title: Knowledge, attitudes, experience and behaviour of frontline health care workers during the early phase of 2009 influenza A(H1N1) pandemic, Birmingham, UK.

text: OBJECTIVES During the early ('containment') phase of the influenza A(H1N1) pandemic, when the severity of the pandemic was unclear, health care workers (HCWs) across the UK were deployed to swab and prescribe antiviral drugs to suspected cases. This study describes the knowledge, attitudes, experience and behaviour of frontline HCWs in Birmingham, West Midlands, during this period. METHODS During June 2009, a 25-item semi-structured questionnaire was used to survey HCWs who undertook defined clinical duties as part of the public health response during the early phase of the pandemic. Participants were clinical staff based in a primary care out-of-hours service provider. RESULTS The response rate was 50% (n = 20). All respondents provided direct clinical care that necessitated prolonged close contact with potentially infectious cases. Knowledge and use of personal protective equipment and infection control procedures was consistently high. However, the main source of infection control advice was local guidance. Uptake of, and attitude towards, vaccination as a preventive measure and antiviral prophylaxis was poor. CONCLUSIONS HCWs were prepared to provide an essential health care response during the pandemic even when the severity of disease was unclear. However, more needs to be done to change health care workers' negative attitudes towards taking antivirals and receiving influenza vaccination.


title: Bronchoscopic removal of staple-line reinforcement material.

text: We report a case of a 60-year-old man who presented with severe productive cough caused by an endobronchial foreign body, which was due to the migration of a staple-line reinforcement material (Seamguard, W.L.Gore & Associates, Inc., Flagstaff, AZ). This material was placed over 5 years ago during a right upper lobe lobectomy for a poorly differentiated adenocarcinoma, (T1N0M0). We were able to remove the entire staple line by performing 2 separate flexible bronchoscopic interventions during a 1-year period without any consequences, thereby preventing an open thoracotomy. Our technique involved trimming the projecting reinforcement material with endoscopic scissors and removing it by pulling or pushing the staple line with a grasping forceps. Three-dimensional computed tomographic scanning was useful to detect the exact anatomic location and relation of the bronchial airway, great vessels, and pulmonary tissue to the foreign body. The use of absorbable staple-line reinforcement could avoid such a complication.


title: The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review.

text: BACKGROUND Vital signs, i.e. respiratory rate, oxygen saturation, pulse, blood pressure and temperature, are regarded as an essential part of monitoring hospitalized patients. Changes in vital signs prior to clinical deterioration are well documented and early detection of preventable outcomes is key to timely intervention. Despite their role in clinical practice, how to best monitor and interpret them is still unclear. OBJECTIVE To evaluate the ability of vital sign trends to predict clinical deterioration in patients hospitalized with acute illness. DATA SOURCES PubMed, Embase, Cochrane Library and CINAHL were searched in December 2017. STUDY SELECTION Studies examining intermittently monitored vital sign trends in acutely ill adult patients on hospital wards and in emergency departments. Outcomes representing clinical deterioration were of interest. DATA EXTRACTION Performed separately by two authors using a preformed extraction sheet. RESULTS Of 7,366 references screened, only two were eligible for inclusion. Both were retrospective cohort studies without controls. One examined the accuracy of different vital sign trend models using discrete-time survival analysis in 269,999 admissions. One included 44,531 medical admissions examining trend in Vitalpac Early Warning Score weighted vital signs. They stated that vital sign trends increased detection of clinical deterioration. Critical appraisal was performed using evaluation tools. The studies had moderate risk of bias, and a low certainty of evidence. Additionally, four studies examining trends in early warning scores, otherwise eligible for inclusion, were evaluated. CONCLUSIONS This review illustrates a lack of research in intermittently monitored vital sign trends. The included studies, although heterogeneous and imprecise, indicates an added value of trend analysis. This highlights the need for well-controlled trials to thoroughly assess the research question.


title: Cardiac cycle-related volume change in unruptured cerebral aneurysms: a detailed volume quantification study using 4-dimensional CT angiography.

text: BACKGROUND AND PURPOSE The hemodynamic factors of aneurysms were recently evaluated using computational fluid dynamics in a static vessel model in an effort to understand the mechanisms of initiation and rupture of aneurysms. However, few reports have evaluated the dynamic wall motion of aneurysms due to the cardiac cycle. The objective of this study was to quantify cardiac cycle-related volume changes in aneurysms using 4-dimensional CT angiography. METHODS Four-dimensional CT angiography was performed in 18 patients. Image data of 1 cardiac cycle were divided into 10 phases and the volume of the aneurysm was then quantified in each phase. These data were also compared with intracranial vessels of normal appearance. RESULTS The observed cardiac cycle-related volume changes were in good agreement with the sizes of the aneurysms and normal vessels. The cardiac cycle-related volume changes of the intracranial aneurysms and intracranial normal arteries were 5.40%±4.17% and 4.20±2.04%, respectively, but these did not differ statistically (P=0.12). CONCLUSIONS We successfully quantified the volume change in intracranial aneurysms and intracranial normal arteries in human subjects. The data may indicate that cardiac cycle-related volume changes do not differ between unruptured aneurysms and normal intracranial arteries, suggesting that the global integrity of an unruptured aneurysmal wall is not different from that of normal intracranial arteries.


title: Opened Proton Pump Inhibitor Capsules Reduce Time to Healing Compared With Intact Capsules for Marginal Ulceration Following Roux-en-Y Gastric Bypass.

text: BACKGROUND & AIMS Marginal ulceration, or ulceration at the gastrojejunal anastomosis, is a common complication of Roux-en-Y gastric bypass (RYGB). Acidity likely contributes to the pathophysiology, and proton pump inhibitors (PPIs) frequently are prescribed for treatment. However, patients with gastric bypass only have a small gastric pouch and rapid small-bowel transit, which limits the opportunity for capsule breakdown and PPI absorption. Soluble PPIs (open capsules [OCs]) might be absorbed more easily than intact capsules (ICs). We compared time to ulcer healing, number of endoscopic procedures, and use of health care for patients with marginal ulceration who received PPIs in OC vs IC form. METHODS We performed a retrospective study of 164 patients diagnosed with marginal ulceration who underwent RYGB at the Brigham and Women's Hospital from 2000 through 2015. Patients received high-dose PPIs and underwent repeat endoscopy every 3 months until ulcer healing was confirmed. We used time-to-event analysis with a Cox proportional hazards model to evaluate the association between mode of PPI administration and time to ulcer healing, in addition to Cox multivariate regression analysis. Total charge (procedural and maintenance) was determined by comparison of categorized charges incurred from time of ulcer diagnosis to resolution. The primary outcome was time to healing of marginal ulceration in RYGB patients receiving high-dose PPIs in OC vs IC form. RESULTS A total of 162 patients were included (115 received OC and 49 received IC). All patients were followed up until ulcer healing was confirmed. The median time to ulcer healing was 91.0 days for the OC group vs 342.0 days for the IC group (P < .001). OC was the only independent predictor of time to ulcer healing (P < .001) when we controlled for known risk factors. The number of endoscopic procedures (P = .02) and overall health care utilization (P = .05) were lower in the OC than the IC group. CONCLUSIONS Patients with marginal ulceration after RYGB who receive OC PPIs have shorter ulcer healing times, fewer endoscopic procedures, and use less health care resources compared with patients who receive IC PPIs. Given these results and the high prevalence of marginal ulceration in this patient population, the use of OC PPIs is a low-risk, low-cost alternative that should be considered.


title: Serum Cholinesterase Levels Are Associated With 2-Year Ischemic Outcomes After Angioplasty and Stenting for Peripheral Artery Disease.

text: PURPOSE To prospectively investigate the associations of serum cholinesterase (CHE) levels with ischemic outcomes after angioplasty and stenting for lower limb peripheral artery disease (PAD). METHODS A prospective cohort study enrolled 108 patients with Rutherford category 2-3 ischemia who had successful primary unilateral angioplasty and self-expanding bare metal stent implantation for superficial femoral artery (SFA) stenosis. The primary endpoint was a composite of nonfatal myocardial infarction, nonfatal stroke or transient ischemic attack, cardiovascular death, or >80% target lesion restenosis within 2 years after peripheral angioplasty. Target lesion restenosis (restenosis endpoint) and the composite of the aforementioned atherothrombotic events (atherothrombotic endpoint) within 2-year follow-up were defined as secondary endpoints. RESULTS CHE levels were not available in 4 patients due to technical problems and 4 patients were lost to follow-up. The remaining 100 patients (median age 65 years; 62 men) met the minimum sample size requirement for statistical analysis. Median CHE levels were significantly lower in patients who subsequently experienced the primary endpoint compared with patients without ischemic events [7.1 (IQR 6.3-8.1) vs 8 (IQR 7-9.3) kU/L, p=0.007]. A CHE level <8.3 kU/L was identified as the best cutoff value to predict the primary endpoint, providing an 82.1% sensitivity and 44.3% specificity. The primary endpoint occurred significantly more often in patients with low CHE <8.3 kU/L than in patients with higher CHE levels (32 vs 7 patients, p=0.01). In multivariable Cox regression analysis, low CHE was associated with a 2.6-fold increased risk (95% CI 1.1 to 5.9, p=0.03) of the primary endpoint. Moreover, patients who suffered the secondary restenosis endpoint had significantly lower median CHE levels than patients without restenosis [7.1 (IQR 6.3-8.2) vs 7.9 (IQR 7-8.9) kU/L, p=0.02], and restenosis occurred more frequently in patients with low CHE compared with those with higher CHE levels (27 vs 7 patients, p=0.04). CONCLUSION Low CHE is associated with an increased risk of long-term adverse ischemic events following SFA angioplasty with stent implantation for PAD.


More than 80 clinical trials launch to test coronavirus treatments.


title: Emerging trends in the outsourcing of medical and surgical care.

text: As total health care expenditures are expected to constitute an increasing portion of the US gross domestic product during the coming years, the US health care system is anticipating a historic spike in the need for care. Outsourcing medical and surgical care to other nations has expanded rapidly, and several ethical, legal, and financial considerations require careful evaluation. Ultimately, the balance between cost savings, quality, and patient satisfaction will be the key determinant in the future of medical outsourcing.


title: Identification and characterization of a porcine monocytic cell line supporting porcine reproductive and respiratory syndrome virus (PRRSV) replication and progeny virion production by using an improved DNA-launched PRRSV reverse genetics system.

text: In this study, an improved DNA-launched (plasmid DNA transfection-based) reverse genetics system with reduced cost and labor was developed for porcine reproductive and respiratory syndrome virus (PRRSV) by introduction of ribozyme elements at both termini of the viral genomic cDNA that were placed under the control of a eukaryotic hybrid promoter. The rescue efficacy of PRRSV with this system was approximately 10-50-fold higher than the in vitro-transcribed RNA-based system and the traditional DNA-launched system without the engineered ribozyme elements, as determined by reporter GFP level in transfected cells and the peak titer of the recovery virus. By using this new reverse genetics system, we identified and characterized a porcine monocytic cell line, 3D4/31, capable of supporting PRRSV replication, progeny virion production, and attachment on the cell surface. The establishment of this improved reverse genetic system and the identification of a porcine monocytic cell line supporting PRRSV replication will aid future studies of host-virus interaction of PRRSV.


title: USE OF COMPUTED TOMOGRAPHY FOR INVESTIGATION OF RHINITIS AND SINUSITIS IN A GREATER RHEA (RHEA AMERICANA).

text: Sinusitis is a common finding in avian species; however, it presents unique treatment challenges in ratites. A 6-yr-old male greater rhea ( Rhea americana ) presented acutely with right infraorbital sinus swelling and chemosis. Oral antibiotics were prescribed based on bacterial culture results with incomplete resolution of clinical signs. A computed tomography scan of the skull demonstrated a mixed-density soft tissue mass with extensive destruction of the right nasal bone, hard palate, maxilla, and frontal bone. The affected tissue was surgically resected and histopathology was consistent with inspissated necrotic tissue. Aerobic culture of the mass grew a multidrug-resistant Escherichia coli and was treated with amikacin. Ten months postsurgery, no further clinical signs were observed. Advanced diagnostic imaging with computed tomography and surgical therapy facilitated complete resolution of this resistant bacterial sinusitis in a species that is not typically amenable to frequent handling and restraint.


Coronavirus: hospitals must learn from past pandemics.


title: Threshold parameters for a model of epidemic spread among households and workplaces.

text: The basic reproduction number R0 is one of the most important concepts in modern infectious disease epidemiology. However, for more realistic and more complex models than those assuming homogeneous mixing in the population, other threshold quantities can be defined that are sometimes more useful and easily derived in terms of model parameters. In this paper, we present a model for the spread of a permanently immunizing infection in a population socially structured into households and workplaces/schools, and we propose and discuss a new household-to-household reproduction number RH for it. We show how RH overcomes some of the limitations of a previously proposed threshold parameter, and we highlight its relationship with the effort required to control an epidemic when interventions are targeted at randomly selected households.


title: Robot-assisted laparoscopy, natural orifice transluminal endoscopy, and single-site laparoscopy in reproductive surgery.

text: Minimally invasive gynecologic surgery is continuously pushing its limits by embracing ever more sophisticated technology. This is also true for reproductive surgery, arguably the birthplace of gynecologic endoscopy, where minimally invasive treatment of uterine, tubal, ovarian, and peritoneal pathology has long become the gold standard. This article describes in some detail three novel minimally invasive surgery approaches that have seen the light during the past decade: robot-assisted laparoscopic surgery, natural orifice transluminal endoscopic surgery, and single-incision laparoscopic surgery. These fascinating technologies, far from being widely adopted, are sure to generate scientific controversy for years to come. Nonetheless, they follow in the footsteps of the tradition of innovation that is a defining aspect of our specialty and hold the promise to potentially revolutionize the field of reproductive surgery.


title: Two-criteria optimisation problem for ventral hernia repair.

text: Two-criteria optimisation problem related to laparoscopic ventral hernia repair is formulated in this paper. An optimal implant from a given set and its orientation is sought. The implant is subjected to kinematic extortions due to a patient's body movement and intra-abdominal pressure. The first criterion of the optimisation problem deals with the reaction force in the implant fastener, while the deflection of the implant constitutes the second criterion. A two-stage optimization procedure is proposed and the optimal solution is determined with the aid of minimization of an additional objective function. Numerical examples for typical locations of hernia are provided.


title: Type-III interferon, not type-I, is the predominant interferon induced by respiratory viruses in nasal epithelial cells.

text: As an innate immune response against diverse viral infections, a host induces two types of interferon (IFN), type-I (IFN-β/α) and type-III (IFN-λ). We investigated IFN inductions by respiratory viruses, including respiratory syncytial virus (RSV), measles virus and mumps virus in human nasal epithelial cells (NECs). IFN-λ, but not IFN-β/α, was induced by respiratory virus infection in primary NECs and immortalized NECs through transfection with the human telomerase reverse transcriptase gene (hTERT-NECs). In contrast, both IFN-λ and IFN-β/α were induced by RSV infection in human bronchiolar carcinoma cell line A549. Suppression of retinoic acid-inducible gene-I (RIG-I) expression using siRNA significantly reduced IFN-λ1 production in RSV-infected hTERT-NECs, while suppression of melanoma differentiation-associated gene 5 (MDA5) expression did not. Exogenous IFN-λ1 treatment suppressed RSV replication and chemokine induction in hTERT-NECs. These data indicate that IFN-λ, but not IFN-β/α, contributes to the main first line defense via RIG-I-dependent pathway against respiratory virus infection in NECs.


title: Tissue expanders: early experience of a novel treatment option for perineal herniation.

text: PURPOSE Acquired perineal hernias through the reconstructed pelvic floor can complicate radical pelvic operations including abdominoperineal resection of rectum. Operative intervention is indicated for symptomatic hernias. There is a lack of consensus as to the best operative technique. Here we present a novel method for repairing perineal herniation using saline-filled tissue expanders. METHODS Perineal hernia repair may be affected either via an abdominal or via a perineal approach. After adhesiolysis to remove small bowel from the pelvis, a Natrelle™ 150SH tissue expander (Allergan Inc., California, USA) or Siltex™ Round Becker (Mentor Medical Systems, Holland) of appropriate size is inserted in the pelvis and the button placed in a subcutaneous pocket in the perineal skin. The tissue expander is then filled with saline until it fills the true anatomical pelvis without bladder compression. The volume may be increased or decreased postoperatively by accessing the subcutaneous button. RESULTS We have performed this procedure in three patients with some success, all of whom have experienced symptomatic relief. The tissue expander may subsequently be removed without recurrence of symptoms, due to the fibrous capsule which forms. One patient required re-operation to elevate a herniating tissue expander. The tissue expander was removed earlier than anticipated to avoid deep pelvic infection in another. CONCLUSION Our early experience suggests that using saline-filled tissue expanders to fill dead space in the pelvis after radical surgery may prove to be a valuable approach to perineal herniation, particularly if adjuvant radiotherapy is planned.


title: Arthroscopically Assisted Transosseous Foveal Repair of Triangular Fibrocartilage Complex.

text: The radioulnar ligament of the triangular fibrocartilage complex (TFCC), especially the deep fibers inserted at the ulnar fovea, is the key component for the distal radioulnar joint (DRUJ) stability. Traumatic injuries to the TFCC foveal insertion would cause DRUJ instability. Traditionally, arthroscopic techniques of the TFCC repair are suturing the ulnar-sided disruption peripherally to the dorsal or ulnar capsule instead of suturing the TFCC to the fovea and thus fail to restore the DRUJ stability if the TFCC is detached from the fovea. Recently, some arthroscopic foveal repair techniques have been reported using a suture anchor or transosseous sutures to address the foveal tear. This technical note describes an arthroscopic transosseous technique to reattach the foveal-disrupted TFCC. A 1.6-mm small osseous tunnel is created on the radial border of the fovea and 4 sutures are passed into the tunnel by using a 16-gauge needle. The TFCC could be sutured arthroscopically with these 4 sutures and be compressed against the fovea. Our technique provides not only a good suture construct for TFCC foveal reattachment but also an anatomic contact surface between the torn TFCC and its foveal footprint for healing. We recommend this technique as an alternative for repairing TFCC foveal tear.


Intersectionality as a lens to the COVID-19 pandemic: implications for sexual and reproductive health in development and humanitarian contexts.


title: Outcomes of Locoregional Tumor Therapy for Patients with Hepatocellular Carcinoma and Transjugular Intrahepatic Portosystemic Shunts.

text: PURPOSE Locoregional therapy for hepatocellular carcinoma (HCC) can be challenging in patients with a transjugular intrahepatic portosystemic shunt (TIPS). This study compares safety and imaging response of ablation, chemoembolization, radioembolization, and supportive care in patients with both TIPS and HCC. METHODS This retrospective study included 48 patients who had both a TIPS and a diagnosis of HCC. Twenty-nine of 48 (60%) underwent treatment for HCC, and 19/48 (40%) received best supportive care (i.e., symptomatic management only). While etiology of cirrhosis and indication for TIPS were similar between the two groups, treated patients had better baseline liver function (34 vs. 67% Child-Pugh class C). Tumor characteristics were similar between the two groups. A total of 39 ablations, 17 chemoembolizations, and 10 yttrium-90 radioembolizations were performed on 29 patients. RESULTS Ablation procedures resulted in low rates of hepatotoxicity and clinical toxicity. Post-embolization/ablation syndrome occurred more frequently in patients undergoing chemoembolization than ablation (47 vs. 15%). Significant hepatic dysfunction occurred more frequently in the chemoembolization group than the ablation group. Follow-up imaging response showed objective response in 100% of ablation procedures, 67% of radioembolization procedures, and 50% of chemoembolization procedures (p = 0.001). When censored for OLT, patients undergoing treatment survived longer than patients receiving supportive care (2273 v. 439 days, p = 0.001). CONCLUSIONS Ablation appears to be safe and efficacious for HCC in patients with TIPS. Catheter-based approaches are associated with potential increased toxicity in this patient population. Chemoembolization appears to be associated with increased toxicity compared to radioembolization.


title: Giant vertebral aneurysm: A case report detailing successful treatment with combined stenting and surgery.

text: Background Giant aneurysms (>25 mm) arising from the vertebral artery (VA) often present with slow progression of symptoms and signs because of gradual brainstem and cranial nerve compression. The underlying pathophysiology is not well understood, and treatment, wherever possible, is tailored to each singular case. Endovascular management does not usually solve the problem of mass compression, whereas surgical treatment involves several complications. Case Description A 58-year-old woman presented with a continuously growing giant right VA aneurysm, partially thrombosed, even after endovascular treatment (placement of two diversion flow stents). Operative partial aneurysmectomy and intraoperative placement of an endovascular balloon allowed removal from circulation without significant bleeding with a good neurological outcome. Conclusions The variability of VA thrombosed giant aneurysms implies a customized therapeutic strategy. Combined endovascular techniques and surgical clipping allow safe and successful trapping and aneurysmectomy. This case highlights the benefits of treating similar pathologies with a combination of both techniques.


title: Adoption of robotic sacrocolpopexy at an academic institution.

text: OBJECTIVES To describe the introduction of robotic sacrocolpopexy (RSC) in a urogynecology fellowship program, including operative times and patient outcomes. METHODS Data were retrospectively extracted from all women who underwent RSC between May 1, 2009 and December 31, 2011 by a single urogynecologist with fellow and resident assistance. Patient demographics, operative times, intraoperative complications, length of hospital stay, and postoperative course were analyzed. Cases were grouped chronologically in blocks of 10 for analysis. Trend analysis of operative time was done with linear and negative binomial regression. Fisher's exact test was used to compare complications among blocks. RESULTS Fifty-two patients (mean age 58.5±8.4 years) underwent RSC. The majority (75%) had stage III prolapse. Forty-one patients (79%) had concomitant procedures, including supracervical hysterectomy (44%), bilateral salpingo-oophorectomy (9.6%), midurethral sling (9.6%), and lysis of adhesions (40.4%). There was no trend toward decreased operative time with increased surgical experience (linear regression P=.453, negative binomial regression P=.998). Mean operative time was 301.1±53.1 minutes (range 205-440). Overall complication rate was not associated with number of robotic cases performed (P=.771). Nine cases (17.3%) were converted to laparotomy. Five of these occurred in the first 15 cases. There were 2 bladder injuries (3.8%) and no bowel injuries. CONCLUSIONS Although a learning curve was not demonstrated, the adoption of RSC into a urogynecology fellowship program yields similar rates of bladder/bowel injuries, postoperative complications, and operative times when compared with other published studies.


title: Glial ATP and Large Pore Channels Modulate Synaptic Strength in Response to Chronic Inactivity.

text: A key feature of neurotransmission is its ability to adapt to changes in neuronal environment, which is essential for many brain functions. Homeostatic synaptic plasticity (HSP) emerges as a compensatory mechanism used by neurons to adjust their excitability in response to changes in synaptic activity. Recently, glial cells emerged as modulators for neurotransmission by releasing gliotransmitters into the synaptic cleft through pathways that include P2X7 receptors (P2X7R), connexons, and pannexons. However, the role of gliotransmission in the activity-dependent adjustment of presynaptic strength is still an open question. Here, we investigated whether glial cells participate in HSP upon chronic inactivity and the role of adenosine triphosphate (ATP), connexin43 hemichannels (Cx43HCs), and pannexin1 (Panx1) channels in this process. We used immunocytochemistry against vesicular glutamate transporter 1 (vGlut1) to estimate changes in synaptic strength in hippocampal dissociated cultures. Pharmacological manipulations indicate that glial-derived ATP and P2X7R are required for HSP. In addition, inhibition of Cx43 and Panx1 channels reveals a pivotal role for these channels in the compensatory adjustment of synaptic strength, emerging as new pathways for ATP release upon inactivity. The involvement of Panx1 channels was confirmed by using Panx1-deficient animals. Lacking Panx1 in neurons is sufficient to prevent the P2X7R-dependent upregulation of presynaptic strength; however, the P2X7R-dependent compensatory adjustment of synapse density requires both neuronal and glial Panx1. Together, our data supports an essential role for glial ATP signaling and Cx43HCs and Panx1 channels in the homeostatic adjustment of synaptic strength in hippocampal cultures upon chronic inactivity.


title: The effect of alveolar dead space on the measurement of end-expiratory lung volume by modified nitrogen wash-out/wash-in in lavage-induced lung injury.

text: BACKGROUND The accuracy of end-expiratory lung volume measurement by the modified nitrogen wash-out/wash-in method (EELV-N(2)) depends on the precise determination of carbon dioxide elimination (V(CO(2))), which is affected by alveolar dead space (V(D-alv)). The purpose of this study was to investigate the influence of V(D-alv) on EELV-N(2). METHODS Six piglets with lavage-induced acute lung injury were mechanically ventilated in a decremental PEEP trial that was reduced from 20 to 4 cm H(2)O in steps of 4 cm H(2)O every 10 min. EELV was measured by the modified EELV-N(2) method and computed tomography scan (EELV-CT), volumetric capnography, blood gas measurements, and hemodynamic data were recorded at each PEEP level. The data were divided into higher and lower PEEP groups. RESULTS During the decremental PEEP trial, EELV-N(2) exhibited a high correlation (r(2) = 0.86, P < .001) with EELV-CT, with a bias of -48.6 ± 150.7 mL (1 ± 18%). In the higher PEEP group, EELV-N(2) was not correlated with EELV-CT, with a bias of -168.1 ± 171.5 mL (-14 ± 14%). However, in the lower PEEP group, EELV-N(2) exhibited a high correlation (r(2) = 0.86, P < .001) with EELV-CT, with a bias of 11.2 ± 97.2 mL (6 ± 17%). The measurement bias was negatively correlated with V(D-alv) (r(2) = 0.44, P = .04) and V(CO(2)) (r(2) = 0.47, P = .03) in the higher PEEP group. CONCLUSIONS In this surfactant-depleted model, EELV measurement by the modified EELV-N(2) method reveals a systematic underestimation at high PEEP levels that is partly due to an increase in V(D-alv).


title: Methods for sampling of airborne viruses.

text: To better understand the underlying mechanisms of aerovirology, accurate sampling of airborne viruses is fundamental. The sampling instruments commonly used in aerobiology have also been used to recover viruses suspended in the air. We reviewed over 100 papers to evaluate the methods currently used for viral aerosol sampling. Differentiating infections caused by direct contact from those caused by airborne dissemination can be a very demanding task given the wide variety of sources of viral aerosols. While epidemiological data can help to determine the source of the contamination, direct data obtained from air samples can provide very useful information for risk assessment purposes. Many types of samplers have been used over the years, including liquid impingers, solid impactors, filters, electrostatic precipitators, and many others. The efficiencies of these samplers depend on a variety of environmental and methodological factors that can affect the integrity of the virus structure. The aerodynamic size distribution of the aerosol also has a direct effect on sampler efficiency. Viral aerosols can be studied under controlled laboratory conditions, using biological or nonbiological tracers and surrogate viruses, which are also discussed in this review. Lastly, general recommendations are made regarding future studies on the sampling of airborne viruses.


title: Screening of COVID-19 in children admitted to the hospital for acute problems: preliminary data.

text: BACKGROUND The new Coronavirus identified in Whuan at the end of 2019 (SARS-CoV-2) belongs to the Beta Coronavirus genus and is responsible for the new Coronavirus 2019 pandemia (COVID-19). Infected children may be asymptomatic or present fever, dry cough, fatigue or gastrointestinal symptoms. The CDC recommends that clinicians should decide to test patients based on the presence of signs and symptoms compatible with COVID-19. MATERIAL AND METHODS 42 children (the majority < 5 years of age) were referred, to our Pediatric Department, as possible cases of COVID-19 infection. Blood analysis, chest X-ray, and naso-oropharyngeal swab specimens for viral identification of COVID-19 were requested. RESULTS None of the screened children resulted positive for COVID-19 infection. At first presentation, the most frequent signs and symptoms were: fever (71.4%), fatigue (35.7%) and cough (30.9%). An high C-reactive protein value and abnormalities of chest X-ray (bronchial wall thickening) were detected in 26.2% and 19% of patients, respectively. Almost half of patients (45.2%) required hospitalization in our Pediatric Unit and one patient in Intensive Care Unit. CONCLUSIONS Testing people who meet the COVID-19 suspected case definition criteria is essential for clinical management and outbreak control. Children of all ages can get COVID-19, although they appear to be affected less frequently than adults, as reported in our preliminary survey. Further studies are needed to confirm our observations.


Covid-19: a remote assessment in primary care.


title: Transvenous Embolization in Pediatric Plexiform Arteriovenous Malformations.

text: BACKGROUND Transvenous embolization is a developing concept for curative therapy of cerebral arteriovenous malformations (AVMs). The feasibility of this endovascular method has not been reported in children. OBJECTIVE To report our experience treating pediatric AVMs with the transvenous approach (TVA). METHODS A cohort of 7 pediatric patients (younger than 18 years of age) who underwent the TVA for cerebral AVMs between January 2012 and January 2014. The TVA was used alone or in conjunction with other arterial approaches in definitive embolization sessions. Patient demographics, AVM characteristics, clinical outcomes, and angiographic results were independently assessed. Pial arteriovenous fistulae and vein of Galen malformations were excluded. Control angiograms were obtained at 6 months, and curative treatment was determined by the anatomic obliteration of the nidus. RESULTS All patients had anatomic exclusion of the AVM. The mean size was 2 ± 0.6 cm, and hemorrhage was the most common presentation (100%, n = 7). Most AVMs were deeply placed (71%, n = 5), and a proximal approach to the nidus was achieved in all cases. Transvenous embolization alone was performed in 3 patients (43%), whereas combined arterial and venous embolization was required in 4 patients (57%). The mean follow-up period was 20.2 ± 10.5 months. There were no hemorrhagic or thromboembolic events, and venous infarction was not documented. No recurrence was documented. CONCLUSION This is the first report that demonstrates the feasibility of transvenous Onyx embolization of AVMs in the pediatric population. Such a technique may be considered in certain AVMs that meet anatomic criteria in which microsurgery and radiosurgery might not be indicated.


The "dangerous" infected patient. An approach to characterizing the risks posed by persons with communicable infectious diseases.


title: [Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia].

text: Objective: To investigate the clinical and coagulation characteristics of the critical Coronavirus disease 2019 (COVID-19) patients with acro-ischemia in the intensive care unit (ICU). Methods: The retrospective study included 7 critical COVID-19 patients with acro-ischemia in a single center in Wuhan, from Feb 4 to Feb 15, 2020. The clinical and laboratory data before and during the ICU stay were analyzed. Results: The median age of 7 patients was 59 years and 4 of them were men. 3 of them were associated with underlying comorbidities. Fever, cough, dyspnea and diarrhea were common clinical symptoms. All patients had acro-ischemia presentations including finger/toe cyanosis, skin bulla and dry gangrene. D-dimer, fibrinogen and fibrinogen degradation product (FDP) were significantly elevated in most patients. Prothrombin time (PT) were prolonged in 4 patients. D-dimer and FDP levels increased progressively when COVID-2019 exacerbated, and 4 patients were diagnosed with definite disseminated intravascular coagulation (DIC). 6 patients received low molecular weight heparin (LMWH) treatment, after which their D-dimer and FDP decreased, but there was no significant improvement in clinical symptoms. 5 patients died finally and the median time from acro-ischemia to death was 12 days. Conclusions: The existence of hypercoagulation status in critical COVID-2019 patients should be monitored closely, and anticoagulation therapy can be considered in selected patients. More clinical data is needed to investigate the role of anticoagulation in COVID-2019 treatment.


title: Ultrasound liver map technique for laparoscopic liver resections: perioperative outcomes are not impaired by technical complexity.

text: Intraoperative liver ultrasound has a crucial role to guide open liver surgery. A 4-step ultrasound liver map technique for laparoscopic liver resection (LLR) has been standardized in our center. The aim of this study was to evaluate outcomes of our technique according to the hepatectomy technical complexity. A difficulty scale (DS) ranging from 1 to 10 was applied to each LLR. A cumulative sum control-chart analysis identified 3 periods of gradually increasing DS. Perioperative outcomes of the 3 periods were compared. 300 LLRs performed between 2006 and 2018 were analyzed. Median DS was 3 for first 100 cases (P1), 5 for cases 101-200 (P2) and 6 for cases 201-300 (P3). A significantly greater percentage of postero-superior segments resections (P1 11%, P2 36%, P3 46%, p < 0.001) were performed in P3. P3 LLRs had a significantly longer transection time (p < 0.001) and wider cut surface area (p < 0.001), but median blood losses were similar among the 3 periods (P1 100 cc, P2 100 cc, P3 140 cc). There were no differences among periods in overall morbidity (P1 12%, P2 17%, P3 17%), major morbidity (P1 1%, P2 2%, P3 3%) and length of hospital stay (5 days in all the three groups). Despite the increasing surgical complexity of LLR, ultrasound liver map technique allows good perioperative outcomes.


title: Optical coherence tomography for glaucoma diagnosis: An evidence based meta-analysis.

text: PURPOSE Early detection, monitoring and understanding of changes in the retina are central to the diagnosis of glaucomatous optic neuropathy, and vital to reduce visual loss from this progressive condition. The main objective of this investigation was to compare glaucoma diagnostic accuracy of commercially available optical coherence tomography (OCT) devices (Zeiss Stratus, Zeiss Cirrus, Heidelberg Spectralis and Optovue RTVue, and Topcon 3D-OCT). PATIENTS 16,104 glaucomatous and 11,543 normal eyes reported in 150 studies. METHODS Between Jan. 2017 and Feb 2017, MEDLINE®, EMBASE®, CINAHL®, Cochrane Library®, Web of Science®, and BIOSIS® were searched for studies assessing glaucoma diagnostic accuracy of the aforementioned OCT devices. Meta-analysis was performed pooling area under the receiver operating characteristic curve (AUROC) estimates for all devices, stratified by OCT type (RNFL, macula), and area imaged. RESULTS 150 studies with 16,104 glaucomatous and 11,543 normal control eyes were included. Key findings: AUROC of glaucoma diagnosis for RNFL average for all glaucoma patients was 0.897 (0.887-0.906, n = 16,782 patient eyes), for macula ganglion cell complex (GCC) was 0.885 (0.869-0.901, n = 4841 eyes), for macula ganglion cell inner plexiform layer (GCIPL) was 0.858 (0.835-0.880, n = 4211 eyes), and for total macular thickness was 0.795 (0.754-0.834, n = 1063 eyes). CONCLUSION The classification capability was similar across all 5 OCT devices. More diagnostically favorable AUROCs were demonstrated in patients with increased glaucoma severity. Diagnostic accuracy of RNFL and segmented macular regions (GCIPL, GCC) scans were similar and higher than total macular thickness. This study provides a synthesis of contemporary evidence with features of robust inclusion criteria and large sample size. These findings may provide guidance to clinicians when navigating this rapidly evolving diagnostic area characterized by numerous options.


title: Impact of Powered and Tissue-Specific Endoscopic Stapling Technology on Clinical and Economic Outcomes of Video-Assisted Thoracic Surgery Lobectomy Procedures: A Retrospective, Observational Study.

text: INTRODUCTION Video-assisted thoracic surgery (VATS) lung resections are complex procedures with a critical role played by endoscopic staplers in the transection of vessels, bronchi, and lung tissue. This retrospective, observational study compared hospital resource use, costs, and complications of VATS lobectomy procedures for whom powered versus manual endoscopic surgical staplers were used. METHODS Patients ≥ 18 years of age undergoing elective VATS lobectomy during an inpatient admission from January 1, 2012 to September 30, 2016 were identified from the Premier Healthcare Database (first admission = index admission). Use of either powered or manual endoscopic staplers during the index admission was identified from hospital administrative records. Multivariable regression analyses adjusting for patient, hospital, and provider characteristics and hospital-level clustering were carried out to compare the following outcomes between the powered and manual stapler groups: hospital length of stay (LOS), operating room time (ORT), hospital costs, complications (bleeding and/or transfusions, air leak complications, pneumonia, and infection), discharge status, and 30-, 60-, and 90-day all-cause readmissions. RESULTS The powered and manual stapler groups comprised 659 patients (mean age 66.1 years; 53.6% female) and 3100 patients (mean age 66.7 years; 54.8% female), respectively. In the multivariable analyses, the powered stapler group had shorter LOS (4.9 vs. 5.9 days, P < 0.001), lower total hospital costs ($23,841 vs. $26,052, P = 0.009), and lower rates of combined hemostasis complications (bleeding and/or transfusions; 8.5% vs. 16.0%, P < 0.001) and transfusions (5.4% vs. 10.9%, P = 0.002), compared with the manual stapler group. Other outcomes did not differ significantly between the study groups. Similar trends were observed in subanalyses comparing devices across predominant manufacturers in each group, and in subanalyses of patients with comorbid chronic obstructive pulmonary disease. CONCLUSION In this analysis of VATS lobectomy procedures, powered staplers were associated with significant benefits with respect to selected types of hospital resource use, costs, and clinical outcomes when compared with manual staplers. FUNDING Johnson & Johnson.


Occupational and environmental health nurses must monitor credible sources for accurate information, provide timely education to workers, and ensure adequate workplace policies to protect their workforce against Middle East Respiratory Syndrome (MERS).


title: Acute abdominal pain due to internal herniation of the sigmoid colon, fallopian tube and left ovary, a rare presentation of Allen Masters syndrome.

text: In 1955, Allen and Masters describe a painful syndrome which associates traumatic delivery to laceration found on the posterior leaf of the broad ligament. Herniation through this defect is a rare entity, accounted for about 4-7% of all internal hernias. Normally, it involves the small bowel. The authors present the case of a multiparous woman admitted at emergency for constipation and abdominal pain. The CT scan showed an extremely rare case of internal hernia of the sigmoid colon, fallopian tube and left ovary through a large defect of the broad ligament. The patient underwent a full laparoscopic surgery that allowed the reduction of the hernia and the suture of the defect with very good outcome.


title: Radiotherapy for cranial and brain metastases from prostate cancer: a systematic review.

text: Intracranial metastasis from prostate cancer is rare. As treatment of castration-resistant prostate cancer improves, the incidence of men with intracranial metastasis from prostate cancer is increasing. Radiation therapy for treatment of intracranial metastasis from prostate cancer is systematically reviewed. A comprehensive review examining peer-reviewed, English language articles from 1990 to 2015 was performed on multiple databases, yielding 1274 articles. These articles were reviewed and selected for studies that met the following inclusion criteria: (1) patients with intracranial metastases from prostate cancer; (2) patients underwent radiation therapy as primary or adjuvant therapy; (3) the sample size of patients was larger than 2. All studies that met inclusion criteria utilized whole-brain radiation therapy (WBRT) in at least one patient. Other treatment regimens included stereotactic radiosurgery (SRS), surgical resection followed by WBRT, as well as concurrent cabazitaxel and WBRT. The range of average time from initial diagnosis of prostate cancer to diagnosis of brain metastasis was 29-45 months. The range of reported median survival time after WBRT was 4-9 months, whereas median survivals after SRS ranged from 9 to 13 months. Intracranial metastases from prostate cancer occur late in the disease process, and are increasing as novel therapies for metastatic disease prolong survival. The reviewed literature suggests that outcomes of patients with prostate cancer intracranial metastases appear similar to those of intracranial metastases from other histologies. Prospective examinations of systemic therapies that cross the blood-brain barrier in conjunction with targeted radiotherapy appear warranted for this increasingly common clinical problem.


title: Robot-assisted radical perineal prostatectomy: first experience of 15 cases.

text: Objective Minimally invasive techniques are increasingly evolving and preferred to reduce surgical induced morbidity and mortality and minimize the challenges of surgical techniques. Especially radical perineal prostatectomy (RPP) includes some challenges like working in a deep and narrow space and challenging ergonomics for the surgeons. Because of these issues open RPP is still performed in experienced centers. In order to reduce these difficulties, robot- assisted radical perineal prostatectomy (r-RPP) is developed. In this study, we report our first clinical results for r-RPP. Material and methods Between November 2016 and February 2017, 15 patients underwent r-RPP in our center. Multiparametric magnetic resonance imaging was performed for all patients to exclude locally advanced disease. The patients with chronic obstructive pulmonary disease and locally advanced prostate cancer were not chosen for r-RPP method. The patient was positioned in the exaggerated lithotomy with 15 degrees of Trendelenburg position. After incision and dissection of subcutaneous tissue, dissection was advanced to the margin of posterior recto-urethral muscle fibers. Then a GelPOINT® device was placed and robotic system was docked. Results The mean age of the patients was 60.2±7.8 years. The mean body mass index of the patients was 28.8±1.9 kg/m2. Four patients had previous major abdominal surgeries. Preoperative mean prostate specific antigen value was 7.3±2.4 ng/mL. The mean prostate volume was 40.8±12.4 cc. Mean perineal dissection time was 60±10.1 minutes. Mean console time and total operation time was 95±11.3 and 167±37.4 minutes, respectively. The mean time of postoperative catheterization was 8.3±1.7 days. Early continence rate was 40% after urethral catheter removal and at 3rd month of the surgery mean continence rate was 94% for all patients. Conclusion We demonstrate that r-RPP is a feasible and efficient method. But still this method needs for further studies in this area.


title: A novel method for creating custom shaped ballistic gelatin trainers using plaster molds.

text: Simulation based procedural training is an effective and frequently used method for teaching vascular access techniques which often require commercial trainers. These can be prohibitively expensive, which allows for homemade trainers made of gelatin to be a more cost-effective and attractive option. Previously described trainers are often rectangular with a flat surface that is dissimilar to human anatomy. We describe a novel method to create a more anatomically realistic trainer using ballistic gelatin, household items, and supplies commonly found in an emergency department such as the plaster wrap typically used to make splints.


title: 'No touch' technologies for environmental decontamination: focus on ultraviolet devices and hydrogen peroxide systems.

text: PURPOSE OF REVIEW This article reviews 'no touch' methods for disinfection of the contaminated surface environment of hospitalized patients' rooms. The focus is on studies that assessed the effectiveness of ultraviolet (UV) light devices, hydrogen peroxide systems, and self-disinfecting surfaces to reduce healthcare-associated infections (HAIs). RECENT FINDINGS The contaminated surface environment in hospitals plays an important role in the transmission of several key nosocomial pathogens including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp., Clostridium difficile, Acinetobacter spp., and norovirus. Multiple clinical trials have now demonstrated the effectiveness of UV light devices and hydrogen peroxide systems to reduce HAIs. A limited number of studies have suggested that 'self-disinfecting' surfaces may also decrease HAIs. SUMMARY Many studies have demonstrated that terminal cleaning and disinfection with germicides is often inadequate and leaves environmental surfaces contaminated with important nosocomial pathogens. 'No touch' methods of room decontamination (i.e., UV devices and hydrogen peroxide systems) have been demonstrated to reduce key nosocomial pathogens on inoculated test surfaces and on environmental surfaces in actual patient rooms. Further UV devices and hydrogen peroxide systems have been demonstrated to reduce HAI. A validated 'no touch' device or system should be used for terminal room disinfection following discharge of patients on contact precautions. The use of a 'self-disinfecting' surface to reduce HAI has not been convincingly demonstrated.


title: A lethal disease model for hantavirus pulmonary syndrome in immunosuppressed Syrian hamsters infected with Sin Nombre virus.

text: Sin Nombre virus (SNV) is a rodent-borne hantavirus that causes hantavirus pulmonary syndrome (HPS) predominantly in North America. SNV infection of immunocompetent hamsters results in an asymptomatic infection; the only lethal disease model for a pathogenic hantavirus is Andes virus (ANDV) infection of Syrian hamsters. Efforts to create a lethal SNV disease model in hamsters by repeatedly passaging virus through the hamster have demonstrated increased dissemination of the virus but no signs of disease. In this study, we demonstrate that immunosuppression of hamsters through the administration of a combination of dexamethasone and cyclophosphamide, followed by infection with SNV, results in a vascular leak syndrome that accurately mimics both HPS disease in humans and ANDV infection of hamsters. Immunosuppressed hamsters infected with SNV have a mean number of days to death of 13 and display clinical signs associated with HPS, including pulmonary edema. Viral antigen was widely detectable throughout the pulmonary endothelium. Histologic analysis of lung sections showed marked inflammation and edema within the alveolar septa of SNV-infected hamsters, results which are similar to what is exhibited by hamsters infected with ANDV. Importantly, SNV-specific neutralizing polyclonal antibody administered 5 days after SNV infection conferred significant protection against disease. This experiment not only demonstrated that the disease was caused by SNV, it also demonstrated the utility of this animal model for testing candidate medical countermeasures. This is the first report of lethal disease caused by SNV in an adult small-animal model.


title: Proper training in laparoscopic hernia repair is necessary to minimize the rising recurrence rate in Japan.

text: INTRODUCTION The Japan Society for Endoscopic Surgery reported that the recurrence rate for inguinal hernia repair in Japan was less than 1% in 2010. However, its 2012 survey found that the recurrence rate had increased to 4% for the transabdominal preperitoneal procedure and 5% for the totally extraperitoneal procedure. We held 14 hernia repair training courses from 2011 to 2016 with help from Covidien. This study aimed to determine the effect of this training on the recurrence rate. METHODS Training was composed of a theoretical revision of inguinal anatomy, dry laboratory suturing, a video lecture, and practice on an animal model. We made inquiries about the length of each surgeon's career, post-training changes in surgical methods, and recurrence rates before and after training. RESULTS We received responses from 159 of 300 trainees (53%). The mean career length was 12.7 ± 8.2 years. The annual number of transabdominal preperitoneal procedures performed increased from 20.9 ± 29.9 to 32.4 ± 56.1 after training (P < 0.001), and the number of totally extraperitoneal procedures increased from 9.5 ± 13.9 to 13.9 ± 16.9 (P = 0.0218). The annual number of procedures performed via the anterior approach decreased from 153.1 ± 28.4 to 28.4 ± 52.2 after training (P < 0.001). The pre-training transabdominal preperitoneal procedure recurrence rate was 0.9%, and this decreased to 0.4% after training. There was no pre-training recurrence rate for the totally extraperitoneal procedure, but this was 0.4% after training. CONCLUSION The high recurrence rate after inguinal hernia repair in Japan was mainly due to inadequate training in the laparoscopic method. Our laparoscopic hernia repair training course achieved low recurrence rates.


Four Strategies for Plastic Surgery Education Amidst the COVID-19 Pandemic.


title: Validity of acute stroke lesion volume estimation by diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomographic Score depends on lesion location in 496 patients with middle cerebral artery stroke.

text: BACKGROUND AND PURPOSE Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) has been used to estimate diffusion-weighted imaging (DWI) lesion volume in acute stroke. We aimed to assess correlations of DWI-ASPECTS with lesion volume in different middle cerebral artery (MCA) subregions and reproduce existing ASPECTS thresholds of a malignant profile defined by lesion volume ≥100 mL. METHODS We analyzed data of patients with MCA stroke from a prospective observational study of DWI and fluid-attenuated inversion recovery in acute stroke. DWI-ASPECTS and lesion volume were calculated. The population was divided into subgroups based on lesion localization (superficial MCA territory, deep MCA territory, or both). Correlation of ASPECTS and infarct volume was calculated, and receiver-operating characteristics curve analysis was performed to identify the optimal ASPECTS threshold for ≥100-mL lesion volume. RESULTS A total of 496 patients were included. There was a significant negative correlation between ASPECTS and DWI lesion volume (r=-0.78; P<0.0001). With regards to lesion localization, correlation was weaker in deep MCA region (r=-0.19; P=0.038) when compared with superficial (r=-0.72; P<0.001) or combined superficial and deep MCA lesions (r=-0.72; P<0.001). Receiver-operating characteristics analysis revealed ASPECTS≤6 as best cutoff to identify ≥100-mL DWI lesion volume; however, positive predictive value was low (0.35). CONCLUSIONS ASPECTS has limitations when lesion location is not considered. Identification of patients with malignant profile by DWI-ASPECTS may be unreliable. ASPECTS may be a useful tool for the evaluation of noncontrast computed tomography. However, if MRI is used, ASPECTS seems dispensable because lesion volume can easily be quantified on DWI maps.


title: Adult stem cells underlying lung regeneration.

text: Despite the massive toll in human suffering imparted by degenerative lung disease, including COPD, idiopathic pulmonary fibrosis and ARDS, the scientific community has been surprisingly agnostic regarding the potential of lung tissue, and in particular the alveoli, to regenerate. However, there is circumstantial evidence in humans and direct evidence in mice that ARDS triggers robust regeneration of lung tissue rather than irreversible fibrosis. The stem cells responsible for this remarkable regenerative process has garnered tremendous attention, most recently yielding a defined set of cloned human airway stem cells marked by p63 expression but with distinct commitment to differentiated cell types typical of the upper or lower airways, the latter of which include alveoli-like structures in vitro and in vivo. These recent advances in lung regeneration and distal airway stem cells and the potential of associated soluble factors in regeneration must be harnessed for therapeutic options in chronic lung disease.


Coronavirus modelling - boost developing world capacity.


title: Movement of airborne contaminants in a hospital isolation room.

text: We analyse the characteristics of a force-ventilated isolation room, and the contributions to transport caused by the movement of people and doors opening/closing. The spread of fine droplets and particles can be understood, to leading order, by considering the movement of passive contaminants. A scaled (1:10) model of an isolation room (with water instead of air) was used to analyse the dilution of a passive contaminant (food dye), released either instantaneously or at a constant rate. The high level of turbulence, typical of isolation rooms, ensures that the dye concentration is uniform within the model room and mixing is perfect, and the measured mean concentration can be predicted theoretically. In a second series of experiments, the exchange generated by a door opening/closing is measured for different opening angles. A dipolar vortex is generated at the tip of the door which moves into the centre of the room, with a large coherent structure moving along the wall. The exchange volume is comparable to the swept volume of the door. Larger droplets and particles do not move passively. Their movement within a turbulent flow is studied by combining a Lagrangian model of particle movement with a kinematic simulation of a pseudo turbulent flow. The results show that while the mean fall velocity of particles is largely unchanged, turbulence significantly enhances horizontal and vertical dispersion. The horizontal spread as a function of the level of turbulence and droplet properties is estimated. The conclusions from both studies are brought together and discussed in the context of the airborne spread of contaminants within a general hospital room.


Iran Without Mandatory Quarantine and with Social Distancing Strategy Against Coronavirus Disease (COVID-19).


title: Molecular design and optimization of 99mTc-labeled recombinant affibody molecules improves their biodistribution and imaging properties.

text: UNLABELLED Affibody molecules are a recently developed class of targeting proteins based on a nonimmunoglobulin scaffold. The small size (7 kDa) and subnanomolar affinity of Affibody molecules enables high-contrast imaging of tumor-associated molecular targets, particularly human epidermal growth factor receptor type 2 (HER2). (99m)Tc as a label offers advantages in clinical practice, and earlier studies demonstrated that (99m)Tc-labeled recombinant Affibody molecules with a C-terminal cysteine could be used for HER2 imaging. However, the renal retention of radioactivity exceeded tumor uptake, which might complicate imaging of metastases in the lumbar region. The aim of this study was to develop an agent with low renal uptake and preserved tumor targeting. METHODS A series of recombinant derivatives of the HER2-binding Z(HER2)(:342) Affibody molecule with a C-terminal chelating sequence, -GXXC (X denoting glycine, serine, lysine, or glutamate), was designed. The constructs were labeled with (99m)Tc and evaluated in vitro and in vivo. RESULTS All variants were stably labeled with (99m)Tc, with preserved capacity to bind specifically to HER2-expressing cells in vitro and in vivo. The composition of the chelating sequence had a clear influence on the cellular processing and biodistribution properties of the Affibody molecules. The best variant, (99m)Tc-Z(HER2)(:V2), with the C-terminal chelating sequence -GGGC, provided the lowest radioactivity retention in all normal organs and tissues including the kidneys. (99m)Tc-Z(HER2)(:V2) displayed high uptake of radioactivity in HER2-expressing xenografts, 22.6 ± 4.0 and 7.7 ± 1.5 percentage injected activity per gram of tissue at 4 h after injection in SKOV-3 (high HER2 expression) and DU-145 (low HER2 expression) tumors, respectively. In both models, the tumor uptake exceeded the renal uptake. CONCLUSION These results demonstrate that the biodistribution properties of recombinant (99m)Tc-labeled Affibody molecules can be optimized by modification of the C-terminal cysteine-containing chelating sequence. (99m)Tc-Z(HER2)(:V2) is a promising candidate for further development as a diagnostic radiopharmaceutical for imaging of HER2-expressing tumors. These results may be useful for the development of imaging agents based on other Affibody molecules and, hopefully, other scaffolds.


title: Foodborne viral infections.

text: PURPOSE OF REVIEW The aim of the study was to provide an update on foodborne viral infections describing illness burden, the main aetiological agents (enteric viruses, hepatitis viruses and emerging and zoonotic viruses) and advances in virus detection in foods. RECENT FINDINGS Norovirus (NoV) is the most common viral foodborne pathogen globally (125 million cases and 35 000 deaths). The role of the asymptomatic food handlers in contributing to NoV outbreaks is becoming increasingly clear, with up to one-quarter of outbreaks attributable to them. Handwashing with soap and water remains the best method for removing NoV from fingers. Risk assessment for transmission of emerging viruses through the food chain should include consideration of all means by which food could post a hazard, that is not just consumption. New technologies have demonstrated the widespread nature of viral contamination in the food chain, but this does not necessarily correlate with the risk of disease. Finally, understanding people's knowledge and behaviour is just as important as understanding virus characteristics and epidemiology when assessing risks of foodborne transmission. SUMMARY The predominant viruses transmitted through food tend to be those for which humans are the natural hosts, so that effective control measures need to prevent exposure of foods to human faeces.


The Brazilian slums hiring their own doctors to fight covid-19.


title: Thromboprophylaxis in radical retropubic prostatectomy: efficacy and patient compliance of a dual modality.

text: OBJECTIVES The risk of developing venous thromboembolism (VTE) in urologic patients undergoing major surgery without thromboprophylaxis is high (up to 40%). The aims were to study the acceptability rate of and overall patient satisfaction with an automatic sequential leg compression system and the short-term effectiveness of a combined VTE prevention modality. METHODS One-hundred and eighty-four consecutive patients undergoing radical retropubic prostatectomy were postoperatively treated with enoxaparine and intermittent pneumatic compression of the thigh. By completing a questionnaire, the patients were prospectively studied to evaluate the comfort and tolerability of a compression device (SCD Response Compression System; Covidien, Gosport, UK). The patients were monitored for complications and development of VTE for up to 4 weeks postoperatively. The device used ensures customized and effective compression therapy matching the patient's individual vascular refill by sequential, gradient, circumferential microprocessor-controlled compression cycles. RESULTS No clinically evident VTE, critical bleeding or postoperative death occurred during the study period. Drain output was associated with transfusion requirement (p < 0.001), obesity (p < 0.02) and longer operation duration (p < 0.001). The sequential compression devices were well tolerated by 63% of the patients, in that the sleeves were judged as being pleasant (72%) and nonoppressive (79%). Patients reported bothersome insomnia (23%) and noise (44%), and early removal was required in 3%. CONCLUSIONS Combined mechanical and pharmacological thromboprophylaxis was highly effective, well tolerated, and safe. The device tested showed a high comfort and tolerability profile. The use of combined modalities for VTE prophylaxis is justified in patients at very high risk of VTE, such as those undergoing radical retropubic prostatectomy.


title: Germline mutation of the E-cadherin gene in three sibling cases with advanced gastric cancer: clinical consequences for the other family members.

text: BACKGROUND AND AIMS Germline mutations in the E-cadherin (CDH1) gene have been found in families with hereditary diffuse gastric cancer (HDGC). These families are characterized by a highly penetrant susceptibility to diffuse gastric cancer with an autosomal dominant pattern of inheritance. We describe the clinical presentation of three sibling cases with advanced gastric cancer, the way of confirming the suspicion of underlying HDGC and the clinical management of the other healthy family members. METHODS Screening for CDH1 germline mutation was carried out by denaturing high-performance liquid chromatography and automated DNA sequencing. The clinical suspicion of HDGC has been confirmed by identifying a frameshift mutation in exon 9 (1302_1303insA, 1306_1307delTT) of the E-cadherin gene. RESULTS Eight of nine tested family members were positive for the CDH1 germline mutation. Prophylactic laparoscopic gastrectomies were performed in five mutation carriers. After pathological examination, we could identify intramucosal malignant signet-ring cell carcinoma in all resected stomachs. CONCLUSION This report underlines that prophylactic gastrectomy remains the only option to eliminate the high risk for gastric cancer in CDH1 mutation carriers.


title: Stereotactic Radiofrequency Ablation for Metastatic Melanoma to the Liver.

text: PURPOSE To evaluate the outcome of patients with melanoma liver metastasis treated with stereotactic radiofrequency ablation (SRFA). MATERIAL AND METHOD Following IRB approval, a retrospective evaluation of the treatment of 20 patients with 75 melanoma liver metastases was performed. RESULTS A median number of 2 lesions (range 1-14) per patient with a median size of 1.7 cm (range 0.5-14.5 cm) were treated. 67 lesions were <3 cm (89.3 %) and 8 lesions were >3 cm (10.7 %). Per patient a median of 1 ablation session was performed (range: 1-4) totaling 34 sessions. There were no procedure-related deaths and all major complications (n = 3) could be easily treated by pleural drainages. The primary and secondary success rates were 89.3 and 93.3 %, respectively. The overall local recurrence rate was 13.3 %. Four of ten local recurrences were re-treated successfully by SRFA. During follow-up, 9/20 patients developed extrahepatic metastatic disease and 10/20 had liver recurrence at any location. The median OS from the date of SRFA was 19.3 months, with an OS of 64, 41, and 17 % at 1, 3, and 5 years, with no significant difference for patients with cutaneous and ocular melanoma. The median DFS after SRFA for all 20 patients was 9.5 months, with 37, 9, and 0 % at 1, 3, and 5 years. CONCLUSIONS Due to the high local curative potential and the promising long-term survival rates associated with minimal morbidity and mortality, radiofrequency ablation seems to be an attractive alternative to resection in patients with melanoma liver metastases.


title: A host dicer is required for defective viral RNA production and recombinant virus vector RNA instability for a positive sense RNA virus.

text: Defective interfering (DI) RNAs, helper virus-dependent deletion mutant RNAs derived from the parental viral genomic RNA during replication, have been described for most RNA virus taxonomic groups. We now report that DI RNA production in the chestnut blight fungus, Cryphonectria parasitica, persistently infected by virulence-attenuating positive sense RNA hypoviruses, depends on one of two host dicer genes, dcl-2. We further report that nonviral sequences that are rapidly deleted from recombinant hypovirus RNA virus vectors in wild-type and dicer gene dcl-1 deletion mutant strains are stably maintained and expressed in the Deltadcl-2 mutant strain. These results establish a requirement for dcl-2, the C. parasitica dicer gene responsible for antiviral defense and generation of virus-derived small interfering RNAs, in DI RNA production and recombinant virus vector RNA instability.


title: ESGE and ESGENA Position Statement on gastrointestinal endoscopy and COVID-19: An update on guidance during the post-lockdown phase and selected results from a membership survey.

text: N/A.


title: Single-incision laparoscopic colectomy: outcomes of an emerging minimally invasive technique.

text: PURPOSE Single-incision laparoscopic colectomy (SILC) is an emerging procedure in the field of minimally invasive colon and rectal surgery. The purpose of this study was to evaluate the safety and feasibility of this procedure. METHODS Between July 2009 and April 2010, SILC was performed for 35 patients presenting with pathology of the colon. Surgical procedures included right hemicolectomy, sigmoid resection, and total colectomy. Demographic data, intraoperative parameters, and short-term postoperative outcomes were assessed. RESULTS Thirty two of the 35 patients (91.4%) underwent successful completion of SILC while 3 patients required laparoscopic modifications. The mean incision length was 3.4 cm with a range of 2-6 cm. The mean total operative time (OT) for right, left, and total colectomies was 158.8 ± 31.8 min, 127.0 ± 37.1 min, and 216.3 ± 72.6 min, respectively. Overall, the OT was not significantly different between patients with a body mass index (BMI) ≥ 25 kg/m(2) (147.9 ± 47.9 min) compared to those with a BMI <25 kg/m(2) (123.1 ± 40.9 min). In the subset of patients with malignant disease, the mean lymph node extraction was 23.5 ± 12.0 and all margins were negative. There were no intraoperative complications, and the overall mean length of hospital stay was 2.9 ± 1.0 days (range 2-6 days). The postoperative morbidity rate was 11.4%. CONCLUSIONS Single-incision laparoscopic colectomy is a safe and feasible procedure for benign and malignant diseases of the colon. This modality can be successfully applied for various colorectal procedures without conversion to open surgery, resulting in a short length of hospital stay and a minimal short-term complication rate.


title: Chest CT findings and clinical features of coronavirus disease 2019 in children.

text: OBJECTIVES To describe the CT features and clinical characteristics of pediatric patients with coronavirus disease 2019 (COVID-19). METHODS A total of 9 COVID-19 infected pediatric patients were included in this study. Clinical history, laboratory examination, and detailed CT imaging features were analyzed. All patients underwent the first CT scanning on the same day of being diagnosed by real-time reverse-transcription polymerase chain reaction (rRT-PCR). A low-dose CT scan was performed during follow-up. RESULTS All the child patients had positive results. Four patients had cough and one patient had fever. One patient presented both cough and fever. Two children presented other symptoms like sore throat and stuffy nose. One child showed no clinical symptom. Five patients had positive initial CT findings with subtle lesions like ground-glass opacity (GGO) or spot-like mixed consolidation. Three patients were reported with negative results in the initial and follow-up CT examination. One patient was reported with initial negative CT findings but turning positive during the first follow-up. All patients had absorbed lesions on follow-up CT images after treatment. CONCLUSIONS Pediatric COVID-19 patients have certain imaging and clinical features as well as disease prognosis. Children with COVID-19 tend to have normal or subtle CT findings and relatively better outcome.


title: Laparoscopic liver resection: is there a learning curve?

text: BACKGROUND Laparoscopic liver resection (LLR) is becoming an accepted treatment option for resecting both benign and malignant tumours. However, it is critical that the laparoscopic approach does not compromise the technical quality of the liver resection. The aim of this paper was to review the learning curve of LLR in a specialist HPB unit. METHODS A prospective database was searched to identify patients undergoing LLR over a 4-year period. To assess the effect of the learning curve on outcome, the series was evaluated during two eras--early versus late. RESULTS Fifty-one (27 males, median age 68 years) patients were identified with 37 having LLR. The most common indication was for colorectal liver metastases, and the most common procedure was a non-anatomical metastectomy. Changes in management decisions (n = 14) occurred more frequently during the first era (9 vs. 5; p > 0.05). More patients underwent right hepatectomy in the late group (3 vs. 1; p < 0.05). There did not appear to be any difference in duration of surgery for laparoscopic left lateral resection between the eras (200 vs. 240 min; p > 0.05) which probably reflected trainees performing more operations during the late era. Left hepatectomy was most commonly performed in the early era compared to more right hepatectomies during the late era. CONCLUSION LLR is associated with a learning curve, but once this has been overcome it can be safely utilised in the management of malignant liver lesions even for major resections, surgical training and simultaneous resections.


title: The impact of gestational age on targeted amniotic cell profiling in experimental neural tube defects.

text: PURPOSE The proportions of select stem cells in term amniotic fluid have been shown to correlate with the type and size of experimental neural tube defects (NTDs). We sought to determine the impact of gestational age upon this form of targeted amniotic cell profiling. METHODS Sprague-Dawley fetuses with retinoic acid-induced NTDs (n = 110) underwent amniotic fluid procurement at four time points in gestation. Samples were analyzed by flow cytometry for the presence of cells concomitantly expressing Nestin and Sox-2 (neural stem cells, aNSCs) and cells concomitantly expressing CD29 and CD44 (mesenchymal stem cells, aMSCs). Statistical analysis was by nonparametric Kruskal-Wallis ANOVA (p < 0.05). RESULTS There was a statistically significant impact of gestational age on the proportions of both aMSCs (p = 0.01) and aNSCs (p < 0.01) in fetuses with isolated spina bifida. No such impact was noted in normal fetuses (p > 0.10 for both cells), in isolated exencephaly (p > 0.10 for both cells), or in combination defects (p > 0.10 for both cells). Gestational age had no effect on aNSC/aMSC ratios. CONCLUSIONS Targeted quantitative amniotic cell profiling varies with gestational age in experimental isolated spina bifida. This finding should be considered prior to the eventual translation of this diagnostic adjunct into the prenatal evaluation of these anomalies. © 2014 S. Karger AG, Basel.


title: Effects of long-acting GnRH antagonist, degarelix acetate, on plasma insulin-like peptide 3, testosterone and luteinizing hormone concentrations, and scrotal circumference in male goats.

text: We recently reported that plasma insulin-like peptide 3 (INSL3) concentrations increased soon after endogenous and exogenous stimulations of LH in male goats and bulls. However, the effects of LH suppression on INSL3 secretion are unknown in domestic animals. Here, we examined the effects of a long-acting GnRH antagonist (degarelix acetate; 4 mg/kg) on the secretions of plasma INSL3 and testosterone in two phases, an immediate and a long-term phase in male goats (n = 6; aged, 13-16 months). During the immediate phase, blood was taken at 15-minute intervals for 8 hours on Days -5, 0, and 3. The GnRH antagonist was administered after 2-hour sampling of Day 0. Moreover, a daily blood sample was taken from Day 0 to Day 7, followed by twice a week until 9 weeks and finally at week 10. The scrotal circumference was recorded before treatment and continued biweekly until week 10. Concentrations of LH, INSL3, and testosterone in plasma were determined by EIA and the pulsatile nature of secretion analyzed using pulse XP software. The mean concentrations, pulse frequency (per hour), and pulse amplitude (peak-nadir) of plasma LH and testosterone reduced from pretreatment to posttreatment Day 0 and Day 3 (P < 0.05). A decline in mean concentrations, pulse frequency, and pulse amplitude of INSL3 was exhibited on posttreatment Day 3 compared with pretreatment (P < 0.01). During long-term sampling, a decline (P < 0.01) in plasma testosterone and INSL3 concentrations was observed 1 day after treatment and remained lower until 8.5 weeks after treatment, and thereafter returned to pretreatment levels. A reduction in scrotal circumference was recorded 4 weeks after treatment and remained lower until 10 weeks after treatment (P < 0.05). In conclusion, the acute regulation of INSL3 by LH was confirmed by reduction of plasma INSL3 levels within 3 days after GnRH antagonist treatment in male goats. Although the onset of suppression of testosterone was more rapid than that of INSL3, the low levels persisted for 8.5 weeks for both hormones, and subsequently the concentrations returned to pretreatment levels. A significant reduction in testicular size was also observed. The quick, long-lasting, and transient suppression of testosterone and INSL3 after a single injection implies a potential application of this antagonist in reversible long-term chemical castration in male goats.


Simultaneous laparoscopic 'Venetian blinds' closure and mesh-reinforced ventral hernia repair with revision of gastric band to bypass.


title: Cost analysis of multiplex PCR testing for diagnosing respiratory virus infections.

text: We performed a cost analysis study using decision tree modeling to determine whether the use of multiplex PCR testing for respiratory viruses (xTAG RVP test) is a more or less costly strategy than the status quo testing methods used for the diagnosis of respiratory virus infections in pediatric patients. The decision tree model was constructed by using four testing strategies for respiratory virus detection, viz., direct fluorescent-antibody staining (DFA) alone, DFA plus shell vial culture (SVC), the xTAG RVP test alone, or DFA plus the xTAG RVP test. A review of the charts of 661 pediatric patients was used to determine the length of hospital stay, the number of days in isolation, antibiotic usage, and all other medical procedures performed. The cost of hospitalization by diagnostic status was determined on the basis of the average cost per patient and the number of patients in each arm of the decision tree. The cost per case was the highest for DFA plus SVC at $3,914 (in Canadian dollars), and the lowest was for the xTAG RVP test alone at $3,623, while the costs of DFA alone ($3,911) and DFA plus RVP ($3,849) were intermediate. When all four diagnostic strategies were compared, the least costly strategy was the xTAG RVP test alone when the prevalence of infection was 11% or higher and DFA alone when the prevalence was under 11%. These data indicate a savings of $291 per case investigated if the strategy of using the xTAG RVP test alone was used to replace the status quo test of DFA plus SVC, resulting in a savings of $529,620 per year in direct costs for the four Hamilton, Ontario, Canada, hospitals on the basis of the testing of specimens from 1,820 pediatric inpatients. We conclude that the use of the xTAG RVP test is the least costly strategy for the diagnosis of respiratory virus infections in children and would generate a significant savings for hospitals.


title: Early detection of Zika virus infection among travellers from areas of ongoing transmission in China.

text: Nine imported Zika virus (ZIKV) infections (four through temperature monitoring and epidemiological investigation at entry and five by active surveillance tracking of index case contacts during follow-up; from Venezuela [n = 5], Samoa [n = 3] and both Samoa and Fiji [n = 1]) were detected in mainland China from February 1 to 29, 2016. The minimal incubation period lasted 5.2 days, with mean lag time to diagnosis of 2.6 days. Diagnosis relied on positive real-time reverse transcriptase polymerase chain reaction for ZIKV RNA in serum (n = 7), urine (n = 4) or saliva (n = 3), respectively. All cases recovered rapidly without serious complications.


title: Stapled diverticulectomy for solitary caecal diverticulitis.

text: Caecal diverticulitis is an uncommon phenomenon in western countries. The clinical diagnosis is often difficult as it mimics other acute abdominal conditions like appendicitis, colitis or neoplasia. Diagnosis is often made at operation. Operative strategy has been controversial and there is no broad consensus emerging. We report the case of a 71-year-old woman, known to have chronic obstructive pulmonary disease, who presented acutely with right iliac fossa pain. A clinical diagnosis of appendicitis was made. At laparoscopy, a solitary, inflamed, gangrenous caecal diverticulum was found. A laparoscopic stapled diverticulectomy was performed. The patient made a steady post-operative recovery. Histology confirmed diverticulitis. We conclude that stapled diverticulectomy for solitary caecal diverticulitis is a safe and effective surgical strategy when confronted with this scenario.


title: Safety of modern starches used during surgery.

text: Various hydroxyethyl starch (HES) preparations have been used for decades to augment blood volume. There has been concern recently regarding possible adverse outcomes when using HES in the intensive care setting, especially in patients with septic shock. However, the pharmacokinetic and pharmacodynamic properties of HES preparations depend on their chemical composition and source material. Thus, different clinical conditions could result in differing effectiveness and safety for these preparations. Consequently, we assessed the safety of tetrastarches when used during surgery, using a formal search, that yielded 59 primary full publications of studies that met a priori inclusion criteria and randomly allocated 4529 patients with 2139 patients treated with tetrastarch compared with 2390 patients treated with a comparator. There were no indications that the use of tetrastarches during surgery induces adverse renal effects as assessed by change or absolute concentrations of serum creatinine or need for renal replacement therapy (39 trials, 3389 patients), increased blood loss (38 trials, 3280 patients), allogeneic erythrocyte transfusion (20 trials, 2151 patients; odds ratio for HES transfusion 0.73 [95% confidence interval = 0.61-0.87], P = 0.0005), or increased mortality (odds ratio for HES mortality = 0.51 [0.24-1.05], P = 0.079).


A Proposed Lottery System to Allocate Scarce COVID-19 Medications: Promoting Fairness and Generating Knowledge.


title: Flexible thoracoscopy may facilitate video-assisted thoracoscopic lobectomy.

text: BACKGROUND Video-assisted thoracoscopic lobectomy was introduced in the early 1990s but has not yet gained widespread acceptance. The VATS approach is still controversial although several studies suggest less postoperative morbidity compared with open thoracotomy. Nevertheless, some patients report long-lasting chest wall pain following VATS procedures, and, in theory, such pain may be related to intercostal nerve injury. The present study presents our experience with a commercially available flexible thoracoscope. METHODS The study was designed as a case-control series of prospectively collected data to determine if performing VATS with a flexible thorascope could have benefits for both the patient and the surgeon. RESULTS During the last 24 months 128 of 274 consecutive lobectomies (47%) were scheduled as VATS procedures with a new flexible high-definition thoracoscope. Six operations (4.6%) were converted to open surgery but only one case was converted during the last 12 months. There was no hospital mortality. The median duration of the operation was 105 min (range: 50-289 min), and the median postoperative hospital stay was 4 days (range: 2-27 days). At routine follow-up 2 weeks postoperatively all but three patients (2%) were considered pain free, which was significantly less than in 15 consecutive VATS lobectomies with rigid thoracoscopy performed prior to the introduction of flexible VATS (p = 0.02). CONCLUSIONS Video-assisted thoracoscopic lobectomy by flexible thoracoscopy is feasible and in our opinion easier and safer compared with rigid thoracoscopy. In our experience all parts of the operation are better visualized and many surgical pitfalls may be avoided. Even during early phases of setting up the VATS lobectomy program, the duration of the operation is comparable with open surgery, and postoperative pain is low, possibly because porthole angulation is minimized.


title: Feasibility of endoscopic closure of an iatrogenic colon perforation occurring during colonoscopy.

text: BACKGROUND Colon perforation is one of the most dreaded complications of colonoscopy. Traditionally, patients with a colon perforation have been treated surgically. Although there are several case reports documenting the usefulness of endoscopic closure of colon perforations, there are few current data evaluating the feasibility of endoscopic closure for an iatrogenic perforation on consecutive patients undergoing colonoscopy. OBJECTIVE To assess the incidence of colon perforations and the utility of immediate endoscopic closure during colonoscopy. DESIGN Retrospective, observational study. SETTING Tertiary-care academic medical center. PATIENTS All patients who underwent colonoscopy at 1 institution from June 2002 to December 2008 were identified. INTERVENTION An attempt at immediate colon perforation closure by endoscopic means. MAIN OUTCOME MEASUREMENTS Successful endoscopic closure of colon perforation. RESULTS During the study period, a total of 8601 colonoscopies were performed (2472 therapeutic interventions, 28.7%). A total of 12 iatrogenic colon perforations occurred, yielding a rate of 1.4/1000. Five (41.7%) occurred during a diagnostic colonoscopy (0.8/1000), and 7 perforations (58.3%) occurred as the result of a therapeutic intervention (2.8/1000). Endoscopic closure of the perforation site was possible in 5 patients (42%). Seven patients were treated surgically (large defects [n = 3], including 1 failed endoscopic closure, difficult endoscope position [n = 2], stool contamination [n = 1], and endoscopist's inexperience with closure of mucosal defects [n = 1]). LIMITATION Retrospective design. CONCLUSIONS In this study, the incidence of colon perforations was 1.4/1000. Endoscopic closure of iatrogenic colon perforations was attempted in 50% of patients and was successful in 83%. All patients with successful endoscopic closure had lesions smaller than 10 mm.


title: Formulation and characterization of poloxamine-based hydrogels as tissue sealants.

text: In situ cross linkable polyethylene glycol (PEG)-based polymers play an increasing role in surgical practice as sealants that provide a barrier to fluid/gas leakage and adhesion formation. This study investigated the gelation behavior and physical properties of hydrogels formed from homogeneous and blended solutions of two acrylated poloxamines (Tetronics® T1107 and T904) of various molecular weights and hydrophilic/lipophilic balances relative to a PEG control. Hydrogels were formed by reverse thermal gelation at physiological temperature (T1107-containing formulations) and covalent crosslinking by Michael-type addition with dithiothreitol. All poloxamine-based hydrogels exhibited thermosensitive behavior and achieved significantly reduced swelling, increased tensile properties and increased tissue bond strength relative to the PEG hydrogel at physiological temperature. Swelling and tensile properties of all poloxamine-based hydrogels were significantly greater at 37°C relative to 4°C, suggesting that their improved physical properties derive from cooperative crosslinking by both noncovalent and covalent mechanisms. Poloxamine-based hydrogels were cytocompatible and underwent hydrolytic degradation over 2-5weeks, depending on their T1107/T904 composition. In conclusion, select poloxamine-based hydrogels possess a number of properties potentially beneficial to tissue sealant applications, including a substantial increase in viscosity between room/physiological temperatures, resistance to cell adhesion and maintenance of a stable volume during equilibration.


title: Understanding the significance, reasons and patterns of abnormal vital signs after gastric bypass for morbid obesity.

text: Anastomotic leaks and bleeding are the two most feared major complications in patients undergoing laparoscopic gastric bypass (LRYGB). This study was designed to evaluate if there is a clinical correlation between abnormal vital signs and postoperative leaks and bleeding. After IRB approval and adherence to HIPAA guidelines, a retrospective review of medical records was performed on 518 patients who underwent LRYGB between October 2002 and October 2006. Vital signs from each patient were monitored hourly. Eight patients out of 518 (1.54%) were discovered to have anastomotic leak. A marked increase in heart rate up to 120 bpm at 20 h after surgery occurred in five of eight patients (62.5%). Of the eight patients who had a leak, seven (87.5%) experienced sustained tachycardia above 120 bpm. On the other hand, 20 patients out of 518 (3.86%) were discovered to have postoperative bleeding. A gradual rather than a dramatic increase in heart rate was recorded in 17 of 20 patients (85%) starting 8 h after surgery. Five patients (25%) had unsustained tachycardia above 120 bpm. Twelve patients in this group (60%) were seen to have cyclical tachycardia that never exceeded 120 bpm at any point during hospitalization. Marginal hypotension was found in seven patients (35%) in this group. Sustained tachycardia with a heart rate exceeding 120 bpm appears to be an indicator of anastomotic leak. Tachycardia less than 120 bpm that has occurred in a cyclical pattern strongly pointed toward postoperative bleeding. Anastomotic leaks and bleeding are the two most feared major complications in patients undergoing LRYGB. This study was designed to evaluate if there is a clinical correlation between abnormal vital signs and postoperative leaks and bleeding.


COVID-19 Pandemic-Induced Panic Disorder.


title: CLARITY for High-resolution Imaging and Quantification of Vasculature in the Whole Mouse Brain.

text: Elucidating the normal structure and distribution of cerebral vascular system is fundamental for understanding its function. However, studies on visualization and whole-brain quantification of vasculature with cellular resolution are limited. Here, we explored the structure of vasculature at the whole-brain level using the newly developed CLARITY technique. Adult male C57BL/6J mice undergoing transient middle cerebral artery occlusion and Tie2-RFP transgenic mice were used. Whole mouse brains were extracted for CLARITY processing. Immunostaining was performed to label vessels. Customized MATLAB code was used for image processing and quantification. Three-dimensional images were visualized using the Vaa3D software. Our results showed that whole mouse brain became transparent using the CLARITY method. Three-dimensional imaging and visualization of vasculature were achieved at the whole-brain level with a 1-μm voxel resolution. The quantitative results showed that the fractional vascular volume was 0.018 ± 0.004 mm3 per mm3, the normalized vascular length was 0.44 ± 0.04 m per mm3, and the mean diameter of the microvessels was 4.25 ± 0.08 μm. Furthermore, a decrease in the fractional vascular volume and a decrease in the normalized vascular length were found in the penumbra of ischemic mice compared to controls (p < 0.05). In conclusion, CLARITY provides a novel approach for mapping vasculature in the whole mouse brain at cellular resolution. CLARITY-optimized algorithms facilitate the assessment of structural change in vasculature after brain injury.


title: Can In-Bag Manual Morcellation Represent an Alternative to Uncontained Power Morcellation in Laparoscopic Myomectomy? A Randomized Controlled Trial.

text: AIMS The study aimed to evaluate feasibility and safety of in-bag manual morcellation compared to uncontained power morcellation during laparoscopic myomectomy. METHODS A total of 72 women undergoing laparoscopic myomectomy were randomized into 2 treatment groups: 34 patients underwent in-bag manual morcellation (experimental group) and 38 were submitted to uncontained power morcellation (control group). The primary end point was the comparison of morcellation operative time (MOT). Total operative time (TOT), rate of intraoperative complication, and postoperative outcomes in the 2 groups were regarded as secondary outcomes. RESULTS Mean MOT and TOT were longer in the experimental group than in the control one (MOT: 9.47 ± 5.05 vs. 6.16 ± 7.73 min; p = 0.01; TOT: 113.24 ± 28.12 vs. 96.74 ± 33.51 min; p = 0.01). No intraoperative complications occurred in either group and no cases of bag disruption or laparotomic conversion were recorded. No significant difference in hemoglobin drop, hospital stay, and postoperative outcomes was reported between groups. CONCLUSION In-bag manual morcellation appears a safe and feasible procedure and, despite slightly longer operative time, could represent an alternative to uncontained power morcellation.


title: Adopting a Patient-Centered Approach to Primary Outcome Analysis of Acute Stroke Trials Using a Utility-Weighted Modified Rankin Scale.

text: BACKGROUND AND PURPOSE Although the modified Rankin Scale (mRS) is the most commonly used primary end point in acute stroke trials, its power is limited when analyzed in dichotomized fashion and its indication of effect size challenging to interpret when analyzed ordinally. Weighting the 7 Rankin levels by utilities may improve scale interpretability while preserving statistical power. METHODS A utility-weighted mRS (UW-mRS) was derived by averaging values from time-tradeoff (patient centered) and person-tradeoff (clinician centered) studies. The UW-mRS, standard ordinal mRS, and dichotomized mRS were applied to 11 trials or meta-analyses of acute stroke treatments, including lytic, endovascular reperfusion, blood pressure moderation, and hemicraniectomy interventions. RESULTS Utility values were 1.0 for mRS level 0; 0.91 for mRS level 1; 0.76 for mRS level 2; 0.65 for mRS level 3; 0.33 for mRS level 4; 0 for mRS level 5; and 0 for mRS level 6. For trials with unidirectional treatment effects, the UW-mRS paralleled the ordinal mRS and outperformed dichotomous mRS analyses. Both the UW-mRS and the ordinal mRS were statistically significant in 6 of 8 unidirectional effect trials, whereas dichotomous analyses were statistically significant in 2 to 4 of 8. In bidirectional effect trials, both the UW-mRS and ordinal tests captured the divergent treatment effects by showing neutral results, whereas some dichotomized analyses showed positive results. Mean utility differences in trials with statistically significant positive results ranged from 0.026 to 0.249. CONCLUSIONS A UW-mRS performs similar to the standard ordinal mRS in detecting treatment effects in actual stroke trials and ensures the quantitative outcome is a valid reflection of patient-centered benefits.


title: [The impact of viruses in lower respiratory tract infections of the adult. Part III: therapy and prevention].

text: In industrialized countries respiratory tract infections are one of the most common reasons for medical consultations. It is assumed that almost one third of these infections include the lower respiratory tract (LRTI), e. g. acute bronchitis, acute exacerbation of chronic obstructive pulmonary disease (COPD), community- or hospital-acquired pneumonia and influenza. Due to a lack of sufficient and valid investigations to prove the presence of respiratory viruses their impact in the pathogenesis of lower respiratory tract infection has probably been underestimated for a long time. Therefore, there might have been many cases of unnecessary antibiotic treatment, especially in cases of acute bronchitis or acute exacerbations of COPD, because of an assumed bacteriological cause. With the introduction of more sensitive investigational procedures, such as polymerase chain reaction, it is possible to sufficiently prove respiratory viruses and therefore illuminate their role in the pathogenesis of lower respiratory tract infections of the adult. We have reviewed the current literature on the impact of viruses in lower respiratory tract infections to elucidate the role of viruses in the pathogenesis of lower respiratory tract infections. The preceding parts of this series provided an introduction to the frequently found viruses, pathogenesis, and diagnostic procedures (part I) as well as common viral infections of the lower respiratory tract (part II). The present 3 (rd) part deals with therapy for and prevention of viral LRTI.