title: The Shared Epitope Phenomenon - A potential impediment to virtual crossmatch accuracy.

text: With the implementation of the new Kidney Allocation System (KAS), there is increased reliance on a virtual crossmatch/histocompatibility risk assessment (vXM) for evaluating potential presence, as well as strength, of HLA antibodies against a potential donor. The accuracy of such an assessment depends on the precision in the identification of the recipient's antibody profile and the potential donor's HLA typing. While the development of the single antigen bead (SAB) multiplex assay has improved the sensitivity and specificity of HLA-antibody detection, several limitations of the assay (specific to certain sensitized patients) can complicate accurate interpretation of results. In this report, we focus on the "shared-epitope" phenomenon, a condition in which antibody strength can be underrepresented, or its presence completely missed, due to binding of the antibody to competing targets on multiple antigens (beads), effectively "diluting" the resulting MFI-readout. Here, we provide a relevant background to understand this phenomenon and present a couple of case studies illustrating how it can be investigated, leading to a more accurate histocompatibility consultation.


title: Initial Experience of Dual-Port Laparoscopic Distal Gastrectomy for Gastric Cancer: A Single-Arm Study.

text: INTRODUCTION Dual-port laparoscopic gastrectomy (DPLG) has been widely performed in recent years for treating gastric cancers. The present study reports our initial experience of dual-port laparoscopic distal gastrectomy (DPLDG). METHODS From November 2016 to August 2018, 38 consecutive patients underwent DPLDG in our center. The observational outcomes included 30-day morbidity and mortality rates, time to first flatus, time to first oral liquid diet, time to first oral semiliquid diet, time to drainage tube removal, visual analogue scale (VAS) score, postoperative 4-day recovery rate, additional analgesic use, hospital stay and cosmetic benefits. RESULTS Mean operative time was 191.6 ± 44.4 min, mean intra-operative blood loss was 39.8 ± 48.7 ml, and the mean number of dissected lymph nodes was 38.3 ± 13.7 nodes. One case was converted to five-port laparoscopic surgery, and no intraoperative complications occurred in any of the cases. The mean time to postoperative first flatus was 45.3 ± 18.0 h. The mean time to intake of an oral liquid diet was 56.7 ± 30.4 h. The mean time to drainage tube removal was 97.9 ± 52.3 h. The mean VAS scores for the 3 days after surgery were 2.3 ± 0.7, 2.0 ± 0.6 and 1.6 ± 0.5, respectively. A total of 81.6% of the enrolled patients met the postoperative 4-day recovery standard, and 15.8% of patients received additional analgesics. The mean postoperative hospital stay was 6.0 ± 2.0 days. No deaths were observed, and the 30-day morbidity rate was 13.2%. CONCLUSION DPLDG is a feasible and safe procedure for experienced surgeons with acceptable short-term outcomes, reduced invasiveness and good cosmetic effects.


title: Embolic strokes of undetermined source: the case for a new clinical construct.

text: Cryptogenic (of unknown cause) ischaemic strokes are now thought to comprise about 25% of all ischaemic strokes. Advances in imaging techniques and improved understanding of stroke pathophysiology have prompted a reassessment of cryptogenic stroke. There is persuasive evidence that most cryptogenic strokes are thromboembolic. The thrombus is thought to originate from any of several well established potential embolic sources, including minor-risk or covert cardiac sources, veins via paradoxical embolism, and non-occlusive atherosclerotic plaques in the aortic arch, cervical, or cerebral arteries. Accordingly, we propose that embolic strokes of undetermined source are a therapeutically relevant entity, which are defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources, with a clear indication for anticoagulation. Because emboli consist mainly of thrombus, anticoagulants are likely to reduce recurrent brain ischaemia more effectively than are antiplatelet drugs. Randomised trials testing direct-acting oral anticoagulants for secondary prevention of embolic strokes of undetermined source are warranted.


title: Splenic Rhythms and Postprandial Dynamics in Physiology, Portal Hypertension, and Functional Hyposplenism: A Review.

text: BACKGROUND Before the discovery of immunological and haematological functions of the spleen, it had for centuries been considered to be a digestive organ of variable size with a role in the portal vein system and nutritional metabolism. In the 19th and 20th centuries, volume changes in the spleen related to nutrition were studied using plethysmographic measurements. Rhythmical and regulatory functions of the spleen were demonstrated in the haemodynamics of the splanchnic region and were described as a "hepatolienal pendulum," a "Windkessel function," or a "pressure compensation." These studies were mainly published in German-speaking countries and have not, as far as is known, been discussed in the English-speaking world so far. SUMMARY This review explores the historical development of the rhythmical regulatory function of the spleen in the splanchnic region. Older studies and results are followed up in the modern literature, wherever possible, up to the present. The clinical relevance is illustrated with portal hypertension (with congestive or hyperdynamic splenomegaly), coeliac disease, and chronic inflammatory bowel diseases (with functional hyposplenism). Key Message: The spleen's rhythmical regulatory function in nutrition is based on an autonomous rhythm comprising cycles of contractions and dilations of the spleen of around 1 min. These cycles can be influenced by sympathetically mediated single contractions with a release of pooled blood or by portal vein congestion. After food ingestion, the spleen responds either with contraction according to a vasomotor reaction or postprandial congestion with significant increases in volume. The spleen's rhythmical function is lost in the clinical picture of portal hypertension or in coeliac disease and chronic inflammatory bowel diseases. In the aforementioned gastrointestinal diseases, we recommend taking more account of the haemodynamics between the spleen, liver, and intestine. New innovative techniques for recording splenograms are required which, besides elastographic measurements of spleen stiffness, could offer an important tool for early detection, diagnosis, and therapeutic evaluation.


title: Influence of menstrual phase and arid vs. humid heat stress on autonomic and behavioural thermoregulation during exercise in trained but unacclimated women.

text: KEY POINTS Despite an attenuated fluctuation in ovarian hormone concentrations in well-trained women, one in two of such women believe their menstrual cycle negatively impacts training and performance. Forthcoming large international events will expose female athletes to hot environments, and studies evaluating aerobic exercise performance in such environments across the menstrual cycle are sparse, with mixed findings. We have identified that autonomic heat loss responses at rest and during fixed-intensity exercise in well-trained women are not affected by menstrual cycle phase, but differ between dry and humid heat. Furthermore, exercise performance is not different across the menstrual cycle, yet is lower in humid heat, in conjunction with reduced evaporative cooling. Menstrual cycle phase does not appear to affect exercise performance in the heat in well-trained women, but humidity impairs performance, probably due to reduced evaporative power. ABSTRACT We studied thermoregulatory responses of ten well-trained [V̇O2 max , 57 (7) ml min-1 kg-1 ] eumenorrheic women exercising in dry and humid heat, across their menstrual cycle. They completed four trials, each of resting and cycling at fixed intensities (125 and 150 W), to assess autonomic regulation, then self-paced intensity (30 min work trial), to assess behavioural regulation. Trials were in early-follicular (EF) and mid-luteal (ML) phases in dry (DRY) and humid (HUM) heat matched for wet bulb globe temperature (WBGT, 27°C). During rest and fixed-intensity exercise, rectal temperature was ∼0.2°C higher in ML than EF (P < 0.01) independent of environment (P = 0.66). Mean skin temperature did not differ between menstrual phases (P ≥ 0.13) but was higher in DRY than HUM (P < 0.01). Local sweat rate and/or forearm blood flow differed as a function of menstrual phase and environment (interaction: P ≤ 0.01). Exercise performance did not differ between phases [EF: 257 (37), ML: 255 (43) kJ, P = 0.62], but was 7 (9)% higher in DRY than HUM [263 (39), 248 (40) kJ; P < 0.01] in conjunction with equivalent autonomic regulation and thermal strain but higher evaporative cooling [16 (6) W m2 ; P < 0.01]. In well-trained women exercising in the heat: (1) menstrual phase did not affect performance, (2) humidity impaired performance due to reduced evaporative cooling despite matched WBGT and (3) behavioural responses nullified thermodynamic and autonomic differences associated with menstrual phase and dry vs. humid heat.


title: A single asparagine-linked glycosylation site of the severe acute respiratory syndrome coronavirus spike glycoprotein facilitates inhibition by mannose-binding lectin through multiple mechanisms.

text: Mannose-binding lectin (MBL) is a serum protein that plays an important role in host defenses as an opsonin and through activation of the complement system. The objective of this study was to assess the interactions between MBL and severe acute respiratory syndrome-coronavirus (SARS-CoV) spike (S) glycoprotein (SARS-S). MBL was found to selectively bind to retroviral particles pseudotyped with SARS-S. Unlike several other viral envelopes to which MBL can bind, both recombinant and plasma-derived human MBL directly inhibited SARS-S-mediated viral infection. Moreover, the interaction between MBL and SARS-S blocked viral binding to the C-type lectin, DC-SIGN. Mutagenesis indicated that a single N-linked glycosylation site, N330, was critical for the specific interactions between MBL and SARS-S. Despite the proximity of N330 to the receptor-binding motif of SARS-S, MBL did not affect interactions with the ACE2 receptor or cathepsin L-mediated activation of SARS-S-driven membrane fusion. Thus, binding of MBL to SARS-S may interfere with other early pre- or postreceptor-binding events necessary for efficient viral entry.


Endovascular Coiling for a Ruptured Proximal Lenticulostriate Artery Aneurysm.


title: Input strategy analysis for an air quality data modelling procedure at a local scale based on neural network.

text: In recent years, a significant part of the studies on air pollutants has been devoted to improve statistical techniques for forecasting the values of their concentrations in the atmosphere. Reliable predictions of pollutant trends are essential not only for setting up preventive measures able to avoid risks for human health but also for helping stakeholders to take decision about traffic limitations. In this paper, we present an operating procedure, including both pollutant concentration measurements (CO, SO₂, NO₂, O₃, PM10) and meteorological parameters (hourly data of atmospheric pressure, relative humidity, wind speed), which improves the simple use of neural network for the prediction of pollutant concentration trends by means of the integration of multivariate statistical analysis. In particular, we used principal component analysis in order to define an unconstrained mix of variables able to improve the performance of the model. The developed procedure is particularly suitable for characterizing the investigated phenomena at a local scale.


title: Rapid Direct Nucleic Acid Amplification Test without RNA Extraction for SARS-CoV-2 Using a Portable PCR Thermocycler.

text: There is an ongoing worldwide coronavirus disease 2019 (Covid-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). At present, confirmatory diagnosis is by reverse transcription polymerase chain reaction (RT-PCR), typically taking several hours and requiring a molecular laboratory to perform. There is an urgent need for rapid, simplified, and cost-effective detection methods. We have developed and analytically validated a protocol for direct rapid extraction-free PCR (DIRECT-PCR) detection of SARS-CoV-2 without the need for nucleic acid purification. As few as six RNA copies per reaction of viral nucleocapsid (N) gene from respiratory samples such as sputum and nasal exudate can be detected directly using our one-step inhibitor-resistant assay. The performance of this assay was validated on a commercially available portable PCR thermocycler. Viral lysis, reverse transcription, amplification, and detection are achieved in a single-tube homogeneous reaction within 36 min. This minimizes hands-on time, reduces turnaround-time for sample-to-result, and obviates the need for RNA purification reagents. It could enable wider use of Covid-19 testing for diagnosis, screening, and research in countries and regions where laboratory capabilities are limiting.


title: Transcleral approach for closing retinal tears using DuraSeal™ hydrogel sealant.

text: PURPOSE The aim of this study was to evaluate an innovative approach for closing retinal tears using DuraSeal™ (DS) hydrogel sealant in a rabbit model. METHODS Retinal detachment with a small tear was performed on 20 New Zealand rabbits. Thereafter, rabbits were divided into two groups; the experimental group received a transscleral injection of 0.1 ml DS into the subretinal space whereas the control group received sham injection of saline. Eyes were clinically evaluated using indirect ophthalmoscopy, retinal function was recorded in ten rabbits by electroretinography and the sealant's toxicity was evaluated histopathologically. RESULTS We found that the DS hydrogel was easily injected transsclerally into the subretinal space of the detached retinas with no major complications. Retinal reattachment was seen in both groups within 2 weeks with no toxicity to the sensory retina. There were no significant differences in retinal function between groups. CONCLUSION Subretinal injection of hydrogel through a transscleral route is easy to perform and may open a new avenue in the treatment of retinal detachment. However, the efficacy of the DS as a tamponade for sealing retinal tear is yet to be definite. Long-term clinical, functional, and toxicological studies are needed to evaluate its full potential for clinical applications.


title: Reported changes in health-related behaviours in Chinese urban residents in response to an influenza pandemic.

text: Strategies to lessen the impact of pandemic influenza include behavioural modifications of the general public regarding medical care, personal hygiene and protection, and social distancing. We conducted a telephone survey of Beijing residents to evaluate potential behavioural changes in the general public in the event of an influenza pandemic occurring. We used a two-stage Mitofsky-Waksberg telephone survey of Beijing residents aged 15 years. The sample was weighted to reflect the 2000 census. We asked the respondents about their current healthcare-seeking behaviours for influenza-like illness (ILI), protective measures (personal hygiene, social distancing), and compliance with health authorities. We then asked what they would do during a hypothetical pandemic. We interviewed 256 Beijing participants in our study (response rate 56%). The percent of participants consulting a doctor for ILI rose from the current 41% [95% confidence interval (CI) 35-47] to 74% (95% CI 68-79) during a pandemic. Fifty-five percent (95% CI 48-62) of the participants would seek care from a more specialized hospital during a pandemic than currently. More than 90% of the participants reported already practising hand-washing or covering their coughs or sneezes during a non-pandemic period; this percentage changed little under a pandemic scenario. Compared to the current social distancing practices, more people would avoid crowded places (77% vs. 92%, P<0.01), use a mask outside the home (10% vs. 58%, P<0.01), and take time off from work or school (17% vs. 38%, P<0.01) during a pandemic. Moreover, 26% of the participants (95% CI 21-32) would stockpile food or water, and 55% (95% CI 49-61) would stockpile medicines. Some of the behavioural changes reported by Beijing participants might help to alleviate the damage caused by a potential pandemic. However, increased use of medical care at referral hospitals will further strain the healthcare system during a pandemic.


title: Systematic Review of the Costs and Benefits of Prescribed Cannabis-Based Medicines for the Management of Chronic Illness: Lessons from Multiple Sclerosis.

text: INTRODUCTION Cannabis-based medicines (CBMs) may offer relief from symptoms of disease; however, their additional cost needs to be considered alongside their effectiveness. We sought to review the economic costs and benefits of prescribed CBMs in any chronic illness, and the frameworks used for their economic evaluation. METHODS A systematic review of eight medical and economic databases, from inception to mid-December 2016, was undertaken. MeSH headings and text words relating to economic costs and benefits, and CBMs were combined. Study quality was assessed using relevant checklists and results were synthesised in narrative form. RESULTS Of 2514 identified records, ten studies met the eligibility criteria, all for the management of multiple sclerosis (MS). Six contained economic evaluations, four studies reported utility-based quality of life, and one was a willingness-to-pay study. Four of five industry-sponsored cost-utility analyses for MS spasticity reported nabiximols as being cost-effective from a European health system perspective. Incremental cost-effectiveness ratios per quality-adjusted life-year (QALY) gained for these five studies were £49,257 (UK); £10,891 (Wales); €11,214 (Germany); €4968 (Italy); and dominant (Spain). Nabiximols for the management of MS spasticity was not associated with statistically significant improvements in EQ-5D scores compared with standard care. Study quality was moderate overall, with limited inclusion of both relevant societal costs and discussions of potential bias. CONCLUSIONS Prescribed CBMs are a potentially cost-effective add-on treatment for MS spasticity; however, this evidence is uncertain. Further investment in randomised trials with in-built economic evaluations is warranted for a wider range of clinical indications. SYSTEMATIC REVIEW REGISTRATION PROSPERO Registration Number: CRD42014006370.


title: Wound complication among different skin closure techniques in the emergency cesarean section: a randomized control trial.

text: Objective Cesarean section is the most commonly performed obstetrical surgical procedure; however, there are no standard guidelines on appropriate skin closure techniques and materials. Only few comparative studies have been conducted on different skin closure techniques, and they have shown conflicting results. Therefore, we compared different skin closure techniques during emergency cesarean section to identify the best technique with minimal wound complication rates. Methods Patients were randomized into 3 groups (group A, n=100; group B, n=102; and group C, n=98). In group A, the skin was closed using staples; in group B, via the subcuticular technique using monocryl 3-0; and in group C, using mattress suture nylon (2-0). The primary outcome was a composite of wound complications, including infection, seroma, gaping, and need for resuturing and antibiotic administration. The secondary outcome included closure time, pain perception, patient satisfaction, and cost. Analyses were performed in accordance with the intention-to-treat principle. Results The composite wound complication rate in the entire cohort was 16.6% (n=50); the complication rate was significantly higher in group A than in the other groups. Infection was the most common wound complication observed in the entire study group (86%) and was significantly higher in group A than in groups B and C (P≤0.001). Conclusion The use of staples for cesarean section skin closure is associated with an increased risk of wound complications and prolonged hospital stay postoperative visits.


title: Histopathological Effects of Tissue Adhesives on Experimental Peripheral Nerve Transection Model in Rats.

text: OBJECTIVE Our aim was to evaluate the histopathological effects of tissue adhesives on peripheral nerve regeneration after experimental sciatic nerve transection in rats and to search whether these tissue adhesives may possess a therapeutic potential in peripheral nerve injuries. METHODS This experimental study was performed using 42 female Wistar-Albino rats distributed in 6 groups subsequent to transection of right sciatic nerves. Group I underwent external circumferential neurolysis; Group II received suture repair; Group III had local polymeric hydrogel based tissue adhesive administration; Group IV received suture repair and polymeric hydrogel based tissue adhesive application together; Group V had gelatin based tissue adhesive application and Group VI had suture repair and gelatin based tissue adhesive together. After a 6-week follow-up period, biopsies were obtained from site of neural injury and groups were compared with respect to histopathological scoring based on inflammatory, degenerative, necrotic and fibrotic changes. RESULTS There were remarkable differences between control group and study groups with respect to inflammation (p=0.001), degeneration (p=0.002), necrosis (p=0.007), fibrosis (p<0.001) and vascularity (p=0.001). Histopathological scores were similar between study groups and the only noteworthy difference was that Group V displayed a lower score for necrosis and higher score in terms of vascularization. CONCLUSION Our results imply that tissue adhesives can be useful in repair of peripheral nerve injuries by decreasing the surgical trauma and shortening the duration of intervention. Results with gelatin based tissue adhesive are especially promising since more intense vascularity was observed in tissue after application. However, trials on larger series with longer durations of follow-up are essential for reaching more reliable conclusions.


A message from the Guest Editor.


title: Italian validation of CoViD-19 Peritraumatic Distress Index and preliminary data in a sample of general population.

text: INTRODUCTION Peritraumatic distress is an important predictor of post-traumatic stress disorder and although several questionnaires are available for its measurement, none of these are specific to CoViD-19. The new CoViD-19 Peritraumatic Distress Index (CPDI), developed in China, is characterized as a rapid compilation tool (10 minutes), easily understandable and appreciated by people. AIM The objectives of this study were: (1) the validation of the Italian version of the CPDI, and (2) the measurement of the prevalence of peritraumatic distress in this phase 1 CoViD-19. METHOD CPDI has been translated using a standard forward-backward-translation procedure and offered online to 329 people (191 females and 137 males, aged 46.49 ± 13.58 years). The CPDI showed an internal-consistency of Cronbach's α =0.916. Content validity was judged satisfactory by two psychologists experienced in stress and trauma. The construct validity is given by the high correlation with the dimensions of Intrusion, Avoidance and Hyperarousal as measured by the Impact of Event Scale-Revised (r=0.63, r=0.57, r=0.71, respectively). RESULTS Our results are comparable to the Chinese ones. A third of people experienced symptoms of mild/moderate and severe peritraumatic distress. Females have higher scores, compared to males. Older people are more resilient, compared to younger, and those who have been in quarantine report less distress than those didn't, as evidenced by the results of the multivariate logistic regression model. High distress was associated with use of psychotropic drugs (AOR=4.28; 95% CI=1.55-11.85), sleeping remedies (AOR=4.05; 95% CI=2.07-7.94), be worried about dying in case of contagion CoViD-19 (AOR=3.33; 95% CI=1.83-6.06), female gender (AOR=2.95; 95% CI=1.58-5.53) and have a religious belief (AOR=1.97; 95% CI=1.05-3.70). To be aged 51-71 years, to have been in quarantine and to have received psychological support were variables associated with lower distress scores. CONCLUSIONS The psychometric properties of the Italian version are satisfactory and confirm that CPDI is a tool fast, non-intrusive, administered online, and therefore 'safe' in a phase with a high risk of contagion. It allows, like a psychic thermoscan, to quickly detect the needs of the population and propose equally rapid interventions.


title: Effects of Vitamin D Supplementation on Serum 25-Hydroxyvitamin D Concentrations and Physical Performance in Athletes: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

text: BACKGROUND There is currently no systematic review examining the effects of vitamin D supplementation among athletes. A rigorous systematic review and meta-analysis is important to provide a balanced view of current knowledge on the effect of vitamin D on serum 25-hydroxyvitamin D [25(OH)D] concentrations and physical performance. OBJECTIVES This systematic review of randomized controlled trials (RCTs) evaluated the effects of oral vitamin D supplementation on serum 25(OH)D concentrations and physical performance in athletes. METHODS Multiple electronic databases were searched, and study eligibility, methodological quality assessment, and data extraction were completed independently and in duplicate. Studies were stratified by baseline vitamin D sufficiency, season, and latitude. A cut-off of 30 ng/ml (75 nmol/l) of 25(OH)D was used for sufficiency. Absolute mean differences (AMDs) between vitamin D and placebo using random effects analysis, and heterogeneity using Q statistic and I 2 index, were calculated. AMD with 95% confidence interval (CI), p value, and I 2 are reported. RESULTS In total, 13 RCTs (2005-2016) with 532 athletes (vitamin D 311, placebo 221) were eligible. A total of 433 athletes (vitamin D 244, placebo 189) had complete outcome data. Among athletes with baseline values suggesting insufficiency, vitamin D supplementation led to significant increases from 3000 IU (AMD 15.2 ng/ml; 95% CI 10.7-19.7, p < 0.0001, I 2 = 0%) and 5000 IU (AMD 27.8 ng/ml; 95% CI 16.9-38.8, p < 0.0001, I 2 = 78%) per day at >45° latitudes. Both doses led to sufficiency concentrations during winter months. Among athletes with baseline vitamin D suggesting sufficiency, serum 25(OH)D sufficiency was maintained from different doses at both latitudes. Of 13 included trials, only seven measured different physical performances and none demonstrated a significant effect of vitamin D supplementation during 12 weeks of follow-up. CONCLUSION Despite achieving sufficiency in vitamin D concentrations from ≥3000 IU supplementation, physical performance did not significantly improve. Between-study heterogeneity was large, and well-designed RCTs examining the effect of vitamin D supplementation on serum 25(OH)D concentrations, physical performance, and injuries in different sports, latitudes, ethnicities, and vitamin D status are needed.


UK's response to covid-19: crude, unadjusted mortality figures are not the whole story.


Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine.


Are my patients with rheumatic diseases at higher risk of COVID-19?


title: Surveillance for healthcare-acquired febrile respiratory infection in pediatric hospitals participating in the Canadian Nosocomial Infection Surveillance Program.

text: OBJECTIVE To determine the rates of healthcare-acquired febrile respiratory infection (HA-FRI) in Canadian pediatric hospitals and to determine the vaccination status of patients with healthcare-acquired respiratory syncytial virus (RSV) infection, influenza, or pneumococcal infection who were also eligible for immunoprophylaxis. METHODS Prospective surveillance was conducted in 8 hospitals from January 1 to April 30, 2005. All hospitalized patients less than 18 years of age were eligible, except for patients housed in standard newborn nurseries or psychiatric units. Infection control professionals reviewed laboratory reports, conducted ward rounds, and reviewed medical records to identify case patients. Descriptive analyses were completed, as well. RESULTS A total of 96 case patients were identified; 52 (54%) were male, and 48 (50%) were aged 1 year or less. Seventy-two patients (75%) had chronic medical conditions. Respiratory viruses accounted for 72 (71%) of 101 pathogens identified, and RSV was the virus most frequently identified. Of these 96 patients, 9 (9%) died, and 3 (3%) of the deaths were related to the patient's HA-FRI. The mean incidence rate was 0.97 infections/1,000 patient-days (range, 0.29-1.50 infections/1,000 patient-days). Only 2 (15%) of 13 influenza vaccine-eligible children who acquired influenza while hospitalized were reported to have been vaccinated, but influenza vaccination status was unknown for most children. However, 4 (80%) of 5 RSV prophylaxis-eligible children who had healthcare-acquired RSV infection had received immunoprophylaxis with anti-RSV monoclonal antibody. CONCLUSIONS HA-FRI is mainly caused by viruses such as RSV, and it primarily affects children under 1 year of age and those with chronic medical conditions.


title: Isolation of primary human hepatocytes from normal and diseased liver tissue: a one hundred liver experience.

text: Successful and consistent isolation of primary human hepatocytes remains a challenge for both cell-based therapeutics/transplantation and laboratory research. Several centres around the world have extensive experience in the isolation of human hepatocytes from non-diseased livers obtained from donor liver surplus to surgical requirement or at hepatic resection for tumours. These livers are an important but limited source of cells for therapy or research. The capacity to isolate cells from diseased liver tissue removed at transplantation would substantially increase availability of cells for research. However no studies comparing the outcome of human hepatocytes isolation from diseased and non-diseased livers presently exist. Here we report our experience isolating human hepatocytes from organ donors, non-diseased resected liver and cirrhotic tissue. We report the cell yields and functional qualities of cells isolated from the different types of liver and demonstrate that a single rigorous protocol allows the routine harvest of good quality primary hepatocytes from the most commonly accessible human liver tissue samples.


title: Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review.

text: OBJECTIVE Binasal prongs are the most commonly used interface for the delivery of nasal positive airway pressure (CPAP) to preterm infants. However, they are associated with pressure-related nasal injury, which causes pain and discomfort. Nasal injury may necessitate a change in interface and occasionally damage is severe enough to require surgical repair. We aim to determine the incidence and risk factors for nasal injury in preterm infants, and to provide clinicians with strategies to effectively prevent and treat it. DESIGN We conducted a systematic search of databases including MEDLINE (PubMed including the Cochrane Library), EMBASE, CINAHL and Scopus. Included studies enrolled human preterm infants and were published prior to 20 February 2017. RESULTS Forty-five studies were identified, including 14 ra ndomised controlled trials, 10 observational studies, two cohort studies, eight case reports and 11 reviews. The incidence of nasal injury in preterm infants ranged from 20-100%. Infants born <30 weeks' gestation are at highest risk. Strategies shown to reduce nasal injury included: nasal barrier dressings (2 studies, n=244, risk ratio (RD) -0.12, 95%, CI - 0.20 to -0.04), nasal high flow therapy as an alternative to binasal prong CPAP (7 studies, n=1570, risk difference (RD) -0.14, 95% CI -0.17 to -0.10), and nasal masks rather than binasal prongs (5 studies, n=544, RR 0.80, 95% CI 0.64 to 1.00). CONCLUSIONS AND RELEVANCE Nasal injury is common in preterm infants born <30 weeks' gestational age receiving CPAP via binasal prongs. Larger randomised trials are required to fully evaluate strategies to reduce nasal injury.


title: Economic benefits of pharmacy technicians practicing at advanced scope: A systematic review.

text: OBJECTIVE To critically appraise the literature to determine the cost and time savings for institutions when pharmacy technicians practice in advanced scope roles. METHODS A systematic review was registered with Prospero and conducted in January 2019. Searches were conducted in Business Source Pro, CINAHL, EconLit, EMBASE, InformGlobal, Medline, ProQuest, PubMed, Scopus and Web of Science. Search terms included pharmacy technician/pharmacy assistant and cost or time or economic evaluation. After article selection in the web-based platform Covidence©, data was extracted, and a narrative review was performed. RESULTS A total of 16 publications were eligible for inclusion in the review. Pharmacy technicians practicing at advanced scope led to both cost savings and time savings. Six studies reported a cost saving, six reported a time saving and four reported both time and cost savings. Annual savings ranged from AUD $4526 - $88,719.89, linked primarily to the difference in wages between pharmacists and pharmacy technicians. Studies that focused on time savings evaluated checking dispensed items, taking medication histories and entering chemotherapy orders; demonstrating savings of up to 5 min per task completed. CONCLUSION(S) Appropriately trained pharmacy technicians practicing at advanced scope have the potential to save time and reduce hospital costs. Identifying the cost saving opportunities from technicians acting in advance scope roles will provide incentives for hospitals to expand their technician workforce.


title: Health Hyperbolism: A Study in Health Crisis Rhetoric.

text: The Ebola virus had only been in the United States for 2 months before it became a major national health concern. However, while some citizens panicked about the looming health crisis, others remained calm, offering explanations for why a rapid spread of the virus was unlikely. Examining the distinctions between these different reactions can contribute to a better understanding of the coping strategies citizens use when facing a health crisis. We consider how citizens respond to fear by focusing on whether or not hyperbolic rhetoric was used as a means for processing and managing fear. Approximately 400 tweets and Facebook posts from the Centers for Disease Control and Prevention, the White House, and The Alex Jones Show were examined to make conclusions about how citizens respond to messages from these mediated forums. At the intersection of health communication and critical rhetoric, we advance an operational definition of health hyperbolism derived from public response to opinion leaders. Ultimately, we find that health hyperbolism contains language illustrative of distrust, blame, anger, misrepresentation, conspiracy, and curiosity.


title: Estimated GFR and the Effect of Intensive Blood Pressure Lowering After Acute Intracerebral Hemorrhage.

text: BACKGROUND The kidney-brain interaction has been a topic of growing interest. Past studies of the effect of kidney function on intracerebral hemorrhage (ICH) outcomes have yielded inconsistent findings. Although the second, main phase of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) suggests the effectiveness of early intensive blood pressure (BP) lowering in improving functional recovery after ICH, the balance of potential benefits and harms of this treatment in those with decreased kidney function remains uncertain. STUDY DESIGN Secondary analysis of INTERACT2, which randomly assigned patients with ICH with elevated systolic BP (SBP) to intensive (target SBP<140mmHg) or contemporaneous guideline-based (target SBP<180mmHg) BP management. SETTING & PARTICIPANTS 2,823 patients from 144 clinical hospitals in 21 countries. PREDICTORS Admission estimated glomerular filtration rates (eGFRs) of patients were categorized into 3 groups based on the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) creatinine equation: normal or high, mildly decreased, and moderately to severely decreased (>90, 60-90, and <60mL/min/1.73m(2), respectively). OUTCOMES The effect of admission eGFR on the primary outcome of death or major disability at 90 days (defined as modified Rankin Scale scores of 3-6) was analyzed using a multivariable logistic regression model. Potential effect modification of intensive BP lowering treatment by admission eGFR was assessed by interaction terms. RESULTS Of 2,623 included participants, 912 (35%) and 280 (11%) had mildly and moderately/severely decreased eGFRs, respectively. Patients with moderately/severely decreased eGFRs had the greatest risk for death or major disability at 90 days (adjusted OR, 1.82; 95% CI, 1.28-2.61). Effects of early intensive BP lowering were consistent across different eGFRs (P=0.5 for homogeneity). LIMITATIONS Generalizability issues arising from a clinical trial population. CONCLUSIONS Decreased eGFR predicts poor outcome in acute ICH. Early intensive BP lowering provides similar treatment effects in patients with ICH with decreased eGFRs.


title: COVID-19 Government Response Event Dataset (CoronaNet v.1.0).

text: Governments worldwide have implemented countless policies in response to the COVID-19 pandemic. We present an initial public release of a large hand-coded dataset of over 13,000 such policy announcements across more than 195 countries. The dataset is updated daily, with a 5-day lag for validity checking. We document policies across numerous dimensions, including the type of policy, national versus subnational enforcement, the specific human group and geographical region targeted by the policy, and the time frame within which each policy is implemented. We further analyse the dataset using a Bayesian measurement model, which shows the quick acceleration of the adoption of costly policies across countries beginning in mid-March 2020 through 24 May 2020. We believe that these data will be instrumental for helping policymakers and researchers assess, among other objectives, how effective different policies are in addressing the spread and health outcomes of COVID-19.


title: Thoracoscopic thymectomy in children: our preliminary experience.

text: INTRODUCTION The aim of this study is to present a preliminary series of six children affected by an anterior mediastinal mass, resulting in a thymoma. We treated this pediatric population by a video-assisted thoracoscopic thymectomy. PATIENTS AND METHODS We performed a retrospective study from January 2000 to January 2012 of all children affected by an anterior mediastinal mass, resulting in a thymoma. Data included sex, age at surgery, clinical and radiological features, surgical procedure, follow-up, and complications. RESULTS Video-assisted thoracoscopic thymectomy was performed in six children (five boys and one girl). Four patients presented with dyspnea and/or thoracic pain treated with analgesic and corticosteroid therapy without any benefits. Two patients were asymptomatic. Preoperatively, exams included radiological imaging, blood, and immunological test. All 6 patients were treated with a thoracoscopic approach; of these patients, 5 were treated with a thoracoscopic right-side thymectomy and 1 with a left-side approach. Patients were treated by a three-trocar technique, and thymectomy was performed using Valleylab (now Covidien) (Boulder, CO) LigaSure™. The mean operative time was 120 minutes. The mean hospital stay was 5 days. In all cases histological findings revealed no malignancy. The mean follow-up was 38 months. DISCUSSION Thoracoscopic thymectomy facilitated the goal of early thymectomy. The right-side approach is preferred because it gains a good visualization of the venous anatomy for dissection. The left side allows a good extended resection of both the thymus and perithymic fat. Thoracoscopic thymectomy should be consider a valid, less invasive alternative to the most radical open approach.


Risks associated with opioid use--reply.


title: Erythropoietin in traumatic brain injury associated acute kidney injury: A randomized controlled trial.

text: BACKGROUND Acute kidney injury (AKI) in traumatic brain injury (TBI) is poorly understood and it is unknown if it can be attenuated using erythropoietin (EPO). METHODS Pre-planned analysis of patients included in the EPO-TBI (ClinicalTrials.gov NCT00987454) trial who were randomized to weekly EPO (40 000 units) or placebo (0.9% sodium chloride) subcutaneously up to three doses or until intensive care unit (ICU) discharge. Creatinine levels and urinary output (up to 7 days) were categorized according to the Kidney Disease Improving Global Outcome (KDIGO) classification. Severity of TBI was categorized with the International Mission for Prognosis and Analysis of Clinical Trials in TBI. RESULTS Of 3348 screened patients, 606 were randomized and 603 were analyzed. Of these, 82 (14%) patients developed AKI according to KDIGO (60 [10%] with KDIGO 1, 11 [2%] patients with KDIGO 2, and 11 [2%] patients with KDIGO 3). Male gender (hazard ratio [HR] 4.0 95% confidence interval [CI] 1.4-11.2, P = 0.008) and severity of TBI (HR 1.3 95% CI 1.1-1.4, P < 0.001 for each 10% increase in risk of poor 6 month outcome) predicted time to AKI. KDIGO stage 1 (HR 8.8 95% CI 4.5-17, P < 0.001), KDIGO stage 2 (HR 13.2 95% CI 3.9-45.2, P < 0.001) and KDIGO stage 3 (HR 11.7 95% CI 3.5-39.7, P < 0.005) predicted time to mortality. EPO did not influence time to AKI (HR 1.08 95% CI 0.7-1.67, P = 0.73) or creatinine levels during ICU stay (P = 0.09). CONCLUSIONS Acute kidney injury is more common in male patients and those with severe compared to moderate TBI and appears associated with worse outcome. EPO does not prevent AKI after TBI.


title: Spontaneous Resolution of Carotid Stenosis with Free Floating Thrombus: A Brief Overview of Possible Mechanisms and Management.

text: Free floating thrombus is uncommon in the carotid arteries, and it is defined as an elongated thrombus attached to the arterial wall with circumferential blood flow at its distal most aspect. The majority of patients present with acute neurological deficits and usually have an underlying unstable atherosclerotic plaque. We present two cases of carotid stenosis associated with free floating thrombus. Both patients shared similar clinical presentation and were managed according to the standard workflow for suspected ischemic strokes from our institution. Conservative management was decided based on a multidisciplinary decision that intervention of any kind would be associated with high risk of periprocedural complications. Complete resolution of the atherosclerotic plaque and free floating thrombus in a short period occurred. We further discuss the mechanism behind such a dramatic radiographic and clinical improvement with medical therapy, hypothesizing that plaque erosion is a plausible explanation, based on pathology studies.


title: Laparoscopic distal pancreatectomy with division of the pancreatic neck for benign and borderline malignant tumor in the proximal body of the pancreas.

text: BACKGROUND Conventional laparoscopic distal pancreatectomy (DP) is now regarded as a safe, effective treatment modality; however, pancreatic transections are mostly believed to be somewhere between the body and tail of the pancreas. Laparoscopic DP, with its division at the pancreatic neck (subtotal pancreatectomy [STP]), is more challenging because there are major vascular structures, such as the celiac axis, coronary vein, and superior mesenteric vein-splenic vein-portal vein (SMV-SV-PV) confluence around the pancreatic neck portion to be dissected. PATIENTS AND METHODS Ten patients underwent laparoscopic STP with pancreatic division at the level of SMV-SV-PV confluence for benign and borderline pancreatic disease. RESULTS Three patients were male and 7 were female, with a median age of 60 years (range, 28-73). All patients had benign or borderline malignant tumors in the body near the neck of the pancreas, with a median tumor size of 3 cm (range, 1-9.2). The operation time was a median of 287.5 minutes (range, 160-480). The intraopeative bleeding was a median of 300 mL (range, 100-700). Spleen preservation was carried out in 8 patients. Compared with open DP with the division of the pancreatic neck, a more frequent rate of spleen preservation (P = 0.004), longer operation time (P = 0.006), and early postoperative recovery presented by early intake of a soft diet (P = 0.001) and earlier discharge (P = 0.03) were significantly more frequent in the laparoscopic STP group. In a comparative study with laparoscopic DP, the longer segment of resected pancreas (P < 0.001), smaller amount of blood loss (P = 0.019), and high rate of spleen preservation (P = 0.019) were also noted in the laparoscopic STP group. CONCLUSIONS Laparoscopic DP with division of the pancreatic neck is considered feasible and safe.


title: Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review.

text: BACKGROUND AND OBJECTIVE Medication adherence is poor in patients with chronic conditions. Behavioral economic interventions may reduce biases that are associated with poor adherence. The objective of this review is to map the available evidence on behavioral economic interventions to improve medication adherence in adults with chronic conditions in high-income settings. METHODS We conducted a scoping review and reported the study using the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Review checklist. We searched PubMed, EMBASE, SCOPUS, PsycINFO, EconLit, and CINAHL from database inception to 29 August, 2018 for peer-reviewed studies and included a search of the gray literature. Data on study characteristics, study design, and study outcomes were extracted by one reviewer. Twenty-five percent of the studies were verified by a second reviewer. RESULTS Thirty-four studies, targeting diabetes mellitus, human immunodeficiency virus, and cardiovascular and renal diseases met our inclusion criteria. All but two studies were from the USA. The majority of interventions used financial incentives, often in conjunction with other behavioral economic concepts. Non-financial interventions included framing, social influences, reinforcement, and feedback. The effectiveness of interventions was mixed. CONCLUSIONS Behavioral economic informed interventions show promise in terms of improving medication adherence. However, there is no single simple intervention. This review highlighted the importance of targeting non-adherent patients, understanding their reasons for non-adherence, providing reminders and feedback to patients and physicians, and measuring clinical outcomes in addition to medication adherence. Further research in settings that differ from the US health system is needed.


title: Single-layer versus double-layer laparoscopic intracorporeally sutured gastrointestinal anastomoses in the canine model.

text: OBJECTIVE The objective of this study was to compare the gross and histopathologic changes following 1- versus 2-layer hand-sewn suture techniques in laparoscopic gastrointestinal anastomosis in dogs. METHODS This was an experimental prospective study of 16 healthy mixed breed male and female dogs. Animals were randomly divided into 2 groups. Two-layer side-to-side hand-sewn laparoscopic gastrojejunostomies were performed in group A, so that simple interrupted sutures were placed in the outer layer and simple continuous suture was used in the inner layer. The 1-layer simple continuous anastomosis between the stomach and jejunum was done in group B precisely. Specimen were collected from the sites of anastomosis, and H&E statining was performed for light microscopic studies. RESULTS All animals survived the surgery. There was no gross inflammation, ischemia, apparent granulation tissue, abscess or fistula formation, leakage or stricture formation, and all sites of anastomosis were patent. Several adhesion formations were found in the abdomen with the higher incidence in the control group. Mean scores of leukocyte infiltration and granulation tissue formation at the sites of anastomosis were statistically insignificant between groups (P>0.05). CONCLUSIONS Gross and histopathologic findings revealed that hand-sewn laparoscopic gastrointestinal anastomosis with the 1-layer suture technique is comparable to the 2-layer suture technique.


title: Is video laryngoscope-assisted flexible tracheoscope intubation feasible for patients with predicted difficult airway? A prospective, randomized clinical trial.

text: BACKGROUND Failed intubation may result in both increased morbidity and mortality. The combination of a video laryngoscope and a flexible tracheoscope used as a flexible video stylet may improve the success rate of securing a difficult airway. We tested the hypothesis that this combination is a feasible way to facilitate intubation in patients with a predicted difficult airway in that it will shorten intubation times and reduce the number of intubation attempts. METHODS We conducted a randomized, prospective trial in 140 patients with anticipated difficult airways undergoing elective or urgent surgery. After insertion of video laryngoscope, patients were randomly assigned to either having their tube placed with the use of a preformed stylet (control group) or with a flexible tracheoscope (intervention group). The primary outcome measures were time to successful intubation and number of intubation attempts. RESULTS The number of intubations requiring 2 or more intubation attempts was similar in the 2 groups (14% control vs 13% intervention, P = 1.0); the number of patients requiring 3 or more intubation attempts was not significantly different (8.6% control vs 1.4% intervention, P = 0.12). Distribution for time to intubation also did not differ between the control (median of 66 seconds, interquartile range 47-89) and the intervention group (median of 71 seconds, interquartile range 52-100; P = 0.35). In the control group, 4 patients, all with cervical spine pathology, had the trachea intubated successfully with the video laryngoscope plus flexible tracheoscope after 3 failed attempts with video laryngoscope and rigid stylet. For these 4 patients, time from the decision to change the intubation method to successful intubation with a flexible tracheoscope was 36 ± 14 seconds. Overall success probability for cervical spine patients was 100% (20/20) in the intervention group and 80% (16/20) in the control group, with an exact 95% confidence interval for the difference of 1.4% to 44%, P = 0.04. CONCLUSIONS Flexible tracheoscope-assisted video laryngoscopic intubation is a feasible alternative to video laryngoscope only intubation in patients with predicted difficult airways. A flexible tracheoscope used in combination with video laryngoscope may also further increase the success rate of intubation in select patients with a proven difficult airway, particularly when in-line stabilization is required.


Reply to defining the role of radiofrequency ablation and stereotactic ablative radiotherapy in patients with high-risk, early-stage non-small cell lung cancer.


title: Abelson Kinase Inhibitors Are Potent Inhibitors of Severe Acute Respiratory Syndrome Coronavirus and Middle East Respiratory Syndrome Coronavirus Fusion.

text: UNLABELLED The highly pathogenic severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) cause significant morbidity and morality. There is currently no approved therapeutic for highly pathogenic coronaviruses, even as MERS-CoV is spreading throughout the Middle East. We previously screened a library of FDA-approved drugs for inhibitors of coronavirus replication in which we identified Abelson (Abl) kinase inhibitors, including the anticancer drug imatinib, as inhibitors of both SARS-CoV and MERS-CoV in vitro Here we show that the anti-CoV activity of imatinib occurs at the early stages of infection, after internalization and endosomal trafficking, by inhibiting fusion of the virions at the endosomal membrane. We specifically identified the imatinib target, Abelson tyrosine-protein kinase 2 (Abl2), as required for efficient SARS-CoV and MERS-CoV replication in vitro These data demonstrate that specific approved drugs can be characterized in vitro for their anticoronavirus activity and used to identify host proteins required for coronavirus replication. This type of study is an important step in the repurposing of approved drugs for treatment of emerging coronaviruses. IMPORTANCE Both SARS-CoV and MERS-CoV are zoonotic infections, with bats as the primary source. The 2003 SARS-CoV outbreak began in Guangdong Province in China and spread to humans via civet cats and raccoon dogs in the wet markets before spreading to 37 countries. The virus caused 8,096 confirmed cases of SARS and 774 deaths (a case fatality rate of ∼10%). The MERS-CoV outbreak began in Saudi Arabia and has spread to 27 countries. MERS-CoV is believed to have emerged from bats and passed into humans via camels. The ongoing outbreak of MERS-CoV has resulted in 1,791 cases of MERS and 640 deaths (a case fatality rate of 36%). The emergence of SARS-CoV and MERS-CoV provides evidence that coronaviruses are currently spreading from zoonotic sources and can be highly pathogenic, causing serious morbidity and mortality in humans. Treatment of SARS-CoV and MERS-CoV infection is limited to providing supportive therapy consistent with any serious lung disease, as no specific drugs have been approved as therapeutics. Highly pathogenic coronaviruses are rare and appear to emerge and disappear within just a few years. Currently, MERS-CoV is still spreading, as new infections continue to be reported. The outbreaks of SARS-CoV and MERS-CoV and the continuing diagnosis of new MERS cases highlight the need for finding therapeutics for these diseases and potential future coronavirus outbreaks. Screening FDA-approved drugs streamlines the pipeline for this process, as these drugs have already been tested for safety in humans.


Mesenchymal Stem Cell Therapy Can Transcend Perianal Crohn's Disease: How Colorectal Surgeons Can Help in the COVID-19 Crisis.


title: Noninvasive positive pressure ventilation in the acute care setting: where are we?

text: Noninvasive positive pressure ventilation (NPPV) is a technique used to deliver mechanical ventilation that is increasingly utilised in acute and chronic conditions. The present review examines the evidence supporting the use of NPPV in acute respiratory failure (ARF) due to different conditions. Strong evidence supports the use of NPPV for ARF to prevent endotracheal intubation (ETI), as well as to facilitate extubation in patients with acute exacerbations of chronic obstructive pulmonary disease and to avoid ETI in acute cardiogenic pulmonary oedema, and in immunocompromised patients. Weaker evidence supports the use of NPPV for patients with ARF due to asthma exacerbations, with post-operative or post-extubation ARF, pneumonia, acute lung injury, acute respiratory distress syndrome, or during bronchoscopy. NPPV should be applied under close clinical and physiological monitoring for signs of treatment failure and, in such cases, ETI should be promptly available. A trained team, careful patient selection and optimal choice of devices can optimise outcome of NPPV. Noninvasive positive pressure ventilation is increasingly being used in the management of acute respiratory failure but caregivers must respect evidence-supported indications and avoid contraidincations. Additionally, the technique must be applied in the appropriate location by a trained team in order to avoid disappointing results.


title: New mothers' experiences of social disruption and isolation during the severe acute respiratory syndrome outbreak in Hong Kong.

text: In Hong Kong during the severe acute respiratory syndrome outbreak of 2003, sustained uncertainty caused daily stress for residents for > 3 months. Expectant women experienced unexpected social disruption and isolation within their day-to-day life that have not been described in their own voice. The purpose of this study was to describe the experiences of women who became mothers during the outbreak and the ways in which these experiences impacted their early post-partum mothering. A phenomenological research design was chosen. The participants' responses then led the interview process. As the women's experiences had many similarities, saturation was reached after eight interviews. Four themes emerged: living with uncertainty, intense vigilance, isolation, and disrupted expectations. The participants spoke of disrupted daily routines as they tried to eliminate their risk of contracting this disease, including relationship difficulties with their spouse. None of the women had the birth experience they had hoped for because of changes in hospital practices.


title: Improved Early Recognition of Coronavirus Disease-2019 (COVID-19): Single-Center Data from a Shanghai Screening Hospital.

text: BACKGROUND In December 2019, an outbreak of a novel coronavirus disease (COVID-19; previously known as 2019-nCoV) was reported in Wuhan, Hubei province, China, which has subsequently affected more than 200 countries worldwide including Europe, North America, Oceania, Africa and other places. The number of infected people is rapidly increasing, while the diagnostic method of COVID-19 is only by nucleic acid testing. OBJECTIVE To explain the epidemiological characteristics, clinical features, imaging manifestations and to judge diagnostic value of COVID-19 by analyzing the clinical data of COVID-19 suspected and confirmed patients in a non-outbreak, Shanghai, China. To clarify the early epidemiology and clinical characteristics about COVID-19. METHODS Cross-sectional, single-center case reports of the 86 patients screened at Zhoupu Hospital in Pudong New District, Shanghai, China, from January 23 to February 16, 2020. Epidemiology, demography, clinical, laboratory and chest CTs were collected and analyzed. The screened patients were divided into COVID-19 and non-COVID-19 based on nucleic acid test results. RESULTS Of the 86 screened patients, 11 were confirmed (12.8%) by nucleic acid testing (mean age 40.73 ± 11.32, 5 males). No significant differences were found in clinical symptoms including fever, cough, dyspnea, sore throat, and fatigue (P > 0.05). No statistical difference was observed in plasma C-reactive protein (CRP) between the two groups (COVID-19 and non-COVID-19 ) of patients (P = 0.402), while the white blood cell count and lymphocyte count of the confirmed patients were slightly lower than those of the suspected patients (P < 0.05). Some non-COVID-19 chest CTs also showed subpleural lesions, such as ground-glass opacities (GGO) combined with bronchiectasis; or halo nodules distributed under the pleura with focal GGO; consolidation of subpleural distribution or combined with air bronchi sign and vascular bundle sign, etc. CONCLUSION The early clinical manifestations and imaging findings of COVID-19 are not characteristic in non-outbreak areas. Etiological testing should be performed as early as possible for clinically suspected patients.


Author Reply-Bariatric Surgery and Liver Function Tests in Nonalcoholic Fatty Liver Disease.


title: Middle East Respiratory Syndrome Coronavirus.

text: Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is an emerging infectious disease that can present with flu-like symptoms. In individuals with comorbidities or who are immunosuppressed, it can be deadly. The disease is transmitted through contact with someone who has MERS-CoV. The occupational health nurse must be cognizant of and educate the workforce about MERS-CoV transmission, prevention, and treatment.


title: A New Algorithm to Reduce the Incidence of Gastroesophageal Reflux Symptoms after Laparoscopic Sleeve Gastrectomy.

text: BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is one of the most prefered treatment option for morbid obesity. However, the effects of LSG on gastroesophageal reflux disease (GERD) are controversial. Asymptomatic GERD and hiatal hernia (HH) is common in obese patients. Therefore, it is important to identify the high risk patients prior to surgery. This study aims to evaluate efficacy of cruroplasty for HH during LSG in morbidly obese patients using ambulatory pH monitoring (APM) results, and to investigate the patients' selection criteria for this procedure. METHODS This retrospective study includes outcomes of 59 patients who underwent LSG and HH repair according to our patient selection algorithm. Outcomes included preoperative GERD Health-Related Quality of Life (GERD-HRQL) questionnaire, APM results, percentage of postoperative excess weight loss, and total weight loss. RESULTS For a total of 402 patients, APM was applied in 70 patients who had a positive score of GERD-HRQL, and 59 patients underwent LSG and concomitant HH repair who had a DeMeester score of 14.7% or above. There was no statistically significant difference in weight loss at 6 and 12-month follow-up. Two patients (3.3%) had symptoms of GERD at 12 months postoperatively, and only one (1.6%) patient required treatment of proton pump inhibitor for reflux. In the total cohort, 11 (2.7%) patients also evolved de novo GERD symptoms. CONCLUSIONS This study confirm that careful attention to patient selection and surgical technique can reduce the symptoms of GERD at short-term. Routine bilateral crus exploration could be a major risk factor of postoperative GERD.


title: Intraoperative injection of radiocolloid for sentinel node biopsy in breast cancer.

text: UNLABELLED Preoperative injection of radiocolloid for axillary sentinel node biopsy in breast cancer is uncomfortable for patients. This study evaluated the reliability of radiocolloid injection as determined by sentinel node identification rate and positive sentinel node biopsy rate, after the patient has been anesthetized in the operating room as compared with preoperative injection. METHODS After institutional review board approval, a retrospective cohort of patients with breast cancer who underwent sentinel node biopsy from January 2005 through December 2010 was evaluated for analysis. Patients who received intraoperative injection of radiocolloid were compared with those who received their injection preoperatively. Patients with incomplete pathologic staging or having received neoadjuvant chemotherapy were excluded. All patients received radiocolloid injections into the retroareolar tissue; some also received intradermal injection directly over the tumor. All injections contained 37 MBq (1 mCi) in 0.5 mL of filtered (0.22-μm) (99m)Tc-sulfur colloid. RESULTS Over the 6-y study period there were 904 sentinel node biopsy procedures, and 165 patients were excluded from analysis. Of the 739 sentinel node biopsies that were analyzed, 647 had preoperative injection of radiocolloid and 92 had intraoperative injection. The overall sentinel lymph node identification rates were similar for the 2 groups: 93.5% for the preoperative injection group and 94.6% for the intraoperative injection group (not statistically significant). The identification rates remained comparable for both groups when analyzed by T stage of the tumor. The average number of sentinel lymph nodes removed was similar between preoperative and intraoperative injection: 2.60 and 2.70 nodes, respectively. The overall rates of positive sentinel nodes were comparable for the 2 groups: 25.6% for the preoperative injection group and 26.4% for the intraoperative injection group (not statistically significant). When analyzed by T stage, the positive sentinel node rates remained similar between the 2 groups. CONCLUSION The sentinel lymph node identification rate of 94.6% for the intraoperative injection group was similar to other published sentinel lymph node identification rates (96%-100%). The positive sentinel lymph node rate was also comparable to that of published series. Intraoperative injection of radiocolloid for axillary sentinel node biopsy appears equivalent to preoperative injection and is a less painful experience for breast cancer patients.


title: Mini-laparoscopic live donor nephrectomy with the use of 3-mm instruments and laparoscope.

text: PURPOSE To analyze our preliminary outcomes on the use of 3 mm instruments for laparoscopic live donor nephrectomy (LLDN). METHODS Our series includes thirteen patients, who underwent LLDN using 3-mm instruments and laparoscope and 5-mm transumbilical trocar. The patients were followed at 7 and 14 days from discharge and were specifically asked about their cosmetic satisfaction. At follow-up, the recipient graft function was controlled, as well as the donor's cosmetic results. Eight months after surgery, all thirteen patients were asked to fill out the Patient Scar Assessment Questionnaire and Scoring System (PSAQ). RESULTS All patients presented good recovery after surgery. Regarding cosmetic outcomes, the donors expressed their satisfaction toward the minimal incision size and optimal esthetic results at 7 and 14 days from discharge home. The low scores on each section of the PSAQ confirmed the favorable outcomes. Early graft function was satisfactory at 1 and 3 months after the kidney transplantation. Furthermore, there were no major complications in the recipients. CONCLUSIONS Our persistent positive results with the use of 3-mm instruments during LLDN support this technique as a good alternative to the standard laparoscopic approach for minimizing the incision site, while maintaining safety and excellent clinical outcomes. The fact that the general laparoscopic standards are maintained could make this approach a very attractive alternative to the other minimally invasive approaches for live donor nephrectomy. The hope is in that the higher degree of satisfaction in the donor population demonstrated in this study may likely enhance living kidney donation.


title: Serious adverse events with tocilizumab: pharmacovigilance as an aid to prioritize monitoring in COVID-19.

text: Given its approval for the treatment of cytokine release syndrome, tocilizumab is under investigation in severe coronavirus disease-2019. To characterize serious adverse events (AEs) with tocilizumab, we queried the worldwide FDA Adverse Event Reporting System and perform disproportionality analysis, selecting only designated medical events (DMEs) where tocilizumab was reported as suspect, with a focus on hepatic reactions. The reporting odds ratios (RORs) were calculated, deemed significant by a lower limit of the 95% confidence interval (LL95%CI)>1. 2,433 reports of DMEs were recorded with tocilizumab, mainly in rheumatic diseases. Statistically significant RORs emerged for 13 DMEs, with drug-induced liver injury (N=91; LL95%CI 3.07), pancreatitis (151; 1.41), and pulmonary fibrosis (222; 7.21) as unpredictable AEs. 174 cases of liver-related DMEs were retrieved (proportion of death=18.4%), with median onset of 27.5 days. These serious unpredictable reactions occurring in chronic real-world tocilizumab use may support patients' care and monitoring of ongoing clinical trials.


title: EEG asymmetry during aortic arch surgeries associated with selective preferential cerebral hypothermia.

text: Intraoperative EEG monitoring is increasingly used during aortic arch procedures for early detection of acute neurologic dysfunction. In those procedures involving cardiopulmonary bypass, increased neuroprotection may be gained by using hypothermic circulatory arrest and selective cerebral perfusion. Several techniques for cerebral perfusion exist; yet no studies have noted distinct EEG patterns associated with different techniques. In this study, we reviewed EEG records of six aortic arch procedures that used cannulation of the innominate artery to provide selective antegrade cerebral perfusion. In each case, a transient hemispheric asymmetry was noted within 2 minutes of the start of head cooling, consisting of enhanced suppression over the right compared with the left hemisphere, which was confirmed by power analysis. The EEG returned to baseline during passive-head rewarming in five cases, whereas a brief left-sided partial seizure occurred during rewarming in one case. These findings suggest that antegrade cerebral perfusion using cannulation of the innominate artery results in enhanced cooling of the right hemisphere as detected by intraoperative EEG monitoring. Characterization of this finding is necessary to prevent misinterpretation of ischemia by EEG.


title: Infusion pump development and implications for nurses.

text: Infusion pumps are commonplace in today's healthcare settings and their design and development has kept pace with technology over the decades. In the 1970s and 1980s infusion pumps began to emerge in the UK market and were basic, mechanical devices with limited functions. Today, infusion pumps have a plethora of functions and features and a range of alarms to help alert the user and the patient that infusions are nearing completion, have ended or their range of sensors has detected that the infusion pump, or patient, requires attention. The role of the nurse in safely managing this ever-changing technology should not be underestimated. This paper reviews the progress made over the past 40 years in the UK healthcare setting and how the nurses have had to keep up to speed with the technology as it develops. It highlights the importance of fully integrating infusion pumps into intravenous (IV) therapy training and assessment. The important role the nurse plays is highlighted as well as exploring how he or she can help organisations better understand infusion pumps in the day-to-day management of patients undergoing intravenous therapy.


Bereavement and Grief During the COVID-19 Pandemic.


title: Trends and results of the first 5 years of Fundamentals of Laparoscopic Surgery (FLS) certification testing.

text: INTRODUCTION FLS is an educational program developed by the Society of American Gastrointestinal and Endoscopic Surgeons and endorsed by the American College of Surgeons. The goal of the FLS program is to teach and assess the basic cognitive and psychomotor skills required to perform laparoscopic surgery. The purpose of this study is to review the results from the first 5 years of FLS certification testing. METHODS FLS test data were prospectively collected for all participants taking the FLS certification examination since its inception. Deidentified data were reviewed and analyzed using standard descriptive statistics. RESULTS The FLS examination was taken by 2,689 participants between October 2004 and December 2009. There was a yearly increase in the number of individuals seeking FLS certification. Complete demographic information was available for 1,882 participants: 12% were junior residents (PGY 1-3), 69% were senior residents (PGY 4-5) or fellows, and 19% were attending surgeons. A breakdown of participants by specialty revealed that 88% were general surgeons, 4% were gynecologists, 2% were urologists, and 6% were labeled as "other." The mean (standard deviation, SD) score on the cognitive examination was 519 (157), with a 93% pass rate. The mean score on the technical skills examination was 525 (117), with a 92% pass rate. After combining both scores, the overall FLS certification pass rate was 88%. CONCLUSIONS The FLS certification examination has gained widespread acceptance among laparoscopic surgeons in training and practice, with a marked increase in testing since the American Board of Surgery mandate for certification was announced. The overall pass rate of 88% on the examination approaches the target pass rate of 90% established during the test-setting process.


title: Editorial - Child oral health; is there anything more to know?

text: It seems a strange thing to be writing about child oral health in the middle of a virus pandemic that has, in the UK at least, paused all routine dental care. Perhaps not; as thoughts turn to the return of "normal" opera- tion there are concerns over potential ongoing impacts from COVID-19 on health services including stricter infection-control requirements and economic impacts from the lockdown. It invites ridicule to try and predict what will happen in the coming years, but the economic and social impacts are likely to increase vulnerability among the already vulnerable and the delivery of dental care is likely to be more problematic and more expensive. More than ever we need to reduce the burden of avoidable dental disease.


title: Challenging the Stigma of Mental Illness Through Creative Storytelling: A Randomized Controlled Trial of This Is My Brave.

text: This Is My Brave (TIMB) is a contact-based mental illness stigma reduction program set in theaters. A randomized controlled trial of TIMB, compared the effect of TIMB videos to a comparison and control condition video. Pre- and post-surveys (153 adults) assessed mental illness stigma, beliefs about recovery and empowerment, and willingness to seek treatment. Univariate ANCOVAs revealed participants in the TIMB video condition experienced a greater reduction in perceived difference from people with mental illnesses than the comparison and control groups. Participants in the comparison and TIMB video conditions experienced greater reductions in social distance than the control group. Contrary to our hypothesis, participants in the TIMB video condition did not endorse improved beliefs about recovery and empowerment as compared to the comparison and control groups. These findings provide evidence for TIMB as an effective program for stigma reduction, particularly reducing perceived difference from people with mental illnesses and decreasing desired social distance.


Resurgence of "bow and arrow" related ocular trauma: Collateral damage arising from COVID-19 lockdown in India?


title: The COVID-19 Pandemic: Crisis Management for Plastic Surgeons.

text: The worldwide outbreak of coronavirus disease 2019 (COVID-19) has forced healthcare systems across the United States to undertake broad restructuring to address the ongoing crisis. The framework of crisis management can assist plastic surgeons navigate the dynamic environment of the COVID-19 pandemic. This manuscript outlines crisis management tools at a number of different levels, from hospital-wide to plastic surgeon-specific, and it offers a practical discussion of the coronavirus situation as it affects plastic surgeons. While there are innumerable ways that this virus is currently changing plastic surgeons' practices, it is crucial to remember that these changes are temporary, and they will be best met by being confronted head-on.


title: Determinants and Drivers of Infectious Disease Threat Events in Europe.

text: Infectious disease threat events (IDTEs) are increasing in frequency worldwide. We analyzed underlying drivers of 116 IDTEs detected in Europe during 2008-2013 by epidemic intelligence at the European Centre of Disease Prevention and Control. Seventeen drivers were identified and categorized into 3 groups: globalization and environment, sociodemographic, and public health systems. A combination of >2 drivers was responsible for most IDTEs. The driver category globalization and environment contributed to 61% of individual IDTEs, and the top 5 individual drivers of all IDTEs were travel and tourism, food and water quality, natural environment, global trade, and climate. Hierarchical cluster analysis of all drivers identified travel and tourism as a distinctly separate driver. Monitoring and modeling such disease drivers can help anticipate future IDTEs and strengthen control measures. More important, intervening directly on these underlying drivers can diminish the likelihood of the occurrence of an IDTE and reduce the associated human and economic costs.


title: Mother to Child SARS-CoV-2 Transmission: Fact or Fantasy.

text: The emerging coronavirus called SARS-CoV-2 has spread rapidly around the world. Responsible for severe pneumonitis (Covid-19), there are also doubts concerning a possible mother-to-fetal transmission of this virus. Current data are patchy and obtained from small groups of patients. They tend to support the idea that the mother-to-fetal transmission of SARS-CoV-2 is very rare, but the period between infection and childbirth was often very short and may not allow sufficient replication to consider transplacental passage. Here, we reviewed the existing virological data and those remaining to explore. Thus, the natural history of SARS-CoV-2 infection in pregnant women and the risk of transmission in utero is not yet fully understood and defined. Four months from the emergence of this virus, it is therefore reasonable to wait for the results of specific studies on larger cohorts which, to be conclusive, must meet the best scientific criteria.


title: Human Coronavirus: Host-Pathogen Interaction.

text: Human coronavirus (HCoV) infection causes respiratory diseases with mild to severe outcomes. In the last 15 years, we have witnessed the emergence of two zoonotic, highly pathogenic HCoVs: severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). Replication of HCoV is regulated by a diversity of host factors and induces drastic alterations in cellular structure and physiology. Activation of critical signaling pathways during HCoV infection modulates the induction of antiviral immune response and contributes to the pathogenesis of HCoV. Recent studies have begun to reveal some fundamental aspects of the intricate HCoV-host interaction in mechanistic detail. In this review, we summarize the current knowledge of host factors co-opted and signaling pathways activated during HCoV infection, with an emphasis on HCoV-infection-induced stress response, autophagy, apoptosis, and innate immunity. The cross talk among these pathways, as well as the modulatory strategies utilized by HCoV are also discussed. Expected final online publication date for the Annual Review of Microbiology Volume 73 is September 9, 2019. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.


title: RNA interference of influenza A virus replication by microRNA-adapted lentiviral loop short hairpin RNA.

text: Limitations of the current vaccines and antivirals against influenza A virus (IAV) pandemic underscore the urgent need for developing novel anti-influenza strategies. RNA interference (RNAi) induced by small interfering RNA (siRNA) has become a powerful new means to inhibit viral infection in a gene-specific manner. However, the efficacy of the siRNA delivery platform and the relatively high cost of administration have hindered widespread application of siRNA. In this study, we developed a microRNA (miRNA)-30-based lentivirus delivery system by embedding a synthetic short hairpin RNA (shRNA) stem into the context of endogenous precursor of miRNA-30 (shRNAmir) to express a silencer of the influenza gene. We showed that the miRNA-based lentivirus vector was able to express and process a single nucleoprotein (NP)-targeting shRNAmir, which could potently inhibit IAV replication. We further showed that miRNA-based lentivirus vector carrying tandemly linked NP and polymerase PB1 shRNAmirs could express and process double shRNAmirs. Despite the relatively low levels of NP and PB1 miRNAs produced in the stably transduced cells, the combination of two miRNAs exerted a great degree of inhibition on influenza infection. Given the advantage of combinatorial RNAi in preventing emergence of mutant virus, miRNA-based lentiviral vectors are valuable tools for anitiviral activities. To the best of our knowledge, this is the first study demonstrating that a miRNA-based RNAi strategy can be applied for better control of influenza virus infection.


title: Directional Atherectomy Followed by a Paclitaxel-Coated Balloon to Inhibit Restenosis and Maintain Vessel Patency: Twelve-Month Results of the DEFINITIVE AR Study.

text: BACKGROUND Studies assessing drug-coated balloons (DCB) for the treatment of femoropopliteal artery disease are encouraging. However, challenging lesions, such as severely calcified, remain difficult to treat with DCB alone. Vessel preparation with directional atherectomy (DA) potentially improves outcomes of DCB. METHODS AND RESULTS DEFINITIVE AR study (Directional Atherectomy Followed by a Paclitaxel-Coated Balloon to Inhibit Restenosis and Maintain Vessel Patency-A Pilot Study of Anti-Restenosis Treatment) was a multicenter randomized trial designed to estimate the effect of DA before DCB to facilitate the development of future end point-driven randomized studies. One hundred two patients with claudication or rest pain were randomly assigned 1:1 to DA+DCB (n=48) or DCB alone (n=54), and 19 additional patients with severely calcified lesions were treated with DA+DCB. Mean lesion length was 11.2±4.0 cm for DA+DCB and 9.7±4.1 cm for DCB (P=0.05). Predilation rate was 16.7% for DA+DCB versus 74.1% for DCB; postdilation rate was 6.3% for DA+DCB versus 33.3% for DCB. Technical success was superior for DA+DCB (89.6% versus 64.2%; P=0.004). Overall bail-out stenting rate was 3.7%, and rate of flow-limiting dissections was 19% for DCB and 2% for DA+DCB (P=0.01). One-year primary outcome of angiographic percent diameter stenosis was 33.6±17.7% for DA+DCB versus 36.4±17.6% for DCB (P=0.48), and clinically driven target lesion revascularization was 7.3% for DA+DCB and 8.0% for DCB (P=0.90). Duplex ultrasound patency was 84.6% for DA+DCB, 81.3% for DCB (P=0.78), and 68.8% for calcified lesions. Freedom from major adverse events at 1 year was 89.3% for DA+DCB and 90.0% for DCB (P=0.86). CONCLUSIONS DA+DCB treatment was effective and safe, but the study was not powered to show significant differences between the 2 methods of revascularization in 1-year follow-up. An adequately powered randomized trial is warranted. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Unique Identifier: NCT01366482.


title: Viral and cellular subnuclear structures in human cytomegalovirus-infected cells.

text: In human cytomegalovirus (HCMV)-infected cells, a dramatic remodelling of the nuclear architecture is linked to the creation, utilization and manipulation of subnuclear structures. This review outlines the involvement of several viral and cellular subnuclear structures in areas of HCMV replication and virus-host interaction that include viral transcription, viral DNA synthesis and the production of DNA-filled viral capsids. The structures discussed include those that promote or impede HCMV replication (such as viral replication compartments and promyelocytic leukaemia nuclear bodies, respectively) and those whose role in the infected cell is unclear (for example, nucleoli and nuclear speckles). Viral and cellular proteins associated with subnuclear structures are also discussed. The data reviewed here highlight advances in our understanding of HCMV biology and emphasize the complexity of HCMV replication and virus-host interactions in the nucleus.


Infographic. Cooling strategies to attenuate PPE-induced heat strain during the COVID-19 pandemic.


title: [Etiological structure of influenza and other ARVI in St. Petersburg during epidemic seasons 2012-2016.]

text: The etiological structure of influenza and other acute respiratory viral infections including their rate of incidence in St. Petersburg and Leningrad region during 4 epidemic seasons has been studied. Seasonality of some respiratory viruses was shown and peaks of circulation of RSV, adenovirus, parainfluenza viruses, rhinovirus, bocavirus, metapneumovirus and coronavirus were marked. The interference of influenza A viruses and RSV, RSV and rhinoviruses was highlighted. A high incidence of adenovirus infection in organized communities and RSV infection in children was revealed.


title: Gastrointestinal behavior of nano- and microsized fenofibrate: In vivo evaluation in man and in vitro simulation by assessment of the permeation potential.

text: INTRODUCTION The purpose of this study was (i) to evaluate the gastrointestinal behavior of micro- and nanosized fenofibrate in humans and (ii) to develop a simple yet qualitatively predictive in vitro setup that simulates the observed absorption-determining factors. MATERIALS AND METHODS Commercially available micro- and nanoparticles of fenofibrate (Lipanthyl® and Lipanthylnano®, respectively) were administered orally to five healthy volunteers in fasting and postprandial conditions. Intraluminal and systemic drug concentrations were determined as reference data for the development of a predictive in vitro setup. To capture the observed solubility/permeability interplay, in vitro dissolution testing was performed in the presence of a permeation bag with sink conditions. RESULTS In fasting conditions, intake of nanosized fenofibrate generated increased duodenal concentrations compared to microsized fenofibrate, which was reflected in an improved systemic exposure. In postprandial conditions, duodenal concentrations were greatly enhanced for both formulations, however without an accompanying increase in systemic exposure. It appeared that micellar encapsulation of the highly lipohilic fenofibrate limited its potential to permeate from fed state intestinal fluids. To capture these in vivo observations in an in vitro setup, classic dissolution testing was combined with permeation assessment into a permeation bag with sink conditions. In case of fasting conditions, the dissolution/permeation approach allowed for an improved discriminative power between micro- and nanosized fenofibrate by better simulating the dynamic interplay of dissolution and absorption. In case of postprandial conditions, the observed solubility-permeability interplay could be simulated using the dissolution/permeation approach in combination with biorelevant media (FeSSGFFortimel and FeSSIF-V2) to mimic micellar entrapment and reduced permeation potential of fenofibrate. CONCLUSION For the first time, reduced permeation of a lipophilic drug despite increased intraluminal concentrations, was demonstrated in humans. Dissolution testing using biorelevant media in combination with permeation assessment into a sink permeation bag appeared to be a simple yet pragmatic approach to capture this solubility-permeability interplay in early formulation evaluation.


title: Streptococcal infections in cats: ABCD guidelines on prevention and management.

text: OVERVIEW Streptococcus canis is most prevalent in cats, but recently S equi subsp zooepidemicus has been recognised as an emerging feline pathogen. S CANIS INFECTION S canis is considered part of the commensal mucosal microflora of the oral cavity, upper respiratory tract, genital organs and perianal region in cats. The prevalence of infection is higher in cats housed in groups; and, for example, there may be a high rate of vaginal carriage in young queens in breeding catteries. A wide spectrum of clinical disease is seen, encompassing neonatal septicaemia, upper respiratory tract disease, abscesses, pneumonia, osteomyelitis, polyarthritis, urogenital infections, septicaemia, sinusitis and meningitis. S EQUI SUBSP ZOOEPIDEMICUS INFECTION S equi subsp zooepidemicus is found in a wide range of species including cats. It was traditionally assumed that this bacterium played no role in disease of cats, but it is now considered a cause of respiratory disease with bronchopneumonia and pneumonia, as well as meningoencephalitis, often with a fatal course. Close confinement of cats, such as in shelters, appears to be a major risk factor. As horses are common carriers of this bacterium, contact with horses is a potential source of infection. Additionally, the possibility of indirect transmission needs to be considered. DIAGNOSIS Streptococci can be detected by conventional culture techniques from swabs, bronchoalveolar lavage fluid or organ samples. Also real-time PCR can be used, and is more sensitive than culture. TREATMENT In suspected cases, treatment with broad-spectrum antibiotics should be initiated as soon as possible and, if appropriate, adapted to the results of culture and sensitivity tests.


title: Preference of neuromuscular patients regarding equipment for daytime mouthpiece ventilation: a randomized cross-over study.

text: BACKGROUND Patients with neuromuscular disorders (NMDs) are likely to develop respiratory failure which requires noninvasive ventilation (NIV). Ventilation via a mouthpiece (MPV) is an option to offer daytime NIV. OBJECTIVES To determine the preferred equipment for MPV by patients with NMDs. METHODS Two MPV equipment sets were compared in 20 patients with NMDs. Set 1, consisted of a non-dedicated ventilator for MPV (PB560, Covidien) with a plastic angled mouthpiece. Set 2, consisted of a dedicated MPV ventilator (Trilogy 100, Philips Respironics) without back-up rate and kiss trigger combined with a silicone straw mouthpiece. The Borg dyspnea score, ventilator free time, transcutaneous oxygen saturation (SpO2) and carbon dioxide tension (TcCO2 ) were recorded with and without MPV. Patient perception was assessed by a 17-items list. RESULTS TcCO2 measurements and total perception score were not different between the two MPV sets. Dyspnea score was lower with the non-dedicated versus dedicated equipment, 1 (0.5) vs 3 (1-6), p<0.01. All patients with a ventilator free time lower than 6 hours preferred a set backup rate rather than a kiss trigger. Sixty five percent of patients preferred the commercial arm support and 55% preferred the plastic angled mouthpiece. CONCLUSIONS Dedicated and non-dedicated MPV equipment are deemed effective and comfortable. Individualization of arm support and mouthpiece is advised to ensure success of MPV. A ventilator free time lower than 6 hours seems to be a useful indicator to a priori set a back-up rate rather than a rate at zero associated to the kiss trigger.


title: National trends in prescription drug expenditures and projections for 2020.

text: PURPOSE To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2020 in the United States, with a focus on the nonfederal hospital and clinic sectors. METHODS Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2020 were reviewed, including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for specialty drugs, biosimilars, and diabetes medications. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2020 were based on a combination of quantitative analyses and expert opinion. RESULTS In 2019, overall US pharmaceutical expenditures grew 5.4% compared to 2018, for a total of $507.9 billion. This increase was driven to similar degrees by prices, utilization, and new drugs. Adalimumab was the top drug in US expenditures in 2019, followed by apixaban and insulin glargine. Drug expenditures were $36.9 billion (a 1.5% increase from 2018) and $90.3 billion (an 11.8% increase from 2018) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals growth was driven by new products and price increases. Several new drugs that will likely influence spending are expected to be approved in 2020. Specialty and cancer drugs will continue to drive expenditures. CONCLUSION For 2020 we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 9.0% to 11.0% and 2.0% to 4.0%, respectively, compared to 2019. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.


title: Low-cost reusable instrumentation for laparoendoscopic single-site nephrectomy: assessment in a porcine model.

text: PURPOSE To test different sets of prebent instruments and a new reusable access device for laparoendoscopic single-site (LESS) surgery. MATERIALS AND METHODS Three surgeons with previous experience in LESS performed 12 nephrectomies in six pigs. In all procedures, a multichannel access device (X-CONE) and a 5-mm extra-long telescope were used. Four sets of prebent instruments with different profiles (S-portal) were tested: Standard (one straight scissors and one curved grasper), Cuschieri, Carus, and Leroy set (each of them consisting of two curved instruments with different configurations). Assessment was performed based on both objective (procedure time; time to manage the pedicle; time to free kidney) and subjective parameters (entry/exit of instruments; triangulation; dissection up/down; dissection lateral; retraction; interdependence). The subjective assessment tool used was a Likert type scale (1 = easy to 5 = prohibitive). The access device was assessed by using objective (time to complete insertion of device after skin incision) and subjective (significant air leakage, movement constraint) parameters. RESULTS Time to insertion of the X-CONE was <1 minute in all the cases. Surgeons reported significant insufflant leakage in 58% of cases. The procedure was completed in 10/12 (83%) cases. Mean operative time was 8.3 ± 4.2 minutes, being lower for the Carus group (4.5 min) and higher for the standard group (13 min). Among the different sets, the standard one obtained the best mean scores for all subjective parameters. CONCLUSIONS X-CONE allows easy abdominal access, and its reusable properties represent cost savings for LESS compared with disposable devices. Prebent instruments might also represent attractive low-cost tools for LESS.


title: [Precautions in ophthalmic practice in the prevention and control of the novel coronavirus pneumonia epidemic].

text: 新型冠状病毒肺炎是新中国成立以来在我国发生的传播速度最快、感染范围最广、防控难度最大的一次重大突发公共卫生事件，眼科工作者在抗击疫情中积极行动起来。本文结合目前最新的基础和临床研究进展以及在疫情防控中的实践经验，针对眼部是否为新型冠状病毒（2019-nCoV）感染途径、眼科医师疫情期间临床工作的防护、2019-nCoV眼部感染及临床表现以及针对公众的眼部防护科普教育等方面进行阐述，指出眼科目前应关注的问题和积极开展工作的环节，并给予指导意见，希望能为疫情的科学防控和精准施策提供参考。（中华眼科杂志，2020，56：）.


Keep up with the latest coronavirus research.


title: Effect of surface-enhanced laser desorption/ionization time-of-flight mass spectrometry on identifying biomarkers of laryngeal carcinoma.

text: The aim is to study the serum protein fingerprint of patients with laryngeal carcinoma (LC) and to screen for protein molecules closely related to LC during the onset and progression of the disease with surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS). Serum samples from 68 patients with LC and 117 non-cancer control samples (75 healthy volunteers and 42 Vocal fold polyps). Q10 protein chips and PBSII-C protein chips reader (Ciphergen Biosystems Inc.) were used. The protein fingerprint expression of all the Serum samples and the resulting profiles between cancer and non-cancer groups were analyzed with Biomarker Wizard system. A group of proteomic peaks were detected. Three differently expressed potential biomarkers were identified with the relative molecular weights of 5,915, 6,440 and 9,190 Da. Among the three peaks, the one with m/z 6,440 was down-regulated, and the other two peaks with m/z 5,915 and 9,190 were up-regulated in LC. This diagnostic model could distinguish LC patients from controls with a sensitivity of 92.1% and a specificity of 91.9%. Moreover, blind test data showed a sensitivity of 86.7% and a specificity of 89.1%. The data suggested that SELDI technology could be used to screen proteins with altered expression levels in the serum of LC patients. These protein peaks were considered as specific serum biomarkers of LC and have the potential value for further investigation.


title: Occurrence of and risk factors for electroencephalogram burst suppression during propofol-remifentanil anaesthesia.

text: BACKGROUND Suppression ratio (SR) derived from bispectral index (BIS) monitoring is correlated to EEG burst suppression. It may occur during deep anaesthesia, but also in the case of metabolic or haemodynamic brain injury. The goal of the study was to describe the occurrence of SR and to determine factors associated with SR during propofol-remifentanil general anaesthesia maintenance. METHODS We conducted a post hoc analysis of BIS recordings in consecutive patients included in two multi-centre trials, undergoing non-cardiac surgery using a dual closed-loop BIS controller allowing automated propofol-remifentanil administration. The percentage of time spent with a BIS value between 40 and 60 (T(BIS 40-60)) was measured. Two groups of patients were defined: the SR group, including patients with at least one episode of SR value >10% lasting more than 1 min, and the control group. Factors associated with SR were analysed using a stepwise multivariate analysis. RESULTS A total of 1494 patients [age=57 (17) yr; T(BIS 40-60)=76 (17%)] were analysed and 131 (8.7%) patients constituted the SR group. The main independent factors associated with SR were advanced age [odds ratio (95% confidence interval)=4.80 (1.85-12.43) (P=0.027), 10.59 (3.76-29.81) (P<0.0001), for categories of age 60-80 and >80 yr, respectively], history of coronary artery disease (CAD) [2.53 (1.47-4.37) (P=0.001)] and male gender [1.57 (1.03-2.40) (P=0.03)]. CONCLUSIONS The occurrence of SR during BIS-controlled propofol and remifentanil anaesthesia is mainly observed in elderly male patients or in patients with a history of CAD. The mechanisms underlying SR and the potential consequences for the patient's postoperative outcome remain unsolved.


Italian doctors call for protecting healthcare workers and boosting community surveillance during covid-19 outbreak.


Call for independent monitoring of disease outbreak preparedness.