title: Emergency cesarean section on severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) confirmed patient.

text: Background Since the first case of severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) occurred in Wuhan in December 2019, the virus has spread globally. The World Health Organization declared the virus outbreak a pandemic on March 11, 2020. On January 19, 2020, a 35-year-old woman who returned from China was confirmed as the first SARS-CoV-2 infected case in Korea. Since then, it has spread all over Korea. Case We report the first case of a SARS-CoV-2 positive woman delivering a baby through cesarean section at 37+6 weeks of pregnancy in the Republic of Korea. Conclusions This case suggested that negative pressure operating room, skillful medical team, and enhanced personal protective equipment including N95 masks, surgical cap, double gown, double gloves, shoe covers, and powered air-purifying respirator are required at the hospital for safe delivery in such a case.


title: Coronavirus disease 2019: initial high resolution computed tomography imaging feature analysis: report of seven cases.

text: The number of reported cases of the new coronavirus disease named "severe acute respiratory syndrome-coronavirus 2" (SARS-CoV-2) has increased since December 2019. The initial high-resolution computed tomography (HRCT) images of seven patients with diagnosed COVID-19 in the Affiliated Hospital of Hangzhou Normal University, China, were collected and analyzed. The study showed that all patients had close contact with COVID-19 patient and presented with fever. The initial white blood cell counts of all patients were normal. The percentage of lymphocytes decreased in three patients. In all seven patients with COVID-19, ground glass opacity (GGO) was found in the HRCT images, mainly distributed in the subpleural region of the lungs. The HRCT scans of six patients showed bilateral lobar lesions, mainly peripheral subpleural distribution; one patients showed unilateral lobar involvement. The right lung was more extensively involved than the left lung in six patients, and the lower lobe was more extensively involved than the upper lobe in five patients. The initial chest HRCT images of the lungs of COVID-19 patients had specific characteristics; the typical manifestations of the bilateral lungs showed extensive GGO-type infiltrate, with thickened vascular bundles and focal center consolidation. Pleural effusion, bilateral hilar, and mediastinal lymphadenopathy were rare.


title: Intrathecal injection of magnesium sulfate: shivering prevention during cesarean section: a randomized, double-blinded, controlled study.

text: BACKGROUND Regional anesthesia is known to significantly impair thermoregulation and predispose patients to hypothermia. We hypothesized that the addition of an intrathecal injection of magnesium sulfate (MgSO4) to bupivacaine would improve perioperative shivering in female patients undergoing elective caesarean section. METHODS In a block-randomized, double-blinded, controlled trial 72 patients scheduled for elective caesarean section with spinal anesthesia were separated into two groups. In the treatment group, 2 ml of 0.5% bupivacaine plus 25 mg MgSO4 (0.5 ml) were injected intrathecally, and in the control group 2 ml of 0.5% bupivacaine plus 0.5 ml normal saline were injected intrathecally. Core temperature was measured before and after drug injection at predetermined intervals. Sedation was graded using the Ramsay sedation scale. RESULTS No significant intergroup differences in appearance of shivering were seen immediately or at 5, 30, 40, 50, 60, and 90 min after block administration. However, at 10, 15, and 20 min post block, there was a significant difference in shivering. The group administered MgSO4 showed lower shivering grades compared with the control group. Core temperature was significantly reduced in the MgSO4 group compared to the normal saline group 30 min after blocking. CONCLUSIONS Intrathecal injection of MgSO4 improved perioperative shivering in female patients undergoing elective caesarean section.


Secondary prevention by stroke subtype: impact of the Korean experience.


title: Incidence and clinical implications of upper extremity deep vein thrombosis after laparoscopic bariatric procedures.

text: Upper extremity deep vein thrombosis (UEDVT) represents less than 10 % of thromboembolic events, but has been associated with higher incidence of asymptomatic pulmonary embolism. Data regarding UEDVT and its treatment is limited. Our objective was to investigate UEDVT incidence, diagnosis, and treatment in our bariatric patient population. We conducted a retrospective review of patients undergoing laparoscopic bariatric surgery at our institution. Variables analyzed included patient demographics, body mass index (BMI), history of venous thromboembolic event (VTE), type of procedure, and other comorbidities. One thousand five hundred three patients were included in the study. Twenty patients developed VTE events, of which five suffered UEDVT. Although infrequent, awareness of UEDVT is necessary in order to initiate treatment in a timely fashion and to prevent major complications.


Comparing Apples and Oranges: High-End Cardiac 320-Detector Row CT vs Archaic SPECT Protocols.


title: Wax Lining in an Impression Tray and Accuracy in Gypsum Cast Fabrication.

text: PURPOSE Controversy exists as to whether lining a metal-perforated impression tray with wax will yield a distorted irreversible hydrocolloid impression. Two current textbooks have completely different recommendations, but there is no evidence to support either theory. This project evaluates distortion in gypsum casts that have been prepared from wax-lined and unlined metal impression trays. The purpose of this study was to assess the influence of wax on the border and in the palate of metal-perforated impression trays on the dimensional stability of the resulting irreversible hydrocolloid impression. MATERIALS AND METHODS A dentaform was prepared with marks on the cusp tips of teeth 6 and 11 and distobuccal cusps of teeth 2 and 15. Using a standard maxillary rim lock impression tray, alginate impressions were made using a dentaform with no wax lining, wax lining the border of the tray, and wax lining the border and the palate (n = 10). Casts were randomized. Six measurements were taken using a stereographic measuring microscope, from tooth #6 to #11, #11 to #15, #15 to #2, #2 to #6, #6 to #15, and #2 to #11. An acrylic template was used to position the cast in a reproducible position on the microscope. RESULTS Trays lined with wax on the border and the palate yielded casts with significantly different dimensions when compared to those poured from unlined or border-lined trays (p < 0.05). Casts produced from unlined and border-lined trays were not significantly different in dimension from the dentaform (p > 0.05). CONCLUSION There is no difference between the metal tray with no wax, the metal tray with a wax around the border, and the dentaform. The clinician can make irreversible hydrocolloid impressions using wax on the periphery or without wax on the periphery and feel confident that the impression has not been compromised in its ability to accurately reproduce the maxillary arch when used. Caution should be exercised when adding wax to the palate of the impression tray.


title: A free-standing condensation enzyme catalyzing ester bond formation in C-1027 biosynthesis.

text: Nonribosomal peptide synthetases (NRPSs) catalyze the biosynthesis of many biologically active peptides and typically are modular, with each extension module minimally consisting of a condensation, an adenylation, and a peptidyl carrier protein domain responsible for incorporation of an amino acid into the growing peptide chain. C-1027 is a chromoprotein antitumor antibiotic whose enediyne chromophore consists of an enediyne core, a deoxy aminosugar, a benzoxazolinate, and a beta-amino acid moiety. Bioinformatics analysis suggested that the activation and incorporation of the beta-amino acid moiety into C-1027 follows an NRPS mechanism whereby biosynthetic intermediates are tethered to the peptidyl carrier protein SgcC2. Here, we report the biochemical characterization of SgcC5, an NRPS condensation enzyme that catalyzes ester bond formation between the SgcC2-tethered (S)-3-chloro-5-hydroxy-beta-tyrosine and (R)-1-phenyl-1,2-ethanediol, a mimic of the enediyne core. SgcC5 uses (S)-3-chloro-5-hydroxy-beta-tyrosyl-SgcC2 as the donor substrate and exhibits regiospecificity for the C-2 hydroxyl group of the enediyne core mimic as the acceptor substrate. Remarkably, SgcC5 is also capable of catalyzing amide bond formation, albeit with significantly reduced efficiency, between (S)-3-chloro-5-hydroxy-beta-tyrosyl-(S)-SgcC2 and (R)-2-amino-1-phenyl-1-ethanol, an alternative enediyne core mimic bearing an amine at its C-2 position. Thus, SgcC5 is capable of catalyzing both ester and amide bond formation, providing an evolutionary link between amide- and ester-forming condensation enzymes.


Infographic. Graduated return to play guidance following COVID-19 infection.


title: The comparison of the effectiveness of lincocin® and azitro® in the treatment of covid-19-associated pneumonia: A prospective study.

text: The COVID-19 virus has spread rapidly around the world and there are many patients in multiple countries. Great efforts have been made to find effective medications against the COVID-19. This study aims to compare the effectiveness of LINCOCIN® and AZITRO® in the treatment of COVID-19 associated pneumonia. A total of 24 hospitalized patients aged between 30-80 years who were admitted to the Tarsus Medical Park Hospital between February to March 2020 was included in the study. The patients were divided into LINCOCIN® and AZITRO® treatment groups. Bronchoalveolar-lavage PCR results were compared after treatment. The mean age was 58.4±15.4 years in the LINCOCIN® group and 59.1±16.6 years in the AZITRO® group. In the LINCOCIN® group, the rate of males was 66.7% and it was 58.3% in the AZITRO® group. There were no statistical differences in terms of age and gender between the groups. On the 6th day after starting treatment, negative bronchoalveolar PCR result was 83.3% in the LINCOCIN® group and 33.3% in the AZITRO® group. The negative bronchoalveolar PCR proportion was significantly higher in the LINCOCIN® group than in the AZITRO® group. LINCOCIN® usage may be more appropriate in the treatment of COVID-19 associated pneumonia. Further studies with a large sample size should clarify these results.


title: Online Antenatal Care During The COVID-19 Pandemic: Opportunities and Challenges.

text: UNSTRUCTURED During this ongoing global Coronavirus Disease (COVID-19) pandemic, people in different regions of the world have been greatly affected. Recently delivered mothers and currently pregnant women face a dilemma during this period, since they need professional antenatal care while there are high infection risks of severe respiratory syndrome coronavirus (SARS-CoV-2) in hospitals. Therefore, online antenatal care would be a preferable choice for these women because it could provide pregnancy-related information and online clinic consultations. In addition, online antenatal care could help to provide relatively cheaper medical services and diminish health inequality due to its convenience and cost-effectiveness, especially in developing countries or regions. However, some pregnant women will doubt the reliability of such online information. Therefore, it is important to determine how to ensure the quality of online services and establish a stable mutual trust between pregnant women and online programs. Here we report how the COVID-19 pandemic brings not only opportunities for the development and popularization of online antenatal care programs but also challenges.


title: Gastric tube insertion under direct vision using the King Vision™ video laryngoscope: a randomized, prospective, clinical trial.

text: BACKGROUND The frequency of malpositioning of gastric tubes in the trachea has been reported to be 0.3-15%, which may cause severe complications, such as pneumonia, if not detected promptly. If a gastric tube can be guided into the esophagus under direct vision with a video laryngoscope, misplacement of the gastric tube into the trachea can be avoided. We compared gastric tube insertion under direct vision using a video laryngoscope with the conventional method of blind insertion. METHODS We enrolled 60 patients who required a transnasal gastric tube to facilitate elective abdominal surgery under general anesthesia. The participants were recruited consecutively into one of two groups, a group of 30 patients in whom a gastric tube was inserted using a King Vision™ video laryngoscope (KV group), and a group of 30 patients who underwent conventional blind insertion of the gastric tube (Blind group). The success rate, the time taken to insert the gastric tube, and the incidence of complications were compared. RESULTS In the KV group, the time required for gastric tube placement was 52.5 ± 17.1 seconds, with a success rate of 100%. Slight oral hemorrhage occurred in two participants and slight epistaxis in one participant. In the Blind group, the time required for gastric tube placement was 65.9 ± 39.9 seconds, with a success rate of 90% (27 out of 30 patients). Slight oral hemorrhage occurred in two participants, slight epistaxis occurred in two participants, and tracheal malposition occurred in one participant but was detected promptly and corrected using the video laryngoscope. There were no significant differences in the time required for placing the gastric tube, the success rate, or the incidence of complications between the groups. CONCLUSIONS Gastric tube insertion using a King Vision video laryngoscope was straightforward, and was particularly useful for detecting and correcting tracheal malpositioning. TRIAL REGISTRATION TRIAL REGISTRY NUMBER UMIN000011014.


title: Research data management in academic institutions: A scoping review.

text: OBJECTIVE The purpose of this study is to describe the volume, topics, and methodological nature of the existing research literature on research data management in academic institutions. MATERIALS AND METHODS We conducted a scoping review by searching forty literature databases encompassing a broad range of disciplines from inception to April 2016. We included all study types and data extracted on study design, discipline, data collection tools, and phase of the research data lifecycle. RESULTS We included 301 articles plus 10 companion reports after screening 13,002 titles and abstracts and 654 full-text articles. Most articles (85%) were published from 2010 onwards and conducted within the sciences (86%). More than three-quarters of the articles (78%) reported methods that included interviews, cross-sectional, or case studies. Most articles (68%) included the Giving Access to Data phase of the UK Data Archive Research Data Lifecycle that examines activities such as sharing data. When studies were grouped into five dominant groupings (Stakeholder, Data, Library, Tool/Device, and Publication), data quality emerged as an integral element. CONCLUSION Most studies relied on self-reports (interviews, surveys) or accounts from an observer (case studies) and we found few studies that collected empirical evidence on activities amongst data producers, particularly those examining the impact of research data management interventions. As well, fewer studies examined research data management at the early phases of research projects. The quality of all research outputs needs attention, from the application of best practices in research data management studies, to data producers depositing data in repositories for long-term use.


title: Knowledge and practices of dentists regarding MERS-CoV. A cross-sectional survey in Saudi Arabia.

text: OBJECTIVES To assess virus knowledge among dentists in Saudi Arabia and to identify factors associated with recommended management practices of patients. Method: A structured questionnaire was distributed to dentists in major Saudi cities between September 2016 and December 2017. The questionnaire investigated participants' knowledge about Middle East Respiratory Syndrome Coronavirus (MERS-CoV) transmission, consequences, patient identification and history taking practices. Data was collected using paper-based questionnaires or an online link sent to dentists registered with Saudi Dental Society nationwide. The analysis was carried using Statistical Package for Social Sciences for Windows, version 22.0 (IBM Corp., Armonk, NY, USA) logistic regression, odds ratio and confidence intervals to identify the relationship between variables. RESULTS A total of 423 dentists responded the paper-based questionnaire. Overall the knowledge was good with gaps in history taking practices. Best management practices of MERS-CoV patients were significantly higher among dentists with better knowledge of virus transmission (odd ration [OR]=1.16, p less than 0.0001), patients' identification (OR=1.40, p less than 0.0001) and those knowing that corona infection can be fatal (OR= 2.44, p=0.02). CONCLUSION Best management practices depends on correct patient identification. Educational campaigns should target dentists, given the unique nature of dental practice.


title: Femoroacetabular Impingement in Elite Ice Hockey Goaltenders: Etiological Implications of On-Ice Hip Mechanics.

text: BACKGROUND Femoroacetabular impingement (FAI) is particularly prevalent in ice hockey. The butterfly goalie technique is thought to involve extreme ranges of hip motion that may predispose goaltenders to FAI. PURPOSE To quantify hip mechanics during 3 common goaltender movements and interpret their relevance to the development of FAI. STUDY DESIGN Descriptive laboratory study. METHODS Fourteen collegiate and professional goaltenders performed skating, butterfly save, and recovery movements on the ice. Hip mechanics were compared across the 3 movements. RESULTS The butterfly did not exhibit the greatest range of hip motion in any of the 3 planes. Internal rotation was the only hip motion that appeared close to terminal in this study. When subjects decelerated during skating—shaving the blade of their skate across the surface of the ice—the magnitude of peak hip internal rotation was 54% greater than in the butterfly and 265% greater than in the recovery. No movement involved levels of concomitant flexion, adduction, and internal rotation that resembled the traditional impingement (FADIR) test. CONCLUSION The magnitude of internal rotation was the most extreme planar hip motion (relative to end-range) recorded in this study (namely during decelerating) and appeared to differentiate this cohort from other athletic populations. Consequently, repetitive end-range hip internal rotation may be the primary precursor to symptomatic FAI in hockey goaltenders and provides the most plausible account for the high incidence of FAI in these athletes. Resection techniques should, therefore, focus on enhancing internal rotation in goaltenders, compared with flexion and adduction. While the butterfly posture can require significant levels of hip motion, recovering from a save and, in particular, decelerating during skating are also demanding on goaltenders' hip joints. Therefore, it appears critical to consider and accommodate a variety of sport-specific hip postures to comprehensively diagnose, treat, and rehabilitate FAI.


title: Nitrous oxide-based versus nitrous oxide-free general anaesthesia and accidental awareness during general anaesthesia in surgical patients.

text: BACKGROUND Accidental awareness during general anaesthesia (AAGA) is when a patient unintentionally becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. Incidence estimates for AAGA vary, with the most common estimate being one to two cases per 1000 general anaesthetics. Evidence linking nitrous oxide use and an increased risk of AAGA has come from observational studies data but the literature is contradictory, with some studies finding a protective effect of nitrous oxide. OBJECTIVES To assess the effect of general anaesthesia including nitrous oxide on the risk of AAGA in patients aged five years and over. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registers ((www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/network/en/) and Current Controlled Trials (www.isrctn.com/)) for eligible studies on December 9 2015. In addition, we conducted forward and backward citation searching using key identified papers. SELECTION CRITERIA We considered all randomized controlled trials (RCTs), including quasi-randomized studies and cluster-randomized studies, of participants aged five years or older receiving general anaesthesia for any type of surgery.We included trials in which participants receiving general anaesthesia that included nitrous oxide for maintenance at a concentration of at least 30% were compared with participants receiving no nitrous oxide during general anaesthesia. The intervention group must have received nitrous oxide in conjunction with an additional anaesthetic. We excluded studies where the depth of anaesthesia differed between the study arms. For inclusion in the review, studies needed to state in their methods that they planned to assess AAGA. We defined this as when a patient becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane to identify studies. We extracted data and conducted 'Risk of bias' assessment using the Covidence database. MAIN RESULTS We included 15 studies. The total number of participants included in the analyses was 3520. Most studies were small with fewer than 120 participants, although two larger studies with 2012 and 671 participants were included. There was considerable variation in many of the study characteristics, including the anaesthetics used. The concentrations of nitrous oxide varied between 50% and 70%, and half of the studies used clinical signs and haemodynamic changes to monitor depth of anaesthesia.As it was not possible to blind the anaesthetist to the anaesthetic used, we rated all studies at high risk of performance bias and we therefore downgraded the quality of evidence by one level for risk of bias using the GRADE approach. Other types of bias were generally low, or were rated unclear due to missing information.No studies were designed to measure AAGA as the primary outcome, and were therefore statistically underpowered to answer this review question. Despite the inclusion of 3520 participants, only three awareness events were reported by two studies. In one study the event was due to technical failure. Due to the rarity of the events, we did not consider it appropriate to pool the data, and we therefore downgraded the quality of evidence by a further level for imprecision using GRADE. AUTHORS' CONCLUSIONS It is not possible to draw any conclusions from this review. The included studies were mainly small (fewer than 120 participants) and there were limited estimates of effect, with only two studies reporting any events. We cannot therefore determine whether the use of nitrous oxide in general anaesthesia increases, decreases or has no effect on the risk of accidental awareness.


title: Long-lasting protective antiviral immunity induced by passive immunotherapies requires both neutralizing and effector functions of the administered monoclonal antibody.

text: Using FrCas(E) retrovirus-infected newborn mice as a model system, we have shown recently that a long-lasting antiviral immune response essential for healthy survival emerges after a short treatment with a neutralizing (667) IgG2a isotype monoclonal antibody (MAb). This suggested that the mobilization of adaptive immunity by administered MAbs is key for the success in the long term for the MAb-based passive immunotherapy of chronic viral infections. We have addressed here whether the anti-FrCas(E) protective endogenous immunity is the mere consequence of viral propagation blunting, which would simply give time to the immune system to react, and/or to actual immunomodulation by the MAb during the treatment. To this aim, we have compared viral replication, disease progression, and antiviral immune responses between different groups of infected mice: (i) mice treated with either the 667 MAb, its F(ab')(2) fragment, or an IgM (672) with epitopic specificity similar to that of 667 but displaying different effector functions, and (ii) mice receiving no treatment but infected with a low viral inoculum reproducing the initial viral expansion observed in their infected/667 MAb-treated counterparts. Our data show that the reduction of FrCas(E) propagation is insufficient on its own to induce protective immunity and support a direct immunomodulatory action of the 667 MAb. Interestingly, they also point to sequential actions of the administered MAb. In a first step, viral propagation is exclusively controlled by 667 neutralizing activity, and in a second one, this action is complemented by FcgammaR-binding-dependent mechanisms, which most likely combine infected cell cytolysis and the modulation of the antiviral endogenous immune response. Such complementary effects of administered MAbs must be taken into consideration for the improvement of future antiviral MAb-based immunotherapies.


title: Investigation of Antibacterial Activity and Biofilm Formation of Silicones Coated With Minocycline-Rifampicin, Silver Nitrate, and Nitrofurantoin for Short-term Utilization in In Vitro Urinary System Models.

text: OBJECTIVE To analyze antimicrobial activity and biofilm formation on silicones coated with antimicrobial substances in in vivo short-term catheterization simulation using our newly developed in vitro urinary system model and to compare minocycline-rifampin (MR)-, silver nitrate-, and nitrofurantoin (NF)-coated silicone discs. MATERIALS AND METHODS Silicone discs were exposed to bacterial urine suspension for 168 hours. The antimicrobial activities were assessed in the medium, and the inhibition zone diameters were measured. The weight of the silicones was measured for biofilm growth assessment before and after the experiment, and confocal microscopy images were taken. RESULTS Although the inhibition zone diameters of silver nitrate silicones were larger than those of pure silicone (PS), MR, and NF silicones, biofilm formation could not be prevented (P < .05). MR and NF silicones were superior to PS in terms of antimicrobial efficacy and prevention of biofilm formation (P < .05). In terms of biofilm prevention, no differences were detected between NF and MR silicones apart from a slightly superior ability of MR silicones to inhibit Escherichia coli (P > .05). Biofilm formation occurred on all silicone discs. CONCLUSION In short-term urinary catheter utilization, antimicrobial efficacy and biofilm formation prevention were superior in coated silicones, regardless of the type of antibiotic used, compared with the control group (PS). As the study was conducted in an in vitro setting, the findings should be substantiated with in vivo studies on the grounds that different results may be obtained in these settings.


title: Narrowed TCR diversity for immunised mice challenged with recombinant influenza A-HIV Env(311-320) virus.

text: Understanding CD8+ T cell responses generated by live virus vectors is critical for the rational design of next generation HIV CTL-based vaccines. We used recombinant influenza viruses expressing the HIV Env(311-320) peptide in the neuraminidase stalk to study response magnitude, cytokine production and repertoire diversity for the elicited CD8+ D(d)Env(311) CTL set. The insertion of the CD8+ D(d)Env(311) epitope into the NA stalk resulted in a decrease in viral fitness that was reflected in lower lung viral titres. While not affecting the magnitude of endogenous primary influenza-specific responses, the introduction of the D(d)Env(311) CD8+ T cell epitope altered the hierarchy of responses following secondary challenge. The CD8+ K(d)NP(147) response increased 9-fold in the spleen following secondary infection whereas the CD8+ D(d)Env(311) response increased 15-fold in the spleen. Moreover, this study is the first to describe narrowing of CD8+ TCR repertoire diversity in the context of an evolving secondary immune response against influenza A virus. Analysis of Vbeta bias for CD8+ D(d)Env(311) T cell responses showed a narrowing of CD8+ Vbeta8.1/8.2 D(d)Env(311) TCR repertoire diversity. This work further emphasizes the importance of understanding vaccine-induced CD8+ T cell responses.


title: Urgent laparoscopic mesh splenopexy for torsion of wandering spleen and distal pancreas: A case report.

text: Wandering spleen is a condition in which an incomplete fusion of the splenic ligaments allows the spleen to move within the abdomen, predisposing it to splenic torsion along its vascular pedicle. Torsion of a wandering spleen is an uncommon occurrence, especially in children, and associated torsion of the distal pancreas is even more unusual, with only four cases having been reported in adults. Non-specific clinical presentation makes radiologic evaluation essential in order to obtain a diagnosis and to send the patient for early surgery before life-threatening complications arise. Here we present a rare case of torsion of wandering spleen together with volvulus of the distal pancreas in a 13-year-old girl. In this case, prompt radiological assessment allowed for an early diagnosis, and the patient was successfully treated with urgent laparoscopic derotation of both the spleen and the distal pancreas as well as mesh splenopexy. To the best of our knowledge, this procedure has never been described in a pediatric setting.


Guidelines for institutions granting bariatric privileges utilizing laparoscopic techniques. Society of American Gastrointestinal and Endoscopic Surgeons Guidelines Committee.


Reply to: Standards and Stereotypes in COVID-19.


title: Comparison of Inspiratory Effort, Workload and Cycling Synchronization Between Non-Invasive Proportional-Assist Ventilation and Pressure-Support Ventilation Using Different Models of Respiratory Mechanics.

text: BACKGROUND This study assessed lung models for the influence of respiratory mechanics and inspiratory effort on breathing pattern and simulator-ventilator cycling synchronization in non-invasive ventilation. MATERIAL AND METHODS A Respironics V60 ventilator was connected to an active lung simulator modeling mildly restrictive, severely restrictive, obstructive and mixed obstructive/restrictive profiles. Pressure-support ventilation (PSV) and proportional-assist ventilation (PAV) were set to obtain similar tidal volume (VT). PAV was applied at flow assist (FA) 40-90% of resistance (Rrs) and volume assist (VA) 40-90% of elastance (Ers). Measurements were performed with system air leak of 25-28 L/minute. Ventilator performance and simulator-ventilator asynchrony were evaluated. RESULTS At comparable VT, PAV had slightly lower peak inspiratory flow and higher driving pressure compared with PSV. Premature cycling occurred in the obstructive, severely restrictive and mildly restrictive models. During PAV, time for airway pressure to achieve 90% of maximum during inspiration (T90) in the severely restrictive model was shorter than those of the obstructive and mixed obstructive/restrictive models and close to that measured in the PSV mode. Increasing FA level reduced inspiratory trigger workload (PTP₃₀₀) in obstructive and mixed obstructive/restrictive models. Increasing FA level decreased inspiratory time (TI) and tended to aggravate premature cycling, whereas increasing VA level attenuated this effect. CONCLUSIONS PAV with an appropriate combination of FA and VA decreases work of breathing during the inspiratory phase and improves simulator-ventilator cycling synchrony. FA has greater impact than VA in the adaptation to inspiratory effort demand. High VA level might help improve cycling synchrony.


title: Association between alcohol consumption and impaired work performance (presenteeism): a systematic review.

text: OBJECTIVES The aim of this review was to explore the notion of alcohol-related presenteeism; that is, whether evidence in the research literature supports an association between employee alcohol consumption and impaired work performance. DESIGN Systematic review of observational studies. DATA SOURCES MEDLINE, Web of Science, PsycINFO, CINAHL, AMED, Embase and Swemed+ were searched through October 2018. Reference lists in included studies were hand searched for potential relevant studies. ELIGIBILITY CRITERIA We included observational studies, published 1990 or later as full-text empirical articles in peer-reviewed journals in English or a Scandinavian language, containing one or more statistical tests regarding a relationship between a measure of alcohol consumption and a measure of work performance. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data. Tested associations between alcohol consumption and work performance within the included studies were quality assessed and analysed with frequency tables, cross-tabulations and χ2 tests of independence. RESULTS Twenty-six studies were included, containing 132 tested associations. The vast majority of associations (77%) indicated that higher levels of alcohol consumption were associated with higher levels of impaired work performance, and these positive associations were considerably more likely than negative associations to be statistically significant (OR=14.00, phi=0.37, p<0.001). Alcohol exposure measured by hangover episodes and composite instruments were over-represented among significant positive associations of moderate and high quality (15 of 17 associations). Overall, 61% of the associations were characterised by low quality. CONCLUSIONS Evidence does provide some support for the notion of alcohol-related presenteeism. However, due to low research quality and lack of longitudinal designs, evidence should be characterised as somewhat inconclusive. More robust and less heterogeneous research is warranted. This review, however, does provide support for targeting alcohol consumption within the frame of workplace interventions aimed at improving employee health and productivity. PROSPERO REGISTRATION NUMBER CRD42017059620.


title: Preventing stem cell transplantation-associated viral infections using T-cell therapy.

text: Hematopoietic stem cell transplantation is the treatment of choice for many hematologic malignancies and genetic diseases. However, viral infections continue to account for substantial post-transplant morbidity and mortality. While antiviral drugs are available against some viruses, they are associated with significant side effects and are frequently ineffective. This review focuses on the immunotherapeutic strategies that have been used to prevent and treat infections over the past 20 years and outlines different refinements that have been introduced with the goal of moving this therapy beyond specialized academic centers.


title: Applying Dixon and Dixon's Integrative Model for Environmental Health Research toward a critical analysis of childhood lead poisoning in Canada.

text: Occurrences of childhood lead poisoning resulting from exposure to residential sources of lead is an underresearched area in Canada. Dixon and Dixon's Integrative Model for Environmental Health Research substantiates this claim by grouping Canadian research on this health topic into the model's 4 domains: physiological, vulnerability, epistemological, and health protection. This process is useful not only for identifying research gaps within the Canadian context but also in setting the groundwork for a future critical analysis to illuminate the sociopolitical and economic influences that shape healthcare knowledge, and ultimately, influence how healthcare providers and policy makers produce and use this information.


title: Prostate specific antigen testing among the elderly--when to stop?

text: PURPOSE Prostate specific antigen testing is common in the elderly despite evidence that older men without aggressive prostate cancer are unlikely to benefit from diagnosis and treatment. We evaluated the relationship between prostate specific antigen and the risk of aggressive prostate cancer developing in men of various ages. MATERIALS AND METHODS This longitudinal cohort study consisted of 849 men (122 with and 727 without prostate cancer) with serial prostate specific antigen measurements participating in the Baltimore Longitudinal Study of Aging. The primary outcome measure was the proportion of men by prostate specific antigen and age who died of prostate cancer or in whom aggressive prostate cancer developed (death from prostate cancer, a prostate specific antigen 20 ng/ml or greater, or Gleason score 8 or greater). RESULTS No participants between 75 and 80 years old with a prostate specific antigen less than 3.0 ng/ml died of prostate cancer. In contrast, men of all ages with a prostate specific antigen of 3.0 ng/ml or greater had a continually increasing probability of death from prostate cancer (Fisher's exact test p <0.001). The time to death or diagnosis of aggressive prostate cancer after age 75 years was not significantly different between the prostate specific antigen categories of 3 to 3.9 and 4 to 9.9 ng/ml (p = 0.634), whereas the time to death or diagnosis of high risk prostate cancer was significantly longer for the prostate specific antigen category of less than 3 vs 3 ng/ml or greater (p = 0.019). CONCLUSIONS Men 75 to 80 years old with a prostate specific antigen less than 3 ng/ml are unlikely to die of or experience aggressive prostate cancer during their remaining life, suggesting that prostate specific antigen testing might be safely discontinued for these men.


Important interactions of immunosuppressants with experimental therapies for novel coronavirus disease (COVID-19): how to act.


title: Acute viral lower respiratory tract infections in Cambodian children: clinical and epidemiologic characteristics.

text: BACKGROUND Viruses are detected in most hospitalized children admitted for acute respiratory infections. Etiologic understanding is needed to improve clinical management and prevention, particularly in resource-limited tropical countries. METHODS A 3-year prospective descriptive study was conducted among Cambodian children admitted to 2 provincial hospitals for acute lower respiratory tract infection. Molecular detection for 18 viral pathogens using multiplex polymerase chain reaction/reverse transcription polymerase chain reactions was performed. RESULTS We enrolled 1006 children less than 5 years of age of whom 423 (42%), 428 (42%) and 155 (16%) had pneumonia, bronchiolitis and unclassified lower respiratory tract infections, respectively. Of the 551 (55%) with documented viral infection, a single virus was detected in 491 (89%), including rhinovirus (n = 169; 34%), respiratory syncytial virus (n = 167; 34%), parainfluenza virus (n = 40; 8%), human metapneumovirus (n = 39; 8%), influenza virus (n = 31; 6%), bocavirus (n = 16; 3%), adenovirus (n = 15; 3%), coronavirus (n = 9; 2%) and enterovirus (n = 5; 1%). Coinfections with multiple viruses were detected in 6% (2 viruses detected in 59 cases; 3 viruses detected in 1 case). CONCLUSION Similar to other tropical countries, rhinovirus and respiratory syncytial virus were the principal viral pathogens detected among children hospitalized for lower tract respiratory infection in Cambodia.


Sample Pooling as a Strategy to Detect Community Transmission of SARS-CoV-2.


title: Characteristics and Outcomes of Coronavirus Disease Patients under Nonsurge Conditions, Northern California, USA, March-April 2020.

text: Limited data are available on the clinical presentation and outcomes of coronavirus disease (COVID-19) patients in the United States hospitalized under normal-caseload or nonsurge conditions. We retrospectively studied 72 consecutive adult patients hospitalized with COVID-19 in 2 hospitals in the San Francisco Bay area, California, USA, during March 13-April 11, 2020. The death rate for all hospitalized COVID-19 patients was 8.3%, and median length of hospitalization was 7.5 days. Of the 21 (29% of total) intensive care unit patients, 3 (14.3% died); median length of intensive care unit stay was 12 days. Of the 72 patients, 43 (59.7%) had underlying cardiovascular disease and 19 (26.4%) had underlying pulmonary disease. In this study, death rates were lower than those reported from regions of the United States experiencing a high volume of COVID-19 patients.


title: Exploring the receptor origin of vibration-induced reflexes.

text: STUDY DESIGN An experimental design. OBJECTIVES The aim of this study was to determine the latencies of vibration-induced reflexes in individuals with and without spinal cord injury (SCI), and to compare these latencies to identify differences in reflex circuitries. SETTING A tertiary rehabilitation center in Istanbul. METHODS Seventeen individuals with chronic SCI (SCI group) and 23 participants without SCI (Control group) were included in this study. Latency of tonic vibration reflex (TVR) and whole-body vibration-induced muscular reflex (WBV-IMR) of the left soleus muscle was tested for estimating the reflex origins. The local tendon vibration was applied at six different vibration frequencies (50, 85, 140, 185, 235, and 265 Hz), each lasting for 15 s with 3-s rest intervals. The WBV was applied at six different vibration frequencies (35, 37, 39, 41, 43, and 45 Hz), each lasting for 15 s with 3-s rest intervals. RESULTS Mean (SD) TVR latency was 39.7 (5.3) ms in the SCI group and 35.9 (2.7) ms in the Control group with a mean (95% CI) difference of -3.8 (-6.7 to -0.9) ms. Mean (SD) WBV-IMR latency was 45.8 (7.4) ms in the SCI group and 43.3 (3.0) ms in the Control group with a mean (95% CI) difference of -2.5 (-6.5 to 1.4) ms. There were significant differences between TVR latency and WBV-IMR latency in both the groups (mean (95% CI) difference; -6.2 (-9.3 to -3.0) ms, p = 0.0001 for the SCI group and -7.4 (-9.3 to -5.6) ms, p = 0.011 for Control group). CONCLUSIONS The results suggest that the receptor of origin of TVR and WBV-IMR may be different.


title: Large-volume blood patch to multiple sites in the epidural space through a single-catheter access site for treatment of spontaneous intracranial hypotension.

text: BACKGROUND AND PURPOSE Spontaneous intracranial hypotension can be a therapeutic challenge to the treating physician. In this study, we present our experience with the administration of a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site. MATERIALS AND METHODS A retrospective review was conducted of patients with spontaneous intracranial hypotension who underwent a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site from 2010 to 2012. Patient demographic data, clinical charts, indications for treatment, radiographic images, procedure notes, and postprocedure hospital course were reviewed. RESULTS Overall, 9 patients were identified who underwent 20 blood patch procedures. Patients were selected to undergo the large-volume procedure either because they had a failed site-directed epidural blood patch or if imaging demonstrated multiple possible leak sites. There were 6 women and 3 men, with an average age of 33.5 years. The mean volume of blood injected per procedure was 54.1 mL (median=55 mL; range=38-70 mL). All patients had an orthostatic headache as one of their presenting symptoms; 22% also presented with neurocognitive decline and behavioral changes; 89% of patients had improvement or resolution of their symptoms; and 80% of patients who had a previously failed site-directed epidural blood or fibrin glue patch improved with a large volume catheter-directed blood patch. CONCLUSIONS Our experience supports the use of a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site for the treatment of spontaneous intracranial hypotension. Additionally, our results indicate a role for this procedure in refractory cases of spontaneous intracranial hypotension.


title: The impact of a three-phase video-assisted debriefing on nursing students' debriefing experiences, perceived stress and facilitators' practices: A mixed methods study.

text: BACKGROUND As an integral part of simulation, debriefing helps learners to construct knowledge through reflecting, internalizing, and relating. Video-assisted debriefing (VAD) adds audio-visual captures and reviews to support traditional verbal debriefing (VD), but evidence evaluating its educational effects has been mixed, with limited attention focusing on its structure development. AIMS This study aimed to 1) investigate the effects of a three-phase VAD in enhancing nursing students' debriefing experiences and perceived stress compared to VD and 2) to explore its impact on facilitators' debriefing practices. METHODS A mixed-methods design was adopted. The quantitative phase involved a prospective controlled trial on 145 nursing students from a university in Singapore who were randomized into the intervention cluster (n = 72) and the control cluster (n = 73). The debriefing experience scale (DES), the stress visual analogue scale (Stress VAS), and the debriefing assessment for simulation in healthcare (DASH© student version) were used as outcome measures. For the qualitative component, a purposive sample of eight facilitators evaluated their own debriefing practices using the DASH© instructor version and each completed an open-ended question survey. Qualitative data were analyzed using content analysis. RESULTS Students from the intervention cluster significantly improved their debriefing experiences (p = 0.01), experienced comparable stress, and had better impressions of VAD facilitators' practices (p < 0.001) compared to those in the control cluster. Repeated VAD significantly reduced students' stress (p < 0.001). Students viewed the VAD facilitators as more effective than the VD facilitators. Three categories were derived from the qualitative comments: the act of debriefing, the crux of VAD, and debriefing for success. CONCLUSION The three-phase VAD significantly improved nursing students' debriefing experiences without adding extra stress. It also helped to improve facilitators' practices. Future research will benefit from exploring how experts facilitate the three-phase VAD "on the ground" and its effect on learning transfer and cost-effectiveness.


title: Central and peripheral reservoirs of feline immunodeficiency virus in cats: a review.

text: Infection with feline immunodeficiency virus (FIV), a lentivirus similar to human immunodeficiency virus (HIV), results in lifelong viral persistence and progressive immunopathology in the cat. FIV has the ability to infect and produce infectious virus in a number of different cell types. FIV provirus can also be maintained in a replication-competent but transcriptionally quiescent state, facilitating viral persistence over time. Immediately after the initial infection, FIV infection quickly disseminates to many anatomical compartments within the host including lymphoid organs, gastrointestinal tract and brain. Collectively, the anatomic and cellular compartments that harbour FIV provirus constitute the viral reservoir and contain foci of both ongoing viral replication and transcriptionally restricted virus that may persist over time. The relative importance of the different phenotypes observed for infected cells, anatomic compartment, replication status and size of the reservoir represent crucial areas of investigation for developing effective viral suppression and eradication therapies. In this review, we discuss what is currently known about FIV reservoirs, and emphasize the utility of the FIV-infected cat as a model for the HIV-infected human.


title: Transumbilical single-incision laparoscopic hepatectomy using precoagulation and clipless technique in a patient with combined hepatocellular-cholangiocarcinoma: a case report.

text: We report our first case of single-incision laparoscopic hepatectomy in a 43-year-old woman with a 30-mm solitary combined hepatocellular-cholangiocarcinoma. A port of single-incision laparoscopic surgery was inserted through the abdominal wall using a 2.5-cm single incision in the umbilical area. To obtain adequate operative view for the tumor in segment 6, a 5-mm flexible endoscope, roticulated instruments, and a miniloop retractor were used. After precoagulation with a 5-mm flexible microwave probe, liver resection was performed using laparoscopic ultrasonic shears, soft-coagulation devices, and a tissue-sealing knife. Subsequently, cholecystectomy was carried out for a gallbladder polyp. The procedure was successfully completed without conversion to conventional laparoscopic technique. The operation time was 180 minutes and operative blood loss was uncountable. Transumbilical single-incision laparoscopic hepatectomy using precoagulation and clipless techniques is feasible and seems to provide better cosmetic appearance in selected cases by qualified endoscopic liver surgeons.


title: Familial colorectal cancer risk by subsite of primary cancer: a population-based study in Utah.

text: BACKGROUND Familial occurrence is common in colorectal cancer (CRC), but whether this increased familial risk differs by colonic subsite of the index patients CRC is not well understood. AIM To quantify the risk of CRC in first-degree (FDR), second-degree (SDR) and first cousin (FC) relatives of individuals with CRC, stratified by subsite in the colorectum and age at diagnosis. METHODS Colorectal cancers diagnosed between 1980 and 2010 were identified from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database. Age and gender-matched CRC-free controls were selected to form the comparison group for determining CRC risk in relatives using Cox regression analysis. RESULTS Of the 18,208 index patients diagnosed with CRC, 6584 (36.2%) were located in the proximal colon, 5986 (32.9%) in the distal colon and 5638 (31%) in the rectum. The elevated risk of CRC in relatives was similar in analysis stratified for CRC colorectal subsites in the index cases. FDR had similarly elevated risk of all site CRC, whether the index patient had cancer in the proximal colon [hazards ratio (HR): 1.85; 95% CI: 1.70-2.02], distal colon (HR: 1.90; 95% CI: 1.73-2.08) or rectum (HR: 1.83; 95% CI: 1.66-2.02) compared to relatives of controls. This risk was consistently greater for FDR when cases developed CRC below the age of 60 years. CONCLUSIONS Relatives of CRC patients have a similarly elevated risk of CRC regardless of colonic tumour subsite in the index patient, and it is greatest for relatives of younger age index cases.


Successful Stent-Retriever Thrombectomy for Acute Cerebral Embolization After Transcatheter Aortic Valve Implantation.


Increased risk for severe COVID-19 in patients with inflammatory rheumatic diseases treated with rituximab.


title: Understanding the factors that influence the quality of paid disability support for adults with acquired neurological disability and complex needs: a scoping review protocol.

text: INTRODUCTION Adults with disability as the result of an acquired neurological disorder often have varying and complex support needs. Consequently, adults with complex needs often require paid support to enable them to exercise choice and control and participate fully and effectively in society. Given support is so critical for this population, this scoping review aims to further understand the factors that influence the quality of paid disability support for adults with acquired neurological disability and complex needs. METHODS AND ANALYSIS The methodology proposed by Arksey and O'Malley, with the modifications recommended by Levac and O'Brien and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: extension for Scoping Reviews will be used. Systematic and comprehensive electronic database searches will be conducted in MEDLINE, CINAHL, PsycINFO, Scopus and Embase. The review will follow a six-stage framework including (1) identifying the research question/s, (2) identifying the relevant studies, with (3) study selection and (4) charting of data by two independent coders, (5) collating, summarising and reporting data and (6) expert consultation which will be sought from people with lived experience, as well as clinical and academic experts. Work on this scoping review began in June 2019 and will be completed by June 2020. ETHICS AND DISSEMINATION Ethical approval will not be required to conduct the scoping review. However, the consultation with people with lived experience will be conducted via codesign workshops. The codesign workshops have received ethical approval from La Trobe University Ethics Committee (reference number: HEC19232). It is intended that review findings will be made available to relevant stakeholders through a peer-reviewed publication, conference presentations and workshops.


title: Predictors of outcome after mechanical thrombectomy for anterior circulation large vessel occlusion in patients aged ≥80 years.

text: BACKGROUND There is uncertainty about the role of endovascular recanalization procedures for the treatment of acute ischemic stroke in patients aged ≥80 years. Therefore, careful patient selection is mandatory. Our aim was to find valid predictors of clinical outcome after mechanical thrombectomy (mTE) based on the sparse information available in the emergency setting. METHODS We included consecutive patients aged ≥80 years treated by mTE for anterior circulation thromboembolic vessel occlusion in our department between January 2008 and January 2013. Successful recanalization was defined as a thrombolysis in cerebral infarction (TICI) score of 2b or 3. The rates of parenchymal hemorrhage types I (PHI) and II (PHII) according to the ECASS definition and the rate of focal and diffuse subarachnoid hemorrhage (SAH) were reported. A modified Ranking scale (mRS) score of 0-2 at 90 days was defined as a favorable outcome. We evaluated the influence of gender, smoking habits, atrial fibrillation, diabetes, hypertension, hyperlipidemia, coronary artery and peripheral artery disease, National Institutes of Health Stroke Scale (NIHSS) score, Totaled Health Risks in Vascular Events (THRIVE) score, Alberta Stroke Program Early CT Score (ASPECTS), and duration of symptoms on favorable outcome. Significant predictors were then included in a stepwise logistic regression analysis. Odds ratios (OR), 95% confidence intervals (CI), and receiver operating characteristics (ROC) curves were calculated. p < 0.05 was considered statistically significant. RESULTS In the defined period, we treated 109 patients aged ≥80 years with 116 occluded anterior circulation target vessels. Successful recanalization was achieved in 87.9% of the targets. The rates of PHI, PHII, and focal and diffuse SAH were 6.4, 5.5, 12.8, and 7.3%, with an overlap between PH and SAH. The combined rate of PHII and/or diffuse SAH was 9.2%. Despite good recanalization rates and reasonable rates of hemorrhage, only 19 patients (17.4%) were functionally independent at 90 days. An additional 12 patients (11.0%) suffered from moderate disability (mRS score 3), 26 (23.9%) were severely disabled (mRS score 4-5) and 52 (47.7%) were deceased. NIHSS, ASPECTS, and THRIVE scores significantly predicted a favorable outcome. Stepwise logistic regression identified NIHSS (OR 0.89; 95% CI 0.82-0.96; p = 0.009) and ASPECTS (OR 2.27; 95% CI 1.28-4.02; p = 0.005) as independent predictors. The ROC area was 0.81. CONCLUSION ASPECTS and NIHSS were independent predictors of a favorable outcome in patients aged ≥80 years after mTE for anterior circulation large vessel occlusion and may support decision making with regard to the treatment modality. Since the chances of gaining functional independence are limited, careful consideration of each individual case is mandatory. Further studies comparing endovascular and standard treatment in octogenarians are warranted.


title: Evidence Base for Multidisciplinary Care of Pediatric/Adolescent Bariatric Surgery Patients.

text: PURPOSE OF REVIEW Severe childhood obesity, defined as having a body mass index (BMI) greater than the 99th percentile for age and gender, is rising in most countries and is associated with early morbidity and mortality. Optimal management of the health of the child with obesity requires a multidisciplinary approach that identifies and treats associated derangements. RECENT FINDINGS Lifestyle interventions such as diet, exercise, and behavioral therapy for the severely obese pediatric patient are generally not effective. Few centers worldwide offer bariatric surgery for adolescents in a multidisciplinary setting, and we are the only center that offers a multidisciplinary approach that incorporates bariatric surgery for severely obese children and adolescents across all age groups. In this paper, we review up-to-date evidence in this subject including ours, and provide details on the multidisciplinary approach to pediatric obesity that accommodates bariatric surgery for children across all age groups.


A sustainable future in health: ensuring as health professionals our own house is in order and leading by example.


title: Treatment of cavernous sinus aneurysms with flow diversion: results in 44 patients.

text: BACKGROUND AND PURPOSE Aneurysms of the cavernous segment of the ICA are difficult to treat with standard endovascular techniques, and ICA sacrifice achieves a high rate of occlusion but carries an elevated level of surgical complications and risk of de novo aneurysm formation. We report rates of occlusion and treatment-related data in 44 patients with cavernous sinus aneurysms treated with flow diversion. MATERIALS AND METHODS Patients with cavernous segment aneurysms treated with flow diversion were selected from a prospectively maintained data base of patients from 2009 to the present. Demographic information, treatment indications, number/type of flow diverters placed, outcome, complications (technical or clinical), and clinical/imaging follow-up data were analyzed. RESULTS We identified 44 patients (37 females, 7 males) who had a flow diverter placed for treatment of a cavernous ICA aneurysm (mean age, 57.2; mean aneurysm size, 20.9 mm). The mean number of devices placed per patient was 2.2. At final angiographic follow-up (mean, 10.9 months), 71% had complete occlusion, and of those with incomplete occlusion, 40% had minimal remnants (<3 mm). In symptomatic patients, complete resolution or significant improvement in symptoms was noted in 90% at follow-up. Technical complications (which included, among others, vessel perforation in 4 patients, groin hematoma in 2, and asymptomatic carotid occlusion in 1) occurred in approximately 36% of patients but did not result in any clinical sequelae immediately or at follow-up. CONCLUSIONS Our series of flow-diversion treatments achieved markedly greater rates of complete occlusion than coiling, with a safety profile that compares favorably with that of carotid sacrifice.


title: Outcomes of a preoperative "bridging" strategy with glycoprotein IIb/IIIa inhibitors to prevent perioperative stent thrombosis in patients with drug-eluting stents who undergo surgery necessitating interruption of thienopyridine administration.

text: AIMS Surgery after drug-eluting stent (DES) implantation may be associated with increased risk for perioperative stent thrombosis (ST). METHODS AND RESULTS We evaluated the outcomes of 67 patients who underwent non-cardiac (n=51) or cardiac (n=16) surgery after DES implantation at our institution between 2008 and 2010 and who underwent preoperative "bridging" with a glycoprotein IIb/IIIa inhibitor. Surgery occurred after a mean time of 13.9 ± 1.7 and 8.7 ± 2 months post stenting for non-cardiac (NCS) and cardiac surgery, respectively. Glycoprotein IIb/IIIa inhibitors were administered preoperatively for a mean of 7.1 ± 0.4 and 7.8 ± 0.7 days, respectively, then discontinued four to six hours before surgery. Most patients received aspirin through the perioperative period (33 NCS patients and 15 cardiac surgery patients). Clopidogrel was restarted as early as possible in the postoperative period. In the non-cardiac surgery group, two patients (3.9%, 95% confidence intervals 0.5% to 13.5%) suffered acute ST in the immediate postoperative period and four patients suffered major bleeding by the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) criteria. One cardiac surgery patient had probable ST one hour postoperatively. CONCLUSIONS In spite of preoperative "bridging" with a glycoprotein IIb/IIIa inhibitor, postoperative stent thrombosis can still occur in patients with prior DES undergoing surgery requiring antiplatelet medication interruption.


Impacts of social distancing on cancer care during COVID-19 pandemic: Hong Kong experience.


title: BreathSens: A Continuous On-Bed Respiratory Monitoring System With Torso Localization Using an Unobtrusive Pressure Sensing Array.

text: The ability to continuously monitor respiration rates of patients in homecare or in clinics is an important goal. Past research showed that monitoring patient breathing can lower the associated mortality rates for long-term bedridden patients. Nowadays, in-bed sensors consisting of pressure sensitive arrays are unobtrusive and are suitable for deployment in a wide range of settings. Such systems aim to extract respiratory signals from time-series pressure sequences. However, variance of movements, such as unpredictable extremities activities, affect the quality of the extracted respiratory signals. BreathSens, a high-density pressure sensing system made of e-Textile, profiles the underbody pressure distribution and localizes torso area based on the high-resolution pressure images. With a robust bodyparts localization algorithm, respiratory signals extracted from the localized torso area are insensitive to arbitrary extremities movements. In a study of 12 subjects, BreathSens demonstrated its respiratory monitoring capability with variations of sleep postures, locations, and commonly tilted clinical bed conditions.


title: A review of reports on single-incision laparoscopic surgery for Crohn's disease.

text: The aim of this review was to analyze the currently available literature on single-incision laparoscopic surgery (SILS) for Crohn's disease (CD) with respect to surgical indications, surgical techniques, feasibility, and possible benefits of SILS for CD. A systematic query of articles published from January 2010 to July 2018 was performed. The studies were assessed for patient's age, gender, body mass index, disease type, SILS procedure, surgical procedure, incision length, operation time, rates of conversion to open surgery, postoperative complications, mortality, length of hospital stay, and rates of reoperation. After an initial review, 11 reports were selected. The surgical techniques and instruments showed wide variation. The mean operation time for SILS tended to be shorter than that for multiport laparoscopic surgery (MLS). The reported rates of conversion to open surgery and postoperative complications were not very different from those reported for MLS. In conclusion, the present review suggests that the SILS technique may be feasible and safe for select patients with CD. However, because we reviewed only a few studies with small sample sizes, prospectively designed trials with a large number of patients are required to clarify the true benefits of SILS for CD.


title: 'Stroke Room': Diagnosis and Treatment at a Single Location for Rapid Intraarterial Stroke Treatment.

text: BACKGROUND For patients with acute ischemic stroke, intra-arterial treatment (IAT) is considered to be an effective strategy for removing the obstructing clot. Because outcome crucially depends on time to treatment ('time-is-brain' concept), we assessed the effects of an intervention based on performing all the time-sensitive diagnostic and therapeutic procedures at a single location on the delay before intra-arterial stroke treatment. METHODS Consecutive acute stroke patients with large vessel occlusion who obtained IAT were evaluated before and after implementation (April 26, 2010) of an intervention focused on performing all the diagnostic and therapeutic measures at a single site ('stroke room'). RESULT After implementation of the intervention, the median intervals between admission and first angiography series were significantly shorter for 174 intervention patients (102 min, interquartile range (IQR) 85-120 min) than for 81 control patients (117 min, IQR 89-150 min; p < 0.05), as were the intervals between admission and clot removal or end of angiography (152 min, IQR 123-185 min vs. 190 min, IQR 163-227 min; p < 0.001). However, no significant differences in clinical outcome were observed. CONCLUSION This study shows for the, to our knowledge, first time that for patients with acute ischemic stroke, stroke diagnosis and treatment at a single location ('stroke room') saves crucial time until IAT.


Hydrogen Breath Testing With Measurement of Orocecal Transit for Diagnosis of Small Bowel Bacterial Overgrowth.


Single-port thoracoscopic surgery using the SILS port.


title: COVID-19 epidemic in the Seine-Saint-Denis Department of Greater Paris: one month and three waves for a tsunami.

text: INTRODUCTION Worldwide, the COVID-19 epidemic has put health systems to the test. The excess mortality is partly due to the influx of patients requiring hospitalization and intensive care. We propose that the chronology of epidemic spread gives a window of time in which hospitals can act to prevent reaching capacity. METHODS The out-of-hospital SAMU Emergency Medical System in an entry point into the French health care system. We recorded the number of patients managed, of patients transferred to emergency departments (ED), and of mobile intensive care units (MICUs) dispatched. Each criterion was compared to the mean of the same criterion over the previous 5 years. The alert threshold which indicated a public health crisis was defined as a 20% increase compared to the 5-year mean. RESULTS The reference period, from January 2015 to December 2019, included 3 381 611 calls, and 1 137 856 patients. The study period, from 17 February to 28 March 2020, included 166 888 calls, and 56 708 patients. The daily numbers of patients managed crossed the threshold on February 25, and increased until the end of the study period. The daily number of patients transferred to ED crossed the threshold on March 16, and increased until the end of the period. The daily number of MICUs dispatched crossed the threshold on March 15, and increased until the end of the period. CONCLUSION The COVID-19 epidemic reached our department in three consecutive waves which overwhelmed the health care system. The first wave preceded by 30 days the massive arrival of critical patients. Health care systems must take advantage of this delay to prepare for the third wave.


title: A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery.

text: OBJECTIVES The aim of this study was a comparison of risk-adjusted outcomes of 3 approaches to carotid revascularization in the open heart surgery (OHS) population. BACKGROUND Without randomized clinical trials, the best approach to managing coexisting severe carotid and coronary disease remains uncertain. Staged carotid endarterectomy (CEA) followed by OHS or combined CEA and OHS are commonly used. A recent alternative is carotid artery stenting (CAS). METHODS From 1997 to 2009, 350 patients underwent carotid revascularization within 90 days before OHS at a tertiary center: 45 staged CEA-OHS, 195 combined CEA-OHS, and 110 staged CAS-OHS. The primary composite endpoint was all-cause death, stroke, and myocardial infarction (MI). Staged CAS-OHS patients had higher prevalence of previous stroke (p = 0.03) and underwent more complex OHS. Therefore, the propensity score adjusted multiphase hazard function models with modulated renewal to account for staging, and competing risks were used. RESULTS Using propensity analysis, staged CAS-OHS and combined CEA-OHS had similar early hazard phase composite outcomes, whereas staged CEA-OHS incurred the highest risk driven by interstage MI. Subsequently, staged CAS-OHS patients experienced significantly fewer late hazard phase events compared with both staged CEA-OHS (adjusted hazard ratio: 0.33; 95% confidence interval: 0.15 to 0.77; p = 0.01) and combined CEA-OHS (adjusted hazard ratio: 0.35; 95% confidence interval: 0.18 to 0.70; p = 0.003). CONCLUSIONS Staged CAS-OHS and combined CEA-OHS are associated with a similar risk of death, stroke, or MI in the short term, with both being better than staged CEA-OHS. However, the outcomes significantly favor staged CAS-OHS after the first year.


title: (99m)Tc-DTPA volume of distribution, half-life and glomerular filtration rate in normal adults.

text: BACKGROUND AND AIM Assessment of volume of distribution (VD) and half-life (T1/2) values during glomerular filtration rate (GFR) investigations is a useful quality control check. The aim of this study was to derive reference data for VD and T1/2 and also to provide reference data for GFR from studies performed using Tc-diethylenetriaminepentaacetic acid (Tc-DTPA). METHODS This was a retrospective study of 126 healthy potential kidney donors (age range 18-59 years). The GFR was evaluated from Tc-DTPA plasma clearance using the 2004 British Nuclear Medicine Society guidelines. The association between VD and body surface area (BSA) was assessed. T1/2 was correlated with age and GFR. The correlation between the Brochner-Mortensen-corrected GFR (BM-GFRCorr) and age was evaluated. RESULTS The uncorrected VD value (l) was 10.1×BSA±40.6% (P<0.01). The corrected VD value (l) was 8.19×BSA±34.4% (P<0.01). In individuals under the age of 40 years, the mean T1/2 was 95.0 min±36.2%. In individuals aged 40 years and above, the T1/2 increased at a rate of 0.49 min/year (P=0.04); the T1/2 (min) was 9480×(1/BM-GFRCorr)±35.1% (P<0.01). In individuals younger than 40 years of age, the correlation between BM-GFRCorr and age was not statistically significant (P=0.45), and the mean GFR was 108 ml/min/1.73 m±27.5%. In individuals aged 40 years and above, the BM-GFRCorr was 170-(1.55×age) ml/min/1.73 m±36.7% (P<0.001). CONCLUSION Well-defined reference data for VD and T1/2 can be used for quality control checks in GFR investigations. In addition to these, reference data for GFR using Tc-DTPA have been defined. This will enhance the interpretation of adult Tc-DTPA GFR measurements.


title: Intraoperative endoscopist-controlled guide wire cannulation technique sphincterotomy during laparoscopic cholecystectomy.

text: BACKGROUND Intraoperative endoscopic sphincterotomy (IOES) is considered superior to preoperative endoscopic sphincterotomy and other treatment modalities for management of common bile duct (CBD) stones. Here we describe the method and results of our technique of IOES in the supine position during laparoscopic cholecystectomy (LC) using a guide wire cannulation (intraoperative supine endoscopic sphincterotomy by endoscopist-controlled guide wire cannulation) [ISEEG] technique). PATIENTS AND METHODS This is a retrospective analysis of the outcome for 36 patients undergoing LC with IOES (ISEEG technique) for acute biliary colic and jaundice with suspicion of choledocholithiasis. RESULTS On confirmation of CBD stones by intraoperative cholangiogram, CBD catheterization was successful in 34/36 (94.44%) patients with successful stone clearance in all of them by the ISEEG technique demonstrating 100% efficacy for stone clearance; the remaining 2 patients needed conversion to open surgery. The median time for the ISEEG technique during intraoperative sphincterotomy was 9 minutes (range, 7-23 minutes). Average hospital stay was 4.8 days (range, 2-15 days). At the 1-month follow-up, all patients were biliary symptom-free. Three of 36 patients (8.33%) had mild postoperative pancreatitis. There was no procedure-related mortality. CONCLUSIONS LC coupled with the ISEEG technique performed by an expert endoscopist is an effective single-stage minimally invasive treatment for CBD stones with good efficacy, good stone clearance rates, and low morbidity.


title: Comparison of two murine models of thrombosis induced by atherosclerotic plaque injury.

text: Arterial thrombosis occurs at sites of erosion or rupture of atherosclerotic vascular lesions. To better study the pathophysiology of this complex phenomenon, there is a need for animal models of localised thrombosis at sites of atherosclerotic lesions with closer resemblance to the human pathology as compared to commonly used thrombosis models in healthy vessels. In the present study, we describe and compare a new model of thrombosis induced by atherosclerotic plaque rupture in the carotid artery from ApoE-/- mice using a suture needle to a milder model of ultrasound-induced plaque injury. Needle injury induces atherosclerotic plaque rupture with exposure of plaque material and formation of a thrombus that is larger, nearly occlusive and more stable as compared to that formed by application of ultrasounds. These two models have common features such as the concomitant involvement of platelet activation, thrombin generation and fibrin formation, which translates into sensitivity toward both antiplatelet drugs and anticoagulants. On the other hand, they display differences with respect to the role of the platelet collagen receptor GPVI, the plaque rupture model being less sensitive to its inhibition as compared to the ultrasound-induced injury, which may be related to the amount of thrombin generated. These models represent an improvement as compared to models in healthy vessels and may help identify specific plaque triggers of thrombosis. They should therefore be useful to evaluate new antithrombotic targets.


title: Risk of importing zoonotic diseases through wildlife trade, United States.

text: The United States is the world's largest wildlife importer, and imported wild animals represent a potential source of zoonotic pathogens. Using data on mammals imported during 2000-2005, we assessed their potential to host 27 selected risk zoonoses and created a risk assessment that could inform policy making for wildlife importation and zoonotic disease surveillance. A total of 246,772 mammals in 190 genera (68 families) were imported. The most widespread agents of risk zoonoses were rabies virus (in 78 genera of mammals), Bacillus anthracis (57), Mycobacterium tuberculosis complex (48), Echinococcus spp. (41), and Leptospira spp. (35). Genera capable of harboring the greatest number of risk zoonoses were Canis and Felis (14 each), Rattus (13), Equus (11), and Macaca and Lepus (10 each). These findings demonstrate the myriad opportunities for zoonotic pathogens to be imported and suggest that, to ensure public safety, immediate proactive changes are needed at multiple levels.


The Use of a Mechanical Stapler in Jejunal Free Flaps in Laryngopharyngectomy Defects.


title: Evolving ablative therapies for hepatic malignancy.

text: The liver is a common site for both primary and secondary malignancy. Hepatic resection and transplantation are the two treatment modalities that have been shown to achieve complete cure, but only 10 to 20% of patients are candidates for these treatments. For the remaining patients, tumor ablation has emerged as the most promising alternative modality. In addition to providing local control and improving survival outcomes, tumor ablation also helps to down stage patients for potential curative treatments, both alone as well as in combination with other treatments. While tumor ablation can be achieved in multiple ways, the introduction of newer ablative techniques has shifted the focus from palliation to potentially curative treatment. Because the long-term safety and survival benefits are not substantive at present, it is important that we strive to evaluate the results from these studies using appropriate comparative outcome methodologies.


title: Testing for Common Respiratory Viruses in Children Admitted to Pediatric Intensive Care: Epidemiology and Outcomes.

text: OBJECTIVES Viral infections are common in children, but there is a lack of data on severe viral infections in critically ill children. We investigated testing for viral infections in children requiring PICU admission and describe the epidemiology and outcomes. DESIGN Multicenter retrospective study. Results of viral testing for nine respiratory viruses using polymerase chain reaction were collected. PARTICIPANTS Children less than 16 years old nonelectively admitted to PICU over a 6-year period. SETTING Two tertiary PICUs in Queensland, Australia. INTERVENTIONS None. MAIN OUTCOME MEASURES Primary outcome was PICU length of stay. Secondary outcomes included need for and duration of intubation and mortality in PICU. Univariate and multivariate regression analyses were performed, adjusting for age, indigenous status, comorbidities, and severity of illness. RESULTS Of 6,426 nonelective admissions, 2,956 (46%) were polymerase chain reaction tested for a virus of which 1,353 (46%) were virus positive. Respiratory syncytial virus was the most common pathogen identified (n = 518, 33%), followed by rhinovirus/enterovirus and adenovirus. Across all patients who underwent polymerase chain reaction testing, identification of a respiratory virus was not significantly associated with longer overall length of stay (multivariate odds ratio, 1.08; 95% CI, 0.99-1.17; p = 0.068) or longer intubation (p = 0.181), whereas the adjusted odds for intubation and mortality were significantly lower (p < 0.01). Subgroup analyses restricted to patients with acute respiratory infections (n = 1,241), bronchiolitis (n = 761), pneumonia (n = 311), confirmed bacterial infection (n = 345), and malignancy (n = 95) showed that patients positive for a virus on testing had significantly longer PICU length of stay (multivariate p < 0.05). In children with pneumonia, identification of a respiratory virus was associated with significantly increased duration of ventilation (p = 0.003). No association between positive test results for multiple viruses and outcomes was observed. CONCLUSION Viral infections are common in critically ill children. Viral infections were associated with lower intubation and mortality rates compared with all children testing negative for viral infections. In several subgroups studied, identification of viral pathogens was associated with longer PICU length of stay while mortality was comparable. Prospective studies are required to determine the benefit of routine testing for respiratory viruses at the time of PICU admission.


title: Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video).

text: BACKGROUND AND AIMS Laparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, determining an appropriate resection line using only the laparoscopic approach is difficult. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique by combining laparoscopic gastric resection with endoscopic submucosal dissection, and we have used this procedure to resect gastric SMTs. In this study, the procedure is presented and its safety and feasibility for resecting gastric SMTs are evaluated. METHODS This retrospective study included 100 patients who underwent LECS for SMTs at the Department of Gastroenterological Surgery, Cancer Institute, between June 2006 and November 2014. The demographics, tumor histopathologic characteristics, and operative and follow-up data were reviewed. RESULTS Complete resection with negative surgical margins was achieved in all patients, and LECS was performed regardless of tumor location. The mean operation time was 174.3 minutes, with an estimated blood loss of 16.3 mL. In addition, the mean time until the initiation of oral intake was 1.4 days, and the mean postoperative hospital stay was 8.4 days. Moreover, no local or distant tumor recurrence was observed. The only severe adverse event was leakage, which was observed in 1 patient. CONCLUSIONS LECS was performed with a reasonable operation time, low blood loss, and minimal adverse events. Therefore LECS is safe and feasible for resecting gastric SMTs.


title: Neurovascular Complications in COVID-19 Infection: Case Series.

text: We present a series of 10 hospitalized patients with confirmed coronavirus 2019 infections who developed severe neurovascular complications and discuss the possible reasons for these findings and their relationship to the novel Severe Acute Respiratory Syndrome coronavirus 2 infection.


title: Groin defects seen at extra-peritoneal laparoscopic dissection during surgical treatment of athletic pubalgia.

text: BACKGROUND Recently new disease process, often referred to as athletic pubalgia (AP), has been acknowledged by the medical community. The patients suffering from this ailment present with unilateral or bilateral chronic groin pain associated with physical activity without a clear diagnosis of a groin hernia. Though physical therapy and medical treatments are considered first line remedies, some believe that surgical treatment may have better, quicker, and more durable outcomes and procedures aimed at groin reinforcement seem to relieve most of symptoms in the majority of the patients. Despite many surgeons consistently noting rectus insertion or adductor thinning, multiple hernia defects are often seen during dissections and the clinical significance of these findings is still not known. MATERIALS AND METHODS Between 2007 and 2011, 40 patients underwent an extra-peritoneal laparoscopic reinforcement of rectus abdominals and insertion of adductor muscles for AP. All patients underwent wide and bilateral groin dissection and the findings were cataloged. RESULTS All of the patients presented with groin defects upon wide dissection. Thirty-four patients (85%) presented with small bilateral indirect inguinal defects and 28 (70%) of these patients did not have any additional defects. Five patients (12.5%) were found to have only unilateral inguinal hernia defects. One patient presented with a small direct defect. In addition to these defects, five patients (12.5%) had additional unilateral femoral hernias, whereas no patient had solitary femoral hernia defects. CONCLUSION AP is a new diagnostic entity with poorly understood etiology. It mostly affects young active adults, often involved in competitive sports and surgical methods may be most effective at achieving the cure. In our experience all of the patients presented with groin defects, though not all were the same. It is our belief that these defects, although likely not the only component, play a significant role in the pathophysiology of AP.


title: Components necessary for high-quality lung cancer screening: American College of Chest Physicians and American Thoracic Society Policy Statement.

text: Lung cancer screening with a low-dose chest CT scan can result in more benefit than harm when performed in settings committed to developing and maintaining high-quality programs. This project aimed to identify the components of screening that should be a part of all lung cancer screening programs. To do so, committees with expertise in lung cancer screening were assembled by the Thoracic Oncology Network of the American College of Chest Physicians (CHEST) and the Thoracic Oncology Assembly of the American Thoracic Society (ATS). Lung cancer program components were derived from evidence-based reviews of lung cancer screening and supplemented by expert opinion. This statement was developed and modified based on iterative feedback of the committees. Nine essential components of a lung cancer screening program were identified. Within these components 21 Policy Statements were developed and translated into criteria that could be used to assess the qualification of a program as a screening facility. Two additional Policy Statements related to the need for multisociety governance of lung cancer screening were developed. High-quality lung cancer screening programs can be developed within the presented framework of nine essential program components outlined by our committees. The statement was developed, reviewed, and formally approved by the leadership of CHEST and the ATS. It was subsequently endorsed by the American Association of Throacic Surgery, American Cancer Society, and the American Society of Preventive Oncology.


title: Social vulnerability index for the older people-Hong Kong and New York City as examples.

text: Many world cities have suffered large-scale disasters, causing a significant loss of lives, property damage, and adverse social and economic impact. Those who are most vulnerable during and in the immediate aftermath of disaster crises are the elderly. Therefore, it is imperative to identify them and determine their specific needs in order to support them. Although several Social Vulnerability Indexes (SVIs) have been developed to assess different types of disaster vulnerability across geographic and population levels, few have been tailored to the older population. Building on the research of Gusmano et al., this study modifies and uses an SVI specifically designed to assess the vulnerability of older populations to emergencies and disasters across seven domains, namely, population size, institutionalization, poverty, living alone, disability, communication obstacles, and access to primary care. Moreover, it is acknowledged that availability of data largely depends on the local context and is always a barrier to production of indices across countries. The present study offers suggestions on how modifications can be made for local adaptation such that the SVI can be applied in different cities and localities. The SVI used in this study provides information to stakeholders in emergency preparedness, not only about natural disasters but also about health hazards and emergencies, which few existing SVI address.


title: A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery.

text: OBJECTIVE To perform a systematic review of economic evaluations of enhanced recovery pathways (ERP) for colorectal surgery. BACKGROUND Although there is extensive literature investigating the clinical effectiveness of ERP, little is known regarding its cost-effectiveness. METHODS A systematic literature search identified all relevant articles published between 1997 and 2012 that performed an economic evaluation of ERP for colorectal surgery. Studies were included only if their ERP included all 5 of the key components (patient information, preservation of GI function, minimization of organ dysfunction, active pain control, and promotion of patient autonomy). Quality assessment was performed using the Consensus on Health Economic Criteria instrument (scored 0-19; high quality ≥ 12). Incremental cost-effectiveness ratios were calculated if sufficient data were provided, using difference in length of stay and overall complication rates as effectiveness measures. RESULTS Of a total of 263 unique records identified (253 from databases and 10 from other sources), 10 studies met our inclusion criteria and were included for full qualitative synthesis. Overall quality was poor (mean quality 7.8). Eight reported lower costs for ERP. The majority (8 of 10) of studies were performed from an institutional perspective and therefore did not include costs related to changes in productivity and other indirect costs (eg, caregiver burden). Five studies provided enough information to calculate ICERs, of which ERP was dominant (less costly and more effective) in all cases for reduction in length of stay and was dominant or potentially cost-effective in 4 and questionable (no difference in costs nor effectiveness) in 1 for reduction in overall complications. CONCLUSIONS The quality of the current evidence is limited but tends to support the cost-effectiveness of ERP. There is need for well-designed trials to determine the cost-effectiveness of ERP from both the institutional and societal perspectives.


title: Management of cats on Lente insulin: tips and traps.

text: The majority of feline diabetic patients require insulin to stabilize their diabetes and lente insulins have been widely available for many years. Management of many cases using Lente insulins is straightforward and can produce an excellent quality and length of life.


Comment on: "Early advice on managing children with cancer during the COVID-19 pandemic and a call for sharing experiences".


Two lineages of dengue virus type 2, Brazil.


title: Laparoscopic excision of a choledochal cyst in 82 consecutive patients.

text: INTRODUCTION Despite it being a benign disease, a choledochal cyst must be removed with the gallbladder (GB) due to the risk of cancer in the biliary tract. Most patients are young females or children, all of whom express strong interest in the cosmetic results in addition to the complete resolution of their medical problems. Here, we introduce a laparoscopic management technique for a choledochal cyst. METHODS Between 2003 and 2011, we performed a laparoscopic choledochal cyst excision procedure on 82 patients using a four-hole method. There were three open-conversion cases, one case involving robotic surgery, and one case involving combined laparoscopic liver resection because the cyst had affected the liver. Excision of the cyst and anastomosis were performed laparoscopically. We will present our method with a video. RESULTS The mean operation time was 230 min. The estimated blood loss was 197 ml. The average hospital stay was 8.6 days. The most common complications were minor bile leakage (7 %) and fluid collection (2.5 %), both of which were managed conservatively. CONCLUSIONS Laparoscopic management can be a treatment of choice for the most instances of choledochal cyst considering its good cosmetic results and its feasible level of operative safety.


title: Endolumenal colon occlusion device for transanal and transrectal surgery--a porcine feasibility study.

text: PURPOSE Although several studies have demonstrated the feasibility of transrectal natural orifice translumenal endoscopic surgery (NOTES), its clinical application has been hindered by concerns regarding potential infectious complications. The aim of this study was to evaluate the feasibility of a newly developed device for endolumenal colon occlusion (ColoShield) in an acute porcine model. METHODS The principle of the ColoShield device is based on two balloons, with negative pressure in between. The ColoShield device and a gauze tamponade as a control group were evaluated in a non-survival study on 16 pigs. The efficacy of the occlusion system in establishing a leak-proof pneumorectum and in sealing the colon from proximal (watertight sealing) was tested by a standardized study course. Finally, the colon/rectum was explanted for macroscopic and microscopic examination. RESULTS A 20-mmHg leak-proof pneumorectum over a period of 10 min could be achieved in seven of eight (87 %) animals with the ColoShield device and in none of eight (0 %) animals with gauze tamponade (p < 0.001). In the watertight sealing test, mean intracolonic pressures of 23.5 ± 18.1 (0-53) mmHg using the ColoShield device and 0 ± 1.1 (0-3) mmHg using gauze tamponade (p = 0.003) were documented proximal to the occlusion system before a leakage occurred. Macroscopic and histopathological examinations revealed no significant impairment of the colon specimen in either group. CONCLUSIONS ColoShield proved to be a safe and effective device for a reversible endolumenal colon occlusion. Further studies should evaluate its impact on procedural sterility during transrectal NOTES.


title: Coaxial robot-assisted laparoendoscopic single-site myomectomy.

text: We report our experience with coaxial robot-assisted laparoendoscopic single-site (RA-LESS) myomectomy, including a detailed description of the technique and outcomes from our first 21 cases. This was a retrospective cohort study carried out at the reproductive endocrinology and gynecologic oncology divisions at two academic medical centers. RA-LESS myomectomy was performed with the da Vinci Si Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA, USA) employing standard rigid 8 or 5 mm instrumentation in a coaxial arrangement through a standard laparoendoscopic single-site (LESS) port (GelPOINT Advanced Access Platform, Applied Medical, Rancho Santa Margarita, CA, USA). Cases were completed between October 2011 and November 2013. Twenty-one patients underwent surgery. Mean age (±SD) was 38.1 ± 5.8 years, and mean BMI was 29.4 ± 4.7 kg/m2. Menorrhagia, pelvic pressure, and urinary frequency were the main presenting symptoms. Mean diameter of the largest tumor was 5.7 ± 1.9 cm (median 5.9 cm, range 2.1-9.5 cm), while mean number of tumors removed was 2.2 ± 1.8, ranging from 1 to 8 per surgery. Mean operative time was 154.2 ± 55.2 min (median 152 min, range 85-290 min). Mean blood loss was 57.9 ± 53.7 cc (median 50 cc, range 5-200 cc) and length of hospital stay ranged between 0 and 3 days (median 0). All procedures were successfully performed without conversion to conventional LESS surgery, multi-port laparoscopy or laparotomy. RA-LESS myomectomy with coaxial use of standard rigid instrumentation is a safe and reproducible addition to the minimally invasive surgeons' armamentarium, with excellent cosmetic and postoperative outcomes in selected patients. Further investigation is needed to define the patient groups that will most benefit from it.


title: End-of-life care in COVID-19: An audit of pharmacological management in hospital inpatients.

text: BACKGROUND Hospital clinicians have had to rapidly develop expertise in managing the clinical manifestations of COVID-19 including symptoms common at the end of life, such as breathlessness and agitation. There is limited evidence exploring whether end-of-life symptom control in this group requires new or adapted guidance. AIM To review whether prescribing for symptom control in patients dying with COVID-19 adhered to existing local guidance or whether there was deviation which may represent a need for revised guidance or specialist support in particular patient groups. DESIGN/SETTING A retrospective review of the electronic patient record of 61 hospital inpatients referred to the specialist palliative care team with swab-confirmed COVID-19 who subsequently died over a 1-month period. Intubated patients were excluded. RESULTS In all, 83% (40/48) of patients were prescribed opioids at a starting dose consistent with existing local guidelines. In seven of eight patients where higher doses were prescribed, this was on specialist palliative care team advice. Mean total opioid dose required in the last 24 h of life was 14 mg morphine subcutaneous equivalent, and mean total midazolam dose was 9.5 mg. For three patients in whom non-invasive ventilation was in place higher doses were used. CONCLUSION Prescription of end-of-life symptom control drugs for COVID-19 fell within the existing guidance when supported by specialist palliative care advice. While some patients may require increased doses, routine prescription of higher starting opioid and benzodiazepine doses beyond existing local guidance was not observed.


title: Impact of the COVID-19 Global Pandemic on the Otolaryngology Fellowship Application Process.

text: On March 11, 2020, the World Health Organization declared coronavirus disease 2019 a global pandemic. In addition to massive social disruption, this pandemic affected the traditional fellowship interview season for otolaryngology subspecialties, including head and neck surgical oncology, facial plastic and reconstructive surgery, laryngology, rhinology, neurotology, and pediatric otolaryngology. The impact on the fellowship interview process, from the standpoint of the institution and the applicant, necessitated the use of alternative interview processes. This change may alter the future of how interviews and the match proceed for years to come, with nontraditional methods of interviewing becoming a mainstay. While the impact this pandemic has on the fellowship match process is not yet fully realized, this commentary aims to discuss the challenges faced on both sides of the equation and to offer solutions during these unprecedented times.


title: Preliminary study of diagnostic utility of molecular beacons in bladder cancer.

text: OBJECTIVES To investigate the feasibility of molecular beacons (MBs) for screening urine samples from patients with suspected bladder cancer. Our previous study showed that MBs could detect bladder cancer cells and cells shed in the urine from patients with bladder cancer. METHODS Samples from 35 patients with bladder cancer and 35 healthy adults were initially evaluated. Cyanine 3-labeled MBs linked to a survivin mRNA probe were used to detect exfoliative cells in urine. Exfoliative cytology, enzyme-linked immunosorbent assay, and Western blotting of the tissues were used to confirm the MB results. We then evaluated the urine samples from 187 patients with suspected bladder cancer. All 187 patients also underwent cystoscopy. RESULTS In the initial cohort evaluated, MBs detected cancerous cells in 28 (80%) of the 35 patients with confirmed bladder cancer. Survivin protein was detected by Western blotting in 25 (71.4%) of the 35 patients. The sensitivity and specificity of enzyme-linked immunosorbent assay was 54.3% (20 of 35) and 68.6% (24 of 35), respectively. In a large group of patients with suspected bladder cancer, the sensitivity of MBs was 77.3% (85 of 110) and the specificity was 76.6% (59 of 77) compared with the cystoscopy data. Differences in the protein levels between the tumor grades and stages were not significant. CONCLUSIONS Our results have demonstrated that it is feasible to detect survivin mRNA in the exfoliated cells in urine using MBs. With further development, MBs could be used in a noninvasive clinical diagnostic procedure for the early detection of bladder cancer and postoperative follow-up.