title: Recognition and management of respiratory coinfection and secondary bacterial pneumonia in patients with COVID-19.

text: The pathophysiology of COVID-19 is not fully known. Respiratory infection caused by more than one viral pathogen (viral co-infection) or both viral and bacterial pathogens (combined viral and bacterial pneumonia) have been described. Secondary bacterial pneumonia can follow the initial phase of viral respiratory infection or occur during the recovery phase. No obvious pattern or guidelines exist for viral coinfection, combined viral and bacterial pneumonia, or secondary bacterial pneumonia in the context of SARS-CoV-2. Based on existing clinical data and experience with similar viruses such as influenza and SARS-CoV, the management approach in the context of COVID-19 should, ideally, take into consideration the overall presentation as well as the trajectory of illness.


title: Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a systematic review with meta-analysis.

text: AIM To investigate pain, activities of daily living (ADL) function, sport function, quality of life and satisfaction at different time points after hip arthroscopy in patients with femoroacetabular impingement (FAI). DESIGN Systematic review with meta-analysis. Weighted mean differences between preoperative and postoperative outcomes were calculated and used for meta-analysis. DATA SOURCES EMBASE, MEDLINE, SportsDiscus, CINAHL, Cochrane Library, and PEDro. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies that evaluated hip pain, ADL function, sport function and quality of life before and after hip arthroscopy and postoperative satisfaction in patients with symptomatic FAI. RESULTS Twenty-six studies (22 case series, 3 cohort studies, 1 randomised controlled trial (RCT)) were included in the systematic review and 19 in the meta-analysis. Clinically relevant pain and ADL function improvements were first reported between 3 and 6 months, and sport function improvements between 6 months and 1 year after surgery. It is not clear when quality of life improvements were first achieved. On average, residual mild pain and ADL and sport function scores lower than their healthy counterparts were reported by patients following surgery. Postoperative patient satisfaction ranged from 68% to 100%. CONCLUSIONS On average, patients reported earlier pain and ADL function improvements, and slower sport function improvements after hip arthroscopy for FAI. However, average scores from patients indicate residual mild hip pain and/or hip function lower than their healthy counterparts after surgery. Owing to the current low level of evidence, future RCTs and cohort studies should investigate the effectiveness of hip arthroscopy in patients with FAI. TRIAL REGISTRATION NUMBER CRD42015019649.


Challenges of diabetes management during the COVID-19 pandemic.


title: Postoperative quality of life after laparoscopy-assisted pylorus-preserving gastrectomy compared With laparoscopy-assisted distal gastrectomy: A cross-sectional postal questionnaire survey.

text: BACKGROUND Little is known about postgastrectomy syndrome and quality of life (QOL after laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG). The aim of this study was to assess postgastrectomy syndrome and QOL after LAPPG as compared with laparoscopy-assisted distal gastrectomy with Billroth-I reconstruction (LADGBI). METHODS Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaires were sent by mail to 167 patients. To balance the characteristics of the groups, propensity score matching was performed. RESULTS Of the 167 patients sent questionnaires, 112 (67%) responded, including 47 who underwent LAPPG and 65 who underwent LADGBI. After propensity score matching, the LAPPG group scored significantly better on the diarrhea and dumping subscales. Multiple regression analysis showed that female sex and LADGBI were independent factors predicting dumping. Evaluation of outcome measures for singular symptom showed that the LAPPG group scored significantly worse on the acid regurgitation subscale, but significantly better on the lower abdominal pain and early dumping abdominal subscales. CONCLUSION LAPPG is superior to LADGBI for ameliorating postgastrectomy syndrome and maintaining QOL. LAPPG is recommended for patients with cT1N0 middle third gastric cancer.


title: A reliable parameter for primary closure of the free anterolateral thigh flap donor site.

text: BACKGROUND Primary closure of the donor site after flap harvest is key to achieving a satisfactory result. The authors investigated the width of the harvested anterolateral thigh flap allowing primary closure of the donor site. METHODS Sixty-five consecutive patients undergoing reconstructive procedures using anterolateral thigh flaps were divided into two groups: group A, primary closure of the donor site; and group B, donor site covered with split-thickness skin graft. Maximum flap width and thigh circumference were measured at the midpoint of the line connecting the lateral superior margin of the patella and the anterior superior iliac spine. The maximum flap width-to-thigh circumference ratio was calculated. Patients' body mass index and age were recorded. The outcome was evaluated by the surgeon. RESULTS Primary closure of the donor site was possible in 56 patients (86 percent), and in nine patients (14 percent) a split-thickness skin graft was necessary. All of the donor sites were closed primarily when the flap width was less than 16 percent of the thigh circumference. There was a significant correlation between body mass index and the ratio (p<0.001, r=-0.573) and between patient age and the ratio (p=0.033, r=0.267). Muscle herniation was significantly higher in group B (p=0.029). CONCLUSIONS The flap width-to-thigh circumference ratio is a reliable parameter for preoperative planning of primary closure of the anterolateral thigh flap donor site. Primary closure can be achieved if the flap width-to-thigh circumference ratio is less than 16 percent. The patient's body mass index and age have to be taken into consideration.


title: MRI characteristics in acute ischemic stroke patients with preceding direct oral anticoagulant therapy as compared to vitamin K antagonists.

text: BACKGROUND Despite the utility of neuroimaging in the diagnostic and therapeutic management of patients with acute ischemic stroke (AIS), imaging characteristics in patients with preceding direct oral anticoagulants (DOAC) compared to vitamin K antagonists (VKA) have hardly been described. We aimed to determine presence of large vessel occlusion (LVO), thrombus length, infarction diameter, and occurrence of hemorrhagic transformation in AIS patients with preceding DOAC as compared to VKA therapy. METHODS Using a prospectively collected cohort of AIS patients, we performed univariate and multivariable regression analyses regarding imaging outcomes. Additionally, we provide a sensitivity analysis for the subgroup of patients with confirmed therapeutic anticoagulation. RESULTS We included AIS in patients with preceding DOAC (N = 75) and VKA (N = 61) therapy, median age 79 (IQR 70-83), 39% female. Presence of any LVO between DOAC and VKA patients (29.3% versus 37.7%, P = 0.361), and target LVO for endovascular therapy (26.7% versus 27.9%, P = 1.0) was equal with a similar occlusion pattern. DOAC as compared to VKA were associated with a similar rate of target LVO for EVT (aOR 0.835, 95% CI 0.368-1.898). The presence of multiple lesions and characteristics of the thrombus were similar in DOAC and VKA patients. Acute ischemic lesion diameter in real world patients was equal in patients taking DOAC as compared to VKA. Lesion diameter in VKA patients (median 13 mm, IQR 6-26 versus median 20 mm, IQR 7-36, P = 0.001), but not DOAC patients was smaller in the setting of confirmed therapeutic VKA. The frequency of radiological hemorrhagic transformation and symptomatic intracranial hemorrhage in OAC patients was low. Sensitivity analysis considering only patients with confirmed therapeutic anticoagulation did not change any of the results. CONCLUSION Preceding DOAC treatment showed equal rates of LVO and infarct size as compared to VKA in AIS patients. This study adds to the knowledge of imaging findings in AIS patients with preceding anticoagulation.


title: Iatrogenic cerebral gas embolism-A systematic review of case reports.

text: BACKGROUND Cerebral gas embolism is a complication of several medical procedures and occurs when gas enters the cerebral circulation. Knowledge about etiology and outcome in affected patients is limited, and prospective trials on management and treatment are hardly feasible. Case reports are therefore an important source of information. METHODS A systematic literature search was conducted in June 2016 and May 2018, supplemented by a manual search. Titles and abstracts were systematically assessed for eligibility, followed by full-text screening for included papers. Screening and data extraction were performed independently by two researchers. Cases of cerebral gas embolism due to any iatrogenic cause were included. Criteria for exclusion were: animal studies, non-cerebral localization, extravascular gas only, and non-iatrogenic causes. 264 cases reported in 189 papers were included. RESULTS A broad range of procedures leading to iatrogenic cerebral gas embolism (ICGE) were identified and a comprehensive list is presented in this article. Procedures were mostly reported as conducted correctly, but procedure related error, patient activity, or defective equipment were also reported as causes. Neurological, neuropsychological, and cardiopulmonary symptoms were common. The diagnosis was frequently based on or confirmed by radiology, usually CT. Hyperbaric oxygen therapy was applied in a large number of cases. CONCLUSION The reported causes, symptoms and signs, and outcomes of ICGE vary significantly, and awareness of the condition in the medical community is essential. A standardized method of reporting could facilitate higher quality research in the field.


Care for laboratory animals during COVID-19 crisis.


title: Tending and mending: Affiliative responses to the COVID-19 pandemic by healthcare professionals in Italy.

text: The physical and social isolation measures associated with the 2019 novel coronavirus (COVID-19) outbreak, although certainly necessary to contain the spread of the virus, represent a particularly distressing aspect that might accentuate the fears and pain associated with the disease, especially for patients, their family members, and health-care professionals. Affiliative responses to the crises are emerging as ad hoc or formally endorsed practices within COVID-19 facilities in Italy, aimed at establishing links of communication between patients and family members by using new communication technologies. Tending to the emotional needs of patients and mending the affiliative connections interrupted by the disease are good examples of interdisciplinary cohesion and affiliative responses to the COVID-19 emergency. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Reporter Replicons for Antiviral Drug Discovery against Positive Single-Stranded RNA Viruses.

text: Single-stranded positive RNA ((+) ssRNA) viruses include several important human pathogens. Some members are responsible for large outbreaks, such as Zika virus, West Nile virus, SARS-CoV, and SARS-CoV-2, while others are endemic, causing an enormous global health burden. Since vaccines or specific treatments are not available for most viral infections, the discovery of direct-acting antivirals (DAA) is an urgent need. Still, the low-throughput nature of and biosafety concerns related to traditional antiviral assays hinders the discovery of new inhibitors. With the advances of reverse genetics, reporter replicon systems have become an alternative tool for the screening of DAAs. Herein, we review decades of the use of (+) ssRNA viruses replicon systems for the discovery of antiviral agents. We summarize different strategies used to develop those systems, as well as highlight some of the most promising inhibitors identified by the method. Despite the genetic alterations introduced, reporter replicons have been shown to be reliable systems for screening and identification of viral replication inhibitors and, therefore, an important tool for the discovery of new DAAs.


title: Comparison of perioperative morbidity and mortality rates in dogs with noninvasive adrenocortical masses undergoing laparoscopic versus open adrenalectomy.

text: OBJECTIVE To describe the clinicopathologic features of a cohort of dogs with adrenocortical masses that underwent laparoscopic adrenalectomy and to compare perioperative morbidity and mortality rates in these dogs with rates for dogs that underwent open adrenalectomy for resection of similarly sized (maximal diameter, ≤ 5 cm) adrenocortical masses. DESIGN Retrospective case series. ANIMALS 48 client-owned dogs that underwent laparoscopic (n = 23) or open (25) adrenalectomy for noninvasive tumors (ie, tumors that did not invade the vena cava or other surrounding organs). Procedures-Medical records were reviewed. History, clinical signs, physical examination findings, clinicopathologic findings, imaging results, and surgical variables were recorded. A 3- or 4-port approach was used for laparoscopic adrenalectomy. Surgical time, perioperative complications, postoperative and overall hospitalization times, and perioperative deaths were recorded and compared between groups. RESULTS The surgical method for 1 dog was converted from a laparoscopic to an open approach. Perioperative death occurred in no dogs in the laparoscopic group and 2 dogs in the open adrenalectomy group. Surgical time was shorter for laparoscopic (median, 90 minutes; range, 40 to 150 minutes) than for open (median, 120 minutes; range, 75 to 195 minutes) adrenalectomy. Laparoscopic adrenalectomy was associated with shorter hospitalization time and more rapid discharge from the hospital after surgery, compared with the open procedure. CONCLUSIONS AND CLINICAL RELEVANCE With careful patient selection, laparoscopic adrenalectomy was associated with a low complication rate and low conversion rate for resection of adrenocortical masses as well as shorter surgical and hospitalization times, compared with open adrenalectomy.


title: Infection and propagation of Crimean-Congo hemorrhagic fever virus in embryonated chicken eggs.

text: The embryonated chicken egg (ECE) provides a convenient, space-saving incubator for the cultivation of many kinds of animal viruses where the egg can be easily observed for viral replication throughout the development of the chicken embryo. Within the family Bunyaviridae, the embryonated egg has been used as a host system for many viruses such as Rift Valley fever virus and Akabane virus. The current study was conducted to determine the cultivation of Crimean-Congo hemorrhagic fever virus (CCHFV) in ECE. Four-day-old eggs were infected with CCHFV via the yolk sac route and harvested embryonic tissues and amino-allantoic fluid (AAF) that were used for virus passage and viral RNA (vRNA) detection. Quantification of vRNA copies was performed by quantitative reverse transcription polymerase chain reaction (qRT-PCR). Our study indicated that CCHFV caused the death of the embryonated egg in a dose-dependent manner and the 50% egg infectious dose (EID50) was determined to be 6.47×10(5) copies/egg. CCHFV replicated and passaged well in the egg and high viral loads were detected both in embryonic tissue (10(9-10) copies/g) and AAF (10(7-9) copies/ml) of the embryonated egg. Thus, ECE could be used for viral cultivation and preservation, and as a potential host infection model for the study of the pathogenesis of CCHFV.


title: Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome.

text: BACKGROUND Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common disorder in which the two main clinical features are pelvic pain and lower urinary tract symptoms. There are currently many approaches for its management, using both pharmacological and non-pharmacological interventions. The National Institute of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) score is a validated measure commonly used to measure CP/CPPS symptoms. OBJECTIVES To assess the effects of non-pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). SEARCH METHODS We performed a comprehensive search using multiple databases, trial registries, grey literature and conference proceedings with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017. SELECTION CRITERIA We included randomised controlled trials. Inclusion criteria were men with a diagnosis of CP/CPPS. We included all available non-pharmacological interventions. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data from the included studies, performed statistical analyses and rated quality of evidence (QoE) according to the GRADE methods. MAIN RESULTS We included 38 unique studies with 3290 men with CP/CPPS across 23 comparisons.1. Acupuncture: (three studies, 204 participants) based on short-term follow-up, acupuncture reduces prostatitis symptoms in an appreciable number of participants compared with sham procedure (mean difference (MD) in total NIH-CPSI score -5.79, 95% confidence interval (CI) -7.32 to -4.26, high QoE). Acupuncture likely results in little to no difference in adverse events (moderate QoE). It probably also decreases prostatitis symptoms compared with standard medical therapy in an appreciable number of participants (MD -6.05, 95% CI -7.87 to -4.24, two studies, 78 participants, moderate QoE).2. Circumcision: (one study, 713 participants) based on short-term follow-up, early circumcision probably decreases prostatitis symptoms slightly (NIH-CPSI score MD -3.00, 95% CI -3.82 to -2.18, moderate QoE) and may not be associated with a greater incidence of adverse events compared with control (a waiting list to be circumcised, low QoE).3. Electromagnetic chair: (two studies, 57 participants) based on short-term follow-up, we are uncertain of the effects of the use of an electromagnetic chair on prostatitis symptoms. It may be associated with a greater incidence of adverse events compared with sham procedure (low to very low QoE).4. Lifestyle modifications: (one study, 100 participants) based on short-term follow-up, lifestyle modifications may be associated with a greater improvement in prostatitis symptoms in an appreciable number of participants compared with control (risk ratio (RR) for improvement in NIH-CPSI scores 3.90, 95% CI 2.20 to 6.92, very low QoE). We found no information regarding adverse events.5. Physical activity: (one study, 85 participants) based on short-term follow-up, a physical activity programme may cause a small reduction in prostatitis symptoms compared with control (NIH-CPSI score MD -2.50, 95% CI -4.69 to -0.31, low QoE). We found no information regarding adverse events.6. Prostatic massage: (two studies, 115 participants) based on short-term follow-up, we are uncertain whether the prostatic massage reduces or increases prostatitis symptoms compared with control (very low QoE). We found no information regarding adverse events.7. Extracorporeal shockwave therapy: (three studies, 157 participants) based on short-term follow-up, extracorporeal shockwave therapy reduces prostatitis symptoms compared with control (NIH-CPSI score MD -6.18, 95% CI -7.46 to -4.89, high QoE). These results may not be sustained at medium-term follow-up (low QoE). This treatment may not be associated with a greater incidence of adverse events (low QoE).8. Transrectal thermotherapy compared to medical therapy: (two studies, 237 participants) based on short-term follow-up, transrectal thermotherapy alone or in combination with medical therapy may decrease prostatitis symptoms slightly when compared with medical therapy alone (NIH-CPSI score MD -2.50, 95% CI -3.82 to -1.18, low QoE). One included study reported that participants may experience transient adverse events.9. Other interventions: there is uncertainty about the effects of other interventions included in this review. We found no information regarding psychological support or prostatic surgery. AUTHORS' CONCLUSIONS Some of the interventions can decrease prostatitis symptoms in an appreciable number without a greater incidence of adverse events. The QoE was mostly low. Future clinical trials should include a full report of their methods including adequate masking, consistent assessment of all patient-important outcomes including potential treatment-related adverse events and appropriate sample sizes.


title: Outpatient kidney recovery after acute kidney injury requiring dialysis: a systematic review protocol.

text: BACKGROUND Acute kidney injury requiring dialysis (AKI-D) during hospitalization is associated with both in-hospital and post-discharge mortality. Its incidence has risen over time in Canada and the USA. While the majority of AKI-D will recover to dialysis independence at the time of hospital discharge, 10-30% will transition to outpatient dialysis. The risk factors that determine dialysis independence after AKI-D and its optimal outpatient management remain unclear. Eliciting prognostic predictors of kidney recovery in patients who remain on dialysis after hospital discharge will guide subsequent clinical decision making. The objective of this study is to assess the association between patient- and treatment-related factors with short- and long-term outcomes in patients who remained dialysis-dependent after hospitalization with AKI-D. METHODS A literature search in EMBASE, MEDLINE, and PubMed will be performed based on pre-specified criteria. There are no restrictions on language and publication dates. The supplemental search will include manual scan of bibliographies of eligible studies and grey literature assessment. Pre-specified criteria will be used to select eligible studies. Relevant data will be extracted and quality assessments performed per validated tools. Qualitative data synthesis will be performed to reflect directions of associations. Meta-analysis will be formed if two or more studies with similar prognostic factors, outcomes, and adequate quality are identified. Strength of association will be quantified as odds ratios. Reporting of this review will be guided by recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. DISCUSSION This systematic review aims to synthesize association between modifiable and non-modifiable prognostic factors with renal outcomes in AKI-D patients who remain dialysis-dependent after hospital discharge. Our findings will help inform the development of evidence-based management and guide long-term treatment planning for AKI-D patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42019127394 .


title: Beyond H&E: integration of nucleic acid-based analyses into diagnostic pathology.

text: Veterinary pathology of infectious, particularly viral, and neoplastic diseases has advanced significantly with the advent of newer molecular methodologies that can detect nucleic acid of infectious agents within microscopic lesions, differentiate neoplastic from nonneoplastic cells, or determine the suitability of a targeted therapy by detecting specific mutations in certain cancers. Polymerase chain reaction-based amplification of DNA or RNA and in situ hybridization are currently the most commonly used methods for nucleic acid detection. In contrast, the main methodology used for protein detection within microscopic lesions is immunohistochemistry. Other methods that allow for analysis of nucleic acids within a particular cell type or individual cells, such as laser capture microdissection, are also available in some laboratories. This review gives an overview of the factors that influence the accurate analysis of nucleic acids in formalin-fixed tissues, as well as of different approaches to detect such targets.


title: Molecular characterization of breast cancer needle core biopsy specimens by the 21-gene Breast Recurrence Score test.

text: BACKGROUND AND OBJECTIVE Recent COVID-19 pandemic guidelines recommend genomic assessment of core biopsies to help guide treatment decisions in estrogen receptor (ER)-positive early-stage breast cancer. Herein we characterize biopsy and excisional breast cancer specimens submitted for 21-gene testing. METHODS US samples submitted to Genomic Health for 21-gene testing (01/2004-04/2020) were assessed by pathologists and analyzed by a standardized quantitative reverse transcription-polymerase chain reaction. Predefined cutoffs were: ESR1 (positive ≥6.5), PGR (positive ≥5.5), and ERBB2 (negative <10.7). ER status by immunohistochemistry (IHC) and lymph node status were determined locally. Median and interquartile range were reported for continuous variables, and total and percent for categorical variables. Distributions were assessed overall, by age, and by nodal involvement. RESULTS Of 919 701 samples analyzed, 13% were biopsies and 87% were excisions. Initial assay success rates were 94.5% (biopsies) and 97.3% (excisions). ER IHC concordance with central ESR1 was 96.8% (biopsies) and 97.6% (excisions). Biopsy and excisional medians were: Recurrence Score results 16 (each); ESR1 10.2 (each); PGR 7.7 and 7.6; ERBB2 9.4 and 9.2, respectively. CONCLUSIONS Biopsy submissions for 21-gene testing are common and consistently generate results that are very similar to the experience with excisions. The 21-gene test can be performed reliably on core biopsies.


title: Surfactin Inhibits Membrane Fusion during Invasion of Epithelial Cells by Enveloped Viruses.

text: Because membrane fusion is a crucial step in the process by which enveloped viruses invade host cells, membrane fusion inhibitors can be effective drugs against enveloped viruses. We found that surfactin from Bacillus subtilis can suppress the proliferation of porcine epidemic diarrhea virus (PEDV) and transmissible gastroenteritis virus (TGEV) in epithelial cells at a relatively low concentration range (15 to 50 μg/ml), without cytotoxicity or viral membrane disruption. Membrane fusion inhibition experiments demonstrate that surfactin treatment significantly reduces the rate at which the virus fuses to the cell membrane. Thermodynamic experiments show that the incorporation of small amounts of surfactin hinders the formation of negative curvature by lamellar-phase lipids, suggesting that surfactin acts a membrane fusion inhibitor. A fluorescent lipopeptide similar to surfactin was synthesized, and its ability to insert into the viral membrane was confirmed by spectroscopy. In vivo experiments have shown that oral administration of surfactin to piglets protects against PEDV infection. In conclusion, our study indicates that surfactin is a membrane fusion inhibitor with activity against enveloped viruses. As the first reported naturally occurring wedge lipid membrane fusion inhibitor, surfactin is likely to be a prototype for the development of a broad range of novel antiviral drugs.IMPORTANCE Membrane fusion inhibitors are a rapidly emerging class of antiviral drugs that inhibit the infection process of enveloped viruses. They can be classified, on the basis of the viral components targeted, as fusion protein targeting or membrane lipid targeting. Lipid-targeting membrane fusion inhibitors have a broader antiviral spectrum and are less likely to select for drug-resistant mutations. Here we show that surfactin is a membrane fusion inhibitor and has a strong antiviral effect. The insertion of surfactin into the viral envelope lipids reduces the probability of viral fusion. We also demonstrate that oral administration of surfactin protects piglets from PEDV infection. Surfactin is the first naturally occurring wedge lipid membrane fusion inhibitor that has been identified and may be effective against many viruses beyond the scope of this study. Understanding its mechanism of action provides a foundation for the development of novel antiviral agents.


title: SILS v SILS+1: a Case-Matched Comparison for Colorectal Surgery.

text: BACKGROUND Single-incision laparoscopic surgery (SILS) is safe and feasible for benign and malignant colorectal diseases. SILS has comparable or improved outcomes compared to multiport laparoscopy but technical limitations when operating in the pelvis. To address these limitations, we developed an innovative SILS+1 approach using a single Pfannenstiel incision for pelvis access with one additional umbilical port. Our goal was to compare outcomes for SILS and SILS+1 in lower abdominal and pelvic colorectal surgery. METHODS Review of a prospectively maintained database identified patients who underwent an elective reduced port laparoscopic lower abdominal/pelvic colorectal procedure from 2009 to 2014. Cases were stratified by approach: SILS versus SILS+1 then matched 1:2 on age, gender, body mass index (BMI), comorbidity, and procedure. Demographic, perioperative, and postoperative outcome variables were evaluated. The main outcome measures were operative time, conversion rate, length of stay, complication, morbidity, and mortality rates. RESULTS One hundred thirty-two reduced port AR/LAR patients were evaluated-44 SILS and 88 SILS+1. The groups were similar in age, gender, BMI, and ASA class. The primary diagnosis in both cohorts was diverticulitis (90.9 % SILS, 87.5 % SILS+1), and main procedure performed an anterior rectosigmoidectomy (86.4 % SILS, 88.2 % SILS+1). Significantly more SILS+1 patients had previous abdominal surgery (p = 0.01). The operative time was significantly shorter in SILS+1 (mean 166.6 [SD 48.4] vs. 178.0 [SD 70.0], p = 0.03). The conversion rate to multiport or open surgery was also significantly lower with SILS+1 compared to SILS (1.1 vs. 11.4 %, p = 0.02). Postoperatively, the length of stay across the groups was similar. SILS trended towards higher complication and readmission rates (NS). There were no unplanned reoperations or mortality in either group. CONCLUSIONS SILS+1 facilitates pelvic and lower abdominal colorectal surgery, with shorter operative times and lower conversion rates. The additional port improved visualization and outcomes without any impact on length of stay, readmission, or complication rates.


title: 1,25-Dihydroxyvitamin D3 acts directly on the T lymphocyte vitamin D receptor to inhibit experimental autoimmune encephalomyelitis.

text: Multiple sclerosis (MS) is an incurable autoimmune neurodegenerative disease. Environmental factors may be key to MS prevention and treatment. MS prevalence and severity decrease with increasing sunlight exposure and vitamin D(3) supplies, supporting our hypothesis that the sunlight-dependent hormone, 1,25-dihydroxyvitamin D(3) (1,25-(OH)(2) D(3) ), inhibits autoimmune T-cell responses in MS. Moreover, 1,25-(OH)(2) D(3) inhibits and reverses experimental autoimmune encephalomyelitis (EAE), an MS model. Here, we investigated whether 1,25-(OH)(2) D(3) inhibits EAE via the vitamin D receptor (VDR) in T lymphocytes. Using bone marrow chimeric mice with a disrupted VDR only in radio-sensitive hematopoietic cells or radio-resistant non-hematopoietic cells, we found that hematopoietic cell VDR function was necessary for 1,25-(OH)(2) D(3) to inhibit EAE. Furthermore, conditional targeting experiments showed that VDR function in T cells was necessary. Neither 1,25-(OH)(2) D(3) nor T-cell-specific VDR targeting influenced CD4(+) Foxp3(+) T-cell proportions in the periphery or the CNS in these studies. These data support a model wherein 1,25-(OH)(2) D(3) acts directly on pathogenic CD4(+) T cells to inhibit EAE.


title: Stent-Retriever Thrombectomy and Rescue Treatment of M1 Occlusions Due to Underlying Intracranial Atherosclerotic Stenosis: Cohort Analysis and Review of the Literature.

text: BACKGROUND AND PURPOSE Data on the management of large vessel occlusion in patients with anterior circulation acute ischemic stroke (AIS) due to underlying intracranial stenosis are scarce. The aim of this retrospective study was to compare endovascular treatment and outcome in AIS patients with and without underlying stenosis of the M1 segment. MATERIALS AND METHODS A total of 533 acute stroke patients with an isolated M1 occlusion who underwent mechanical thrombectomy between 02/2010 and 08/2017 were included. Underlying intracranial atherosclerotic stenosis (ICAS) was present in 10 patients (1.9%), whereas 523 patients (98.1%) had an embolic occlusion without stenosis. RESULTS There was no difference in age, admission National Institutes of Health Stroke Scale, risk factors, Alberta stroke program early CT score or collaterals between the groups. Procedure time (155 vs 40 min, P = 0.001) was significantly longer in the ICAS group where rescue stent-angioplasty was performed in all patients. There was no statistical difference in final modified thrombolysis in cerebral infarction score between both groups (70 vs 88%, P = 0.115). Favorable outcome (modified Rankin Scale ≤ 2) at 90 days was less frequent in patients with ICAS than in the embolic group (0 vs 49.4%, P = 0.004). The mortality rate tended to be higher in the ICAS group (44.4 vs 19.4%, P = 0.082). CONCLUSION In patients with AIS, rescue therapy with stent placement to treat underlying ICAS of the M1 segment is technically feasible; however, in our study, a significantly lower rate of favorable outcome was observed in these patients compared to those with thromboembolic M1 occlusions. LEVEL OF EVIDENCE Level 3, non-randomized controlled study.


title: Visual outcomes with flow-diverter stents covering the ophthalmic artery for treatment of internal carotid artery aneurysms.

text: BACKGROUND AND PURPOSE Flow-diverting stents can be used to treat intracranial aneurysms that are not amenable to treatment with coils. We analyzed ophthalmic consequences due to coverage of the origin of the ophthalmic artery by flow-diverting stents for the treatment of internal carotid artery aneurysms. MATERIALS AND METHODS From April 2009 to April 2013, the clinical and angiographic outcomes of all 28 patients treated for aneurysms with flow-diverting stents covering the origin of the ophthalmic artery were prospectively collected. The origin of the ophthalmic artery in relation to the target aneurysm was classified by using a 4-type classification. A complete ophthalmic examination was performed by a single ophthalmologist 48 hours before and 1 week after covering the ophthalmic artery. RESULTS Ophthalmic artery patency was normal at the end of endovascular treatment in 24/28 cases (85.7%). With extensive ophthalmic examinations, 11 patients (39.3%) showed new ophthalmic complications. Patients with the ophthalmic artery originating from the aneurysm sac were at high risk for retinal emboli (4/5, 80%). Patients with the ophthalmic artery originating from the inner curve of the carotid siphon were at high risk for optic nerve ischemic atrophy (3/4, 75%). CONCLUSIONS This prospective study shows that covering the ophthalmic artery with a flow-diverting stent is not without potential complications. Ophthalmic complications can occur but are often not diagnosed. The anatomic disposition of the ophthalmic artery in relation to the carotid siphon and aneurysm should be clearly understood because some configurations have a higher risk. When not required, covering of the ophthalmic artery by flow-diverting stents should be avoided.


title: SARS-CoV-2: An immunogenetics call to arms.

text: Susceptibility to viral infection, development of immunity, response to treatment and patient clinical outcomes are all under the control of heritable factors in the host. In the context of the current SARS-Cov-2 pandemic, this review considers existing immunogenetic knowledge of virus-immune system interactions. A major focus is to highlight areas in which work is required in order to improve understanding of antiviral immune responses and to move towards improved patient management.


title: Laparoscopic versus open repair of groin hernias in children: a systematic review and meta-analysis.

text: BACKGROUND Regarding groin hernia repair in children, guidelines do not favor open or laparoscopic repair. Even so, most surgeons prefer an open technique. The aim of this systematic review was to compare short- and long-term outcomes after laparoscopic and open groin hernia repair in children. METHODS Systematic searches were conducted in three databases, and all randomized controlled trials comparing laparoscopic and open groin hernia repair in children under 18 years were included. Outcomes were postoperative complications, intraoperative complications, operative time, length of hospital stay, time to recovery, and wound appearance. The outcomes were compared between open and laparoscopic repairs in meta-analyses. RESULTS We included ten studies with 1270 patients involving 1392 hernias. We found no differences in recurrence rate, testicular atrophy, hydrocele, hematoma, seroma, infection, pain, length of hospital stay, or time to full recovery. Laparoscopic repair was superior regarding wound appearance. Laparoscopic repair had shorter operative time than open repair for bilateral groin hernias. For unilateral groin hernias, extraperitoneal laparoscopic repair was faster than open repair, but open repair was faster than intraperitoneal laparoscopic repair. CONCLUSION Our results indicate similar outcome after laparoscopic and open techniques for groin hernia repair in children. The surgeon's preference as well as the wishes of the patient and parents should therefore determine the surgical approach.


title: A clinical decision-making model for repeat surgical treatment of pectus Bar displacement: distance measurement after nuss procedure.

text: BACKGROUND Bar displacement is one of the most common and serious complications after the Nuss procedure. However, measurements of and factors affecting bar displacement have not been reported. The objectives of this study were to develop a decision model to guide surgeons considering repeat treatment and to estimate optimal cut-off values to determine whether reoperation to correct bar displacement is warranted. METHODS From July 2011 to August 2013, ninety bars were inserted in 61 patients who underwent Nuss procedures for pectus excavatum. Group A did not need surgical intervention and Group B required reoperation for bar displacement. Bar position was measured as the distance from the posterior superior end of the sternal body to the upper border of the metal bar on lateral chest radiographs. The bar displacement index (BDI) was calculated using D0 - Dx / D0 x 100 (D0: bar position the day after surgery; Dx: minimal or maximal distance of bar position on the following postoperative days). The optimal cut-off values of BDI warranting reoperation were assessed on the basis of ROC curve analysis. RESULTS Of the 61 patients, 32 had single bars inserted whereas 29 had parallel bars inserted. There was a significant difference in age (14.0 ± 7.5 vs. 23.3 ± 12.0, p = 0.0062), preoperative Haller index (HI) (4.0 ± 1.1 vs. 5.0 ± 1.0, p = 0.033), and postoperative HI (2.7 ± 0.4 vs. 3.2 ± 0.5 p = 0.006) between the two groups. The optimal cut-off value of BDI was 8.7. CONCLUSIONS We developed a BDI model for surgeons considering performing reoperation after Nuss procedure. The optimal cut-off value of BDI was 8.7. This model may help surgeons to decide objectively whether corrective surgery should be performed. The main factors affecting the relationship between bar displacement and reoperation were age and preoperative HI.


title: Automatic, wearable-based, in-field eating detection approaches for public health research: a scoping review.

text: Dietary intake, eating behaviors, and context are important in chronic disease development, yet our ability to accurately assess these in research settings can be limited by biased traditional self-reporting tools. Objective measurement tools, specifically, wearable sensors, present the opportunity to minimize the major limitations of self-reported eating measures by generating supplementary sensor data that can improve the validity of self-report data in naturalistic settings. This scoping review summarizes the current use of wearable devices/sensors that automatically detect eating-related activity in naturalistic research settings. Five databases were searched in December 2019, and 618 records were retrieved from the literature search. This scoping review included N = 40 studies (from 33 articles) that reported on one or more wearable sensors used to automatically detect eating activity in the field. The majority of studies (N = 26, 65%) used multi-sensor systems (incorporating > 1 wearable sensors), and accelerometers were the most commonly utilized sensor (N = 25, 62.5%). All studies (N = 40, 100.0%) used either self-report or objective ground-truth methods to validate the inferred eating activity detected by the sensor(s). The most frequently reported evaluation metrics were Accuracy (N = 12) and F1-score (N = 10). This scoping review highlights the current state of wearable sensors' ability to improve upon traditional eating assessment methods by passively detecting eating activity in naturalistic settings, over long periods of time, and with minimal user interaction. A key challenge in this field, wide variation in eating outcome measures and evaluation metrics, demonstrates the need for the development of a standardized form of comparability among sensors/multi-sensor systems and multidisciplinary collaboration.


title: [Standardized diagnosis and treatment of colorectal cancer during the outbreak of corona virus disease 2019 in Renji hospital].

text: Corona virus disease 2019 (COVID-19) is currently raging in China. It has been proven that COVID-19 can be transmitted from human to human and cause hospital infection, which seriously threatens surgical staffs and inpatients. Although colorectal surgery is not a front-line subject in the fight against the epidemic, but in this special situation, it is a difficult task to provide the highest quality medical services and ensure the orderly clinical work, on the premise of maximizing the protection for patients and their families, health of medical staff, and the safety of wards and hospitals, We summarize how to carry out the clinical practice of colorectal surgery under the situation of the prevention and control of the COVID-19 epidemiology, including the procedures of diagnose and treatment for emergency patients with colorectal tumor, and share the experiences of the diagnosis of colorectal tumor, the management of patients with colorectal cancer who are scheduled to be admitted for surgery, the protection of wards, the perioperative management. More importantly, we introduce in detail the operative management and perioperative management of colorectal surgery patients suspected or diagnosed with new coronary pneumonia, including prevention and control measures for medical staff, operating rooms and surgical instruments. The main points are as follows: (1) Multidisciplinary team (MDT) must be run through the diagnosis and treatment of colorectal cancer. The members include not only routine departments, but also respiratory department and infectious department. (2) Colonoscopy examination may cause cross infection of COVID-19 to patients and doctors. Therefore, it is prior to examine the emergency cases and life-threatening patients (bleeding, obstruction, gastrointestinal foreign bodies, etc.). If the emergent patients (intestinal obstruction) with suspected or confirmed COVID-19, the surgeons must perform emergency surgery, and intestinal decompressive tube through colonoscopy is not recommended. (3) The colorectal cancer patients with suspected or confirmed COVID-19 should be placed in the isolated room with separate medical devices, and the operative room with negative pressure (under -5 Pa) must be separated. All disposable medical items, body fluids and feces of the patients in perioperative periods must be unified disposed according to the medical waste standard. (4) The surgical medical workers who process colorectal cancer patients with COVID-19 must be protected by three-level. After operation, the medical workers must receive medical observation and be isolated for 14 days. We hope our "Renji experience" will be beneficial to colleagues.


title: Time to endovascular reperfusion and degree of disability in acute stroke.

text: OBJECTIVE Faster time from onset to recanalization (OTR) in acute ischemic stroke using endovascular therapy (ET) has been associated with better outcome. However, previous studies were based on less-effective first-generation devices, and analyzed only dichotomized disability outcomes, which may underestimate the full effect of treatment. METHODS In the combined databases of the SWIFT and STAR trials, we identified patients treated with the Solitaire stent retriever with achievement of substantial reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b-3). Ordinal numbers needed to treat values were derived by populating joint outcome tables. RESULTS Among 202 patients treated with ET with TICI 2b to 3 reperfusion, mean age was 68 (±13), 62% were female, and median National Institutes of Health Stroke Scale (NIHSS) score was 17 (interquartile range [IQR]: 14-20). Day 90 modified Rankin Scale (mRS) outcomes for OTR time intervals ranging from 180 to 480 minutes showed substantial time-related reductions in disability across the entire outcome range. Shorter OTR was associated with improved mean 90-day mRS (1.4 vs. 2.4 vs. 3.3, for OTR groups of 124-240 vs. 241-360 vs. 361-660 minutes; p < 0.001). The number of patients identified as benefitting from therapy with shorter OTR were 3-fold (range, 1.5-4.7) higher on ordinal, compared with dichotomized analysis. For every 15-minute acceleration of OTR, 34 per 1,000 treated patients had improved disability outcome. INTERPRETATION Analysis of disability over the entire outcome range demonstrates a marked effect of shorter time to reperfusion upon improved clinical outcome, substantially higher than binary metrics. For every 5-minute delay in endovascular reperfusion, 1 of 100 patients has a worse disability outcome.


title: Left and right ventricular lead positions are imprecisely determined by fluoroscopy in cardiac resynchronization therapy: a comparison with cardiac computed tomography.

text: AIMS Fluoroscopy is the routine method for localizing left ventricular (LV) and right ventricular (RV) lead positions in cardiac resynchronization therapy (CRT). However, the ability of fluoroscopy to determine lead positions in a standard ventricular segmentation is unknown. We aimed to evaluate the accuracy and reproducibility of fluoroscopy to determine LV and RV lead positions in CRT when compared with cardiac computed tomography (CT). METHODS AND RESULTS Fifty-nine patients undergoing CRT were included. Bi-plane fluoroscopy and cardiac CT were evaluated in all patients. Pacing lead positions were assessed in a standard LV 16-segment model and in a simplistic RV 8-segment model. Four patients with LV lead displacement were excluded from the agreement analysis of LV lead position. Agreement of LV lead position between fluoroscopy and cardiac CT was observed in 19 (35%) patients with fluoroscopy demonstrating a 1-segment and ≥2-segment error in 30 (55%) and 6 (11%) patients, respectively. Agreement of RV lead position was found in 13 (22%) patients with fluoroscopy showing a 1-segment and ≥ 2-segment error in 28 (47%) and 18 (31%) patients, respectively. The interobserver agreement on LV and RV lead positions was poor for fluoroscopy (kappa 0.20 and 0.23, respectively) and excellent for cardiac CT (kappa 0.87 and 0.85, respectively). CONCLUSION Fluoroscopy is inaccurate and modestly reproducible when assessing LV and RV lead positions in a standard ventricular segmentation when compared with cardiac CT. Cardiac CT should be applied to determine the exact pacing site in future research evaluating the optimal pacing lead position in CRT.


title: Hematology/Oncology Fellowship Emergency Restructuring in Response to the COVID-19 Pandemic-Henry Ford Hospital, Michigan.

text: The COVID-19 pandemic has wreaked havoc and created challenges in various subspecialty training programs, including hematology/oncology fellowship programs. The challenge of social distancing, providing care for those infected by COVID-19, continuing appropriate treatment of time-sensitive diseases, and the looming threat of health care worker infections required swift planning and restructuring of training programs. The Accreditation Council for Graduate Medical Education provided leeway to tackle the challenges faced by institutions and training programs in the setting of the COVID-19 pandemic. Currently, there is no established guideline specific to hematology and oncology fellowship programs. While understanding that there is no one-size-fits-all, shared experiences can assist training programs to incorporate best practices and customize their programs to provide an active educational environment that balances patient care needs, didactics, scholarly activities, and wellbeing during the process of rapid changes and adaptation. We share our hematology/oncology fellowship program's restructuring approach in response to the COVID-19 pandemic.


title: A Novel Technique of Hand-Sewn Purse-String Suturing by Double Ligation Method (DLM) for Intracorporeal Circular Esophagojejunostomy.

text: Purpose The optimal method for intracorporeal esophagojejunostomy remains unclear because a purse-string suture for fixing the anvil into the esophagus is difficult to perform with a laparoscopic approach. Therefore, this study aimed to evaluate our novel technique to fix the anvil into the esophagus. Materials and Methods This retrospective study included 202 patients who were treated at our institution with an intracorporeal circular esophagojejunostomy in a laparoscopy-assisted total gastrectomy with a Roux-en-Y reconstruction (166 cases) or a laparoscopy-assisted proximal gastrectomy with jejunal interposition (36 cases). After incising 3/4 of the esophageal wall, a hand-sewn purse-string suture was placed on the esophagus. Next, the anvil head of a circular stapler was introduced into the esophagus. Finally, the circular esophagojejunostomy was performed laparoscopically. The clinical characteristics and surgical outcomes were evaluated and compared with those of other methods. Results The average operation time was 200.3 minutes. The average hand-sewn purse-string suturing time was 6.4 minutes. The overall incidence of postoperative complications (Clavien-Dindo classification grade ≥II) was 26%. The number of patients with an anastomotic leakage and stenosis at the esophagojejunostomy site were 4 (2.0%) and 12 (6.0%), respectively. All patients with stenosis were successfully treated by endoscopic balloon dilatation. There was no mortality. Regarding the materials and devices for anvil fixation, only 1 absorbable thread was needed. Conclusions Our procedure for hand-sewn purse-string suturing with the double ligation method is simple and safe.


title: Atrioventricular conduction after transcatheter aortic valve implantation and surgical aortic valve replacement.

text: INTRODUCTION Atrioventricular conduction abnormalities (AVCA) may complicate transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). The aim of this study was to prospectively evaluate AVCA after TAVI and SAVR. METHODS AND RESULTS Among 50 patients undergoing TAVI and 25 patients undergoing SAVR a continuous 7-day Holter electrocardiogram (ECG) was recorded after the procedure. ECGs during TAVI and 12-lead ECGs before and 1 and 7 days after TAVI and SAVR were analyzed. At baseline, TAVI patients were older (mean 82.1 vs 75.4, P < 0.001), had a longer PR interval (median 200 milliseconds vs 175 milliseconds, P = 0.004) and broader QRS width (median 100 milliseconds vs 80 milliseconds, P = 0.007) than SAVR patients. New AVCA were observed among 29 TAVI patients (58%), mostly new left bundle branch block (76%). Predilatation induced new AVCA in 14 TAVI patients (28%). New AVCA resolved within 24 hours in 15 TAVI patients (30%), and persisted in 14 TAVI (28%) and 3 SAVR patients (12%, P = 0.12). Among patients with persistent QRS width <120 milliseconds during the first 24 hours after TAVI, QRS width remained stable during the remainder of the observation period. During Holter monitoring complete AV block was observed in 4 TAVI patients (8%) and 3 SAVR patients (12%; P = 0.68). CONCLUSIONS Almost half of AVCA during TAVI are induced by predilatation, but half of them resolve within 24 hours. Persistent AVCA are more frequently observed after TAVI than SAVR. If QRS width is below 120 milliseconds the first day after TAVI, the risk of late AVCA seems low.


title: Ruptured visceral artery aneurysms.

text: Visceral artery aneurysms are rare but their estimated mortality due to rupture ranges between 25 and 70%. Treatment of visceral artery aneurysm rupture is usually managed by interventional radiology. Specific embolization techniques depend on the location, affected organ, locoregional arterial anatomy, and interventional radiologist skill. The success rate following treatment by interventional radiology is greater than 90%. The main complication is recanalization of the aneurysm, showing the importance of post-therapeutic monitoring, which should preferably be performed using MR imaging.


Coronavirus: everyone wins when patents are pooled.


title: Transitioning to single-incision laparoscopic inguinal herniorrhaphy.

text: BACKGROUND Laparoendoscopic single-site surgery (LESS) offers cosmetic benefits and may represent further progress towards reducing the invasiveness of surgical interventions. We report our initial experience with LESS totally extraperitoneal (TEP) inguinal herniorrhaphy. MATERIALS AND METHODS Beginning March 2009, we transitioned from a multiport laparoscopic TEP (MLH) technique to a single-incision TEP (SITE) technique. The first 52 consecutive patients who underwent SITE at our institution were compared with the preceding 52 MLH repairs. RESULTS Of the first 52 patients undergoing SITE, there were no conversions to either open or multiport surgery. The mean operative time for the SITE cases did not differ significantly from that of MLH. Complications were equivalent between the 2 groups and included postoperative seroma and urinary retention. CONCLUSIONS Transitioning from MLH to SITE was readily accomplished without significantly altering operative time or morbidity.


title: Submental Island Flap versus Free Flap Reconstruction for Complex Head and Neck Defects.

text: OBJECTIVE Complex soft tissue reconstruction of the head and neck requires a viable, versatile, and dependable flap. Free flaps, such as the radial forearm and anterolateral thigh flap, have been the mainstay of complex head and neck reconstruction. However, a local pedicled flap, such as the submental island flap (SIF), could be a more effective and less demanding alternative. This systematic review and meta-analysis aim to compare free tissue transfer (FTT) with the SIF for head and neck reconstruction. DATA SOURCES We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on outcomes reported in ≥3 studies. REVIEW METHODS Candidate articles were assessed for eligibility by 2 authors. Three authors performed data extraction and methodological quality of the included studies using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. RESULTS The search strategy resulted in 450 studies, of which 7 were included in the analysis, yielding 155 SIF and 198 FTT cases. Operating time and length of stay were significantly lower for the SIF than for FTT (P = .05 and P = .0008). There was no significant difference between the groups for complete flap loss, debulking revisions, and oncologic recurrence. CONCLUSION These results suggest that the SIF reduces length of stay and operating time as compared with FTT in head and neck reconstruction. These findings suggest that the SIF can be considered an alternative reconstructive option to FTT when evaluating intraoral, lateral facial, skull base, and parotidectomy defects, given comparable defect size and tumor biology.


Minimally invasive repair of posterior leaflet mitral valve prolapse with the "respect" approach.


title: Cytokine polymorphisms have a synergistic effect on severity of the acute sickness response to infection.

text: BACKGROUND Functional polymorphisms in immune response genes are increasingly recognized as important contributors to the marked individual differences in susceptibility to and outcomes of infectious disease. The acute sickness response is a stereotypical set of illness manifestations mediated by the proinflammatory cytokines induced by many different pathogens. The genetic determinants of severity of the acute sickness response have not previously been explored. METHODS We examined the impact of functional polymorphisms in cytokine genes with critical roles in the early immune response (tumor necrosis factor-alpha, interleukin-6, interleukin-10, and interferon-gamma) on the severity and duration of illness following acute infection with Epstein-Barr virus, Coxiella burnetii (the causative agent of Q fever), or Ross River virus. RESULTS We found that the interferon-gamma +874T/A and the interleukin-10 -592C/A polymorphisms significantly affected illness severity, cytokine protein levels, and the duration of illness. These cytokine genotypes acted in synergy to potentiate their influence on disease outcomes. CONCLUSIONS These findings suggest that genetically determined variations in the intensity of the inflammatory response underpin the severity of the acute sickness response and predict the recovery time across varied infections.


title: Preparing for pandemic influenza.

text: Influenza is a highly contagious, acute febrile respiratory illness that results in global morbidity and mortality annually. Avian influenza (H5N1) has the potential to cause a pandemic. Avian influenza's epidemiology and clinical description, including common signs/symptoms, transmission, vaccination, and treatment, are presented. Recommended isolation practices for labor and delivery, and proper procedures for identifying and managing infected patients are provided. Potential maternal and newborn outcomes related to influenza and avian influenza are discussed. Pandemic planning issues are outlined, including hospital surge capacity, medical equipment and staffing availability, and the need for altered standards of care. Communities need to designate sites (whether in hospital or in alternative care centers) for labor and delivery services as part of their disaster plan. Pregnant women and newborns are vulnerable groups during routine times and are expected to be disproportionately affected during a pandemic in terms of morbidity and mortality. Therefore, it is essential that hospitals and communities take steps to protect these vulnerable groups as part of the disaster planning process. It is not known whether or when a pandemic will occur, but perinatal and neonatal nurses should become familiar with avian influenza's clinical description and proper infection control procedures to halt potential disease spread.


title: Approach-aversion in calves following injections.

text: We assessed aversion to injections using an avoidance-learning paradigm. Holstein calves (n = 24) were randomly assigned to one of four routes of administration for 0.5 ml of saline: intramuscular (IM), intranasal (IN), subcutaneous (SC) and a null control. Calves were first trained to approach a milk reward of 1 L. Once the latency to approach the reward was consistent, calves received their assigned treatment when approaching the bottle. For the first 3 treatment sessions calves received a 1 L milk reward. This reward was then reduced to 500 mL, and then to 250 mL, and finally to 0 mL, each for 3 sessions. Compared to control calves, calves receiving the intramuscular injections showed a longer latency to approach the milk reward, but only when the milk reward was 0.25 L (P = 0.05) and 0 L (P < 0.01). Calves receiving the intranasal injections showed longer latencies relative to the controls only for the 0 L reward (P = 0.01). Calves receiving the subcutaneous injections did not differ from controls for any of the milk rewards (P > 0.2). We conclude that IM injections are aversive and that SC and IN routes are a refinement to be considered when feasible.


title: Quiescent variability of cerebral, renal, and splanchnic regional tissue oxygenation in very low birth weight neonates.

text: OBJECTIVE In extremely premature neonates, data concerning the normal baseline variability of near-infrared spectroscopy (NIRS)-derived regional oxygen saturation (rSO2) are lacking. We sought to determine: 1) the quiescent variability of cerebral, renal, and splanchnic rSO2 in clinically stable, undisturbed very low birth weight neonates and 2) the effects of different data averaging epochs on site-specific variability. STUDY DESIGN In this prospective, observational study, neonates between 500 and 1250 g underwent seven days of continuous, real-time cerebral, renal, and splanchnic NIRS monitoring starting within the first seventy-two postnatal hours. Demographic, cardiopulmonary, bedside care, and rSO2 data were collected. rSO2 variability was analyzed utilizing data from quiescent periods identified using pre-specified stability criteria. Between- and within-monitoring site comparisons of data averaging methods were made utilizing ANOVA. RESULT Twenty-four subjects (GA 27 ± 0.3 wk, birth weight 988 ± 34 g; mean ± SEM) were monitored. Coefficients of variation (CoVar = SD/mean) were calculated for each monitoring site using varied data averaging epochs. CoVar was lowest for cerebral, intermediate for renal, and highest for splanchnic rSO2 (P < 0.01). For renal and splanchnic sites, shorter epochs (5- and 15-min) resulted in significantly smaller CoVars [P < 0.01 and P < 0.05, respectively]. Splanchnic variability was highly dependent on epoch length, ranging from 16% over 5 min to 23% over 60 min. CONCLUSION 1) rSO2 variability differs significantly between monitoring sites and 2) shorter data sampling epochs decrease rSO2 variability. These observations may assist clinicians in operationally defining minimally significant departures to enable medical decision making utilizing this monitoring technique.


Role of HIV-1 Tat in AIDS pathogenesis: its effects on cytokine dysregulation and contributions to the pathogenesis of opportunistic infection.


title: A randomized, multi-center, prospective study comparing best medical treatment versus best medical treatment plus renal artery stenting in patients with hemodynamically relevant atherosclerotic renal artery stenosis (RADAR) - one-year results of a pre-maturely terminated study.

text: BACKGROUND The indications for conservative "best medical treatment" (BMT) versus additional renal artery stenting are a matter of ongoing debate. The RADAR study aimed to evaluate the impact of percutaneous renal artery stenting on the impaired renal function in patients with hemodynamically significant atherosclerotic renal artery stenosis (RAS). METHODS RADAR is an international, prospective, randomized (1:1) controlled study comparing BMT alone versus BMT plus renal artery stenting in patients with duplex sonographic hemodynamically relevant RAS. Follow-up assessments were at 2, 6, and 12 months and at 3 years. The primary endpoint was change in estimated glomerular filtration rate (eGFR) at 12 months. RESULTS Due to slow enrollment, RADAR was terminated early after inclusion of 86 of the scheduled 300 patients (28.7%). Change in eGFR between baseline and 12 months was 4.3 ± 15.4 ml/min/1.73 m2 (stent group) and 3.0 ± 14.9 ml/min/1.73 m2 (BMT group), p > 0.999. Clinical event rates were low with a 12-month composite of cardiac death, stroke, myocardial infarction, and hospitalization for congestive heart failure of 2.9% in the stent and 5.3% in the BMT group, p = 0.526, and a 3-year composite of 14.8% and 12.0%, p = 0.982. At 3 years, target vessel (re-)vascularization occurred in one patient (3.0%) in the stent group and in 8 patients (29.4%) in the BMT group. CONCLUSION In RADAR, outcomes of renal artery stenting were similar to BMT. These results have to be interpreted with the caveat that the study did not reach its statistically based sample size. TRIAL REGISTRATION Clinicaltrials.gov, NCT00640406. Registered on 17 March 2008.


title: Transanal Endoscopic Operation Versus Conventional Transanal Excision for Rectal Tumors: Case-Matched Study with Propensity Score Matching.

text: BACKGROUNDS Although transanal endoscopic surgery is practiced worldwide, there is no consensus on comparative outcomes between transanal endoscopic operation (TEO) and transanal excision (TAE). In this study, we reviewed our experiences with these techniques and compared patients who underwent TEO and TAE using propensity score matching (PSM). METHODS A total of 207 patients underwent local rectal tumor excision between January 2008 and November 2015. To overcome selection bias, we used PSM to achieve a one-to-one TEO: TAE ratio. We included baseline characteristics, age, sex, surgeon, American Society of Anesthesiologists score, tumor location (clockwise direction), involved circumference quadrants, tumor size, and pathology. RESULTS After PSM, 72 patients were included in each group. The tumor distance from the anal verge was higher in the TEO group (8.0 [5-10] vs. TAE: 4.0 [3-5], p < 0.001). Complication rates did not differ between the groups (TEO: 8.3% vs. TAE: 11.1%, p = 0.39). TEO was associated with a shorter hospital stay (3.01 vs. 4.68 days, p = 0.001), higher negative margin rate (95.8 vs. 86.1%, p = 0.039), and non-fragmented specimen rate vs. TAE (98.6 vs. 90.3%, p = 0.029). CONCLUSIONS TEO was more beneficial for patients with higher rectal tumors. Regardless of tumor location, involved circumference quadrants, and tumor size, TEO may more effectively achieve negative resection margins and non-fragmented specimens. Consequently, although local excision method according to tumor distance may be important, TEO will become the standard for rectal tumors.


title: Effective endovascular treatment of calcified femoropopliteal disease with directional atherectomy and distal embolic protection: final results of the DEFINITIVE Ca⁺⁺ trial.

text: OBJECTIVES The purpose of the DEFINITIVE Ca(++) study was to evaluate the safety and effectiveness of directional atherectomy and distal embolic protection, used together to treat moderate to severely calcified femoropopliteal lesions. BACKGROUND Despite advances in endovascular treatment modalities, treatment of calcified lesions remains a challenge. METHODS A total of 133 subjects with 168 moderate to severely calcified lesions were enrolled. Lesions were treated with directional atherectomy devices, coupled with distal embolic protection. RESULTS The 30-day freedom from MAE rate was 93.1%. Per angiographic core laboratory assessment, the primary effectiveness endpoint (≤50% residual diameter stenosis) was achieved in 92.0% (lower confidence bound of 87.6%) of lesions. By core lab analysis, these results did not achieve the success criteria (90%) for the primary effectiveness objective. Per site assessment, the objective was met with the endpoint being achieved in 97.0% (lower confidence bound 93.8%). A mean residual diameter stenosis of 33.3% was achieved with the directional atherectomy device. This was further decreased to 24.1% with the use of adjunctive therapy. The proportion of asymptomatic subjects [Rutherford Clinical Category (RCC) = 0] increased from 0% at baseline to 52.3% at the 30-day follow-up visit. In total, 88.5% of subjects experienced an improvement of one or more Rutherford categories. CONCLUSIONS The results of the DEFINITIVE Ca++ study demonstrate that the SilverHawk and TurboHawk atherectomy devices are safe and effective in the endovascular treatment of moderate to severely calcified lesions in the superficial femoral and/or popliteal arteries when used with the SpiderFX distal embolic protection device.


title: Dynamics of a Global Zoonotic Research Network Over 33 Years (1980-2012).

text: OBJECTIVE The increasing rate of outbreaks in humans of zoonotic diseases requires detailed examination of the education, research, and practice of animal health and its connection to human health. This study investigated the collaboration network of different fields engaged in conducting zoonotic research from a transdisciplinary perspective. METHODS Examination of the dynamics of this network for a 33-year period from 1980 to 2012 is presented through the development of a large scientometric database from Scopus. In our analyses we compared several properties of these networks, including density, clustering coefficient, giant component, and centrality measures over time. We also elicited patterns in different fields of study collaborating with various other fields for zoonotic research. RESULTS We discovered that the strongest collaborations across disciplines are formed among the fields of medicine; biochemistry, genetics, and molecular biology; immunology and microbiology; veterinary; agricultural and biological sciences; and social sciences. Furthermore, the affiliation network is growing overall in terms of collaborative research among different fields of study such that more than two-thirds of all possible collaboration links among disciplines have already been formed. CONCLUSIONS Our findings indicate that zoonotic research scientists in different fields (human or animal health, social science, earth and environmental sciences, engineering) have been actively collaborating with each other over the past 11 years.


title: A theoretical framework for interaction of nursing discipline with genetics and genomics.

text: Background Since the completion of the Human Genome Project, health science has been strongly influenced by the advances in genetics and genomics. However, the progress of embracing genetics and genomics into nursing discipline is limited. One of the main barriers is lack of understanding on the relevancy of genetics and genomics to nursing discipline. Objectives This paper aims to synthesize and develop a theoretical framework for the interaction of nursing discipline with genetics and genomics. Methods Through content analysis and constant comparative method, a theoretical framework was developed from synthesis of the studies regarding nursing and genetics/genomics indexed in multiple English and Chinese databases. Results Four main theoretical statements were constructed in the framework: 1) There are three ways to show how genetics and genomics can influence nursing discipline: a new specialty, new technologies and a new lens; 2) The significant contribution of nursing discipline to genetics and genomics lies in how nurses could focus on the association between human responses and genes and how nurses could advocate for their clients in the genetic and genomic era; 3) A paradigm shift occurs after a constant interaction of nursing discipline with genetics and genomics; 4) Implementation strategies could be used to facilitate the integration of genetics and genomics to nursing discipline and advance the paradigm shift. Conclusions The framework will help to understand the relationship between nursing discipline and genetics and genomics and implicate the future studies integrating genetics and genomic science into nursing discipline.


Classify viruses - the gain is worth the pain.


title: Medical management of eosinophilic meningitis following bovine graft duraplasty for Chiari malformation Type I repair: case report.

text: Eosinophilic meningitis is a known complication of duraplasty, including that using bovine tissues. Previous authors have relied on surgical removal of the graft for treatment. Authors of the present report describe a 7-year-old girl with eosinophilic meningitis following duraplasty with a bovine pericardium graft who was successfully treated using corticosteroid therapy alone.


Five reasons why data on compassionate use of remdesivir deserved publication (and are worth reading).


title: Remote allergen exposure elicits eosinophil infiltration into allergen nonexposed mucosal organs and primes for allergic inflammation.

text: The natural history of allergic diseases suggests bidirectional and progressive relationships between allergic disorders of the skin, lung, and gut indicative of mucosal organ crosstalk. However, impacts of local allergic inflammation on the cellular landscape of remote mucosal organs along the skin:lung:gut axis are not yet known. Eosinophils are tissue-dwelling innate immune leukocytes associated with allergic diseases. Emerging data suggest heterogeneous phenotypes of tissue-dwelling eosinophils contribute to multifaceted roles that favor homeostasis or disease. This study investigated the impact of acute local allergen exposure on the frequency and phenotype of tissue eosinophils within remote mucosal organs. Our findings demonstrate allergen challenge to skin, lung, or gut elicited not only local eosinophilic inflammation, but also increased the number and frequency of eosinophils within remote, allergen nonexposed lung, and intestine. Remote allergen-elicited lung eosinophils exhibited an inflammatory phenotype and their presence associated with enhanced susceptibility to airway inflammation induced upon subsequent inhalation of a different allergen. These data demonstrate, for the first time, a direct effect of acute allergic inflammation on the phenotype and frequency of tissue eosinophils within antigen nonexposed remote mucosal tissues associated with remote organ priming for allergic inflammation.


title: Thromboaspiration technique as first approach for endovascular treatment of acute ischemic stroke: initial experience at nine Italian stroke centers.

text: BACKGROUND AND PURPOSE Aspiration thrombectomy of large vessel occlusions has made a comeback among recanalization techniques thanks to recent advances in catheter technology resulting in faster recanalization and promising clinical results when used either alone or as an adjunct to stent retriever. This multicenter retrospective study reports angiographic data, complications, and clinical outcome in patients treated with aspiration thrombectomy as the first-line option. MATERIALS AND METHODS We analysed the clinical and procedural data of patients treated from January 2014 to March 2015. Recanalization was assessed according to the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 3 months. RESULTS Overall, 152 patients (mean age 68 years) were treated. Sites of occlusion were 90.8% anterior circulation (including 16.4% tandem extracranial/intracranial occlusions) and 9.2% basilar artery. In 79 patients administration of intravenous tissue plasminogen activator was attempted. Recanalization of the target vessel was obtained in 115/152 cases (75.6%) whereas direct aspiration alone was successful in 83/152 cases (54.6%) with an average puncture to revascularization time of 44.67 min. Symptomatic intracranial hemorrhage occurred in 7.8% and embolization to new territories in 1.9%. 77 patients (50.6%) had a good outcome at 90-day follow-up: 55/96 in the direct aspiration alone group and 22/56 in the aspiration-stent retriever group. CONCLUSIONS Direct aspiration thrombectomy appears a feasible technique with good revascularization results achieved in more than half the patients. In light of the self-reported data, inhomogeneous patient selection, absence of a core imaging laboratory, and a non-standardized approach, the results should be validated in a larger trial.


Endovascular coils for cerebral aneurysm: HELPS has arrived.


Question 2. Should carbon dioxide detectors be used to check correct placement of endotracheal tubes in preterm and term neonates?


COVID-19 on cruise ships: preventive quarantine or abandonment of patients?


title: Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report.

text: BACKGROUND Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system. CASE PRESENTATION A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion. CONCLUSIONS This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy.


title: Influenza A virus replication induces cell cycle arrest in G0/G1 phase.

text: Many viruses interact with the host cell division cycle to favor their own growth. In this study, we examined the ability of influenza A virus to manipulate cell cycle progression. Our results show that influenza A virus A/WSN/33 (H1N1) replication results in G(0)/G(1)-phase accumulation of infected cells and that this accumulation is caused by the prevention of cell cycle entry from G(0)/G(1) phase into S phase. Consistent with the G(0)/G(1)-phase accumulation, the amount of hyperphosphorylated retinoblastoma protein, a necessary active form for cell cycle progression through late G(1) into S phase, decreased after infection with A/WSN/33 (H1N1) virus. In addition, other key molecules in the regulation of the cell cycle, such as p21, cyclin E, and cyclin D1, were also changed and showed a pattern of G(0)/G(1)-phase cell cycle arrest. It is interesting that increased viral protein expression and progeny virus production in cells synchronized in the G(0)/G(1) phase were observed compared to those in either unsynchronized cells or cells synchronized in the G(2)/M phase. G(0)/G(1)-phase cell cycle arrest is likely a common strategy, since the effect was also observed in other strains, such as H3N2, H9N2, PR8 H1N1, and pandemic swine H1N1 viruses. These findings, in all, suggest that influenza A virus may provide favorable conditions for viral protein accumulation and virus production by inducing a G(0)/G(1)-phase cell cycle arrest in infected cells.


title: Vascular geometry of the extracranial carotid arteries: an analysis of length, diameter, and tortuosity.

text: BACKGROUND Stable access is essential for successful intracranial interventions. Quantifying variations in extracranial carotid arteries may help in the selection and development of access catheters. This study describes the vascular dimensions from the aortic arch to the skull base. METHODS CT angiography analysis was performed on 100 patients. The lengths, diameters, and tortuosity of the common carotid artery (CCA) and internal carotid artery (ICA) were measured from the aortic arch to the skull base. RESULTS The mean±SD length of the carotid artery from the aortic arch to the skull base was 22.2±2.2 cm for the right side and 20.8±1.9 cm for the left side (p<0.0001). The length of the right CCA was 13.6±1.2 cm and the length of the left CCA was 12.4±1.4 cm (p<0.0001). The length of the right ICA was 8.6±1.4 cm compared with 8.4±1.4 cm for the left ICA (p=0.3). The ICA length in men and women was 8.9±1.3 cm and 8.2±1.3 cm, respectively (p=0.0001), and the CCA length in men and women was 13.6±1.5 cm and 12.3±1.6 cm, respectively (p<0.0001). The lengths of the CCA and ICA in patients aged ≥60 years were 13.3±1.7 cm and 8.9±1.5 cm, respectively compared with 12.8±1.7 cm and 8.2±1.1 cm, respectively, for patients aged <60 years (p=0.04 for CCA, p=0.0002 for ICA). Tortuosity of the CCA and ICA was 1.2±0.2 and 1.3±0.1, respectively, in patients aged ≥60 years compared with 1.1±0.1 for both the ICA and CCA in patients aged <60 years (p<0.0001 for both). There was a consistent ratio of CCA/ICA length of 1.6±0.3 on the right and 1.5±0.3 on the left (p<0.0001). The arterial diameters did not show any significant difference. CONCLUSIONS The distance from the aortic arch to the skull base is longer on the right than on the left side. Both the CCA and ICA are longer in men and in patients aged ≥60 years. The tortuosity of both segments significantly increases with age.


title: Positive RT-PCR in urine from an asymptomatic patient with novel coronavirus 2019 infection: a case report.

text: Introduction: With the emergence of novel coronavirus disease 2019 (COVID-19) in many countries, medical resources currently focus on the treatment of confirmed patients and screening of suspected cases. Asymptomatic patients may be contagious, which makes epidemic control difficult. We describe an asymptomatic patient with a positive real-time polymerase chain reaction (RT-PCR) test in urine.Case report: An asymptomatic girl was identified during the epidemiological investigation of a confirmed COVID-19 patient. When admitted to the hospital on 24 February 2020, she had no clinical manifestations. A throat swab was negative for RT-PCR, but urine was positive. She was given antiviral and symptomatic supportive treatment. On 26 February, a throat swab RT-PCR was positive. RT-PCR in throat swabs and urine were negative on 3 and 5 March, and on 9 and 12 March, throat swabs were still negative. At follow-up on 26 March, she felt well, throat swab RT-PCR was negative, and isolation was lifted.Conclusion: The urine of asymptomatic patients may be contagious. RT-PCR in urine might be a useful supplement in screening when the RT-PCR is negative in throat swabs.


title: Cryo-electron tomography of mouse hepatitis virus: Insights into the structure of the coronavirion.

text: Coronaviruses are enveloped viruses containing the largest reported RNA genomes. As a result of their pleomorphic nature, our structural insight into the coronavirion is still rudimentary, and it is based mainly on 2D electron microscopy. Here we report the 3D virion structure of coronaviruses obtained by cryo-electron tomography. Our study focused primarily on the coronavirus prototype murine hepatitis virus (MHV). MHV particles have a distinctly spherical shape and a relatively homogenous size ( approximately 85 nm envelope diameter). The viral envelope exhibits an unusual thickness (7.8 +/- 0.7 nm), almost twice that of a typical biological membrane. Focal pairs revealed the existence of an extra internal layer, most likely formed by the C-terminal domains of the major envelope protein M. In the interior of the particles, coiled structures and tubular shapes are observed, consistent with a helical nucleocapsid model. Our reconstructions provide no evidence of a shelled core. Instead, the ribonucleoprotein seems to be extensively folded onto itself, assuming a compact structure that tends to closely follow the envelope at a distance of approximately 4 nm. Focal contact points and thread-like densities connecting the envelope and the ribonucleoprotein are revealed in the tomograms. Transmissible gastroenteritis coronavirion tomograms confirm all the general features and global architecture observed for MHV. We propose a general model for the structure of the coronavirion in which our own and published observations are combined.


title: Tourniquet parent artery occlusion after flow diversion.

text: BACKGROUND The Pipeline Embolization Device (PED) is increasingly used for both on- and off-label purposes for treatment of intracranial aneurysms. The device gradually slows flow of blood into the aneurysm, but the high metal coverage of PED promotes endothelialization of the device. Occasionally, this leads to in-stent stenosis that is clinically well tolerated. We present a multi-institutional Pipeline series that includes three cases of gradual asymptomatic occlusion within the PED and parent vessel. METHODS Institutional databases at each participating center were searched for patients treated with the PED. Patients with at least 50% stenosis or occlusion were selected and all relevant clinical and radiographic data were reviewed. RESULTS A total of 326 cases performed by five neurointerventionalists across four institutions were reviewed. Among these there were three cases of complete occlusion and two cases of stenosis of more than 50%, for an occlusion rate of 0.9%. All patients were clinically asymptomatic. CONCLUSIONS A gradual tourniquet-like occlusion can occur following placement of the PED, leading to vessel occlusion. This has been clinically well tolerated by patients in our series due to the formation of pial collaterals as the stenosis progresses, likely due to ischemic preconditioning. Small parent vessel, pre-existing stenosis, fusiform pathology, overlapping devices, and suboptimal antiplatelet therapy seem to be predisposing factors. Further experience and follow-up will allow us to characterize the risk factors and optimize post-procedural therapy for these patients.


Recommendations for Faculty and Expected Student Etiquette in an Online Environment During the Global COVID-19 Pandemic and Beyond.


title: Laparoscopic stapled excision of non-parasitic splenic cysts.

text: BACKGROUND A laparoscopic spleen preserving surgical approach is preferred for the management of symptomatic non-parasitic splenic cysts. The aim of this study was to review our experience with managing this rare presentation. METHODS A retrospective review of all cases of splenic cysts was performed over a 10-year period (2001-2011). Demographic data, clinical history, investigations, operative details and the outcome of each case were reviewed with an emphasis on patients who underwent laparoscopic stapled cyst excision. RESULTS Eleven cases were identified. Seven patients were managed surgically; six by laparoscopic stapled cyst excision and one by open excision of remnant splenic tissue. Laparoscopic management was successful in all six cases and radiological and clinical follow-up (median: 28 months) revealed no evidence of cyst recurrence in five of six cases. One patient developed an asymptomatic, non-progressing and small recurrent anterior cyst and she continues to be observed. CONCLUSION Laparoscopic stapled splenic cyst excision can be performed safely and is particularly effective for large superficial non-parasitic cysts. This technique allows spleen preservation with a low cyst recurrence rate. However, it may not be suitable for deeper intraparenchymal splenic cysts. Further studies are required to refine the management of specific subtypes of non-parasitic splenic cysts.


title: [Risk communication during the COVID-19 pandemic: lessons for lifestyle interventions in cardiovascular prevention].

text: Lifestyle is a cornerstone of cardiovascular prevention and the process of risk communication constitutes an important step to obtain favorable changes in daily habits. Nevertheless, there is no definite consensus on how health operators should provide information on cardiovascular risk, and several models have been proposed in different settings. The current COVID-19 pandemic - with related communication strategies to reduce the spread of the disease and morbidity - may offer an interesting opportunity to reconsider communication in cardiovascular prevention: even though cardiovascular conditions are not communicable diseases, both COVID-19 and cardiac illnesses force a huge segment of the population to major lifestyle changes. This narrative commentary describes similarities between these conditions, mainly focusing on modalities of risk communication, strategies to counteract fake news, actions to enhance the expertise of health operators, and finally on new skills that could derive as a lesson from COVID-19.


title: Exosomes Derived From Bone Marrow Mesenchymal Stem Cells as Treatment for Severe COVID-19.

text: This prospective, non-randomized, open-label, cohort study addresses the safety and efficacy of exosomes (ExoFlo™) derived from allogeneic bone marrow mesenchymal stem cells as treatment for severe COVID-19. During April 2020, ExoFlo was provided to 24 SARS-CoV-2 PCR positive patients at a single hospital center, all of whom met criteria for severe COVID-19 as well as moderate to severe Acute Respiratory Distress Syndrome (ARDS). Patients received a single 15 mL intravenous dose of ExoFlo and were evaluated for both safety and efficacy day 1-14 post-treatment. All safety endpoints were met with no adverse events observed within 72 hours of ExoFlo administration. A survival rate of 83% was observed. 17/24 (71%) of the patients recovered; 3/24 (13%) remained critically ill though stable; 4/24 (16%) expired for reasons unrelated to the treatment. Overall, after one treatment, patients' clinical status and oxygenation improved with an average PaO2/FiO2 ratio increase of 192% (p < 0.001). Laboratory values revealed significant improvements in absolute neutrophil count [mean reduction 32% [(p-value < 0.001)] and lymphopenia with average CD3+, CD4+ and CD8+ lymphocyte counts increasing by 46% (p < 0.05), 45% (p < 0.05), and 46% (p < 0.001), respectively. Likewise, acute phase reactants declined, with mean C-reactive protein (CRP), Ferritin, and D-dimer reduction of 77% (p < .001), 43% (p < .001), 42% (p <0.05), respectively. In conclusion, due to its safety profile, capacity to restore oxygenation, downregulate cytokine storm, and reconstitute immunity, ExoFlo is a promising therapeutic candidate for severe COVID-19. Future RCTs are needed to determine ExoFlo therapeutic potential.


title: Minimally invasive delivery of a novel direct epicardial assist device in a porcine heart failure model.

text: OBJECTIVE Despite advances in design, modern ventricular assist device placement involves median sternotomy and cardiopulmonary bypass and is associated with infectious/embolic complications. In this study, we examine the feasibility and function of a novel minimally invasive, non-blood-contacting epicardial assist device in a porcine ischemic cardiomyopathy model. METHODS Feasibility was first tested in an ex vivo thoracoscopic trainer box with slaughterhouse hearts. Five male Yorkshire swine underwent selective ligation of the circumflex artery to create a posterolateral infarct Twelve weeks after infarct, all animals underwent left minithoracotomy. A custom inflatable bladder was positioned over the epicardial surface of the infarct and firmly secured to the surrounding border zone myocardium with polypropylene mesh and minimally invasive mesh tacks. An external gas pulsation system actively inflated and deflated the bladder in synchrony with the cardiac cycle. All animals then underwent cardiac magnetic resonance imaging to assess ventricular function. RESULTS All subjects successfully underwent off-pump placement of the epicardial assist device via minithoracotomy. Ejection fraction significantly improved from 29.1% ± 4.8% to 39.6% ± 4.23% (P < 0.001) when compared with pretreatment. End-systolic volume decreased (76.6 ± 13.3 mL vs 62.4 ± 12.0 mL, P < 0.001) and stroke volume increased (28.6 ± 3.4 mL vs 37.9 ± 3.1 mL, P < 0.05) when assisted. No change was noted in end-diastolic volume (105.1 ± 11.4 vs 100.3 ± 12.7). On postmortem examination, mesh fixation and device position were excellent in all cases. No adverse events were encountered. CONCLUSIONS Directed epicardial assistance improves ventricular function in a porcine ischemic cardiomyopathy model and may provide a safe alternative to currently available ventricular assist device therapies. Further, the technique used for device positioning and fixation suggests that an entirely thoracoscopic approach is possible.


title: Effective management of patients with diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team.

text: A longitudinal observational study on a convenience sample was conducted between 4 January and 31 December of 2010 to evaluate clinical outcomes that occur when a new Interprofessional Diabetes Foot Ulcer Team (IPDFUT) helps in the management of diabetes-related foot ulcers (DFUs) in patients living in a small urban community in Ontario, Canada. Eighty-three patients presented to the IPDFUT with 114 DFUs of average duration of 19·5 ± 2·7 weeks. Patients were 58·4 ± 1·4 years of age and 90% had type 2 diabetes, HbA1c of 8·3 ± 2·0%, with an average diabetes duration of 22·3 ± 3·4 years; in 69% of patients, 78 DFUs healed in an average duration of 7·4 ± 0·7 weeks, requiring an average of 3·8 clinic visits. Amputation of a toe led to healing in three patients (4%) and one patient required a below-knee amputation. Six patients died and three withdrew. Adding a skilled IPDFUT that is trained to work together resulted in improved healing outcomes. The rate of healing, proportion of wounds closed and complication rate were similar if not better than the results published previously in Canada and around the world. The IPDFUT appears to be a successful model of care and could be used as a template to provide effective community care to the patients with DFU in Ontario, Canada.


Sedation vs Intubation for Patients With Acute Stroke Undergoing Thrombectomy.


Continuous non-invasive cardiac output monitoring during exercise: validation of electrical cardiometry with Fick and thermodilution methods.


title: Racial and Ethnic Health Services Disparities in Pediatric Anesthesia Practice: A Scoping Review.

text: Racial and ethnic disparities in pediatric anesthesia health services could result in minority children being at increased risk of poor outcomes, such as pain, anxiety, or over-exposure to medications. Yet, a comprehensive understanding of the literature on such disparities does not exist to date. The objective of this study is to describe health services disparities in pediatric anesthetic care in the pre-, intra-, or post-operative period by synthesizing current literature. We searched the National Library of Medicine's PubMed/Medline, Embase, and Web of Science for articles published between January 1, 2007, and May 9, 2020, to identify literature on racial and ethnic health services disparities in pediatric anesthesia. We used the Institute of Medicine's definition of disparities. Health services were related to pre-, intra-, or post-operative anesthetic care of pediatric patients (< 18 years old). Out of 2110 studies, 10 studies met the criteria for inclusion. Nine out of the ten articles were single-institutional observational studies, based at tertiary hospitals. Sample sizes ranged from 74 to 37,618 discrete participants, for a total of 69,350 subjects across all studies. Results of these studies present low-quality evidence and heterogeneous conclusions regarding pediatric anesthesia health services disparities. This review demonstrates the paucity and diversity of research on racial and ethnic disparities in pediatric anesthesia health services and suggests how future work might utilize improved data and rigorous study designs.


title: Retrograde access to the posterior inferior cerebellar artery in balloon-assisted coiling of posterior inferior cerebellar artery aneurysms.

text: INTRODUCTION Balloon-assisted coil embolization of proximal posterior inferior cerebellar artery (PICA) aneurysms may be limited by the inferiorly oriented, acutely angulated origin of the PICA from the vertebral artery. The aim of this study is to evaluate retrograde access to the PICA via the contralateral vertebral artery or the posterior communicating artery. METHODS Twenty-nine proximal PICA aneurysms treated by balloon remodeling with navigation of the balloon in the PICA via the contralateral vertebral artery or posterior communicating artery were found in our database between January 2007 and December 2013 and were reviewed. RESULTS Access to the PICA was made via the contralateral vertebral artery in 26 patients (90%), six of them (23%) with a hypoplastic V4 segment. In three patients (10%) the retrograde approach was made via the posterior communicating artery. After balloon remodeling, additional stenting was performed in 16 patients (55%). The complication rate was 3% (1 acute stent thrombosis). Grade 0 or 1 occlusion was obtained in all patients at completion angiography. No recurrence was found during follow-up. CONCLUSIONS Retrograde access to the PICA to perform balloon-assisted coil embolization of proximal PICA aneurysms with or without additional stenting after coiling is safe and effective. Hypoplastic V4 segment of the contralateral vertebral artery is not a contraindication.


title: IMAGING DIAGNOSIS-USE OF RADIOGRAPHY, COMPUTED TOMOGRAPHY, AND ENDOSCOPY IN THE DIAGNOSIS OF ESOPHAGEAL PERFORATION BY AN EXTRA-LUMINAL TRACHEAL RING PROSTHESIS IN A GOLDEN RETRIEVER.

text: A 6-year-old neutered male, Golden retriever presented with regurgitation and excitement-induced coughing. Two years prior, extra-thoracic tracheal collapse was diagnosed and extra-luminal tracheal ring prostheses were placed. Radiographs at presentation showed mineralized and undulant cervical tracheal cartilages. A dorsally broad-based soft tissue opacity bulged into the caudal cervical tracheal lumen. Esophageal dysmotility and barium accumulation were identified at this level on contrast esophography. Computed tomography showed migration of a prosthetic tracheal ring, resulting in perforation of the esophagus. Hair, foreign material, and dynamic tracheal narrowing were identified on esophagoscopy and tracheoscopy, respectively. Esophagostomy and foreign body removal were performed.