (Covidien, Irvine, CA, USA) was used to retrieve those coils. The stent was passed distal to the migrated coil using standard technique. It was then partially deployed and gradually withdrawn along with the entangled coil. Coil retrieval using the fully retrievable intracranial stent is a very simple, safe and easily available alternative for retrieval of distally migrated coil.


title: iBioProVis: Interactive Visualization and Analysis of Compound Bioactivity Space.

text: SUMMARY iBioProVis is an interactive tool for visual analysis of the compound bioactivity space in the context of target proteins, drugs, and drug candidate compounds. iBioProVis tool takes target protein identifiers and, optionally, compound SMILES as input, and uses the state-of-the-art non-linear dimensionality reduction method t-Distributed Stochastic Neighbor Embedding (t-SNE) to plot the distribution of compounds embedded in a 2-D map, based on the similarity of structural properties of compounds and in the context of compounds' cognate targets. Similar compounds, which are embedded to proximate points on the 2-D map, may bind the same or similar target proteins. Thus, iBioProVis can be used to easily observe the structural distribution of one or two target proteins' known ligands on the 2-D compound space, and to infer new binders to the same protein, or to infer new potential target(s) for a compound of interest, based on this distribution. Principal component analysis (PCA) projection of the input compounds is also provided, Hence the user can interactively observe the same compound or a group of selected compounds which is projected by both PCA and embedded by t-SNE. iBioProVis also provides detailed information about drugs and drug candidate compounds through cross-references to widely used and well-known databases, in the form of linked table views. Two use-case studies were demonstrated, one being on ACE2 protein which is SARS-CoV-2 Spike protein receptor. ACE2 binding compounds and 7 antiviral drugs were closely embedded in which two of them have been under clinical trial for COVID-19. AVAILABILITY AND IMPLEMENTATION iBioProVis and its carefully filtered dataset are available at https://ibpv.kansil.org/ for public use. SUPPLEMENTARY INFORMATION Supplementary data are available at Bioinformatics online.


title: Can Chest CT Features Distinguish Patients With Negative From Those With Positive Initial RT-PCR Results for Coronavirus Disease (COVID-19)?

text: OBJECTIVE. The purpose of this study was to explore the value of CT in the diagnosis of coronavirus disease (COVID-19) pneumonia, especially for patients who have negative initial results of reverse transcription-polymerase chain reaction (RT-PCR) testing. MATERIALS AND METHODS. Patients with COVID-19 pneumonia from January 19, 2020, to February 20, 2020, were included. All patients underwent chest CT and swab RT-PCR tests within 3 days. Patients were divided into groups with negative (seven patients) and positive (14 patients) initial RT-PCR results. The imaging findings in both groups were recorded and compared. RESULTS. Twenty-one patients with symptoms (nine men, 12 women; age range, 26-90 years) were evaluated. Most of the COVID-19 lesions were located in multiple lobes (67%) in both lungs (72%) in our study. The main CT features were ground-glass opacity (95%) and consolidation (72%) with a subpleural distribution (100%). Otherwise, 33% of patients had other lesions around the bronchovascular bundle. The other CT features included air bronchogram (57%), vascular enlargement (67%), interlobular septal thickening (62%), and pleural effusions (19%). Compared with that in the group with positive initial RT-PCR results, CT of the group with negative initial RT-PCR results was less likely to show pulmonary consolidation (p < 0.05). CONCLUSION. The less pulmonary consolidation found at CT, the greater is the possibility of negative initial RT-PCR results. Chest CT is important in the screening of patients in whom disease is clinically suspected, especially those who have negative initial RT-PCR results.


title: Comparison of consumption behavior and appetite sensations among patients with type 2 diabetes mellitus after bariatric surgery.

text: BACKGROUND The promising postsurgical weight loss and remission of type 2 diabetes (T2D) from bariatric surgery can be attributed to modified eating physiology after surgical procedures. We sought to investigate the changes in the parameters of consumption behaviors and appetite sensations induced by a mixed meal tolerance test, and to correlate these alterations with age, body mass index, C-peptide levels, and duration of T2D 1 year after bariatric surgery. METHODS A total of 16 obese patients with T2D who underwent mini-gastric bypass (GB) and 16 patients who underwent sleeve gastrectomy (SG) were enrolled in this study and evaluated using a mixed meal tolerance test one year after surgery. A visual analogue scale was used for scoring appetite sensation at different time points. The area under the curve (AUC) and the incremental or decremental AUC (ΔAUC) were compared between the two groups. RESULTS One year after surgery, a decreasing trend in the consumption time was observed in the GB group compared to the SG group, while the duration of T2D before surgery was negatively correlated with the post-operative consumed time in those after GB. Patients who underwent GB had significantly higher fasting scores for fullness and desire to eat, higher AUC0'-180' of scores for desire to eat, as well as more effective post-meal suppression of hunger and desire to eat compared with those undergoing SG one year after surgery. Post-operative C-peptide levels were negatively correlated with ΔAUC0'-180' for hunger and ΔAUC0'-180' for desire to eat in the GB group, while negatively correlated with ΔAUC0'-180' for fullness in the SG group. DISCUSSION Patients with T2D after either GB or SG exhibit distinct nutrient-induced consumption behaviors and appetite sensations post-operatively, which may account for the differential effects on weight loss and glycemic control after different surgery.


title: Pharmacological Treatment with Annexin A1 Reduces Atherosclerotic Plaque Burden in LDLR-/- Mice on Western Type Diet.

text: OBJECTIVE To investigate therapeutic effects of annexin A1 (anxA1) on atherogenesis in LDLR-/- mice. METHODS Human recombinant annexin A1 (hr-anxA1) was produced by a prokaryotic expression system, purified and analysed on phosphatidylserine (PS) binding and formyl peptide receptor (FPR) activation. Biodistribution of 99mTechnetium-hr-anxA1 was determined in C57Bl/6J mice. 12 Weeks old LDLR-/- mice were fed a Western Type Diet (WTD) during 6 weeks (Group I) or 12 weeks (Group P). Mice received hr-anxA1 (1 mg/kg) or vehicle by intraperitoneal injection 3 times per week for a period of 6 weeks starting at start of WTD (Group I) or 6 weeks after start of WTD (Group P). Total aortic plaque burden and phenotype were analyzed using immunohistochemistry. RESULTS Hr-anxA1 bound PS in Ca2+-dependent manner and activated FPR2/ALX. It inhibited rolling and adherence of neutrophils but not monocytes on activated endothelial cells. Half lives of circulating 99mTc-hr-anxA1 were <10 minutes and approximately 6 hours for intravenously (IV) and intraperitoneally (IP) administered hr-anxA1, respectively. Pharmacological treatment with hr-anxA1 had no significant effect on initiation of plaque formation (-33%; P = 0.21)(Group I) but significantly attenuated progression of existing plaques of aortic arch and subclavian artery (plaque size -50%, P = 0.005; necrotic core size -76% P = 0.015, hr-anxA1 vs vehicle) (Group P). CONCLUSION Hr-anxA1 may offer pharmacological means to treat chronic atherogenesis by reducing FPR-2 dependent neutrophil rolling and adhesion to activated endothelial cells and by reducing total plaque inflammation.


title: Ablative Endoscopic Therapies for Barrett's-Esophagus-Related Neoplasia.

text: Barrett's esophagus (BE) is more common in developed countries. Endoscopic therapy is an effective treatment method in management of dysplastic BE. Ablation by thermal energy, freezing, or photochemical injury completely eradicates dysplasia and specialized intestinal metaplasia resulting in neosquamation of esophagus. Among the ablative modalities, radiofrequency ablation (RFA) is the most studied with safe, effective, and durable long-term outcomes. Cryotherapy, argon plasma coagulation, and photodynamic therapy can be offered in select patients when RFA is unavailable, has failed, or is contraindicated. Future research on natural disease progression, biomarkers, advanced imaging, and application of endoscopic techniques will lead to better clinical outcomes for BE-associated neoplasia.


title: Are Italy and Iran really suffering from COVID-19 epidemic? A controversial study.

text: The number of global COVID-19 infected cases is increased rapidly to exceed 370 thousand. COVID-19 is transmitted between humans through direct contact and touching dirty surfaces. This paper aims to find the similarity between DNA sequences of COVID-19 in different countries, and to compare these sequences with three different diseases [HIV, Hand-Foot-Mouth disease (HFMD), and Cryptococcus]. The study used pairwise distance, maximum likelihood tree, and similarity between amino acid to find the results. The results showed that different three main types of viruses namely, COVID-19 are found. The virus in both Italy and Iran is not similar to COVID-19 in China and USA. While, two viruses were spread in Wuhan (before and after December 26, 2019). Besides Cryptococcus and HFMD are found as dominant diseases with Group 1 and Group 3, respectively. Authors claim that the current virus in Italy and Iran that killed thousands of people is not COVID-19 based on the available data.


Covid-19: Trump extends physical distancing to 30 April, as cases climb in New York.


Thoracoscopic esophagectomy and hand-assisted laparoscopic gastric mobilization for esophageal cancer with situs inversus totalis.


title: Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis.

text: Background Cutaneous manifestations of purpura fulminans (PF) present many challenges for clinicians and surgeons. In a state of septic shock complicated by limb ischemia, surgical interventions are necessary to control the pathological cascade and improve patient outcomes. The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults. Methods This systematic review and meta-analysis compared 190 adult patients with etiologies, signs and symptoms, and surgical outcomes associated with cutaneous manifestations of PF. The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical interventions, outcomes, and complications were recorded. Results Seventy-nine studies were eligible for the systematic review, and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. A total of 71/190 (38%) cases reported surgical debridement. Fasciotomies were reported in 12/190 (6%) cases and 20 procedures. Amputations were reported in 154/190 (81%) cases. Reconstruction was reported in 45 cases. Skin grafts were applied in 31 cases. Flaps were used for reconstruction in 28 cases. Median (IQR) surgical procedures per patient were 4 (4, 5) procedures. Infectious organisms causing PF were 32% Neisseria meningitidis (n = 55) and 32% Streptococcus pneumonia (n = 55). Coagulase-negative Staphylococcus (95% confidence interval (CI)(8.2-177.9), p = 0.032), Haemophilus influenza (95%CI (7.2-133), p = 0.029), Streptococcus pneumonia (95% CI (13.3-75.9), p = 0.006), and West Nile Virus (95%CI (8.2-177.9), p = 0.032) were associated with significantly more extensive amputations compared to other organisms. Conclusion This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism. Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF. The majority of cases were not treated in a burn center. The most common surgeries were amputations, with below-the-knee-amputations being the most common procedure. Skin grafting was the most commonly performed reconstructive procedure. The most common complications were secondary infections. Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus, Haemophilus influenza, Streptococcus pneumonia, and West Nile Virus. Interpretation of findings should be cautioned due to limited sample data.


title: Do Sustained Lung Inflations during Neonatal Resuscitation Affect Cerebral Blood Volume in Preterm Infants? A Randomized Controlled Pilot Study.

text: BACKGROUND Sustained lung inflations (SLI) during neonatal resuscitation may promote alveolar recruitment in preterm infants. While most of the studies focus on respiratory outcome, the impact of SLI on the brain hasn't been investigated yet. OBJECTIVE Do SLI affect cerebral blood volume (CBV) in preterm infants? METHODS Preterm infants of gestation 28 weeks 0 days to 33 weeks 6 days with requirement for respiratory support (RS) were included in this randomized controlled pilot trial. Within the first 15 minutes after birth near-infrared spectroscopy (NIRS) measurements using 'NIRO-200-NX' (Hamamatsu, Japan) were performed to evaluate changes in CBV and cerebral tissue oxygenation. Two groups were compared based on RS: In SLI group RS was given by applying 1-3 SLI (30 cmH2O for 15 s) continued by respiratory standard care. Control group received respiratory standard care only. RESULTS 40 infants (20 in each group) with mean gestational age of 32 weeks one day (±2 days) and birth weight of 1707 (±470) g were included. In the control group ΔCBV was significantly decreasing, whereas in SLI group ΔCBV showed similar values during the whole period of 15 minutes. Comparing both groups within the first 15 minutes ΔCBV showed a tendency toward different overall courses (p = 0.051). CONCLUSION This is the first study demonstrating an impact of SLI on CBV. Further studies are warranted including reconfirmation of the present findings in infants with lower gestational age. Future investigations on SLI should not only focus on respiratory outcome but also on the consequences on the developing brain. TRIAL REGISTRATION German Clinical Trials Register DRKS00005161 https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.do.


title: Microwave coagulation therapy for hepatic tumors: review of the literature and critical analysis.

text: BACKGROUND Surgical resection of malignant hepatic tumors has been demonstrated to increase overall survival; however, the majority of patients are not candidates for resection. For patients with unresectable tumors, various chemical and thermal ablation modalities have been developed. microwave coagulation therapy (MCT) is one such thermal ablation modality and the purpose of this review is to evaluate the presently available data for MCT and assess the level of evidence to support its clinical use. METHODS This review is limited to published studies in the English literature including at least 30 patients per study with MCT for hepatocellular cancer (HCC) or colorectal hepatic metastasis (CRHM). Patterns of local recurrence, complications and survival outcome of MCT ablation are presented and discussed including assessment of Asian experience using the 2.4GHZ device and American experience using the 914MHZ device. CONCLUSIONS Although randomized controlled trials comparing RFA and MCT for hepatic ablation are lacking, our review (based on level 2 data) supports that MCT may be optimal when larger necrosis zones and/or ablation of multiple lesions are the objectives. The data support that the potential procedural advantage(s) noted for ablation of CRHM and HCC >3cm, is not supported for HCC <3cm; moreover MCT shares with all other ablation modalities a high rate of locoregional recurrence in HCC; likely due to the multicentricity of this disease process.


title: Evaluation of the Adjuvant Efficacy of Natural Herbal Medicine on COVID-19: A Retrospective Matched Case-Control Study.

text: Since the outbreak of Corona Virus Disease 2019 (COVID-19) in Hubei province, the epidemic scale has increased rapidly, and no effective antiviral drug therapy has been identified yet. This study aimed to evaluate the adjuvant efficacy of Natural Herbal Medicine (NHM) combined with Western medicine in the treatment of COVID-19. We performed a retrospective, 1:1 matched, case-control study of the first cohort of hospitalized COVID-19-confirmed cases (January 17, 2020 to January 28, 2020). A total of 22 of the 36 confirmed patients were included in this study, split into two groups of 11: the NHM group (NHM combined standard Western medicine treatment) and control group (standard Western medicine treatment alone). All patients received appropriate supportive care and regular clinical and laboratory monitoring. Main evaluation indicators included improvement of clinical symptoms such as fever, cough and diarrhea after hospitalization; pathogen nucleic acid test result of respiratory tract and fecal specimens of the patient after hospitalization, and change of chest CT examination after hospitalization. The duration of fever in the NHM group (3.4±2.4 days) was significantly shorter than that in the control group (5.6±2.2 days) (p=0.03). During the whole hospitalization period, the number of cases with diarrhea in the NHM group (two cases) was less than that in the control group (eight cases) (p=0.03). Compared with the control group (7.5±1.6), the duration for improvement (DI) of chest CT in the NHM group (5.6±2.3) was significantly shorter (p=0.04). Our results suggest that NHM could improve the clinical symptoms of COVID-19 patients and may be effective in treating COVID-19; thus, a larger, prospective, randomized, controlled clinical trial should be conducted to further evaluate the adjuvant efficacy of NHM in the treatment of COVID-19.


title: Epidemiology and horizontal transmission of porcine circovirus type 2 (PCV2).

text: Porcine circovirus type 2 (PCV2) is a small, non-enveloped, circular, single-stranded DNA virus of economic importance in the swine industry worldwide. Based on the sequence analyses of PCV2 strains, isolates can be divided into five subtypes (PCV2a-e). PCV2 is an ubiquitous virus based on serological and viremia data from countries worldwide. In addition, PCV2 DNA was discovered in archived samples prior to the first recognition of clinical disease. Recently, a worldwide shift in PCV2 subtype from PCV2a to PCV2b occurred. PCV2 DNA can be detected in fecal, nasal, oral and tonsillar swabs as well as in urine and feces from both naturally and experimentally infected pigs. PCV2 DNA can be detected early in the infectious process and persists for extended periods of time. The effectiveness of disinfectants for reducing PCV2 in vitro is variable and PCV2 is very stable in the pig environment. Limited data exist on the horizontal transmission of PCV2. Direct transmission of PCV2 between experimentally or naturally infected animals and naïve animals has been documented and the incorporation of clinical or subclinically infected animals into a population represents a risk to the herd. Indirect transmission through the oral, aerosol or vaccine routes is likely a lesser risk for the transmission of PCV2 in most swine populations but may be worth evaluating in high heath herds. The objective of this review was to discuss data on the epidemiology and horizontal transmission of PCV2.


title: Low neurologic intensive care unit hemoglobin as a predictor for intra-arterial vasospasm therapy and poor discharge modified Rankin Scale in aneurysmal subarachnoid haemorrhage-induced cerebral vasospasm.

text: BACKGROUND Intra-arterial vasospasm therapy (IAVT) with vasodilators, balloon angioplasty, and cerebral blood flow augmentation devices are therapies for aneurysmal subarachnoid hemorrhage-induced symptomatic cerebral vasospasm refractory to maximal medical management. Our aim was to identify clinical factors predictive of IAVT and/or poor outcome. METHODS A cross-sectional retrospective analysis was performed of 130 patients with aneurysmal subarachnoid hemorrhage including patients without and with symptomatic cerebral vasospasm requiring IAVT. The data were analysed by Student t test, univariate analysis and binary logistic regression. RESULTS The mean±SD patient age was 54±12.2 years, admission hemoglobin was 13.6±1.5 g/dL, and neurologic intensive care unit (NICU) hemoglobin 11±1.4 g/dL. The median Hunt and Hess grade was 2 (range 1,4), Fisher grade 3 (range 3,3), and discharge modified Rankin Scale (mRS) 0.5 (range 0,2). Lower mean NICU hemoglobin was found in patients receiving IAVT than in those not receiving IAVT (M=10.4±0.9 g/dL vs M=11.2±1.4 g/dL, t(115)=-2.52, p=0.01). Further, lower mean NICU hemoglobin was associated with increased IAVT (ρ=-0.3, p<0.01) and higher discharge mRS (ρ=-0.5, p<0.01). In binary logistic regression, lower mean NICU hemoglobin was an independent predictor of IAVT (OR 0.6, 95% CI 0.4 to 0.9, p<0.05) as well as poor discharge mRS (OR 0.6, 95% CI 0.4 to 0.9, p<0.05). Hunt and Hess grade was also an independent predictor of these outcomes. CONCLUSIONS Lower mean hemoglobin during the acute phase of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm is an independent predictor of IAVT and poor discharge mRS. This relationship warrants further evaluation.


title: Single-port laparoscopic total colectomy for medically uncontrolled colitis.

text: PURPOSE New-generation multi-instrument ports for laparoscopic surgery now allow abdominal surgery via a single-access small incision. Here, we detail how laparoscopic total colectomy can be safely performed within the constraints of such single site operating. METHODS Three patients (2 males and 1 female; mean age, 28.3 y; mean body mass index, 24.1 kg/m) requiring urgent total colectomy with end ileostomy for colitis resistant to medical therapy fully consented to have their operation performed by a single-port laparoscopic approach. The single port was placed at the site marked preoperatively for the end ileostomy. The operation commenced with rectosigmoid transection and proceeded with a close pericolic dissection proximally along the colon to the cecum. The resected colon was withdrawn via the port site and the end ileostomy fashioned within this wound. RESULTS The operation was safely completed in its entirety without additional abdominal access in each case. Mean operative time was 206 minutes. All patients are well with normal stoma appearance and function at a minimum follow-up of 4 months. CONCLUSION Judicious patient selection and considered operative technique allow major resectional colonic surgery to be safely performed solely by a single-port technique. Proof of clinical benefit along with refined instrumentation is required if such surgery is to progress from anecdotal reports to mainstream practice.


title: Roux-en-Y gastric bypass after successful weight loss with a laparoscopic adjustable gastric band: rationales and early outcomes in patients of body mass index<35 kg/m(2.).

text: BACKGROUND Laparoscopic adjustable gastric banding (LAGB) has a number of well-established acute and chronic issues that can require revisional surgical procedures. There is no existing data to evaluate conversion of band patients with body mass index (BMI)<35 kg/m(2) from LAGB to a Roux-en-Y gastric bypass (RYGB). This study aims to report on the indications for and the safety profile of conversion of the LAGB to RYGB in patients with BMI<35 kg/m(2). METHODS A review of data from 200 consecutive conversions of LAGB to RYGB was conducted. Fifty-two patients whose BMI was<35 kg/m(2) were included in this analysis. Indications for conversion, technical details, early morbidity, length of hospital stay, and weight loss data were assessed. RESULTS Laparoscopic conversion to RYGB was performed in 100% of patients. The median BMI pre-RYGB was 32.8 kg/m(2). The most common indication for surgery was weight regain after removal of LAGB (28.8%). There was no mortality. Early morbidity was seen in 25% of patients; the most common complication was stricture of the gastrojejunal anastomosis (9 patients). CONCLUSION Morbidity resulting from conversion of LAGB to RYGB in patients with BMI <35 kg/m(2) is similar to that seen in the BMI>35 kg/m(2) population. The procedure is technically challenging and morbidity rates are higher than those reported for surgically 'naïve' patients. It is recommended that this procedure be undertaken by appropriately trained surgeons in high-volume bariatric centers to optimize safety and outcomes.


title: Isobaric laparoendoscopic single-site surgery with wound retractor for adnexal tumors: a single center experience with the initial 100 cases.

text: OBJECTIVE To report our experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery in 100 patients with adnexal tumors at a single center. STUDY DESIGN In each case, a wound retractor was used as a working port through a 2.5-cm vertical umbilical incision. The surgical view was secured with the subcutaneous abdominal wall-lift method. Surgical procedures were performed using conventional laparoscopic instruments under vision with a rigid 30°, 5-mm EndoEYE laparoscope. Clinical data regarding patient demographics and surgical outcomes were retrospectively analyzed. RESULTS Between August 2009 and July 2010, one hundred and seventeen tumors from 100 cases were treated with isobaric LESS surgery (unilateral salpingo-oophorectomy, 46; unilateral cystectomy, 33; bilateral cystectomy, 8; bilateral salpingo-oophorectomy, 6; unilateral cystectomy and contralateral cyst wall ablation, 4; unilateral cystectomy and contralateral salpingo-oophorectomy, 2; and unilateral salpingectomy, 1). Three normal adnexa were prophylactically resected at the same time as contralateral salpingo-oophorectomy of a diseased ovary. Previous abdominal surgery was noted in 20 cases. Emergency surgery was performed in 7 cases. Six pregnant women were treated in the late first trimester. Median tumor diameter was 6.9 cm. Median surgical duration was 55 min and median blood loss was 10 mL. Conversion to conventional laparoscopic surgery was noted in one case of recurrent endometriotic cyst with severe adhesion. Laparotomic conversion was not experienced. Prolonged administration of antibiotics with extended hospitalization was required in 7 cases due to elevated inflammatory parameters. There were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within the umbilicus. With exclusion of 4 endometriotic cysts treated with cyst wall ablation, pathological diagnosis was obtained for 113 tumors (dermoid cyst, 54; endometriotic cyst, 21; serous cystadenoma, 19; mucinous cystadenoma, 9; paraovarian cyst, 8; serous borderline tumor, 1; and paraovarian serous papillary borderline tumor, 1). CONCLUSIONS With efficient wound retraction to create a wide and flexible orifice during instrumentation, the transumbilical wound retraction system combined with the subcutaneous abdominal wall-lift method contributes favorably to LESS surgery as a safe, feasible and reproducible alternative for a variety of ablative and reconstructive applications in the management of adnexal tumors.


Tissue adhesives: cyanoacrylate glue and fibrin sealant.


title: Right ventricular outflow tract repair with a cardiac biologic scaffold.

text: BACKGROUND Surgical reconstruction of congenital heart defects is often limited by the nonresorbable material used to approximate normal anatomy. In contrast, biologic scaffold materials composed of resorbable non-cross-linked extracellular matrix (ECM) have been used for tissue reconstruction of multiple organs and are replaced by host tissue. Preparation of whole organ ECM by decellularization through vascular perfusion can maintain much of the native three-dimensional (3D) structure, strength, and tissue-specific composition. A 3D cardiac ECM (C-ECM) biologic scaffold material would logically have structural and functional advantages over materials such as Dacron™ for myocardial repair, but the in vivo remodeling characteristics of C-ECM have not been investigated to date. METHODS AND RESULTS A porcine C-ECM patch or Dacron patch was used to reconstruct a full-thickness right ventricular outflow tract (RVOT) defect in a rat model with end points of structural remodeling function at 16 weeks. The Dacron patch was encapsulated by dense fibrous tissue and showed little cellular infiltration. Echocardiographic analysis showed that the right ventricle of the hearts patched with Dacron were dilated at 16 weeks compared to presurgery baseline values. The C-ECM patch remodeled into dense, cellular connective tissue with scattered small islands of cardiomyocytes. The hearts patched with C-ECM showed no difference in the size or function of the ventricles as compared to baseline values at both 4 and 16 weeks. CONCLUSIONS The C-ECM patch was associated with better functional and histomorphological outcomes compared to the Dacron patch in this rat model of RVOT reconstruction.


title: Laparoscopic rectal resection of deep infiltrating endometriosis.

text: PURPOSE Deep infiltrating endometriosis with colorectal involvement is a complex disorder, often requiring segmental bowel resection. Complete removal of all visible lesions is considered the adequate treatment of infiltrating endometriosis in order to reduce recurrence. In this article, we describe our experience with laparoscopic management of deep infiltrating endometriosis with involvement of the rectum. METHODS A retrospective analysis of data from patients with deep infiltrating endometriosis with rectal involvement who underwent a laparoscopic surgery in the years 2002-2009 at the Department of Obstetrics and Gynecology at our institution was done. RESULTS Between 2002 and 2009, a laparoscopic partial rectal resection was performed in 52 patients, and laparoscopic disk resection was performed in 4 cases with deep infiltrating endometriosis. The mean age of patients was 34.4 years (range, 22-62 years). Preoperative symptoms included dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. The laparoscopic procedure was converted to formal laparotomy in 3 patients (5.4%). The mean duration of surgery was 145 minutes. Postoperative complications included 3 cases of anastomotic leakage with rectovaginal fistula in two cases and intraabdominal bleeding in 1 case. The mean hospital stay was 7 days. Postoperatively, nine patients had a normal delivery, two of them after in vitro fertilization treatment. CONCLUSION Laparoscopic rectal resection for deep infiltrating endometriosis is a relatively safe procedure, when performed by a surgeon and a gynecologist with sufficient experience in laparoscopic colorectal surgery.


title: Proteinuria: an ignored marker of inflammation and cardiovascular disease in chronic hemodialysis.

text: BACKGROUND Cardiovascular disease is the leading cause of morbidity and mortality in hemodialysis (HD) patients, the main etiologies being diabetes and hypertension. Cardiac and inflammatory biomarkers are usually employed to assess risk or damage, or during follow-up. Proteinuria is considered a strong predictor of morbidity, a cause of inflammation, oxidative stress, hemodynamic alteration, and progression of chronic kidney disease. However, proteinuria is rarely considered in the clinical assessment of HD patients. METHODS This was a concurrent, cohort-observational, cross-sectional study in which 52 chronic HD subjects were divided into three groups according to the degree of proteinuria: Group (G) A: <1 g/day, n = 25; GB: 1-3 g/day, n = 13; GC: >3 g/day, n = 14. Baseline hemoglobin, albuminemia, cholesterol, body mass index, Malnutrition-Inflammatory Score, pro-B-type natriuretic peptide, troponin T, C-reactive protein (CRP), and ultrafiltration rates were analyzed. RESULTS There was no difference between groups in terms of baseline age, gender, hypertension, cause of renal failure, hemoglobin, cholesterol, albumin, CRP levels, cardiac biomarkers, adiponectin, body mass index, or Malnutrition-Inflammatory Score. Time on HD: GA, 34.56 ± 23.3 (range [r]: 6-88); GB, 25.15 ± 19.40 (r: 6-58); GC, 18.21 ± 9.58 (r: 6-74) months; P = 0.048. Proteinuria: GA, 0.33 ± 0.30 (r: 0.0-0.88); GB, 1.66 ± 0.54 (r: 1.03-2.75); GC, 7.18 ± 2.80 (r: 3.04-21.5) g/day; P < 0.001. Mean ultrafiltration rates were significantly different: GA, 2.80 ± 0.73; GB: 1.85 ± 0.96 liters/session; P = 0.003. Fourteen diabetic patients were identified (27%): GA, 3 (12%); GB, 3 (23%); GC, 8 (57%); P = 0.009. A positive and significant correlation was observed between diabetes and proteinuria >3 g/day: rho 0.438, P = 0.027. Although troponin T, pro-B-type natriuretic peptide, adiponectin, and CRP were not different among groups, the positive correlation between troponin T and CRP elevated significantly as proteinuria increased: GA, rho 377, P = 0.063; GB, rho 663, P = 0.013; GC, rho 687, P = 0.007. CONCLUSION In chronic HD, nephrotic-range proteinuria was significantly higher in diabetic nephropathy patients versus other causes. This was associated with inflammation and cardiac stress and was independent of fluid removal. Proteinuria >3 g/day was associated with shorter time on HD. Whether severe proteinuria is associated with shorter survival in HD, independent of diabetes, is to be determined. Proteinuria should be considered in the assessment of cardiovascular and inflammatory states in HD patients.


title: Trunk extensor fatigue decreases jump height similarly under stable and unstable conditions with experienced jumpers.

text: PURPOSE The purpose of this study was to investigate the effects of back extensor fatigue on performance measures and electromyographic (EMG) activity of leg and trunk muscles during jumping on stable and unstable surfaces. METHODS Before and after a modified Biering-Sorensen fatigue protocol for the back extensors, countermovement (CMJ) and lateral jumps (LJ) were performed on a force plate under stable and unstable (balance pad on the force plate) conditions. Performance measures for LJ (contact time) and CMJ height and leg and trunk muscles EMG activity were tested in 14 male experienced jumpers during 2 time intervals for CMJ (braking phase, push-off phase) and 5 intervals for LJ (-30 to 0, 0-30, 30-60, 60-90, and 90-120 ms) in non-fatigued and fatigued conditions. RESULTS A significant main effect of test (fatigue) (p = 0.007, f = 0.57) was observed for CMJ height. EMG analysis showed a significant fatigue-induced decrease in biceps femoris and gastrocnemius activity with CMJ (p = 0.008, f = 0.58 andp = 0.04, f = 0.422, respectively). LJ contact time was not affected by fatigue or surface interaction. EMG activity was significantly lower in the tibialis anterior with LJ following fatigue (p = 0.05, f = 0.405). A test x surface (p = 0.04, f = 0.438) interaction revealed that the non-fatigued unstable CMJ gastrocnemius EMG activity was lower than the non-fatigued stable condition during the onset-of-force phase. CONCLUSION The findings revealed that fatiguing the trunk negatively impacts CMJ height and muscle activity during the performance of CMJs. However, skilled jumpers are not additionally affected by a moderately unstable surface as compared to a stable surface.


title: Laparoscopic partial nephrectomy in the treatment of renal cell carcinoma: a minimally invasive means to nephron preservation.

text: With the advent of cross-sectional imaging, the incidence of asymptomatic detected small renal masses, 'incidentalomas', has increased in the past 20 years. Recent studies have demonstrated that patients with renal masses have worse renal function at baseline and have more comorbidities than the general population. Nephron-sparing surgery allows for maximal preservation of functioning nephrons with comparable oncologic outcomes. Recently, laparoscopic partial nephrectomy has emerged as a minimally invasive nephron-sparing surgical option for treating the appropriately selected renal mass. While open-partial nephrectomy has undisputedly become standard of care for the management of the small renal mass (<4 cm), laparoscopic partial nephrectomy is becoming the preferred option for select patients in institutions in which advanced laparoscopic experience is available.


title: The use of flow perfusion culture and subcutaneous implantation with fibroblast-seeded PLLA-collagen 3D scaffolds for abdominal wall repair.

text: Highly cellularised 3D-tissue constructs designed to repair large, complex abdominal wall defects were prepared using poly (lactic acid) (PLLA)-collagen scaffolds in vitro using a flow perfusion bioreactor. The PLLA-collagen scaffolds had a unique structure consisting of a collagen sponge formed within the pores of a mechanically stable knitted mesh of PLLA. The effect of the flow perfusion bioreactor culturing conditions was investigated in vitro for 0, 7, 14 and 28 days on scaffolds seeded with dermal fibroblasts. The cultured constructs were subsequently studied subcutaneously (SC) in an in vivo animal model. The results of in vitro studies demonstrated that the perfusion system facilitated increased cell proliferation and homogenous distribution in the PLLA-collagen scaffolds compared to static conditions. A highly cellularised 3D-tissue construct was formed by 7 days incubation under perfusion conditions, with increased cellularity by the 28 day time point. The in vivo model demonstrated that implanting constructs with high cellularity resulted in exceptional cell stabilisation, with the survival of implanted cells and expression of the phenotypically-relevant extracellular matrix proteins collagen types I and III, studied by fluorescence in situ hybridisation (FISH) and immunohistochemistry. The implantation of this porous PPLA-collagen scaffold seeded with dermal fibroblasts following in vitro maturation using a flow perfusion bioreactor system suggests a significant advance over current state-of-the-art procedures for the reconstruction of large, complex abdominal wall tissue defects.


Management of the corpse with suspect, probable or confirmed COVID-19 respiratory infection - Italian interim recommendations for personnel potentially exposed to material from corpses, including body fluids, in morgue structures and during autopsy practice.


title: The Whys and Wherefores of Antibiotic Resistance.

text: The development and rapid dissemination of antibiotic-resistant bacterial pathogens has tarnished the dream of a world without infectious diseases. However, our understanding of these processes, paired with sequence information from terrestrial bacterial populations, indicates that there is no shortage of novel natural products that could be developed into new medicines. Regardless, their therapeutic success in the clinic will depend on the introduction of mandatory controls and use restrictions.


title: The ORF4b-encoded accessory proteins of Middle East respiratory syndrome coronavirus and two related bat coronaviruses localize to the nucleus and inhibit innate immune signalling.

text: The recently emerged Middle East respiratory syndrome coronavirus (MERS-CoV), a betacoronavirus, is associated with severe pneumonia and renal failure. The environmental origin of MERS-CoV is as yet unknown; however, its genome sequence is closely related to those of two bat coronaviruses, named BtCoV-HKU4 and BtCoV-HKU5, which were derived from Chinese bat samples. A hallmark of highly pathogenic respiratory viruses is their ability to evade the innate immune response of the host. CoV accessory proteins, for example those from severe acute respiratory syndrome CoV (SARS-CoV), have been shown to block innate antiviral signalling pathways. MERS-CoV, similar to SARS-CoV, has been shown to inhibit type I IFN induction in a variety of cell types in vitro. We therefore hypothesized that MERS-CoV and the phylogenetically related BtCoV-HKU4 and BtCoV-HKU5 may encode proteins with similar capabilities. In this study, we have demonstrated that the ORF4b-encoded accessory protein (p4b) of MERS-CoV, BtCoV-HKU4 and BtCoV-HKU5 may indeed facilitate innate immune evasion by inhibiting the type I IFN and NF-κB signalling pathways. We also analysed the subcellular localization of p4b from MERS-CoV, BtCoV-HKU4 and BtCoV-HKU5 and demonstrated that all are localized to the nucleus.


title: Concordance between laboratories in metal ion testing in patients with metal-on-metal hip implants.

text: BACKGROUND Testing of whole blood or serum metal ion levels has become an important part of assessing and monitoring the performance of metal-on-metal bearings, both in hip resurfacing arthroplasty and in total hip replacement. The aim of this study was to determine the concordance between 2 laboratories testing cobalt and chromium ion levels in patients with metal-on-metal bearings. METHODS Serum and whole blood samples from patients who had undergone metal-on-metal resurfacing or large-diameter total hip arthroplasty were tested for cobalt and chromium ions in laboratory A (a recognized laboratory) and laboratory B (tasked with testing clinical specimens). Laboratory A performed cobalt and chromium testing on whole blood, and laboratory B performed cobalt testing on whole blood and chromium testing on serum. RESULTS Samples from 104 patients were tested. Laboratory B reported lower whole blood cobalt levels than laboratory A. Furthermore, laboratory A reported that all patients had elevated whole blood cobalt ion levels compared to the normal reference values for the laboratory, whereas laboratory B reported that 46 patients (44.2%) had whole blood cobalt ion levels within the normal reference range for the laboratory. CONCLUSION This comparative study highlights the importance of using a single laboratory for metal ion testing, as values generated from different laboratories may not be directly comparable. With recent literature suggesting that whole blood cobalt levels as low as 1 ppb may be a predictor of adverse reactions to metal debris, accurate clinical measurement needs to be increasingly exact.


title: Super-factors associated with transmission of occupational COVID-2019 infection among healthcare staff in Wuhan , China.

text: BACKGROUND Globally, there have been many cases of COVID-2019 cases among medical staff, however, the main factors associated with the infection are not well understood. AIM To identify the super-factors causing COVID-19 infection in medical staff in China. METHODS A cross-sectional study was conducted between Jan. 1st, and Feb. 30th, 2020, where front line members of medical staff that took part in the care and treatment of patients with COVID-19 were enrolled. Epidemiological and demographic data between infected and uninfected groups were collected and compared. Social network analysis (SNA) was used to establish socio-metric social links between influencing factors. FINDINGS A total of 92 medical staff were enrolled. In all participant groups, the super-factor identified by the network was wearing a medical protective mask or surgical mask correctly (degree = 572; closeness =25; betweenness centrality = 3·23). Touching the cheek, nose, and mouth while working was the super-factor in the infected group. This was the biggest node in the network and had the strongest influence (degree = 370; closeness = 29; betweenness centrality = 0·37). Self-protection score was the super-factor in the uninfected group but was the isolated factor in the infected group (degree = 201; closeness = 28; betweenness centrality = 5·64). For family members, the exposure history to Huanan Seafood Wholesale Market and the contact history to wild animals were two isolated nodes. CONCLUSION High self-protection score was the main factor that prevented medical staff from contracting COVID-19 infection. The main factor that contributed to COVID-19 infections among medical staff was touching the cheek, nose and mouth while working.


COVID-19: clinical presentation and implications. A primer for obstetricians.


title: Renal ACE2 expression and activity is unaltered during established hypertension in adult SHRSP and TGR(mREN2)27.

text: Differential renal expression of a homolog of the angiotensin-converting enzyme (ACE), that is, ACE2, has been implicated as a genetic basis of polygenetic hypertension in the stroke-prone spontaneously hypertensive rat model. However, data on the role of ACE2 in hypertension are still inconclusive. Therefore, we analyzed kidney ACE2 mRNA, ACE2 protein and ACE2 enzyme activities in the adult polygenetic stroke-prone spontaneously hypertensive rat (SHRSP) and the monogenetic TGR(mREN2)27 rat models, in comparison with their normotensive reference strains, Wistar-Kyoto (WKY) and Spraque-Dawley (SD) rats, respectively. Kidney ACE2 mRNA was studied using quantitative real-time reverse transcriptase-PCR (RT-PCR) in cortex and medulla, whereas protein expression was scored semiquantitatively in detail in different renal structures using immunohistochemistry. Furthermore, total renal tissue ACE2 activity was measured using a fluorimetric assay that was specified by the ACE2 inhibitor DX600. In SHRSP and homozygous TGR(mREN2)27 rats with established hypertension, kidney ACE2 mRNA, protein and tissue ACE2 activities were not different from their respective WKY and SD reference strain, respectively. In addition, when we looked at renal localization, we found ACE2 protein to be predominantly present in glomeruli and endothelium with weak staining in distal and negative staining in proximal tubuli. Thus, our data challenge previous work that implicates ACE2 as a candidate gene for hypertension in SHRSP by reporting a significant reduction of ACE2 in the kidneys of SHRSP. Taken together, renal ACE2 is not altered in the SHRSP and TGR(mREN2)27 genetic rat models with established hypertension.


title: Roux limb volvulus in laparoscopic Roux-en-Y gastric bypass due to Roux limb stabilization suture: case series.

text: BACKGROUND Complications after laparoscopic Roux-en-Y gastric bypass surgery may be related to the type of surgical technique employed. One technique, the placement of a Roux limb stabilization suture, presumably prevents kink at the gastrojejunal anastomosis. However, it can have an adverse effect and we studied a series of cases presenting with intestinal obstruction secondary to this stitch. METHODS A retrospective review of a prospectively collected database of laparoscopic Roux-en-Y gastric bypass cases who had reoperations for Roux limb volvulus was performed at a single bariatric center by a single surgeon. RESULTS Out of 199 patients who underwent laparoscopic Roux en Y gastric bypass with placement of Roux limb stabilization suture, 4 patients (2.01%) presented with Roux limb volvulus postoperatively. BMI was 45.35 ± 2.95. The postoperative time to presentation was 11 ± 10.6 months. All four patients required surgical exploration to reduce the volvulus. In all cases, the Roux limb volvulus was directly attributable to the presence of the stabilization suture. In subsequent 250 cases where this suture was eliminated, there was no volvulus of Roux limb seen. CONCLUSIONS The use of a stabilization suture can result in volvulus of the Roux limb causing intestinal obstruction and this complication can be prevented by avoiding this suture.


title: Effectiveness of border screening for detecting influenza in arriving airline travelers.

text: OBJECTIVES We measured symptom and influenza prevalence, and the effectiveness of symptom and temperature screening for identifying influenza, in arriving international airline travelers. METHODS This cross-sectional study collected data from travelers to Christchurch International Airport, New Zealand, in winter 2008, via a health questionnaire, temperature testing, and respiratory sampling. RESULTS Forms were returned by 15 976 (68%) travelers. Of these, 17% reported at least 1 influenza symptom, with runny or blocked nose (10%) and cough (8%) most common. Respiratory specimens were obtained from 3769 travelers. Estimated prevalence of influenza was 1.1% (4% among symptomatic, 0.2% among asymptomatic). The sensitivity of screening criteria ranged from 84% for "any symptom" to 3% for a fever of 37.8 °C or greater. The positive predictive value was low for all criteria. CONCLUSIONS Border screening using self-reported symptoms and temperature testing has limitations for preventing pandemic influenza from entering a country. Using "any symptom" or cough would lead to many uninfected people being investigated, yet some infected people would remain undetected. If more specific criteria such as fever were used, most infected people would enter the country despite screening.


title: Translaryngeal Tracheostomy Needle Introducer: a simple device to improve safety and reduce complications during Fantoni's translaryngeal tracheostomy procedure: trial on human cadavers.

text: BACKGROUND Percutaneous dilatational tracheostomy (PDT) is the most frequently performed procedure in patients requiring prolonged mechanical ventilation. A crucial step in such procedures is needle insertion into the trachea. To simplify this procedure and increase its safety, we developed a new device, the translaryngeal Tracheostomy Needle Introducer (tTNI), for use with Fantoni's method. This cadaver study was designed to assess the performance of the tTNI on human anatomy. METHODS We tested the tTNI in a cadaver laboratory; the operators included two experts trained in PDT and three without specific training in the procedure. We performed 58 needle insertion attempts on 13 cadavers. We compared the tTNI technique with the standard needle insertion approach using external landmarks. We recorded the number of attempts needed to optimise needle insertion, time required in seconds, final position of the needle and complications related to needle insertion. RESULTS tTNI use resulted in fewer puncture attempts (1.91 ± 1.34 vs. 1.19 ± 0.5, p < 0.001), less time (36.8 ± 51.6 s vs. 13.14 ± 15.57 s, p < 0,001) and increased precision on the first puncture (18.87 ± 25.38° vs. 7.5 ± 12.95°, p < 0,005). We did not observe any complication with tTNI use, whereas complications found using the standard method were in line with the literature. CONCLUSIONS The tTNI is a device that simplifies needle insertion by enhancing the accuracy of insertion with fewer attempts and higher precision, even when used by less experienced operators. Clinical testing is required to evaluate the device performance in patients.


title: Simultaneous Bilateral vs Unilateral Carotid Artery Stenting: 30-Day and 1-Year Results.

text: PURPOSE To evaluate clinical outcomes of simultaneous bilateral carotid artery stenting (sbCAS) compared with unilateral CAS (uCAS). METHODS The database in our institution was queried to identify all patients treated with CAS from January 2005 to December 2012. In this time frame, 120 (18.8%) patients (mean age 64.9 ± 7.7 years; 96 men) underwent sbCAS and 517 (81.2%) patients (mean age 65.7 ± 7.7 years; 421 men) received uCAS. The primary endpoint was the composite of stroke, myocardial infarction, or death within 30 days or any ipsilateral stroke within 1 year. RESULTS There was no significant difference in the rates of the primary endpoint between the sbCAS and uCAS groups (6.7% vs 4.6%, p=0.358). The rates of the primary endpoint among symptomatic patients was 8.0% in the sbCAS group and 5.0% in the uCAS group (p=0.299) and 3.1% and 4.0%, respectively (p=0.821) among asymptomatic patients. During the 30-day periprocedural period, the rates of the primary endpoint did not differ significantly between the sbCAS and uCAS groups among all patients (5.8% vs 4.4%, p=0.479), symptomatic patients (6.8% vs 5.0%, p=0.594), or asymptomatic patients (3.1% vs 3.5%, p>0.999). After this period, the incidences of any ipsilateral stroke were similarly low (0.8% and 0.2%, respectively; p=0.342). CONCLUSION The study showed that simultaneous bilateral CAS had no more adverse events than unilateral CAS during the periprocedural period or within 1 year. This 1-stage strategy may become a valuable alternative in the treatment of patients with severe bilateral carotid stenosis.


Future litigation after Covid-19 pandemic in Italy.


title: Smart placement of a mediastinal drain in a neonate who requires a postoperative open sternum.

text: Crowding of the mediastinum after complex cardiac repair procedures in neonates and young children is a frequent problem. To create space, the sternal wound is kept open, commonly with a plastic stent, for later closure. Despite this maneuver, space is still an issue, and appropriate placement of the mediastinal drain can become a challenge. In this article we describe a simple and effective way to eliminate the problem. Holes are made in the sternal stent, and the drain is pulled through these holes. The drain is elevated away from the heart surface and does not contribute to the crowding.


Intranasal vaccination.


title: Bacillus cereus meningitis in a term neonate.

text: A case of Bacillus cereus meningitis in a term neonate without identifiable risk factors or source of the organism is presented. Prompt identification of the organism and treatment resulted in a favourable outcome.


Arterial Thrombosis and Covid-19 in a Cancer patient


Coronavirus Pandemic.


title: Beyond the Dirty Dozen: A Proposed Methodology for Assessing Future Bioweapon Threats.

text: Background Defense policy planners and countermeasure developers are often faced with vexing problems involving the prioritization of resources and efforts. This is especially true in the area of Biodefense, where each new emerging infectious disease outbreak brings with it questions regarding the causative agent's potential for weaponization. Recent experience with West Nile Virus, Severe Acute Respiratory Syndrome, Monkeypox, and H1N1 Influenza highlights this problem. Appropriately, in each of these cases, the possibility of bioterrorism was raised, although each outbreak ultimately proved to have a natural origin. In fact, determining whether an outbreak has an unnatural origin can be quite difficult. Thus, the questions remain: could the causative agents of these and other emerging infectious disease outbreaks pose a future weaponization threat? And how great is that threat? Should precious resources be diverted from other defense efforts in order to prepare for possible hostile employment of novel diseases by belligerents? Answering such critical questions requires some form of systematic threat assessment. Methods Through extensive collaborative work conducted within NATO's Biomedical Advisory Council, we developed a scoring matrix for evaluating the weaponization potential of the causative agents of such diseases and attempted to validate our matrix by examining the reproducibility of data using known threat agents. Our matrix included 12 attributes of a potential weapon and was provided, along with detailed scoring instructions, to 12 groups of biodefense experts in 6 NATO nations. Study participants were asked to score each of these 12 attributes on a scale of 0-3: Infectivity, Infection-to-Disease Ratio (Reliability), Predictability (& Incubation Period), Morbidity & Mortality (Virulence), Ease of Large-Scale Production & Storage, Aerosol Stability, Atmospheric Stability, Ease of Dispersal, Communicability, Prophylactic Countermeasure Availability, Therapeutic Countermeasure Availability, and Ease of Detection. Reproducibility of scoring data was assessed by examining the standard deviations (SD) of mean scores. Results Our results were unexpected. Several familiar biothreat diseases such as anthrax and tularemia were judged, by our experts, to be less threatening than many others owing to a number of factors including ease of detection, lack of communicability, and the ready availability of countermeasures. Conversely, several toxins were judged by experts to have very high potential as threat agents owing, in part, to their reliability, virulence, and a lack of available countermeasures. Agreement among experts, as determined by lower SD about a mean score, was greater for more familiar threats. Discussion Our study was designed to provide a concise and east-to-apply set of criteria that could be used by NATO nations to evaluate emerging infectious disease threats with respect to their weaponization potential. Our results were unexpected. We believe that a lack of appropriate weighting factors may explain these results and suggest that future studies weigh each of the 12 proposed criteria based on the intended use of the assessment data and other situational factors. We believe that the greatest value of our study lies in a codification of the attributes of a biological weapon.


title: Influence of weight and structure on biological behavior of polypropylene mesh prostheses placed at the esophageal hiatus.

text: BACKGROUND Experimental knowledge about mesh behavior at the esophageal hiatus is rare, but such information is essential in order to find a safe and effective method of mesh reinforcement. This study aimed to investigate the influence of mesh structure on the biological behavior of polypropylene prostheses placed at the hiatus. MATERIALS AND METHODS Twenty-four pigs in three groups of eight underwent implantation of heavyweight small-porous (HW-SP), heavyweight large-porous (HW-LP), or lightweight large-porous (LW-LP) circular polypropylene mesh at the hiatus. Eight weeks later, the meshes were explanted. Macroscopic analysis was performed evaluating mesh deformation, adhesions, and position relative to the hiatal margin. Histological analysis comprised evaluation of foreign body reaction and tissue integration by mononuclear cell count and immunostaining of Ki-67, collagen type I, and collagen type III. RESULTS No mesh-related complications occurred. Mesh shrinkage was observed within all groups and was the lowest for HW-LP, higher for HW-SP, and highest for LW-LP (13.8% versus 19.5% versus 25.5%; P<.001). The adhesion score was highest for HW-SP, lower for HW-LP, and lowest for LW-LP (11.0 versus 8.0 versus 6.0; P<.001). The collagen type I/III ratio was higher for HW-SP compared with HW-LP and LW-LP (3.1 versus 2.2 versus 1.8; P=.014). CONCLUSIONS Heavyweight polypropylene meshes may be advantageous for application at the hiatus. They provide a solid fixation of the esophagogastric junction by adhesions, which may contribute to a reduction of hernia recurrence. In heavyweight meshes, the large-porous structure is associated with superior form stability, and small-porous meshes are superior with regard to solidity of tissue integration, which may prevent mesh migration.


Comprehensive approach to managing hidradenitis suppurativa patients.


title: [Detection of respiratory viruses--how, when, where and why?].

text: Respiratory viruses trigger the majority of common colds, acute respiratory illnesses in children during the cold season as well as acute exacerbations of asthma and chronic obstructive pulmonary disease. They also play a role in community acquired pneumonia. Unfortunately their detection is still difficult. The aim of this review is therefore to introduce the methods of detection and to present the current knowledge of the clinical role of respiratory viruses in different diseases.


title: Can the human coronavirus epidemic also spread through solid waste?

text: Wastes generated in healthcare facilities have been discussed and the World Health Organization has proposed a guideline for controlling the spread of the virus that causes Coronavirus Disease 2019 (COVID-19). However, waste management outside the generating facility should be discussed in more detail, taking into account factors such as virus resistance, differences in waste management systems and the climatic conditions in each affected region. Patients infected by human coronavirus being treated at home are generating infected waste possibly discarded as domestic waste, which can pose risks to workers and the environment, depending on the conditions of transport and disposal. In particular, the spread of the coronavirus may be increased by inadequate waste management, highlighting poor handling conditions associated with inappropriate use of personal protective equipment and other unfavourable conditions presented mainly in developing countries.


title: Rationally designed anti-HIV peptides containing multifunctional domains as molecule probes for studying the mechanisms of action of the first and second generation HIV fusion inhibitors.

text: We have previously shown that the first generation human immunodeficiency virus (HIV) fusion inhibitor T20 (Fuzeon) contains a critical lipid-binding domain (LBD), whereas C34, another anti-HIV peptide derived from the gp41 C-terminal heptad repeat, consists of an important pocket-binding domain (PBD), and both share a common 4-3 heptad repeat (HR) sequence (Liu, S., Jing, W., Cheung, B., Lu, H., Sun, J., Yan, X., Niu, J., Farmar, J., Wu, S., and Jiang, S. (2007) J. Biol. Chem. 282, 9612-9620). T1249, the second generation HIV fusion inhibitor, has both LBD and PBD but a different HR sequence, suggesting that these three anti-HIV peptides may have distinct mechanisms of action. Here we rationally designed a set of peptides that contain multiple copies of a predicted HR sequence (5HR) or the HR sequence plus either LBD (4HR-LBD) or PBD (PBD-4HR) or both (PBD-3HR-LBD), and we compared their anti-HIV-1 activity and biophysical properties. We found that the peptide 5HR exhibited low-to-moderate inhibitory activity on HIV-1-mediated cell-cell fusion, whereas addition of LBD and/or PBD to the HR sequence resulted in a significant increase of the anti-HIV-1 activity. The peptides containing PBD, including PBD-4HR and PBD-3HR-LBD, could form a stable six-helix bundle with the N-peptide N46 and effectively blocked the gp41 core formation, whereas the peptides containing LBD, e.g. 4HR-LBD and PBD-3HR-LBD, could interact with the lipid vehicles. These results suggest that the HR sequence in these anti-HIV peptides acts as a structure domain and is responsible for its interaction with the HR sequence in N-terminal heptad repeat, whereas PBD and LBD are critical for interactions with their corresponding targets. T20, C34, and T1249 may function like 4HR-LBD, PBD-4HR, and PBD-3HR-LBD, respectively, to interact with different target sites for inhibiting HIV fusion and entry. Therefore, this study provides important information for understanding the mechanisms of action of the peptic HIV-1 fusion inhibitors and for rational design of novel antiviral peptides against HIV and other viruses with class I fusion proteins.


title: Bioactive versus bare platinum coils in the treatment of intracranial aneurysms: the MAPS (Matrix and Platinum Science) trial.

text: BACKGROUND AND PURPOSE The ability of polymer-modified coils to promote stable aneurysm occlusion after endovascular treatment is not well-documented. Angiographic aneurysm recurrence is widely used as a surrogate for treatment failure, but studies documenting the correlation of angiographic recurrence with clinical failure are limited. This trial compares the effectiveness of Matrix(2) polyglycolic/polylactic acid biopolymer-modified coils with bare metal coils and correlates the angiographic findings with clinical failure (ie, target aneurysm recurrence), a composite end point that includes any incident of posttreatment aneurysm rupture, retreatment, or unexplained death. MATERIALS AND METHODS This was a multicenter randomized noninferiority trial with blinded end point adjudication. We enrolled 626 patients, divided between Matrix(2) and bare metal coil groups. The primary outcome was target aneurysm recurrence at 12 ± 3 months. RESULTS At 455 days, at least 1 target aneurysm recurrence event had occurred in 14.6% of patients treated with bare metal coils and 13.3% of Matrix(2) (P = .76, log-rank test) patients; 92.8% of target aneurysm recurrence events were re-interventions for aneurysms that had not bled after treatment, and 5.8% of target aneurysm recurrence events resulted from hemorrhage or rehemorrhage, with or without retreatment. Symptomatic re-intervention occurred in only 4 (0.6%) patients. At 455 days, 95.8% of patients with unruptured aneurysms and 90.4% of those with ruptured aneurysms were independent (mRS ≤ 2). Target aneurysm recurrence was associated with incomplete initial angiographic aneurysm obliteration, presentation with rupture, and a larger aneurysmal dome and neck size. CONCLUSIONS Tested Matrix(2) coils were not inferior to bare metal coils. Endovascular coiling of intracranial aneurysms was safe, and the rate of technical success was high. Target aneurysm recurrence is a promising clinical outcome measure that correlates well with established angiographic measurements.


title: An in vivo comparison of the efficacy of hemostatic powders, using two porcine bleeding models.

text: Background Usage of topical hemostatic agents in surgery is increasing, including use during minimally invasive procedures, and even for surgeries that have a low risk of bleeding complications. A novel product, Surgicel® Powder - Absorbable Hemostatic Powder (SP), made from oxidized regenerated cellulose (ORC) fabric, has been developed for adjunctive use in surgical procedures to assist in control of oozing bleeding over broad areas and where access could be difficult with a fabric ORC product. This study compares the new SP to other commercially available hemostatic powder products in two in vivo models. Methods Hemostatic efficacy of SP was compared to two polysaccharide-based hemostats in a porcine liver punch biopsy model and to three polysaccharide-based hemostats and one non-regenerated oxidized cellulose hemostat in a porcine liver abrasion model. Primary outcomes measured were hemostatic efficacy, defined as hemostasis within 10 minutes of application, and time-to-hemostasis (TTH). Results In the punch biopsy model, SP displayed significantly higher effective hemostasis rates than one of the polysaccharide hemostats (p=0.047) and faster TTH than both (p<0.001). In the liver abrasion model, SP had significantly higher effective hemostasis rates (p≤0.002) and faster TTH (p<0.001) than the other four hemostatic agents. The amount of powder applied within the ranges used did not appear to affect hemostatic efficacy. Conclusion In both the liver punch biopsy model of mild to moderate bleeding and the liver abrasion model of mild but diffuse oozing, SP provided more effective hemostasis and faster TTH than other marketed hemostatic powders. The results from this in vivo study suggest that Surgicel Powder may be useful in clinical applications where control of oozing capillary, mild venous, and small arterial hemorrhage is required including bleeding in difficult-to-access locations.


title: Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy for locally advanced cervical cancer: assessment after 52 consecutive patients.

text: BACKGROUND To report the feasibility and reproducibility of single-port extraperitoneal para-aortic (PA) lymphadenectomy exclusively using conventional instruments in locally advanced cervical cancer (LACC) and to evaluate the learning curve. METHODS From January 2011 to January 2013, 52 a total of consecutive patients with LACC were candidates for extraperitoneal PA lymphadenectomy via an original single-port approach that we developed. All patients underwent positron emission tomography-computed tomography that indicated no PA uptake. RESULTS Fifty consecutive patients underwent single-port staging surgery. Two patients had peritoneal carcinomatosis and were not submitted to PA lymphadenectomy. Median age and body mass index were, respectively 47 (range 27-68) years and 23 (range 16-37) kg/m(2). In one case, lymphadenectomy was unfeasible because of renal vessel anomalies (a bifurcated left renal vein crossed the aorta at the level of the inferior mesenteric artery), and two nodes were removed. Conventional instruments were used in all cases. The median operative time was 180 (range 110-270) min. The median and mean number of nodes removed were, respectively, 18 (range 2-47) and 19.4. Six (12 %) patients had metastatic PA disease. No conversion to laparotomy or conventional multiport laparoscopy was required. The median postoperative hospital stay and the interval between staging surgery and the beginning of chemoradiation were, respectively, 2 (range 1-26) days and 16.5 (range 1-60) days. The learning curve was evaluated at seven procedures with a decreased median operative time at 160 (range 110-240) min. CONCLUSIONS Extraperitoneal staging via a single-port left iliac approach is feasible with conventional tools, is reproducible and safe, and offers a high degree of cosmetic satisfaction.


title: Effects of a single night of postpartum sleep on childless women's daytime functioning.

text: STUDY OBJECTIVES The maternal postpartum period is characterized by sleep fragmentation, which is associated with daytime impairment, mental health disturbances, and changes in melatonin patterns. In addition to sleep fragmentation, women undergo a complex set of physiological and environmental changes upon entering the postpartum period, confounding our understanding of effects of postpartum sleep disturbance. The primary study aim was to understand the basic impact of a single night of postpartum-like sleep fragmentation on sleep architecture, nocturnal melatonin levels, mood, daytime sleepiness, and neurobehavioral performance. MEASUREMENTS AND RESULTS For one week prior to entry into the laboratory, eleven healthy nulliparous women kept a stable sleep-wake schedule (verified via actigraphy). Participants contributed three consecutive nights of laboratory overnight polysomnography: (1) a habituation/sleep disorder screening night; (2) a baseline night; and (3) a sleep fragmentation night, when participants were awakened three times for ~30min each. Self-reported sleep quality and mood (Profile of Mood States survey) both decreased significantly after sleep fragmentation compared to baseline measurements. Unexpectedly, daytime sleepiness (Multiple Sleep Latency Test) decreased significantly after sleep fragmentation. Experimental fragmentation had no significant effect on time spent in nocturnal sleep stages, urinary 6-sulfatoxymelatonin concentration, or psychomotor vigilance test performance. Participants continued to provide actigraphy data, and daily PVTs and self-reported sleep quality assessments at home for one week following sleep fragmentation; these assessments did not differ from baseline values. CONCLUSIONS While there were no changes in measured physiological components of a single night of postpartum-like experimental sleep fragmentation, there were decreases in self-reported measures of mood and sleep quality. Future research should examine the effects of multiple nights of modeling postpartum-like sleep fragmentation on objective measures of sleep and daytime functioning.


title: [Exploration on scientific connotation of TCM syndromes and recommended prescriptions against COVID-19 based on TCMTP V2.0].

text: Coronavirus disease 2019(COVID-19) has attracted great attentions from the whole world. Traditional Chinese medicine(TCM) has been widely used and shown satisfying efficacies in treating all stages of COVID-19. In this study, the molecular interaction networks of different stages of COVID-19(the early, severe, critical and recovery stage) were constructed using the links among symptoms-related genes collected from TCMIP V2.0(http://www.tcmip.cn/), an integrated pharmacology network-computing platform for TCM. Following the network topological feature calculation and functional enrichment analysis, we found that the molecular targets and pathways related with the "immune-inflammation system" were involved throughout all the stages of COVID-19. The severe stage and the critical period of COVID-19 were occupied by a large proportion of inflammatory factors and pathways, suggesting that there might be a cytokine storm in these periods, along with respiratory disorders, cardiopulmonary dysfunction, nervous system disorders, etc. Accordingly, the therapeutic targets and pathways hit by the recommended prescriptions against COVID-19 were also aimed to regulate the balance of immune-inflammation system, nutrient absorption and metabolism, abnormal energy metabolism, the cardio-pulmonary function, nerve system function, etc., which may be related to the therapeutic effects of these prescriptions in terms of several clinical symptoms, such as expiratory dyspnea, chest tightness and shortness of breath, abdominal distension and constipation, sweating and limb cold, dizziness, and irritability, etc. The above findings reflect the integrative actions of TCM characterizing by multiple-components, multiple-targets, multiple-pathways, and multiple-effects. This study systematically constructed the molecular networks of different TCM syndromes during the development and progression of COVID-19 and uncovered the biological basis for symptomatic treatment of TCM. Furthermore, our data revealed the pharmacological mechanisms and the scientific connotation of recommended prescriptions, which may provide supports for the prevention and treatment of COVID-19 using TCM.


title: How I Do It: Per-Oral Pyloromyotomy (POP).

text: INTRODUCTION Several surgical treatments exist for treatment of gastroparesis, including gastric electrical stimulation, pyloroplasty, and gastrectomy. Division of the pylorus by means of endoscopy, Per-Oral Pyloromyotomy (POP), is a newer, endoluminal therapy that may offer a less invasive, interventional treatment option. METHODS We describe and present a video of our step by step technique for POP using a lesser curvature approach. The following are technical steps to complete the POP procedure from the lesser curve approach. CONCLUSION In our experience, these methods provide promising initial results with low operative risks, although long-term outcomes remain to be determined.


title: Evaluation of the use of serum C-reactive protein concentration to predict outcome in puppies infected with canine parvovirus.

text: OBJECTIVE To evaluate associations of serum C-reactive protein (CRP) concentration with duration of hospitalization and with outcome in puppies with canine parvoviral enteritis. DESIGN Prospective observational study. Animals-79 client-owned puppies with naturally acquired canine parvovirus infection. PROCEDURES All puppies received supportive care. Serum CRP concentration was measured at the time of admission, approximately every 10 to 12 hours for the first 48 hours, and then every 24 hours until discharge from the hospital or death. Associations between outcome and CRP concentration at various time points or changes in CRP concentration over time were assessed via multiple logistic regression. Associations of CRP concentration with survival time and duration of hospitalization among survivors were estimated with Cox proportional hazards regression. Use of CRP concentration to predict outcome was evaluated by means of receiver operating characteristic curve analysis. RESULTS Serum CRP concentrations at admission and 12 and 24 hours later were positively associated with odds of death, and CRP concentrations at 12 and 24 hours after admission were negatively associated with survival time for puppies. Among survivors, duration of hospitalization was positively associated with CRP concentrations at 12, 24, and 36 hours after admission. Sensitivity and specificity of CRP concentration to differentiate between survivors and nonsurvivors at 24 hours after admission were 86.7% and 78.7%, respectively (considered moderately accurate). CONCLUSIONS AND CLINICAL RELEVANCE Although serum CRP concentration was associated with outcome in puppies with canine parvovirus enteritis, it did not prove to be a good predictor of outcome when used alone.


title: Single-incision laparoscopic cholecystectomy: do patients care?

text: INTRODUCTION Single-incision approaches to laparoscopic cholecystectomy typically involve increasing the size of the umbilical incision and eliminating three smaller incisions, but it is not intuitive that patients would view this as a benefit. We hypothesize that when patient satisfaction with standard laparoscopic cholecystectomy is assessed, most dissatisfaction will be linked to the umbilical incision and, given the option, patients would actually wish to eliminate this incision. METHODS Two hundred eighty-one female patients aged 18 to 40 years who underwent laparoscopic cholecystectomy over a 2-year period were identified, and data were collected on 125 patients. RESULTS Fewer than half of patients correctly remembered the number of incisions they had, with 57 patients (45.6%) recalling fewer incisions than were present. Of 58 patients reporting one site to be more painful, 38 (65.5%) cited the umbilical site as the most painful. Eighty-one patients (68.6%) would have preferred to eliminate an incision, with 51 of these (63.0%) choosing to eliminate the umbilical incision. CONCLUSION As single-incision cholecystectomy enlarges what is already a painful and undesirable incision, and since patients often do not recall the smaller incisions, we should ask ourselves whether surgeons and industry care more about this technique than do the patients to whom we offer it.


title: Laparoscopy may decrease morbidity and length of stay after elective colon cancer resection, especially in frail patients: results from an observational real-life study.

text: BACKGROUND Advantages of laparoscopic approach in colon cancer surgery have been previously demonstrated in controlled, randomized trials and in retrospective analysis of large administrative databases. Nevertheless, evidence of these advantages in prospective, observational studies from real-life settings is scarce. METHODS This is a prospective, observational study, including a consecutive series of patients that underwent elective colonic resection for cancer in 52 Spanish hospitals. Pre-/intraoperative data, related to patient, tumor, surgical procedure, and hospital, were recorded as well as 60-day post-operative outcomes, including wound infection, complications, anastomotic leak, length of stay, and mortality. A univariate and multivariate analysis was performed to determine the influence of laparoscopy on short-term post-operative outcome. A sub-analysis of the effect of laparoscopy according to patients' pre-operative risk (ASA Score I-II vs. III-IV) was also performed. RESULTS 2968 patients were included: 44.2% were initially operated by laparoscopy, with a 13.9% conversion rate to laparotomy. At univariate analysis, laparoscopy was associated with a decreased mortality (p = 0.015), morbidity (p < 0.0001), wound infection (p < 0.0001), and post-operative length of stay (p < 0.0001). At multivariate analysis, laparoscopy resulted as an independent protective factor for morbidity (OR 0.7; p = 0.004), wound infection (OR 0.6; p < 0.0001), and length of post-operative stay (Effect-2 days; p < 0.0001), compared to open approach. These advantages were more relevant in high-risk patients (ASA III-IV), even if the majority of them were operated by open approach (67.1%). CONCLUSIONS In a real-life setting, laparoscopy decreases wound infection rate, post-operative complications, and length of stay, especially in ASA III-IV patients.


title: Performance of SARS-CoV-2 antibody assays in different stages of the infection: Comparison of commercial ELISA and rapid tests.

text: We comparatively assessed sensitivities and specificities of four commercial ELISAs and two rapid tests in 77 patients with PCR confirmed SARS-CoV-2 infection, grouped by intervals since symptom onset. While test sensitivities were low (<40%) within the first 5 days post disease onset, IgM-, IgA- and total antibody-ELISAs increased in sensitivity to >80% between the 6th and 10th day post symptom onset. The evaluated tests (including IgG and rapid tests) provided positive results in all patients at or after the 11th day post onset of disease. Specificities of the ELISAs were 83% (IgA), 98% (IgG) and 97% (IgM and total antibodies).


Susceptibility of felids to coronaviruses.


title: Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis.

text: BACKGROUND Patients undergoing head and neck (H&N) microvascular reconstruction comprise a population at high risk for venous thromboembolism (VTE). Free flap and VTE thromboprophylaxis may coincide but tend to vary from surgeon to surgeon. This study identifies VTE prophylaxis patterns and perceptions among H&N microsurgeons in the United States. METHODS An online survey on VTE prophylaxis practice patterns and perceptions was emailed to 172 H&N microsurgeons in the United States using an anonymous link. RESULTS There were 74 respondents (43% response rate). These surgeons completed residencies in otolaryngology (59%), plastic surgery (31%), and oral maxillofacial surgery (7%). Most underwent fellowship training (95%) and have practiced at an academic center (97%) for at least 6 years (58%), performing an average of 42 ± 31 H&N free flap cases per year (range = 1-190). Most adhered to general VTE prophylaxis guidelines (69%) while 11% did not and 20% were unsure. Nearly all surgeons (99%) would provide prophylactic anticoagulation, mostly in the form of subcutaneous heparin (51%) or enoxaparin (44%); 64% additionally used aspirin, while 4% used aspirin alone. The majority of surgeons (68%) reported having postoperative VTE complications, with six surgeons (8%) reporting patient deaths due to pulmonary embolism. A third of the surgeons have encountered VTE prophylaxis-related adverse bleeding events, but most still believe that chemoprophylaxis is important for VTE prevention (92%). While 35% of surgeons were satisfied with their current practice, most would find it helpful to have official prophylactic anticoagulation guidelines specific to H&N free flap cases. CONCLUSION The majority of microsurgeons experienced postoperative VTE complications after H&N free flap reconstruction despite the routine use of prophylactic anticoagulation. Though bleeding events are a concern, most surgeons believe chemoprophylaxis is important for VTE prevention and would welcome official guidelines specific to this high-risk population.


title: Length of red cell unit storage and risk for delirium after cardiac surgery.

text: BACKGROUND The time that red cell units are stored before transfusion may be associated with postoperative complications, although the evidence is conflicting. However, the association between the length of red cell unit storage and postoperative delirium has not been explored. We hypothesized that the length of storage of transfused red cell units would be associated with delirium after cardiac surgery. METHODS We conducted a case-control study in which patients undergoing coronary artery bypass, valve, or ascending aorta surgery with cardiopulmonary bypass at Johns Hopkins from 2005 to 2011 were eligible for inclusion. Patients were excluded if they did not receive red cell units, received >4 red cell units during hospitalization, received any transfusion after the first postoperative day, or received red cell units that were not exclusively stored for ≤14 days or >14 days. Eighty-seven patients met transfusion-related inclusion criteria and developed postoperative delirium. Controls who did not develop delirium were selected from the same source population of eligible patients and were matched 1:1 based on age (± 5 years), 2- to 2.5-year band of date of surgery, and surgical procedure. For each patient, we calculated the average storage duration of all transfused red cell units. The primary outcome was odds of delirium in patients who were transfused red cell units with exclusive storage duration >14 days compared with that of ≤14 days. Secondary outcomes were odds of delirium with each increasing day of average red cell unit storage duration. We used conditional multivariable regression to test our hypotheses. RESULTS In conditional multivariable analysis of 87 case-control pairs, there was no difference in the odds of patients developing delirium if they were transfused red cell units with an exclusive storage age >14 days compared with that ≤14 days (odds ratio [OR] 1.83; 95% confidence interval, 0.73-4.58, P = 0.20). Each additional day of average red cell unit storage beyond 14 days was associated with a 1.01- to 1.13-fold increase in the odds of postoperative delirium (OR, 1.07; P = 0.03). Each additional day of average storage beyond 21 days was associated with a 1.02- to 1.23-fold increase in the odds of postoperative delirium (OR, 1.12; P = 0.02). CONCLUSIONS Transfusion of red cell units that have been stored for >14 days is not associated with increased odds of delirium. However, each additional day of storage >14 or 21 days may be associated with increased odds of postoperative delirium in patients undergoing cardiac surgery. More research is needed to further characterize the association between delirium and storage duration of transfused red cell units.


title: Correction to: Prognostic Value of Tumor Volume in Glioblastoma Patients: Size Also Matters for Patients with Incomplete Resection.

text: Due to a metadata tagging error the names of Stephanie E. Combs and Jan S. Kirschke were indexed incorrectly. Stephanie E. is the author's given name, and Jan S. is the author's given name.


title: Achieving aesthetic results in facial reconstructive microsurgery: planning and executing secondary refinements.

text: BACKGROUND Free tissue transfer to improve bulk and contour in facial deformities has been proven useful, yet refinements that turn an acceptable result into an excellent result are essential to reconstruction. The authors reviewed their experience and described these refinements. METHODS The charts of 371 free tissue transfer cases (1989 to 2010) performed by the senior author (J.W.S.) were reviewed. Free tissue transfer of a circumflex scapular variant flap or superficial inferior epigastric was performed to treat deformities arising from hemifacial atrophy (n = 126), hemifacial microsomia (n = 89), radiation therapy (n = 40), bilateral malformations including lupus and polymyositis (n = 50), other congenital anomalies (n = 25), facial palsy (n = 17), and burns and trauma (n = 24). RESULTS Revision surgery planning began at initial flap operation where the flap was stretched maximally and interdigitated with recipient tissue. More tissue was required in the malar region. Revision refinement was indicated in all cases (after 6 months). Flap revision involved liposuction, debulking, reelevation, and release of tethering, followed by tissue rearrangement by means of advancement, rotation, transposition, and/or turnover flaps of subcutaneous tissues from the previous free flap. The jawline frequently required more debulking. Periorbital reconstruction was combined with lower lid support with or without canthal repositioning. Conventional face-lift techniques with the flap as superficial musculoaponeurotic system augmented the result. Autologous fat injection to the alar rim, medial canthus, upper eyelid, and lip was a useful adjunct. Severe lip deficiencies were addressed with local flaps. CONCLUSION The keys to improving results were continual critical reassessment, open-mindedness to new approaches, and maintaining high expectations. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.


COVID-19: An initial view from the Scottish critical care frontline.


title: Intracerebral Hemorrhage and Outcome After Thrombolysis in Stroke Patients Using Selective Serotonin-Reuptake Inhibitors.

text: BACKGROUND AND PURPOSE Selective serotonin-reuptake inhibitors (SSRIs) impair platelet function and have been linked to a higher risk of spontaneous intracerebral hemorrhage-an association that may be augmented by oral anticoagulants (OAC). We aimed to assess whether preadmission treatment with SSRIs in patients with acute ischemic stroke is associated with post-thrombolysis symptomatic intracerebral hemorrhage (sICH) and functional outcome. METHODS A multicenter retrospective analysis was conducted in prospective registries of patients treated by thrombolysis within 4.5 hours of stroke onset. The association between preadmission treatment with SSRIs and sICH (ECASS II definition [European Cooperative Acute Stroke Study]) or unfavorable 3-month outcome (modified Rankin Scale >2) was assessed by logistic regression, taking into account potential interaction with concomitant use of antithrombotics. RESULTS Six thousand two hundred forty-two patients were included (mean age, 70.1±14.0 years; median National Institutes of Health Stroke Scale, 9 [5-16]). Preadmission treatment with SSRIs was present in 4.3% (n=266) of patients. Overall, SICH rate was 3.9% (95% confidence interval [CI], 3.5%-4.4%; n=244), and SSRI use was not significantly associated with sICH in unadjusted (odds ratio [OR], 1.28; 95% CI, 0.72-2.27) or adjusted (OR, 1.30; 95% CI, 0.71-2.40) analysis. However, there was a significant interaction of concomitant use of OACs (international normalized ratio <1.7) and SSRI for occurrence of sICH (P=0.01). SICH was significantly more frequent in patients taking both OAC and SSRI (23.1%; 95% CI, 8.2%-50.3%) than in patients taking OAC but not SSRI (adjusted OR, 9.04; 95% CI, 1.95-41.89). Preadmission use of SSRI was associated with unfavorable 3-month outcome (unadjusted OR, 1.90; 95% CI, 1.48-2.46; adjusted OR, 1.59; 95% CI, 1.15-2.19). CONCLUSIONS Preadmission treatment with SSRIs was not significantly associated with an increased risk of post-thrombolysis sICH in this cohort study. However, subgroup analysis suggested an increased risk of sICH in patients taking both SSRI and OAC. Preadmission treatment with SSRIs was associated with unfavorable outcome, which may reflect the prognostic significance of prestroke depression.


title: Clinical and economic assessment of diabetic foot ulcer debridement with collagenase: results of a randomized controlled study.

text: BACKGROUND Despite significant advances, the treatment of diabetic foot ulcers (DFUs) remains a major therapeutic challenge for clinicians, surgeons, and other health care professionals. There is an urgent need for new strategies with clinically effective interventions to treat DFUs to reduce the burden of care in an efficient and cost-effective way. OBJECTIVE This randomized trial evaluated and compared the clinical effectiveness, tolerability, and costs of clostridial collagenase ointment (CCO) debridement to that of debridement using saline moistened gauze (SMG) and selective sharp debridement for the treatment of DFUs. METHODS Randomized, controlled, parallel group, multicenter, open-label, 12-week study of 48 patients with neuropathic DFUs randomized to 4 weeks of treatment with either CCO or SMG after baseline surgical debridement. The primary end point was the condition of the ulcer bed at the end of treatment as measured using a standardized wound assessment tool. Secondary end points were the percentage of reduction in wound area and therapeutic response rates. Adverse events were monitored for the tolerability analysis. In addition, a comparative cost-effectiveness analysis was performed from the perspective of the Centers for Medicare and Medicaid Services as a payer. RESULTS Both the CCO and SMG groups had significantly improved wound assessment scores after 4 weeks of treatment (CCO, -2.5, P = 0.007; SMG, -3.4, P = 0.006). Only CCO treatment resulted in a statistically significant decrease from baseline in the mean wound area at the end of treatment (P = 0.0164) and at the end of follow-up (P = 0.012). In addition, the CCO group exhibited a significantly better response rate at the end of follow-up compared with the SMG group (0.92 vs 0.75, P < 0.05). Reported adverse events were similar between the 2 treatment groups. None of the reported adverse events were considered to be related to treatment. The economic analysis indicated that the direct mean costs per responder in the physician office setting of care were $832 versus $1042 for the CCO group versus the SMG group, whereas the direct mean costs per responder in the hospital outpatient department setting were $1607 versus $1980. CONCLUSIONS CCO treatment provides equivalent debridement of DFUs similar to SMG while fostering better progress toward healing as measured by decreasing wound area over time and improved response rates at the end of follow-up. In addition, CCO yields a more favorable cost-effectiveness ratio in both the physician office and hospital outpatient department settings of care. ClinicalTrials.gov identifier: NCT01056198.


[Role of the cardiac surgeon in the COVID-19 hospital].