title: Bridging the gap between gastric pouch and jejunum: a bariatric nightmare.

text: BACKGROUND Even in a large volume bariatric centre, bariatric surgeons are sometimes confronted with intraoperative anatomical challenges which force even the most experienced surgeon into a pioneering position. In this video we present how a large gap of approximately 8 cm is bridged by applying several techniques that are not part of our standardized surgical procedure. CASE PRESENTATION After creation of a 20 mL gastric pouch we discovered that the alimentary limb could not be advanced further cranially due to a very short a thick jejunal mesentery in a 49 year old male patient during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. By dissecting the gastro-oesophageal junction form the crus, stretching the gastric pouch, transecting the jejunal mesentery, using a retrocolic/retrogastric route, and creating a fully hand-sewn gastrojejunostomy we were able to safely complete the LRYGB. Drains were left near the gastrojejunostomy and the patient was kept nil by mouth for 5 days. On the 5th postoperative day radiographic swallow series were obtained which revealed no sign of leakage. The patient was discharged in good clinical condition on the 6th postoperative day. To date, no complications have occurred. Weight loss results are -31.5 % of the preoperative total body weight. CONCLUSIONS When confronted with a large distance between the gastric pouch and the alimentary limb, several techniques presented in this video may be of aid to the bariatric surgeon. We stress that only experienced bariatric surgeon should embark on these techniques. Inspecting the alimentary limb before the creation of the gastric pouch may prevent the need for such complex techniques.


title: Endovascular intervention for acute ischemic stroke in light of recent trials.

text: Three recently published trials, MR RESCUE, IMS III, and SYNTHESIS Expansion, evaluating the efficacy and safety of endovascular treatment of acute ischemic stroke have generated concerns about the future of endovascular approach. However, the tremendous evolution that imaging and endovascular treatment modalities have undergone over the past several years has raised doubts about the validity of these trials. In this paper, we review the role of endovascular treatment strategies in acute ischemic stroke and discuss the limitations and shortcomings that prevent generalization of the findings of recent trials. We also provide our experience in endovascular treatment of acute ischemic stroke.


title: Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature.

text: BACKGROUND High flow nasal cannula (HFNC) systems utilize higher gas flow rates than standard nasal cannulae. The use of HFNC as a respiratory support modality is increasing in the infant, pediatric, and adult populations as an alternative to non-invasive positive pressure ventilation. OBJECTIVES This critical review aims to: (1) appraise available evidence with regard to the utility of HFNC in neonatal, pediatric, and adult patients; (2) review the physiology of HFNC; (3) describe available HFNC systems (online supplement); and (4) review ongoing and planned trials studying the utility of HFNC in various clinical settings. RESULTS Clinical neonatal studies are limited to premature infants. Only a few pediatric studies have examined the use of HFNC, with most focusing on this modality for viral bronchiolitis. In critically ill adults, most studies have focused on acute respiratory parameters and short-term physiologic outcomes with limited investigations focusing on clinical outcomes such as duration of therapy and need for escalation of ventilatory support. Current evidence demonstrates that HFNC generates positive airway pressure in most circumstances; however, the predominant mechanism of action in relieving respiratory distress is not well established. CONCLUSION Current evidence suggests that HFNC is well tolerated and may be feasible in a subset of patients who require ventilatory support with non-invasive ventilation. However, HFNC has not been demonstrated to be equivalent or superior to non-invasive positive pressure ventilation, and further studies are needed to identify clinical indications for HFNC in patients with moderate to severe respiratory distress.


title: Management of Patients with Cerebellar Ataxia During the COVID-19 Pandemic: Current Concerns and Future Implications

text: The current worldwide severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic that causes coronavirus disease 2019 (COVID-19) has brought some medical systems to the brink of collapse. This crisis is also negatively impacting the care of patients with non-COVID-19 conditions, including those with cerebellar ataxia (CA). Older patients with CA and those with immune-mediated ataxias on immunosuppressive medication are potentially at high risk of developing serious complications of the infection, although it is also possible that immunosuppressive agents may provide a defense against cytokine storm. This has implications for even greater attention to preventing contracting the disease through physical distancing and/or isolation. The CA patient population is also at higher risk because of the neurological complexities of their underlying disorder and the comorbid medical illnesses that often accompany the genetic ataxias. As the disruption of social patterns and healthcare delivery in response to the crisis continues, interruption of rehabilitation, speech and language therapy, and face-to-face consultations threatens to have a negative impact on the course and well-being of CA patients. Mental and physical health is also potentially at greater risk because the prevailing uncertainty and anxiety may be superimposed upon cerebellum-specific neuropsychological challenges. We identify and review some of the short- and long-term consequences of this global pandemic for the community of ataxia patients and their families and for the clinical and academic neurologists/ataxiologists caring for these patients. This includes the recognition that telemedicine has emerged as a principle means of caregiver-patient contact and that neurological manifestations of COVID-19 including those specific to cerebellar neurobiology are increasingly recognized and will require close surveillance and monitoring. This COVID-19 Cerebellum Task Force consensus provides some guidance on how we may approach this uncertain time and consider preparing for the new realities we face in CA patient care once this acute crisis has passed.


title: Social Media Contexts Moderate Perceptions of Animals.

text: The rapid rise of social media in the past decade represents a new space where animals are represented in human society, and this may influence human perceptions, for example driving desire for exotic pet keeping. In this study, 211 participants (49% female) between the ages of 18 to 44 were recruited to an online survey where they viewed mock-up pages from a social media site. All participants saw the same image of a primate but were randomly assigned to a pro exotic pet keeping or anti exotic pet keeping narrative condition. When participants were presented with the anti narrative they perceived the animal to be more stressed (χ2 = 13.99, p < 0.001). In free text comments, participants expressed reservations in the face of a narrative they disagreed with in free text comments. Overall, this study found evidence to suggest that people moderate their discussions on human-animal interactions based on the social network they are in, but these relationships are complex and require further research.


title: Mechanical thrombectomy in acute ischemic stroke-experience from 6 years of practice.

text: INTRODUCTION We present our results from the first 6 years with mechanical thrombectomy in the treatment of ischemic stroke. METHODS Every patient treated with mechanical thrombectomy for acute ischemic stroke from September 2005 to December 2011 was consecutively included in this retrospective analysis. Baseline and outcome data were retrieved from computerized records at the hospital. National Institute of Health Stroke Scale (NIHSS) score and the modified Rankin Scale (mRS) score were used as outcome parameters. Favorable outcome was defined as a mRS score of 0-2, corresponding to independence in activities of daily living. We also evaluated revascularization and severe adverse events, with focus on symptomatic intracranial hemorrhage. RESULTS Good functional outcome (mRS 0-2) was achieved in 50 % (120/240) of all patients. For patients with no neurological deficit prior to stroke onset (i.e., mRS = 0 before stroke), the proportion with good functional outcome was 54 %. Symptomatic hemorrhages occurred in 4.6 % of the cases (5.7 % in the anterior circulation). CONCLUSION In summary, our results supports that mechanical thrombectomy is a safe and effective method to restore blood flow in selected patients suffering from an acute ischemic stroke.


Acute respiratory distress syndrome and steroids in the shadow of coronavirus disease 2019.


title: Managing the pain of knee osteoarthritis.

text: Pain from knee osteoarthritis creates a significant burden for symptomatic patients, who are often forced to change their lifestyle because of their symptoms. Activity modification, therapy, weight loss, nonsteroidal anti-inflammatory drugs, shoe orthotics, bracing, and injections are the nonoperative options available. New technologies are also emerging in the treatment of knee osteoarthritis. Ultimately, these therapeutic modalities should reduce pain and increase the overall functioning of patients. These nonoperative modalities give the clinician several effective options before surgical management is considered.


title: Study on Left Atrial Dimension and Function After Modified Endoscopic Procedure for Atrial Fibrillation at Two Years' Follow-Up.

text: BACKGROUND Modified endoscopic procedures for atrial fibrillation (AF) have a greater success rate because of the increased number of linear lesions. Concerns have been raised about the impact of ablation scars on the left atrium. This study aimed to examine the impact of ablation on left atrial dimension and systolic function after modified endoscopic procedures with echocardiographic measurement. METHODS Of 107 patients undergoing modified endoscopic ablation, 58 had paroxysmal AF and 49 had persistent or long-standing AF. The procedure was performed on the beating heart through three ports on the left chest wall. Three circular and two linear lesions were made on the left atrium. The left atrial appendage was excised by stapler. Echocardiography was performed preoperatively and at the 2-year follow-up. RESULTS Most patients (86.9%) patients were in sinus rhythm (SR) postoperatively. Fourteen patients (5 with paroxysmal AF and 9 with persistent/long-standing AF) failed to maintain SR. Echocardiographic data indicated that the left atrial diameter decreased only in the patients with postoperative SR but continued to increase in patients with fail SR maintenance. Left atrial function was also improved after the procedure, especially in patients with preoperative nonparoxysmal AF or with postoperative SR maintenance. Furthermore, left atrial function in patients who failed to restore SR was not worsened even with left atrial appendage excision. CONCLUSIONS Modified endoscopic procedure for AF improved post-procedural left atrial function of patients with SR maintenance. The left atrial function of patients with failed SR maintenance was also not worsened after left atrial appendage excision.


title: Early Outcomes with Utilization of Tissue Plasminogen Activator in COVID-19 Associated Respiratory Distress: A series of five cases.

text: BACKGROUND Coronavirus patients demonstrate varying degrees of respiratory insufficiency; many will progress to respiratory failure with a severe version of acute respiratory distress syndrome (ARDS) refractory to traditional supportive strategies. Providers must consider alternative therapies to deter or prevent the cascade of decompensation to fulminant respiratory failure. METHODS This is a case-series of five COVID-19 positive patients who demonstrated severe hypoxemia, declining respiratory performance, and escalating oxygen requirements. Patients met the following criteria: COVID-19 positivity, worsening respiratory performance, severe hypoxemia (PaO2<80) despite traditional supportive measures, escalating supplemental oxygen requirements and D-dimer greater than 1.5μg/mL. All patients received protocol directed thrombolytic therapy with Tissue Plasminogen Activator (tPA). RESULTS All five patients improved without deleterious effects of thrombolytic therapy. Patient one was on maximum ventilator support, paralytics, and prone positioning without improvement. During tPA administration his P/F ratio improved from 69 to 127. Ventilator support was weaned immediately on post-treatment day 1 and he was extubated on post treatment day 12. Our second through fifth patients were not intubated at time of initiation of tPA therapy. These patients each required significant oxygen supplementation trending toward intubation. After tPA therapy, all patients demonstrated a noticeable increase in PaO2 values overtime. Three of these patients avoided intubation due to COVID-19 associated respiratory failure. CONCLUSIONS Administration of thrombolytics was followed by overall improvement in patients' oxygen requirements, and in three cases, prevented progression to mechanical ventilation, without deleterious effects. Clinical trials of thrombolytic therapy would further serve to underscore the efficacy and utility of this therapy. LEVEL OF EVIDENCE Level V- Case series of therapeutic effect.


The use of a suture retention device to enhance tissue expansion and healing in the repair of scalp and lower leg wounds.


title: Comparison of the effects of lidocaine pre-administration and local warming of the intravenous access site on propofol injection pain: Randomized, double-blind controlled trial.

text: BACKGROUND Lidocaine reduces pain that occurs upon the intravenous injection of propofol. But, there are few non-pharmacological nursing interventions to reduce propofol injection pain. OBJECTIVE To compare the effects of lidocaine pre-administration and local warming of the intravenous access site on propofol injection pain. DESIGN Prospective, double-blind, randomized controlled trial. SETTING The 555 bed, non-teaching National Cancer Center in Kyunggido, South Korea. PARTICIPANTS A total of 96 patients who underwent thyroidectomy under total intravenous general anesthesia with propofol were randomly allocated to the control, lidocaine pre-administration (LA) or local warming (LW) group. METHODS All three groups received 2% propofol with an effect-site target at 3μg/mL for induction dose. The control group received 2% propofol with no intervention. The lidocaine pre-administration group received 2% propofol 30s after 1% lidocaine 30mg. The local warming group received 2% propofol after warming of the intravenous access site for 1min using 43°C forced air. Propofol injection pain was assessed by four-point verbal categorial scoring (VCS), numerical rating scale (NRS) and surgical pleth index (SPI). RESULTS Pain VCS of the LA group (mean±SD, 1.11±0.45) was significantly reduced (U=-3.92, p<.001) compared to the control group (mean±SD, 1.71±0.74). Pain VCS of the LW group (mean±SD, 0.76±0.44) was significantly reduced (U=-5.17, p<.001) compared to the control group (mean±SD, 1.71±0.74). Pain VCS of the LW group was significantly reduced compared to the LA group (U=-3.33, p=.001]. Pain NRS of the LA group (mean±SD, 4.31±2.32) was significantly reduced (mean difference, 1.82; 95% CI, 0.63-3.00; p=.003) compared to the control group (mean±SD, 6.13±2.39). Pain NRS of the LW group (mean±SD, 3.06±2.37) was significantly reduced (mean difference, 3.07; 95% CI, 1.63-4.51; p<.009) compared to the control group. There were significant differences in pain NRS between the LA group and the LW group (mean difference, 1.25; 95% CI, 0.09-2.42; p=.035). SPI of the LA group (mean±SD, 64.1±16.3) was significantly reduced (mean difference control versus LA, 8.36; 95% CI, 1.64-15.1; p=.016) compared to the control group (mean±SD, 72.5±9.56). SPI of the LW group (mean±SD, 55.0±16.2) was significantly reduced (mean difference control versus LW, 17.4; 95% CI, 10.8-24.0; p<.001) compared to the control group. There was a significant difference in SPI between the LA group and LW group (mean difference, 9.06; 95% CI, 1.02-17.1; p=.028). CONCLUSION Local warming of the intravenous access site by 43°C forced air for 1min is slightly more effective in reducing propofol injection pain compared to lidocaine pre-administration.


title: Considering tapentadol as a first-line analgesic: 14 questions.

text: Tapentadol is the newest centrally acting analgesic to be approved by the US FDA and regulatory bodies in other countries. It has been called the first-in-class of a novel-acting analgesic mechanism of action that combines µ-opioid receptor agonist activity with neuronal norepinephrine-reuptake inhibition in a single molecule. This duality of action should combine inhibition of ascending (afferent) pain-transmitting signals with activation of descending (efferent) pain-attenuating systems (e.g., diffuse noxious inhibitory controls). However, not all novel mechanisms of action impart the characteristics needed for an analgesic to be considered for first-line therapy. These key questions may help inform clinical decision making.


title: Development of an Anti-Adhesive Membrane for Use in Video-Assisted Thoracic Surgery.

text: Background: The need to prevent postoperative adhesions after surgery has been considered a significant challenge in thoracic surgery, especially with the advent of video-assisted thoracic surgery (VATS). While preventive materials for postoperative adhesions have been studied for many years, they are all still in the development phases. Methods: In this animal study, an insoluble hyaluronic acid membrane was used in VATS for wedge resection to test its operability and to examine the body's response to the membrane. Ten beagles were divided into two groups, an experimental group and a negative control group. In the experimental group, an insoluble hyaluronic acid membrane containing glycerol was used as the test membrane (10 x 10 x 0.1 cm3). The test membrane was implanted in the left thoracic cavity of the animal under VATS following wedge resection. The animals were observed for two weeks and then euthanized for examination. Results: Macroscopically, the median adhesion score was lower in the experimental group (0) than in the control group (2.5). On histopathological examination, the test membrane elicited only a minor inflammatory response and foreign body reaction. Conclusion: The test membrane showed satisfactory operability and appears to be a practical material to prevent postoperative adhesions after thoracic surgery in VATS.


title: Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis.

text: BACKGROUND AND PURPOSE A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types. MATERIALS AND METHODS In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization. RESULTS Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87-3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36-3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35-0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37-0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score. CONCLUSIONS Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.


title: Multiple novel astrovirus species in human stool.

text: Diarrhoea remains a significant cause of morbidity and mortality in developing countries where numerous cases remain without identified aetiology. Astroviruses are a recently identified cause of animal gastroenteritis which currently includes two species suspected of causing human diarrhoea. Using pan-astrovirus RT-PCR, we analysed human stool samples from different continents for astrovirus-related RNA sequences. We identified variants of the two known human astrovirus species plus, based on genetic distance criteria, three novel astrovirus species all distantly related to mink and ovine astroviruses, which we provisionally named HMOAstV species A-C. The complete genome of species A displayed all the conserved characteristics of mammalian astroviruses. Each of the now three groups of astroviruses found in human stool (HAstV, AstV-MLB and HMOAstV) were more closely related to animal astroviruses than to each other, indicating that human astroviruses may periodically emerge from zoonotic transmissions. Based on the pathogenic impact of their closest phylogenetic relatives in animals, further investigations of the role of HMOAstV, so far detected in Nigeria, Nepal and Pakistan, in human gastroenteritis are warranted.


title: Diagnosis and management of intracranial dural arteriovenous fistulas.

text: Dural arteriovenous fistula (DAVF) is a rare type of acquired intracranial vascular malformation. Recent progress in neuroimaging technology, such as advanced MRI and CT, provides non-invasive methods to accurately diagnose DAVF, including evaluation of the hemodynamics of the drainage veins. The clinical manifestations of DAVFs vary widely and depend on the location and venous drainage pattern of arteriovenous shunting. Patients with high grade DAVFs having cortical venous reflux should receive aggressive treatment to prevent the occurrence of intracranial hemorrhage and other neurological deficits related to venous congestion. Intra-arterial or intravenous endovascular embolization remains the primary therapy for high grade DAVF, while open surgery and stereotactic radiosurgery can serve as alternative treatment options. Early and accurate diagnosis with appropriate treatment is the goal for clinical management of DAVFs to reduce symptoms and prevent the development of venous congestion and stroke.


title: The role of cardiac imaging in hospitalized COVID-19-positive patients.

text: COVID-19 infection is associated with several cardiac complications with high rates of adverse outcomes. Cardiac imaging has different utility in different clinical scenarios, and the importance of minimizing healthcare worker exposure should be considered. Cardiac imaging should only be ordered if its benefits outweigh its risks, with anticipated changes in acute treatment and outcomes, and no suitable alternative of sufficient adequacy is available. Indications for advanced cardiac imaging for COVID-19 patients in the acute phase are limited, although follow-up imaging in the convalescent stage may provide prognostic importance in recovered COVID-19 patients with positive troponin or decompensated heart failure.


title: NASPGHAN Capsule Endoscopy Clinical Report.

text: Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.


title: Early experience with single-access transumbilical adjustable laparoscopic gastric banding.

text: BACKGROUND Laparoscopic adjustable gastric banding is the most common bariatric procedure performed worldwide; since FDA approval was granted for it in June 2001, the procedure has been steadily gaining popularity in the USA. We herein report our early experience with single-access transumbilical laparoscopic gastric banding. This approach to the procedure is performed mainly through a single incision in the umbilicus. This single incision is also utilized for the implantation of the port for subsequent band adjustments. METHODS Eight patients were carefully selected (body mass indices between 35 and 45 kg/m(2) with peripheral obesity), and each underwent laparoscopic gastric banding using this single-incision transumbilical technique. The same surgeon performed all surgical interventions. For each of the eight patients, the same perioperative protocol and operative techniques were implemented. RESULTS Seven out of eight attempted single-access transumbilical laparoscopic gastric banding procedures were successfully performed using this technique. Mean operative time was 105 min. One out of the eight patients required the insertion of an additional trocar. There were no mortalities or postoperative complications noted during the mean follow-up period of 2.6 months. CONCLUSION Single-access transumbilical laparoscopic adjustable gastric banding is a safe and feasible evolving approach in a selected group of patients. The intraumbilical location of the implanted port facilitates access for subsequent adjustments and provides patients with an improved cosmetic outcome.


title: Validation of a stand-alone near-infrared spectroscopy system for monitoring cerebral autoregulation during cardiac surgery.

text: BACKGROUND Individualizing arterial blood pressure (ABP) targets during cardiopulmonary bypass (CPB) based on cerebral blood flow (CBF) autoregulation monitoring may provide a more effective means for preventing cerebral hypoperfusion than the current standard of care. Autoregulation can be monitored in real time with transcranial Doppler (TCD). We have previously demonstrated that near-infrared spectroscopy (NIRS)-derived regional cerebral oxygen saturation (rS(c)O(2)) provides a clinically suitable surrogate of CBF for autoregulation monitoring. The purpose of this study was to determine the accuracy of a stand-alone "plug-and-play" investigational system for autoregulation monitoring that uses a commercially available NIRS monitor with TCD methods. METHODS TCD monitoring of middle cerebral artery CBF velocity and NIRS monitoring were performed in 70 patients during CPB. Indices of autoregulation were computed by both a personal computer-based system and an investigational prototype NIRS-based monitor. A moving linear correlation coefficient between slow waves of ABP and CBF velocity (mean velocity index [Mx]) and between ABP and rS(c)O(2) (cerebral oximetry index [COx]) were calculated. When CBF is autoregulated, there is no correlation between CBF and ABP; when CBF is dysregulated, Mx and COx approach 1 (i.e., CBF and ABP are correlated). Linear regression and bias analysis were performed between time-averaged values of Mx and COx derived from the personal computer-based system and from COx measured with the prototype monitor. Values for Mx and COx were categorized in 5 mm Hg bins of ABP for each patient. The lower limit of CBF autoregulation was defined as the ABP where Mx incrementally increased to ≥0.4. RESULTS There was correlation and good agreement between COx derived from the prototype monitor and Mx (r = 0.510; 95% confidence interval, 0.414-0.595; P < 0.001; bias, -0.07 ± 0.19). The correlation and bias between the personal computer-based COx and the COx from the prototype NIRS monitor were r = 0.957 (95% confidence interval, 0.945-0.966; P < 0.001 and 0.06 ± 0.06, respectively). The average ABP at the lower limit of autoregulation was 63 ± 11 mm Hg (95% prediction interval, 52-74 mm Hg). Although the mean ABP at the COx-determined lower limit of autoregulation determined with the prototype monitor was statistically different from that determined by Mx (59 ± 9 mm Hg; 95% prediction interval, 50-68 mm Hg; P = 0.026), the difference was not likely clinically meaningful. CONCLUSIONS Monitoring CBF autoregulation with an investigational stand-alone NIRS monitor is correlated and in good agreement with TCD-based methods. The availability of such a device would allow widespread autoregulation monitoring as a means of individualizing ABP targets during CPB.


title: Biogeography of resistance to paralytic shellfish toxins in softshell clam, Mya arenaria (L.), populations along the Atlantic coast of North America.

text: Blooms of Alexandrium spp., the causative agent of paralytic shellfish poisoning (PSP), recur with varying frequency and intensity on the Northwest Atlantic coast of North America, from New York, USA, to northern Canadian waters. Along this latitudinal range blooms co-occur with abundant, intertidal populations of softshell clams, Mya arenaria. Prior work identified a naturally-occurring genetic mutation in Domain II α-subunit of the clams' voltage-gated sodium channels (NaV), which significantly reduces the binding affinity of the paralytic shellfish toxin, saxitoxin (STX). This mutation provides clams with resistance to the deleterious effects of STX, allowing them to continue feeding during Alexandrium spp. blooms and attain very high tissue toxicities. This study used genetic sequencing of the NaV mutation locus in clams from four coastal regions of the Bay of Fundy-Gulf of Maine and the mid-Atlantic to determine the percentage of clams in each region that possess the resistant NaV mutation. The genotype composition was related to the occurrence and magnitude of PSP outbreaks based on shellfish toxicity, primarily that of mussels, Mytilus edulis, used as a proxy for the prevalence and severity of Alexandrium blooms in each region. As hypothesized, the proportion of clams bearing the resistant mutation generally matched up well with the historical incidence and intensity of Alexandrium spp. blooms. The highest percentage of homozygote resistant clams (RR = 70.0%), and the lowest percentage of sensitive clams (SS = 4.5%) were found in eastern Gulf of Maine populations. Exceptions at a few sites where anomalously high numbers of M. arenaria with the resistant mutation were found despite the absence of blooms, may be attributable to larval gene flow. There was no evidence that Alexandrium blooms occurring in Northport Harbor, Long Island, have resulted in a shift in genotypic composition of the local clam population, presumably due to their low cell toxicity. Seasonal mismatch of highly vulnerable M. arenaria postset with toxic blooms at this latitude may also partly explain this result. This study provides strong supporting evidence that Alexandrium blooms can select for resistance to PSP-toxins in M. arenaria populations and proposes a mechanism for the persistence of the sensitive allele throughout the region. Implications for clam aquaculture (seeding) efforts, as well as for shellfish toxicity monitoring are discussed.


title: Learning curves for single incision and conventional laparoscopic right hemicolectomy: a multidimensional analysis.

text: PURPOSE This study aimed to compare the learning curves and early postoperative outcomes for conventional laparoscopic (CL) and single incision laparoscopic (SIL) right hemicolectomy (RHC). METHODS This retrospective study included the initial 35 cases in each group. Learning curves were evaluated by the moving average of operative time, mean operative time of every five consecutive cases, and cumulative sum (CUSUM) analysis. The learning phase was considered overcome when the moving average of operative times reached a plateau, and when the mean operative time of every five consecutive cases reached a low point and subsequently did not vary by more than 30 minutes. RESULTS Six patients with missing data in the CL RHC group were excluded from the analyses. According to the mean operative time of every five consecutive cases, learning phase of SIL and CL RHC was completed between 26 and 30 cases, and 16 and 20 cases, respectively. Moving average analysis revealed that approximately 31 (SIL) and 25 (CL) cases were needed to complete the learning phase, respectively. CUSUM analysis demonstrated that 10 (SIL) and two (CL) cases were required to reach a steady state of complication-free performance, respectively. Postoperative complications rate was higher in SIL than in CL group, but the difference was not statistically significant (17.1% vs. 3.4%). CONCLUSION The learning phase of SIL RHC is longer than that of CL RHC. Early oncological outcomes of both techniques were comparable. However, SIL RHC had a statistically insignificant higher complication rate than CL RHC during the learning phase.


title: Management of 69 Gastric Leakages after 4294 Consecutive Sleeve: The Experience of a High Volume Bariatric Center.

text: PURPOSE To propose an algorithm of treatment for leakage after laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS Sixty-nine patients who developed gastric leakage out of 4294 patients who underwent LSG from 2010 to 2018 were considered in this study. Patients' outcomes in terms of incidence of resolution and time to leakage resolution were compared by leakage characteristics and type of treatment. Three patients were lost to follow up. RESULTS Leakage occurred in a median of 6 days from surgery, and for majority of patients (80.3%), it was in the upper part of the sleeve. The median dimension of leakage was 6.5 mm. Low level leakage resulted in a lower time of resolution (p < 0.001). Patients with clinical leakage were treated with surgery or endoscopic placement of a self-expandable metal stent (SEMS). The median time of leakage resolution was 42 days. The hospitalization time for SEMS was shorter with a 68.3% of complete resolution compared with the 29.4% of surgery. In patients with subclinical and small leakage, a conservative treatment was successful in 87.5%. Overall 39.4% of patients needed a second line treatment after that the first failed. CONCLUSION Leakage could be treated conservatively if subclinical and < 5 mm. Surgery is mandatory if a perigastric collection is present or an organ lesion is suspected. SEMS seems to be the best option to treat high level leakage.


Intracranial Bleeding during Treatment with Sorafenib for Hepatocellular Carcinoma.


title: Transesophageal pulmonary lobectomy with single transthoracic port assistance: study with survival assessment in a porcine model.

text: BACKGROUND AND STUDY AIMS Thoracoscopic pulmonary lobectomy is being performed in an increasing number of patients. The aims of the current study were to assess natural orifice transluminal endoscopic surgery (NOTES) as an alternative to transthoracic endoscopic surgery, and to test the feasibility of peroral transesophageal right upper pulmonary lobectomy with the assistance of a single transthoracic trocar. METHODS In 10 acute and 4 survival pigs, right upper pulmonary lobectomy was performed using a forward-viewing double-channel gastroscope and an operative thoracoscope with a 5-mm working channel inserted through a single transthoracic 12-mm) port. Time, safety, and feasibility of the following steps were recorded in all animals: esophagotomy, hilar dissection, individual ligation of the hilum elements, pulmonary lobectomy, and specimen retrieval. In the survival experiments, esophagotomy was closed using a reticulated laparoscopy suture device and an esophageal stent was placed. These animals were kept alive and monitored for 2 weeks. RESULTS Esophagotomy was performed safely in all animals (mean procedure duration 5.4 ± 1.7 minutes). Dissection of the right upper lobe hilum elements (bronchus, arteries, and veins) was carried out without adverse events. Individual ligation of the hilum elements was performed in all but two cases (time for dissection and ligation 44.2 ± 14.8 minutes). Lobectomy and specimen retrieval were completed in all animals (9.5 ± 3.1 minutes). Esophagotomy closure and stent placement were carried out in 20.0 ± 2.8 minutes in the survival animals. These animals fed normally and gained weight postoperatively without signs of disease. Endoscopic examination before necropsy revealed a pseudo-diverticulum in one animal, and wound dehiscence with confined collection/recess in the remaining animals. CONCLUSIONS Transesophageal right upper pulmonary lobectomy using single transthoracic trocar assistance is feasible and may represent a step towards scar-free pulmonary lobectomy.


title: Long-term follow-up results of umbilical hernia repair.

text: Introduction Multiple suture techniques and various mesh repairs are used in open or laparoscopic umbilical hernia (UH) surgery. Aim To compare long-term follow-up results of UH repair in different hernia surgery groups and to identify risk factors for UH recurrence. Material and methods A retrospective analysis of 216 patients who underwent elective surgery for UH during a 10-year period was performed. The patients were divided into three groups according to surgery technique (suture, mesh and laparoscopic repair). Early and long-term follow-up results including hospital stay, postoperative general and wound complications, recurrence rate and postoperative patient complaints were reviewed. Risk factors for recurrence were also analyzed. Results One hundred and forty-six patients were operated on using suture repair, 52 using open mesh and 18 using laparoscopic repair technique. 77.8% of patients underwent long-term follow-up. The postoperative wound complication rate and long-term postoperative complaints were significantly higher in the open mesh repair group. The overall hernia recurrence rate was 13.1%. Only 2 (1.7%) patients with small hernias (< 2 cm) had a recurrence in the suture repair group. Logistic regression analysis showed that body mass index (BMI) > 30 kg/m2, diabetes and wound infection were independent risk factors for umbilical hernia recurrence. Conclusions The overall umbilical hernia recurrence rate was 13.1%. Body mass index > 30 kg/m2, diabetes and wound infection were independent risk factors for UH recurrence. According to our study results, laparoscopic medium and large umbilical hernia repair has slight advantages over open mesh repair concerning early postoperative complications, long-term postoperative pain and recurrence.


How can we prevent staff-to-staff transmission of coronavirus?


title: Detection of astrovirus in premature infants with necrotizing enterocolitis.

text: BACKGROUND Necrotizing enterocolitis (NEC) is a major cause of mortality and morbidity in very low birth weight infants (<1500 g birth weight). Although the etiology remains unknown, infectious agents could play a key role. The aim of this analysis was to examine the role of human astrovirus (HAstV) in infants with NEC. PATIENTS AND METHODS All patients admitted during a 5-year period at a tertiary neonatal intensive care unit with NEC (Bell stage I-III) who had examination of stool specimens for bacterial and for viral infections were included. Clinical data were reviewed and compared between infants with NEC and astrovirus detection (NEC + HAstV) and infants with NEC without astrovirus detection (NEC - HAstV) in stool specimens. RESULTS Forty infants with NEC were identified between 2002 and 2006 and 8 patients were excluded from statistical evaluation because of incomplete viral examinations. HAstV was detected in stool specimens of 6 (19%) of the remaining 32 patients with NEC. Double infection with rotavirus was identified in 1 patient. No other viruses were detected. Significant differences in patients with NEC - HAstV and NEC + HAstV were only shown for age at onset of illness (P < 0.001) but not for severity of illness, need for surgical intervention, or mortality. CONCLUSIONS This study demonstrates that HAstV may be associated with the development of NEC in a subgroup of patients and provides further evidence for the important role of gastrointestinal viral infections in this most common gastrointestinal emergency in premature infants. HAstV should be included in microbiological examination of stool specimens in patients with NEC.


title: Biomechanical and histologic evaluation of two application forms of surgical glue for mesh fixation to the abdominal wall.

text: The use of an adhesive for mesh fixation in hernia repair reduces chronic pain and minimizes tissue damage in the patient. This study was designed to assess the adhesive properties of a medium-chain (n-butyl) cyanoacrylate glue applied as drops or as a spray in a biomechanical and histologic study. Both forms of glue application were compared to the use of simple-loose or continuous-running polypropylene sutures for mesh fixation. Eighteen adult New Zealand White rabbits were used. For mechanical tests in an ex vivo and in vivo study, patches of polypropylene mesh were fixed to an excised fragment of healthy abdominal tissue or used to repair a partial abdominal wall defect in the rabbit respectively. Depending on the fixation method used, four groups of 12 implants each or 10 implants each respectively for the ex vivo and in vivo studies were established: Glue-Drops, Glue-Spray, Suture-Simple and Suture-Continuous. Biomechanical resistance in the ex vivo implants was tested five minutes after mesh fixation. In vivo implants for biomechanical and histologic assessment were collected at 14 days postimplant. In the ex vivo study, the continuous suture implants showed the highest failure sample tension, while the implants fixed with glue showed lower failure sample tension values. However, the simple and continuous suture implants returned the highest stretch values. In the in vivo implants, failure sample tension values were similar among groups while the implants fixed with a continuous running suture had the higher stretch values, and the glue-fixed implants the lower stretch values. All meshes showed good tissue integration within the host tissue regardless of the fixation method used. Our histologic study revealed the generation of a denser, more mature repair tissue when the cyanoacrylate glue was applied as a spray rather than as drops.


title: World Pneumonia Day 2011-2016: Twitter contents and retweets.

text: Background Twitter is used for World Pneumonia Day (WPD; November 12) communication. We evaluate if themes of #pneumonia tweets were associated with retweet frequency. Methods A total of 28 181 original #pneumonia tweets were retrieved (21 November 2016), from which six subcorpora, 1 mo before and 1 mo after WPD 2011-2016, were extracted (n=6721). Underlying topics were identified via latent Dirichlet allocation and were manually coded into themes. The association of themes with retweet count was assessed via multivariable hurdle regression. Results Compared with personal experience tweets, tweets that both raised awareness and promoted intervention were 2.62 times as likely to be retweeted (adjusted odds ratio [aOR] 2.62 [95% 1.79 to 3.85]) and if retweeted had 37% more retweets (adjusted prevalence ratio [aPR] 1.37 [95% CI 1.06 to 1.78]). Tweets that raised concerns about vaccine price were twice as likely to be retweeted (aOR 2.29 [95% CI 1.36 to 3.84]) and if retweeted, had double the retweet count (aPR 2.05 [95% CI 1.27 to 3.29]) of tweets sharing personal experience. Conclusions The #pneumonia tweets that both raised awareness and promoted interventions and those discussing vaccine price were more likely to engage users than tweets about personal experience. These results help health professionals craft WPD messages that will engage the audience.


title: Youth friendliness in mental health and addiction services: protocol for a scoping review.

text: INTRODUCTION To better reach youth in need of mental health and addiction (MHA) services, there is increasing emphasis on making MHA services 'youth friendly.' However, it is unclear what youth friendliness means on a practical level. This scoping review explores (1) how youth friendliness in mental health services is defined in the literature, (2) what characteristics make MHA services youth friendly and (3) how youth friendliness is expected to impact service use by young people. METHODS A search will be conducted of eight electronic bibliographic databases over the last 15 years (2002-2017) to identify literature on youth friendliness consistent with the modern youth experience. Grey literature will also be searched. The search and literature selection process will include all study designs, as well as non-research literature. Two independent raters will determine eligibility based on a review of the titles and abstracts of the identified literature, followed by full text reviews when required. Data will be extracted from the identified literature and then synthesised using qualitative and quantitative approaches. As a final step, we will conduct stakeholder consultations with youth, family members and service provider groups to validate the findings and identify any characteristics of youth friendliness that they deem important that were not reported in the findings. ETHICS AND DISSEMINATION Results will be disseminated through a peer-reviewed publication, as well as international, national and local conference presentations. Agency reports will be developed to present the findings in a user-friendly format, including a youth-friendliness checklist for youth-serving organisations. Research ethics approval has been obtained for the consultation component of this study.


title: Contemporary carotid imaging: from degree of stenosis to plaque vulnerability.

text: Carotid artery stenosis is a well-established risk factor of ischemic stroke, contributing to up to 10%-20% of strokes or transient ischemic attacks. Many clinical trials over the last 20 years have used measurements of carotid artery stenosis as a means to risk stratify patients. However, with improvements in vascular imaging techniques such as CT angiography and MR angiography, ultrasonography, and PET/CT, it is now possible to risk stratify patients, not just on the degree of carotid artery stenosis but also on how vulnerable the plaque is to rupture, resulting in ischemic stroke. These imaging techniques are ushering in an emerging paradigm shift that allows for risk stratifications based on the presence of imaging features such as intraplaque hemorrhage (IPH), plaque ulceration, plaque neovascularity, fibrous cap thickness, and presence of a lipid-rich necrotic core (LRNC). It is important for the neurosurgeon to be aware of these new imaging techniques that allow for improved patient risk stratification and outcomes. For example, a patient with a low-grade stenosis but an ulcerated plaque may benefit more from a revascularization procedure than a patient with a stable 70% asymptomatic stenosis with a thick fibrous cap. This review summarizes the current state-of-the-art advances in carotid plaque imaging. Currently, MRI is the gold standard in carotid plaque imaging, with its high resolution and high sensitivity for identifying IPH, ulceration, LRNC, and inflammation. However, MRI is limited due to time constraints. CT also allows for high-resolution imaging and can accurately detect ulceration and calcification, but cannot reliably differentiate LRNC from IPH. PET/CT is an effective technique to identify active inflammation within the plaque, but it does not allow for assessment of anatomy, ulceration, IPH, or LRNC. Ultrasonography, with the aid of contrast enhancement, is a cost-effective technique to assess plaque morphology and characteristics, but it is limited in sensitivity and specificity for detecting LRNC, plaque hemorrhage, and ulceration compared with MRI. Also summarized is how these advanced imaging techniques are being used in clinical practice to risk stratify patients with low- and high-grade carotid artery stenosis. For example, identification of IPH on MRI in patients with low-grade carotid artery stenosis is a risk factor for failure of medical therapy, and studies have shown that such patients may fair better with carotid endarterectomy (CEA). MR plaque imaging has also been found to be useful in identifying revascularization candidates who would be better candidates for CEA than carotid artery stenting (CAS), as high intraplaque signal on time of flight imaging is associated with vulnerable plaque and increased rates of adverse events in patients undergoing CAS but not CEA.


Which indexes are appropriate among those derived from selective arterial calcium stimulation and venous sampling (ASVS) for diagnosing pancreatic insulinomas? Evaluation using receiver operating characteristic analyses.


title: Representation of specialties in Coronavirus Disease 2019 (COVID-19) research: analysis of published literature in the first 3 months.

text: OBJECTIVE Coronavirus disease 2019 (COVID-19) has infected more than 1.5 million patients worldwide and is associated with high morbidity and mortality. The volume of research published in a specialty, which may shed light on the perceived impact that a topic plays within that discipline, is unknown for the present pandemic. MATERIALS AND METHODS We analyzed all articles published in the first 3 months on COVID-19 and categorized them by journal type and article content. RESULTS There was a ~100-fold difference in articles published on COVID when categorized by journal type and ~65-fold difference when grouped by article content. CONCLUSIONS There is a wide variation in research published withing various specialties regarding COVID-19. Researchers across specialties need to urgently realize the impact of COVID-19 and publish articles that can help improve understanding of this ongoing pandemic.


title: Coronavirus Disease 2019 (COVID-19) and Pregnancy: Combating Isolation to Improve Outcomes.

text: With the current global coronavirus disease 2019 (COVID-19) pandemic, new challenges arise as social distancing and isolation have become the standard for safety. Evidence supports the protective benefits of social connections and support during pregnancy and labor; there are increased maternal, fetal, and pregnancy risks when pregnant and laboring women lack support. As health care professionals take appropriate precautions to protect patients and themselves from infection, there must be a balance to ensure that we do not neglect the importance of social and emotional support during important milestones such as pregnancy and childbirth. Resources are available to help pregnant women, and technology represents an opportunity for innovation in providing care.


title: Assembly of Viral Membrane Proteins.

text: The generation of computational models is an alternative route to obtain reliable structures for the oligomeric state of membrane proteins. A strategy has been developed to search the conformational space of all possible assemblies in a reasonable time, taking symmetry considerations into account. The methodology tested on M2 from influenza A, shows an excellent agreement with established structures. For Vpu from HIV-1 a series of conformational distinct structures are proposed. For the first time a structural model for a fully assembled transmembrane part of 3a from SARS-CoV is proposed.


title: Usefulness of the LigaSure™ small jaw sealing device for breast reconstruction with a latissimus dorsi flap.

text: BACKGROUND Seromas are the most common complication of latissimus dorsi flap breast reconstruction. Electrocautery for flap elevation can cause seromas and injure the lymph or vessels of the surrounding tissues. Positive effects of the LigaSure Small Jaw (Medtronic [formerly Covidien], Minneapolis, MN, USA) sealing device were examined. METHODS Forty-three latissimus dorsi flap breast reconstruction patients were included. Twenty-three underwent surgery with electrocautery and 21 underwent surgery with LigaSure. The seroma formation rate, total drain volume, drainage indwelling periods at the breast site and donor site, operative time, and hospital stay duration were retrospectively compared. Associations between patient characteristics and these variables were analyzed. RESULTS Seroma incidence rates were 9/23 (39.1%) and 3/21 (14.3%) for the control and experimental groups. One control group patient underwent surgical treatment; the rest underwent conservative treatment. A significant difference in latissimus dorsi flap elevation time was found between the control and experimental groups (105.6 minutes and 77.1 minutes; p = .026). A significant difference in the drainage indwelling periods of the latissimus dorsi donor site was found (13.1 days and 11 days; p = .006). Excised breast mass weight, latissimus dorsi flap weight, breast drain total volume/indwelling period, and latissimus dorsi drain volume/indwelling period showed statistically significant associations. Radiation and chemotherapy were not significantly associated with any variables. CONCLUSION The LigaSure device for latissimus dorsi flap breast reconstruction can reduce seromas, operative time, and hospital stay. It is a reliable and useful surgical sealing device that does not cause injury to the surrounding tissues.


Acute kidney injury associated with COVID-19: another extrapulmonary manifestation.


title: Whole-genome sequencing in outbreak analysis.

text: In addition to the ever-present concern of medical professionals about epidemics of infectious diseases, the relative ease of access and low cost of obtaining, producing, and disseminating pathogenic organisms or biological toxins mean that bioterrorism activity should also be considered when facing a disease outbreak. Utilization of whole-genome sequencing (WGS) in outbreak analysis facilitates the rapid and accurate identification of virulence factors of the pathogen and can be used to identify the path of disease transmission within a population and provide information on the probable source. Molecular tools such as WGS are being refined and advanced at a rapid pace to provide robust and higher-resolution methods for identifying, comparing, and classifying pathogenic organisms. If these methods of pathogen characterization are properly applied, they will enable an improved public health response whether a disease outbreak was initiated by natural events or by accidental or deliberate human activity. The current application of next-generation sequencing (NGS) technology to microbial WGS and microbial forensics is reviewed.


title: Chronic overcirculation-induced pulmonary arterial hypertension in aorto-caval shunt.

text: Pulmonary arterial hypertension is a common complication of congenital heart defects with left-to-right shunts. Current preclinical models do not reproduce clinical characteristics of shunt-related pulmonary hypertension. Aorto-caval shunt was firstly described as a model of right ventricle volume overload. The pathophysiology and the possible determination of pulmonary arterial hypertension of different periods of shunt exposure are still undefined. A method to create standardized, reproducible aorto-caval shunt was developed in growing rats (260±40 g). Three groups of animals were considered: shunt exposure for 10 weeks, shunt exposure for 20 weeks and control (sham laparotomy). Echocardiography and magnetic resonance revealed increased right ventricular end diastolic area in shunt at 10 weeks compared to control. Hemodynamic analysis demonstrated increased right ventricular afterload and increased effective pulmonary arterial elastance (Ea) in shunt at 20 weeks compared to control (1.29±0.20 vs. 0.14±0.06 mmHg/μl, p=0.004). At the same time point, the maximal slope of end-systolic pressure-volume relationship (Ees) decreased (0.5±0.2 mmHg/ml vs. 1.2±0.3, p<0.001). Consequently, right ventricular-arterial coupling was markedly deteriorated with a ≈50% decrease in the ratio of end-systolic to pulmonary artery elastance (Ees/Ea). Finally, left ventricular preload diminished (≈30% decrease in left ventricular end-diastolic volume). Histology demonstrated medial hypertrophy and small artery luminal narrowing. Chronic exposure to aorto-caval shunt is a reliable model to produce right ventricular volume overload and secondary pulmonary arterial hypertension. This model could be an alternative with low mortality and high reproducibility for investigators on the underlying mechanisms of shunt-related pulmonary hypertension.


title: Experience with more than 500 minimally invasive hepatic procedures.

text: OBJECTIVE To evaluate our experience with more than 500 minimally invasive hepatic procedures. SUMMARY BACKGROUND DATA Recent data have confirmed the safety and efficacy of minimally invasive liver surgery. Despite these reports, no programmatic approach to minimally invasive liver surgery has been proposed. METHODS We retrospectively reviewed all patients who underwent a minimally invasive procedure for the management of hepatic tumors between January 2001 and April 2008. Patients were divided into 3 groups: laparoscopy with intraoperative ultrasound and biopsy only, laparoscopic radiofrequency ablation (RFA), and minimally invasive resection. To compare the various forms of surgery, we analyzed the incidence of complications, tumor recurrence, mortality, and cost. Statistical analysis was performed using chi(2) analysis, Student t test, Kaplan-Meier survival analysis with the log-rank test, and multivariable Cox models. RESULTS A total of 590 minimally invasive hepatic procedures were performed during 489 operative interventions. The representative tumor histologies were: hepatocellular carcinoma (HCC; N = 210), colorectal carcinoma (N = 40), miscellaneous liver metastases (N = 42), biliary cancer (N = 20), and benign tumors (N = 176). Thirty-five patients underwent laparoscopic ultrasound and confirmatory biopsy alone; 201 patients underwent 240 laparoscopic RFAs, and 253 patients underwent 306 minimally invasive resections. Conversion rates to open surgery for the RFA and resection group were 2% overall. One hundred ninety-nine (40.6%) patients were cirrhotic; 31 resections were performed in cirrhotic patients. Complication and mortality rates for RFA and resection were comparable (11% vs. 16%, and 1.5% vs. 1.6%). However, complication rates (14% vs. 29%; P = 0.02) and mortality (0.3% vs. 9.7%; P = 0.006) rates were higher in the cirrhotic versus noncirrhotic resection group. Overall recurrence rates for RFA and resection groups were 24% and 23%, respectively. Local recurrence rates were higher in the RFA group (6.3% versus 1.5%; P < 0.06). Overall patient survival differed between HCC patients receiving RFA alone and those receiving RFA and OLT (P < 0.0001). Overall survival for cancer patients receiving RFA versus resection differed significantly when unadjusted for other covariates (P = 0.01), and remained marginally significant in a multivariable model (P = 0.056). CONCLUSIONS Minimally invasive hepatic surgery has become a viable alternative to open hepatic surgery. Our present data are equivalent or superior to those encountered in any large open series. Our experience with RFA confirms a low local recurrence rate and an excellent technique for bridging patients to transplantation. Morbidity and mortality rates for minimally invasive hepatic resections in cirrhotics, is similar to other reported open resection series. This series confirmed excellent interim survival rates after laparoscopic HR and superiority over RFA in the treatment of cancer, with significantly lower local tumor recurrence rate.


title: Non-viral adeno-associated virus-based platform for stable expression of antibody combination therapeutics.

text: Antibody combination therapeutics (ACTs) are polyvalent biopharmaceuticals that are uniquely suited for the control of complex diseases, including antibiotic resistant infectious diseases, autoimmune disorders and cancers. However, ACTs also represent a distinct manufacturing challenge because the independent manufacture and subsequent mixing of monoclonal antibodies quickly becomes cost prohibitive as more complex mixtures are envisioned. We have developed a virus-free recombinant protein expression platform based on adeno-associated viral (AAV) elements that is capable of rapid and consistent production of complex antibody mixtures in a single batch format. Using both multiplexed immunoassays and cation exchange (CIEX) chromatography, cell culture supernatants generated using our system were assessed for stability of expression and ratios of the component antibodies over time. Cultures expressing combinations of three to ten antibodies maintained consistent expression levels and stable ratios of component antibodies for at least 60 days. Cultures showed remarkable reproducibility following cell banking, and AAV-based cultures showed higher stability and productivity than non-AAV based cultures. Therefore, this non-viral AAV-based expression platform represents a predictable, reproducible, quick and cost effective method to manufacture or quickly produce for preclinical testing recombinant antibody combination therapies and other recombinant protein mixtures.


title: Soluble thrombomodulin to evaluate the severity and outcome of community-acquired pneumonia.

text: This study aims to investigate the role of soluble thrombomodulin (sTM) in the evaluation of the severity and outcome of community-acquired pneumonia (CAP) in the emergency department (ED) and compare sTM with two biomarkers-procalcitonin (PCT) and C-reactive protein (CRP)-and two scoring systems-the Pneumonia Severity Index (PSI) and CURB65 score. Patients with CAP were consecutively enrolled in the ED of an urban university hospital. sTM, PCT, and CRP levels were measured on enrollment. In addition, the PSI and CURB65 scores were calculated. For all patients, a 30-day follow-up was performed. A total of 573 patients with CAP were enrolled in this study. sTM, PCT, and CRP levels increased with the aggravation of the disease severity as assessed by the PSI and CURB65 score (all P <0.01). The multivariate logistic regression analysis showed that sTM and the PSI were independent predictors of 30-day mortality, and the receiver operating characteristic curve analysis showed that the accuracy of sTM in the prediction of 30-day mortality was comparable with the PSI (P >0.05) and better than PCT, CRP, and the CURB65 score (P all <0.05). Furthermore, a combination of sTM and scoring systems can enhance the predictive accuracy of 30-day mortality. sTM is useful in the evaluation of the severity and outcome of CAP in the ED. A well-designed, multi-center study will be needed to further investigate the value of sTM in CAP.


title: Risk factors for endophthalmitis after cataract surgery in diabetic patients: a case control study.

text: AIM To identify risk factors associated with post-cataract surgery endophthalmitis (PCE) in type 2 diabetic patients. METHODS A hospital-based retrospective case-control study was conducted on 194 type 2 diabetic patients undergoing cataract surgery in Rajavithi Hospital from January 2007 to December 2015. Fifteen patients with PCE were included as the case group and 179 patients without PCE were included as the control group. Potential factors associated with PCE among both groups including demographics, pre-operative characteristics, surgical settings and complications, were statistically analyzed using Chi-square testing and a logistic regression model. RESULTS Within the case group, 53% were females and the median age was 68y. Univariate analysis of pre-operative characteristics, surgical settings and complications revealed that recent pre-operative fasting plasma glucose, insulin therapy, presence of diabetic retinopathy, and severe non-proliferative or proliferative diabetic retinopathy were significantly associated with PCE. In a multivariate analysis adjusting for blood glucose level, insulin treatment was the only significant factor associated with an increased risk of PCE (OR 3.9, 95%CI 1.0-15.0, P=0.04) compared to patients without insulin treatment. The most common causative organisms were gram-positive bacteria (89%). Staphylococcus species represented the most common group (67%). Median best corrected visual acuity at 1-month and 3-month follow-up was equal at 0.7 logMAR (20/100). CONCLUSION The authors identify insulin treatment as the only risk factor associated with endophthalmitis after cataract surgery in type 2 diabetic patients. Further studies with serum levels of pre-operative glycated hemoglobin (HbA1c) and post-operative fasting plasma glucose level are essential to truly demonstrate the role of peri-operative glycemic markers as a risk factor for PCE.


title: Comparing nonpharmaceutical interventions for containing emerging epidemics.

text: Strategies for containing an emerging infectious disease outbreak must be nonpharmaceutical when drugs or vaccines for the pathogen do not yet exist or are unavailable. The success of these nonpharmaceutical strategies will depend on not only the effectiveness of isolation measures but also the epidemiological characteristics of the infection. However, there is currently no systematic framework to assess the relationship between different containment strategies and the natural history and epidemiological dynamics of the pathogen. Here, we compare the effectiveness of quarantine and symptom monitoring, implemented via contact tracing, in controlling epidemics using an agent-based branching model. We examine the relationship between epidemic containment and the disease dynamics of symptoms and infectiousness for seven case-study diseases with diverse natural histories, including Ebola, influenza A, and severe acute respiratory syndrome (SARS). We show that the comparative effectiveness of symptom monitoring and quarantine depends critically on the natural history of the infectious disease, its inherent transmissibility, and the intervention feasibility in the particular healthcare setting. The benefit of quarantine over symptom monitoring is generally maximized for fast-course diseases, but we show the conditions under which symptom monitoring alone can control certain outbreaks. This quantitative framework can guide policymakers on how best to use nonpharmaceutical interventions and prioritize research during an outbreak of an emerging pathogen.


title: Information transfer in multidisciplinary operating room teams: a simulation-based observational study.

text: BACKGROUND Communication of clinically relevant information between members of the operating room (OR) team is critical for safe patient care. Formal communication processes, such as briefing, sign in and time out, are designed to promote this. AIMS We investigated patterns of communication of clinically relevant information between OR staff in simulated surgical scenarios, to identify factors associated with effective information sharing. We focused on the influence of precase briefing, sign in and time out, which we defined as formal team communications. METHOD Twenty teams of six participated in two scenarios during a day-long course. Participants each received unique, clinically relevant items of information (information probes) prior to simulations and were tested postscenario on recall of the information in the probe. Using videos of the simulations, we coded each time an information probe was mentioned against a structured framework. RESULTS Of the 145 instances where a probe was mentioned at least once, 75 (51.7%) were mentioned during a formal team communication. However, there were 89 instances of a possible 234 (38%) where a probe was never mentioned. Some team members were more likely to mention the information than others. When probes were mentioned during formal team communications, significantly more team members were attentive (1.4 vs 2.3; p<0.001), the information was significantly more likely to be recalled and the team was five times more likely (p=0.01) to recall the information than if the information was only mentioned outside of a formal communication. CONCLUSIONS While our study supports the value of formal team communications during precase briefing, sign in and time out in the Surgical Safety Checklist, our findings suggest suboptimal transmission of information between team members and unequal contributions of information by different professional groups.


title: Detection of Ralstonia solanacearum by loop-mediated isothermal amplification.

text: Ralstonia solanacearum is a pathogenic bacterium that causes wilt in over 200 plant species. Here we report a rapid and sensitive detection of R. solanacearum using an isothermal method for copying DNA known as loop-mediated amplification (LAMP). A set of four primers was designed to replicate the gene coding for the flagellar subunit, fliC, and conditions for detection were optimized to complete in 60 min at 65 degrees C. Magnesium pyrophosphate resulting from the amplification reaction could be detected optically as an increase in the solution turbidity, and the DNA products spread in a reproducible ladder-like banding pattern after electrophoresis in an agarose gel. Replication of the fliC gene was detected only from R. solanacearum. The detection limit of this LAMP assay was between 10(4) to 10(6) colony forming units/ml, and the technique may be useful for developing rapid and sensitive detection methods for the R. solanacearum pathogen in soil and water.


title: Abuse-deterrent and tamper-resistant opioid formulations: what is their role in addressing prescription opioid abuse?

text: About one in every three individuals will experience chronic pain in their lifetime, and opioids are known to be an effective means to treat this condition. Much attention, however, has been given to the fact that prescription opioid analgesics are some of the most frequently abused drugs, and misuse is prominent in patients with chronic pain. Several new opioid formulations that are designed to prevent or deter the abuse of opioids are currently in development, and two have been approved for marketing (morphine sulphate co-formulated with naltrexone hydrochloride [Embeda®] and a new formulation of the extended-release oxycodone [OxyContin®]). In this article, we review the various types of abuse-deterrent and tamper-resistant formulations in clinical development. We believe that continued advances in opioid formulations can help mitigate risk for those with legitimate need for pain control, but only if used rationally in the context of good clinical practice.


title: Bone anchor mesh fixation for complex laparoscopic ventral hernia repair.

text: BACKGROUND Laparoscopic ventral hernia repair (LVHR) has gained wide acceptance by both surgeons and patients, but hernias that approach a bony prominence are more complex due to the difficulty of proper fixation. This study was conducted to evaluate the use of bone anchor mesh fixation for complex LVHR. METHODS A prospective study of patients having complex LVHR with bone anchors was conducted using patients from 2 academic institutions between July 2003 and December 2007. Patient demographic data, characteristics of the hernia, operative details, and postoperative outcomes were recorded. RESULTS A total of 30 patients who had LVHR using bone anchors were evaluated (20 women, 10 men; mean age 60.9 years, range 41-83 years). In all, 17 suprapubic and 13 lateral hernias were included, requiring a mean of 2.8 and 3.2 bone anchors, respectively. The average hernia defect was 263 cm(2) (range 35-690 cm(2)), and the average mesh size was 663 cm(2) (range 255-1360 cm(2)). Mean operative time was 218 minutes (range 98-420 minutes), with an estimated blood loss of 46 mL (range 10-100 mL). The average length of stay was 5.2 days (range 1-26 days). Seven patients (23.3%) developed postoperative complications, and 1 patient in this study died (mortality 3.3%). During follow-up of 13.2 months (range 1-26 months), 2 patients (6.7%) developed a recurrent hernia. CONCLUSIONS Bone anchors can be used successfully in the laparoscopic repair of complex ventral hernias, particularly with suprapubic and lateral hernias that approach a bony prominence. The complication rate is acceptable, with a short hospital stay and low recurrence rate.


title: Characterization of Porcine Epidemic Diarrhea Virus Isolate US/Iowa/18984/2013 Infection in 1-Day-Old Cesarean-Derived Colostrum-Deprived Piglets.

text: Porcine epidemic diarrhea virus (PEDV) was first recognized in North America in April 2013 and has since caused devastating disease. The objective of this study was to characterize disease and viral detection associated with an original North American PEDV isolate inoculated in neonatal piglets. Thirty-six 1-day-old cesarean-derived and colostrum-deprived piglets were randomly assigned to the control (n = 16) or challenged group (n = 20); the latter were orogastrically inoculated with 1 ml of US/Iowa/18984/2013 PEDV isolate titered at 1 × 10(3) plaque-forming units per milliliter. Rectal swabs were collected from all piglets prior to inoculation and every 12 hours postinoculation (hpi) thereafter, with 4 control and 5 challenged piglets euthanized at 12, 24, 48, and 72 hpi. One piglet had a positive real-time quantitative polymerase chain reaction test on rectal swab at 12 hpi, and all remaining piglets were positive thereafter, with highest viral quantities detected at 24 and 36 hpi. Diarrhea was evident in 30% and 100% of challenged piglets at 18 and 24 hpi, respectively. Viral antigen was detected in enterocytes by immunohistochemistry in the duodenum and ileum of piglets euthanized at 12 hpi and was apparent throughout the small intestine of all piglets thereafter, with villus height:crypt depth ratios consistently below 4:1. Viremia was confirmed in 18 of 20 pigs at euthanasia. Clinical disease was severe and developed rapidly following infection with an original North American PEDV isolate, with lesions, viremia, and antigen detection possible by 12 hpi.


title: Inferior vena cava filter misplacement in the right atrium and migration to the right ventricle followed by successful removal using the endovascular technique: A case report and review of the literature.

text: Inferior vena cava filters are effective for preventing the passage of thrombi into the pulmonary arteries in patients with pulmonary embolism and deep vein thrombosis. These filters are indicated in patients with contraindications to anticoagulant therapy or in patients with recurrent acute pulmonary embolism despite the administration of anticoagulant therapy. However, the occurrence of filter-related complications, such as filter migration to the heart, has been increasing. Herein, we report a case of OptEase inferior vena cava filter misplacement in the right atrium. Although the filter migrated to the right ventricle, it was successfully removed and repositioned in the inferior vena cava using endovascular techniques. Unfortunately, moderate tricuspid regurgitation developed, due to the damage to the tricuspid valve that was caused by the procedure. We have also reviewed the relevant literature and discussed the possible strategies for managing cases of filter migration to the heart and preventing filter misplacement.


title: Modification of nonstructural protein 1 of influenza A virus by SUMO1.

text: Nonstructural protein 1 (NS1) is one of the major factors resulting in the efficient infection rate and high level of virulence of influenza A virus. Although consisting of only approximately 230 amino acids, NS1 has the ability to interfere with several systems of the host viral defense. In the present study, we demonstrate that NS1 of the highly pathogenic avian influenza A/Duck/Hubei/L-1/2004 (H5N1) virus interacts with human Ubc9, which is the E2 conjugating enzyme for sumoylation, and we show that SUMO1 is conjugated to H5N1 NS1 in both transfected and infected cells. Furthermore, two lysine residues in the C terminus of NS1 were identified as SUMO1 acceptor sites. When the SUMO1 acceptor sites were removed by mutation, NS1 underwent rapid degradation. Studies of different influenza A virus strains of human and avian origin showed that the majority of viruses possess an NS1 protein that is modified by SUMO1, except for the recently emerged swine-origin influenza A virus (S-OIV) (H1N1). Interestingly, growth of a sumoylation-deficient WSN virus mutant was retarded compared to that of wild-type virus. Together, these results indicate that sumoylation enhances NS1 stability and thus promotes rapid growth of influenza A virus.


title: Unilateral robotic hybrid mini-maze: a novel experimental approach.

text: BACKGROUND A complete Cox maze IV procedure is difficult to accomplish using current endoscopic and minimally invasive techniques. These techniques are hampered by inability to adequately dissect the posterior structures of the heart and place all necessary lesions. We present a novel approach, using robotic technology, that achieves placement of all the lesions of the complete maze procedure. METHODS In three cadaveric human models, the technical feasibility of using robotic instruments through the right chest to dissect the posterior structures of the heart and place all Cox maze lesions was performed. RESULTS The entire posterior aspect of the heart was dissected in the cadaveric model facilitating successful placement of all Cox maze IV lesions with robotic assistance through minimally invasive incisions. CONCLUSION The robotic Cox maze IV procedure through the novel right thoracic approach is feasible. This obviates the need for sternotomy and avoids the associated morbidity of the conventional Cox-maze procedure.


Psychiatry and COVID-19: The Role of Chlorpromazine.


title: Robotic approach to treat Median Arcuate Ligament syndrome: a case report.

text: The Median Arcuate Ligament (MAL) syndrome is the symptomatic compression of the celiac trunk by the MAL and other ganglionic periaortic tissue. Despite its rarity, this condition is significant from a clinical, diagnostic and management standpoint and it is usually a diagnosis of exclusion. A 61-year-old female with history of intermittent postprandial epigastric pain was diagnosed with MAL syndrome during CT scan imaging (no other causes of pain were identified). Patient successfully underwent robotic MAL release with symptoms improvement after surgery. The robotic approach is feasible and may allow a very precise and delicate dissection with release of the MAL.


title: War on Terror Cells: Strategies to Eradicate "Novel Coronavirus" Effectively.

text: Brain-eating amoebae are known to harbor a plethora of viral, bacterial, protozoal, and fungal pathogens and safeguard these pathogens against disinfectants. Due to their ubiquitous distribution in the environment and their status as the trojan horse of the microbial world, amoebae can provide novel coronavirus a means to susceptible hosts and possible transmission to the central nervous system. Here, we hypothesize that pursuing the host that harbor "terror cells" is a valuable approach in eradicating novel coronavirus in affected communities.


title: Laryngeal Mask Ventilation During Lumbar Spine Neurosurgery in Knee-Chest Position is Feasible.

text: BACKGROUND This study describes our experience with laryngeal mask (LM) inserted after anesthetic induction in patients already in knee-chest position for lumbar neurosurgery. METHODS Airway management (need for LM repositioning, orotracheal intubation because of failed LM insertion), anticipated difficult airway, and airway complications were registered. Statistics were compared between groups with the t test or the χ test, as appropriate. RESULTS A total of 358 cases were reviewed from 2008 to 2013. Tracheal intubation was performed in 108 patients and LM was chosen for 250 patients (69.8%). Intubated patients had a higher mean age and rate of anticipated difficult airway; duration of surgery was longer (P<0.001, all comparisons). LM insertion and anesthetic induction proved effective in 97.2% of the LM-ventilated patients; 7 patients (2.8%) were intubated because of persistent leakage. Incidences with airway management were resolved without compromising patient safety. CONCLUSION LM airway management during lumbar neurosurgery in knee-chest position is feasible for selected patients when the anesthetist is experienced.


title: Evaluation of intraperitoneal placement of absorbable and nonabsorbable barrier coated mesh secured with fibrin sealant in a New Zealand white rabbit model.

text: BACKGROUND This study aimed to evaluate the acute and chronic fixation strength of fibrin sealant (FS) as an alternative method of fixation for laparoscopic ventral hernia repair (LVHR). METHODS Representative mesh types for LVHR included one nonabsorbable barrier mesh (Composix) and three absorbable barrier meshes (Sepramesh, Proceed, and Parietex composite). Macroporous polypropylene mesh (Prolite Ultra) served as the control mesh. Three methods of fixation were used, namely, 0-polypropylene suture+FS (ARTISS 4 IU), FS alone (ARTISS), and tacks alone, to secure 3×4-cm pieces of mesh (10 of each combination) to the peritoneal surface of New Zealand white rabbit abdominal wall. After 2 h of incubation at 37 °C, specimens underwent acute testing. Subsequently, a chronic phase was completed using the aforementioned fixation methods (10 of each combination), in which two 4×4-cm pieces of mesh were secured intraperitoneally in each of 75 New Zealand white rabbits, which survived 8 weeks until they were sacrificed. A transparent grid overlay was used to measure the mesh and adhesion area. Adhesion tenacity was characterized using the Garrard adhesion scale. In both the acute and chronic samples, a 3×3-cm area of mesh-tissue interface underwent lap shear testing at a rate of 0.42 mm/s using a tensiometer (Instron 5542). The maximum load sustained by the mesh-tissue construct was recorded as the acute fixation strength in newtons (N). Data are given as means±standard error of the mean. Statistical significance (p<0.05) was determined using a one-way analysis of variance (ANOVA) with Fisher's least significant difference (LSD) posttest or a nonparametric Kruskal-Wallis test (adhesion scores). RESULTS The acute fixation strength was significantly greater for all the meshes secured with either suture+FS or tacks alone than for FS alone (p<0.001 for all comparisons). All the meshes except Proceed demonstrated greater acute fixation strength with suture+FS than with tacks alone (p≤0.016). Composix achieved greater acute fixation with suture+FS than all the other meshes (p≤0.022). Acute fixation with suture + FS was greater for Parietex Composite and ProLite Ultra than for Proceed (p≤0.015). When the animals were sacrificed, 48 of 50 meshes fixed with FS alone were insufficiently affixed to the abdominal wall, which may have resulted in hernia recurrence in a hernia model. The chronic fixation strength was greater for all the mesh types with either suture+FS or tacks only than with FS alone (p≤0.0005). The chronic fixation strength was greater with suture+FS than with tacks for Proceed and ProLite Ultra (p≤0.013). Neither mesh area nor adhesion tenacity differed significantly with any mesh/fixation method combination. CONCLUSIONS In a chronic rabbit model of LVHR, fixation strength with FS alone was inadequate for selected nonabsorbable and absorbable barrier-coated meshes. The acute and chronic fixation strengths of suture+FS were equivalent or superior to the fixation strength of tacks alone. Using a combination of suture and FS for mesh fixation in LVHR may provide adequate fixation while decreasing postoperative pain due to spiral titanium tacks. In this preclinical series, mesh secured to the peritoneal surface by FS alone may have led to early recurrence.


title: Immunosenescence in chronic HIV infected patients impairs essential functions of their natural killer cells.

text: The HIV/AIDS pandemic still represents an important global health issue. There is no sterilizing cure, therefore a continuous treatment is necessary, which caused the emerged idea of HIV as a chronic inflammatory disease that may also affect healthy aging. Considering that the activation profile of some innate cells such as natural killer cells has previously been associated to HIV progression, it remains to be better defined this activation status of NK cells considering the time of HIV infection. In this study, we characterized NK cell phenotype and function during acute and chronic HIV infection and also investigated markers of immunosenescence in these cells. Our results showed that chronic infected patients remained with elevated levels of some plasma inflammatory molecules (IP-10, sCD14) and a concurrent expansion of the non-functional NK cell subset (CD3-CD56-CD16+). NK cells from the chronic infected group displayed an activated profile with higher levels of cytokines and chemokines production (TNF-α, IL-12, IFN-α2, IFN-γ, IL-6, RANTES, MCP-1, IL-10, IL-4 and IL-5). The production of these molecules was positively correlated to the time of infection. Moreover, we noted a possible association of higher global DNA methylation frequency of NK cells in two HIV patients in the advanced stage of disease. Chronic infected patients also showed a trend towards higher production of reactive oxygen species by their NK cells which altogether suggest the evolution of these cells to a senescent state that might be further evaluated.


title: Physical Characteristics of Medical Textile Prostheses Designed for Hernia Repair: A Comprehensive Analysis of Select Commercial Devices.

text: Inguinal hernia repairs are among the most frequent operations performed worldwide. This study aims to provide further understanding of structural characteristics of hernia prostheses, and better comprehensive evaluation. Weight, porosity, pore size and other physical characteristics were evaluated; warp knitting structures were thoroughly discussed. Two methods referring to ISO 7198:1998, i.e., weight method and area method, were employed to calculate porosity. Porosity ranged from 37.3% to 69.7% measured by the area method, and 81.1% to 89.6% by the weight method. Devices with two-guide bar structures displayed both higher porosity (57.7%-69.7%) and effective porosity (30.8%-60.1%) than single-guide bar structure (37.3%-62.4% and 0%-5.9%, respectively). Filament diameter, stitch density and loop structure combined determined the thickness, weight and characteristics of pores. They must be well designed to avoid zero effective porosity regarding a single-bar structure. The area method was more effective in characterizing flat sheet meshes while the weight method was perhaps more accurate in describing stereoscopic void space for 3D structure devices. This article will give instructive clues for engineers to improve mesh structures, and better understanding of warp knitting meshes for surgeons.


title: Using digital technology for home monitoring, adherence and self-management in cystic fibrosis: a state-of-the-art review.

text: Digital healthcare is a rapidly growing healthcare sector. Its importance has been recognised at both national and international level, with the WHO recently publishing its first global strategy for digital health. The use of digital technology within cystic fibrosis (CF) has also increased. CF is a chronic, life-limiting condition, in which the treatment burden is high and treatment regimens are not static. Digital technologies present an opportunity to support the lives of people with CF. We included 59 articles and protocols in this state-of-the-art review, relating to 48 studies from 1999 until 2019. This provides a comprehensive overview of the expansion and evolution of the use of digital technology. Technology has been used with the aim of increasing accessibility to healthcare, earlier detection of pulmonary exacerbations and objective electronic adherence monitoring. It may also be used to promote adherence and self-management through education, treatment management Apps and social media.


title: Task variation during simulated, repetitive, low-intensity work--influence on manifestation of shoulder muscle fatigue, perceived discomfort and upper-body postures.

text: UNLABELLED Work-related musculoskeletal disorders are increasing due to industrialisation of work processes. Task variation has been suggested as potential intervention. The objectives of this study were to investigate, first, the influence of task variation on electromyographic (EMG) manifestations of shoulder muscle fatigue and discomfort; second, noticeable postural shoulder changes over time; third, if the association between task variation and EMG might be biased by postural changes. Outcome parameters were recorded using multichannel EMG, Optotrak and the Borg scale. Fourteen participants performed a one-hour repetitive Pegboard task in one continuous and two interrupted conditions with rest and a pick-and-place task, respectively. Manifestations of shoulder muscle fatigue and discomfort feelings were observed throughout the conditions but these were not significantly influenced by task variation. After correction for joint angles, the relation between task variation and EMG was significantly biased but significant effects of task variation remained absent. PRACTITIONER SUMMARY Comparing a one-hour continuous, repetitive Pegboard task with two interrupted conditions revealed no significant influences of task variation. We did observe that the relation between task variation and EMG was biased by posture and therefore advise taking account for posture when investigating manifestations of muscle fatigue in assembly tasks.


How great is the risk of Middle East respiratory syndrome coronavirus to the global population?


French research strategy to tackle antimicrobial resistance.


Narcolepsy and COVID-19: sleeping on an opportunity?


title: Novel Approaches for the Treatment of the Patient with Resistant Hypertension: Renal Nerve Ablation.

text: Sympathetic innervation of the kidneys plays a major role in the pathogenesis of hypertension through modulation of renin secretion, glomerular filtration rate and renal absorption of sodium. Targeted interventions for renal nerve ablation are being developed for treatment of drug resistant hypertension in the USA and rest of the world. Early studies with the use of radiofrequency based renal denervation systems have shown encouraging results with significant reduction of blood pressure in patients inadequately controlled despite nearly maximal drug therapy regimens. Thus far, the renal denervation procedure has been associated with minimal side effects. Long term efficacy and safety beyond 3 years needs to be determined for renal nerve ablation. This review focuses on the physiology of the renal sympathetic system, the rationale for renal nerve ablation and current evidence in support of the available therapeutic renal denervation systems.


title: Structure of human IFIT1 with capped RNA reveals adaptable mRNA binding and mechanisms for sensing N1 and N2 ribose 2'-O methylations.

text: IFIT1 (IFN-induced protein with tetratricopeptide repeats-1) is an effector of the host innate immune antiviral response that prevents propagation of virus infection by selectively inhibiting translation of viral mRNA. It relies on its ability to compete with the translation initiation factor eIF4F to specifically recognize foreign capped mRNAs, while remaining inactive against host mRNAs marked by ribose 2'-O methylation at the first cap-proximal nucleotide (N1). We report here several crystal structures of RNA-bound human IFIT1, including a 1.6-Å complex with capped RNA. IFIT1 forms a water-filled, positively charged RNA-binding tunnel with a separate hydrophobic extension that unexpectedly engages the cap in multiple conformations (syn and anti) giving rise to a relatively plastic and nonspecific mode of binding, in stark contrast to eIF4E. Cap-proximal nucleotides encircled by the tunnel provide affinity to compete with eIF4F while allowing IFIT1 to select against N1 methylated mRNA. Gel-shift binding assays confirm that N1 methylation interferes with IFIT1 binding, but in an RNA-dependent manner, whereas translation assays reveal that N1 methylation alone is not sufficient to prevent mRNA recognition at high IFIT1 concentrations. Structural and functional analysis show that 2'-O methylation at N2, another abundant mRNA modification, is also detrimental for RNA binding, thus revealing a potentially synergistic role for it in self- versus nonself-mRNA discernment. Finally, structure-guided mutational analysis confirms the importance of RNA binding for IFIT1 restriction of a human coronavirus mutant lacking viral N1 methylation. Our structural and biochemical analysis sheds new light on the molecular basis for IFIT1 translational inhibition of capped viral RNA.


title: A New Formula for Predicting the Fraction of Delivered Oxygen During Low-Flow Oxygen Therapy.

text: BACKGROUND During O2 therapy at low flow in patients who breathe spontaneously, the fraction of delivered O2 (FDO2 ) is unknown. In recent years, FDO2 prediction formulas have been proposed. However, they do not take into account the effect of inspiratory flow (V̇I) on the FDO2 . The aim of this study was to validate a new FDO2 prediction formula, which takes into account the V̇I and compares it with other FDO2 prediction formulas. METHODS During a bench study, spontaneous breathing was generated with a mechanical test lung connected to a mechanical ventilator set to volume control mode. O2 flow from a wall-mounted tube was delivered through a heat-and-moisture exchanger filter. A flow sensor recorded each breath of the V̇I in ambient temperature and barometric pressure conditions. Three parameters [O2 flow at 2, 3, 4, 5, 6 L/min; minute ventilation at 5, 10, 15, 20 L/min; and ratio of the inspiratory time (TI) to the total breathing cycle time (Ttot) (TI/Ttot) of 0.33 (TI/Ttot value) and 0.50 (TI/Ttot value)] were modified to generate many ventilatory patterns. An O2 analyzer continuously examined the FDO2 . RESULTS When the O2 flow and/or TI/Ttot increased, the FDO2 increased. When the minute ventilation increased, the FDO2 decreased. The results of the Bland-Altman method for the FDO2 , calculated by using our mathematical model and the measured FDO2 , showed that the mean ± SD bias value was equal to 1.49 ± 0.84%, and the limits of agreement ranged from -0.17% to 3.14%. The intraclass correlation coefficients were 0.991 for TI/Ttot = 0.33 and 0.994 for TI/Ttot = 0.50, and the coefficient of variation was 2.1% for TI/Ttot = 0.33 and 1.3% for TI/Ttot = 0.50. The results of the Bland-Altman method for the FDO2 calculated by using the Shapiro formula and the FDO2 measured on the bench indicated that the bias value was 0.075 ± 8.66% and the limits of agreement ranged from -16.89% to 17.04%. For the Vincent formula, the bias value was 3.08% ± 8.56% and the limits of agreement ranged from -13.69% to 19.84%. CONCLUSIONS The V̇I has a major impact on FDO2 during O2 therapy at low flow. FDO2 comparisons between frequently used prediction formulas and FDO2 measured on the bench indicated greater differences. Uncritical use of these formulas should be used cautiously to predict FDO2 . In this study, our prediction formula indicated a good accuracy for predicting FDO2 during supplemental oxygenation through a heat-and-moisture exchanger in patients who breathe spontaneously.


title: Combined Use of Mechanical Thrombectomy with Angioplasty and Stenting for Acute Basilar Occlusions with Underlying Severe Intracranial Vertebrobasilar Stenosis: Preliminary Experience from a Single Chinese Center.

text: BACKGROUND AND PURPOSE Acute basilar occlusions have a poor prognosis without recanalization. Many have underlying severe atherosclerotic intracranial stenosis coexisting with acute thrombosis, requiring treatment of both pathologies in the same session, though technical risks may be encountered. The purpose of this study was to evaluate the technical feasibility and safety of combined treatment by using stent retrievers for the thrombosis, together with angioplasty and stent placement for the underlying stenosis. MATERIALS AND METHODS This was a retrospective review of 13 patients with basilar occlusions treated with thrombectomy by the Solitaire stent retriever and angioplasty and intracranial stent placement for underlying severe vertebrobasilar stenosis in the same session. Reperfusion was assessed in terms of the TICI score. Perioperative complications were recorded. Clinical outcomes were assessed by the NIHSS at discharge and the mRS on follow-up at 90 days. RESULTS Of the 30 patients with acute basilar artery occlusions treated with stent retrievers during the study period, 18 had coexisting severe intracranial stenosis. Thirteen patients meeting the criteria for our study received combined mechanical thrombectomy and angioplasty with stent placement. The successful recanalization rate was 100%. Distal vessel embolizations occurred in 3 patients. There were 2 mortalities. On discharge, 10 patients (77%) had an improvement in NIHSS of ≥10 points. At 90 days, 6 patients (46%) had a good functional outcome with an mRS of ≤2. CONCLUSIONS The combined use of mechanical thrombectomy with angioplasty and stent placement for acute basilar occlusions with underlying severe intracranial atherosclerotic stenosis is technically feasible and safe.