title: Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight.

text: BACKGROUND The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions. OBJECTIVES To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting-list control, no treatment, or an attention placebo control group. SEARCH METHODS In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self- and parent-reported outcomes. DATA COLLECTION AND ANALYSIS Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single-study and multiple-study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single-study outcomes. MAIN RESULTS We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster-RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school-aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school-aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events.Compared to standard practice, analyses of physical activity-only interventions suggested high-quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after-school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI -0.04 to 1.01; 2 studies, 255 children, moderate-quality evidence) and for reading was 0.10 (95% CI -0.30 to 0.49; 2 studies, 308 children, moderate-quality evidence). The MD for inhibition control was -1.55 scale points (95% CI -5.85 to 2.75; scale range 0 to 100; SMD -0.15, 95% CI -0.58 to 0.28; 1 study, 84 children, very low-quality evidence). No data were available for average achievement across subjects taught at school.There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI -36.83 to 24.09; scale mean 500, scale SD 70; SMD -0.18, 95% CI -0.93 to 0.58; 1 study, 31 children, low-quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI -0.19 to 0.22; 3 studies, 384 children, very low-quality evidence), for reading achievement SMD 0.00 (95% CI -0.24 to 0.24; 2 studies, 284 children, low-quality evidence), and for inhibition control SMD -0.67 (95% CI -1.50 to 0.16; 2 studies, 110 children, very low-quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions.There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low-quality evidence), but not with overweight. Replacing packed school lunch with a nutrient-rich diet in addition to nutrition education did not improve mathematics (MD -2.18, 95% CI -5.83 to 1.47; scale range 0 to 69; SMD -0.26, 95% CI -0.72 to 0.20; 1 study, 76 children, low-quality evidence) and reading achievement (MD 1.17, 95% CI -4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI -0.35 to 0.61; 1 study, 67 children, low-quality evidence). AUTHORS' CONCLUSIONS Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community-based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school-based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes.


Severe COVID-19-associated pneumonia in 3 patients with systemic sclerosis treated with rituximab.


title: Preliminary results of a new test for rapid diagnosis of septic arthritis with use of leukocyte esterase and glucose reagent strips.

text: BACKGROUND Most currently used tools to diagnose septic arthritis are either not readily available or fail to provide real-time results. Reagent strip tests have identified infections in various body fluids. We hypothesized that combined leukocyte esterase and glucose strip tests can aid in diagnosing septic arthritis in native synovial fluid because (1) leukocyte esterase concentrations would be elevated at the infection site because of secretion by recruited neutrophils, and (2) glucose concentrations would be reduced because of bacterial metabolism. METHODS We prospectively investigated synovial fluid from consecutive patients with an atraumatic joint effusion who underwent arthrocentesis in our emergency department during a one-year period. Leukocyte esterase and glucose strip tests were performed on the synovial fluid. Synovial fluid leukocyte count, crystal analysis, Gram staining, culture, and glucose concentration results were also assessed. RESULTS Nineteen fluids were classified as septic and 127 as aseptic. Considering septic arthritis to be present when the leukocyte esterase reading was positive (++ or +++) and the glucose reading was negative (-) yielded a sensitivity of 89.5% (95% confidence interval [CI], 66.9% to 98.7%), specificity of 99.2% (95% CI, 95.7% to 99.9%), positive predictive value of 94.4% (95% CI, 72.7% to 99.9%), negative predictive value of 98.4% (95% CI, 94.5% to 99.8%), positive likelihood ratio of 114, and negative likelihood ratio of 0.11. The synovial leukocyte counts and polymorphonuclear cell percentages were consistent with the semiquantitative readings on the leukocyte esterase strip tests, and the glucose concentrations were consistent with the glucose strip test results. CONCLUSIONS Combined leukocyte esterase and glucose strip tests can be a useful additional tool to help confirm or rule out a diagnosis of septic arthritis.


title: Nursing leadership in disaster preparedness and response.

text: Nurses serve as leaders in disaster preparedness and response at multiple levels: within their own homes and neighborhoods, at disaster scenes, and the workplace, which can vary from a health care facility, in the community, or at the state, national, or international level. This chapter provides an overview on theories of leadership with a historical context for nursing leadership; setting the context for nursing leadership in disaster preparedness and response. Although few research studies exist, there are numerous examples of nurses who provide leadership for disaster preparedness and response. To define the current state of the science, the research studies cited in this chapter are supplemented with case studies from particular disasters. The major finding of this review is that nursing leadership in disaster preparedness and response is a field of study that needs to be developed.


title: Direct eyelid defect closure: a prospective study of functional and aesthetic outcomes.

text: BACKGROUND/OBJECTIVES Direct closure (DC) of eyelid defects has been retrospectively shown to give excellent outcomes. We present prospective outcome data as further evidence to promote its wider use. SUBJECTS AND METHODS A consecutive, unselected, series of patients undergoing eyelid tumour resection was studied prospectively. DC was attempted at the time of biopsy in all of them. If DC proved impossible, delayed reconstruction using other techniques was later performed. Defect size, pre- and post-operative palpebral aperture (PA) measurements and the final visit patients' and surgeons' satisfaction scores for function and appearance were recorded. RESULTS Seventy-three eyelids of 70 patients were studied. Mean resected specimen width was 16.4 mm (4-26 mm) in the DC group, versus 23.9 mm (11-42 mm) for other, non-DC reconstructions. Primary DC was achieved in 74% of this cohort. Mean final post-operative PA measurements in the DC group were 0.7 mm vertically (p = 0.003) and 0.8 mm horizontally (p = 0.009) less than preoperatively, but there was no statistical difference (p = 0.1) in the final horizontal measurements between the operated and un-operated sides in the DC group. DC satisfaction scores were excellent for both eyelid function and appearance. CONCLUSIONS DC of eyelid defects, irrespective of per-operative PA distortion, gives excellent late post-operative outcomes. We recommend that DC, aligning the closure tension parallel to the lid margin, is attempted whenever wound margin approximation is possible in preference to alternative reconstruction techniques, regardless of any temporary PA distortion and globe displacement that this may cause. Eyelid function and appearance recover to near normal within 2 months.


title: Sole pathogen in acute bronchiolitis: is there a role for other organisms apart from respiratory syncytial virus?

text: BACKGROUND Acute bronchiolitis (AB) is a common disease of young children with peak incidence during the winter season. Respiratory syncytial virus (RSV) is a major causative organism, yet recent relatively small sized studies have suggested an increased role of other organisms as sole or codetected organisms. The aim of this study was to assess the prevalence of sole- and mixed-organisms infections in hospitalized children with AB, using combined antigen-based and polymerase chain reaction assays (PCR). METHODS Sputum or nasal wash specimens obtained from 490 previously healthy children < or =2 years of age hospitalized with AB between December 1, 2005 and March 31, 2006 were tested: (1) For RSV, by rapid antigen detection test; (2) For RSV, influenza A, B, Parainfluenza 1 to 3, and adenovirus antigens by direct fluorescent assay; (3) For influenza A and B, RSV, Parainfluenza 1 to 3 viruses RNA by reverse transcription (RT) PCR assay; (4) For human metapneumovirus and rhinovirus RNA by RT real-time PCR assay; (5) For adenovirus, and Bordetella pertussis DNA by conventional PCR assays; (6) For human bocavirus DNA by real-tine PCR assays. RESULTS At least 1 organism was detected in 465 (91%) children. In 283 (61%), 117 (25%), and 23 (5%) children, 1, 2, and 3/4 organisms were detected, respectively. The most commonly detected organism was RSV, detected in 76%, and as a sole organism in 49%. Rhinovirus, human metapneumovirus, influenza virus A, bocavirus, Bordetella pertussis, and adenovirus were detected as a sole organism in 7%, 2.1%, 1%, 0.6%, 0.6%, and 0.2% of the children, respectively. CONCLUSIONS Respiratory organisms were detected in the majority of the children, of whom about one third suffered from mixed organism infection. RSV was the most prevalent sole detected organism. The relevance of all other organisms may be much less than previously suggested.


Calcium urolithiasis in a breeding population of southern flounder (Paralichthys lethostigma) housed in a low salinity environment.


title: Site-Specific Hydrogen Exchange in a Membrane Environment Analyzed by Infrared Spectroscopy.

text: Hydrogen exchange is a powerful method to examine macromolecules. In membrane proteins, exchange can distinguish between solvent-accessible and -inaccessible residues due to shielding by the hydrophobic environment of the lipid bilayer. Herein, rather than examining which residues undergo hydrogen exchange, we employ a protocol that enables the full deuteration of all polar hydrogens in a membrane protein. We then measure the impact of hydrogen exchange on the shift of the amide I vibrational mode of individually labeled sites. The results enable us to correlate polarity with vibrational shifts, thereby providing a powerful tool to examine specific locations within a membrane protein in its native membrane environment.


The race for coronavirus vaccines: a graphical guide.


Covid-19: Lack of test and trace data are frustrating government scrutiny.


title: Influenza virus-cytokine-protease cycle in the pathogenesis of vascular hyperpermeability in severe influenza.

text: BACKGROUND Severe influenza is characterized by cytokine storm and multiorgan failure with edema. The aim of this study was to define the impact of the cytokine storm on the pathogenesis of vascular hyperpermeability in severe influenza. METHODS Weanling mice were infected with influenza A WSN/33(H1N1) virus. The levels of proinflammatory cytokines, tumor necrosis factor (TNF) alpha, interleukin (IL) 6, IL-1beta, and trypsin were analyzed in the lung, brain, heart, and cultured human umbilical vein endothelial cells. The effects of transcriptional inhibitors on cytokine and trypsin expressions and viral replication were determined. RESULTS Influenza A virus infection resulted in significant increases in TNF-alpha, IL-6, IL-1beta, viral hemagglutinin-processing protease trypsin levels, and viral replication with vascular hyperpermeability in lung and brain in the first 6 days of infection. Trypsin upregulation was suppressed by transcriptional inhibition of cytokines in vivo and by anti-cytokine antibodies in endothelial cells. Calcium mobilization and loss of tight junction constituent, zonula occludens-1, associated with cytokine- and trypsin-induced endothelial hyperpermeability were inhibited by a protease-activated receptor-2 antagonist and a trypsin inhibitor. CONCLUSIONS The influenza virus-cytokine-protease cycle is one of the key mechanisms of vascular hyperpermeability in severe influenza.


title: Rapid Detection of Respiratory Pathogens for Community-Acquired Pneumonia by Capillary Electrophoresis-Based Multiplex PCR.

text: Community-acquired pneumonia (CAP) is a common infectious disease linked to high rates of morbidity and mortality. Fast and accurate identification of the pathogens responsible for CAP will aid in diagnosis. We established a capillary electrophoresis-based multiplex PCR (CEMP) panel to enable the detection of viral and bacterial pathogens associated with CAP. The assay simultaneously detects and identifies the 13 common unculturable CAP viral and bacterial pathogens within 4 h. We evaluated the performance of a commercially available panel with 314 samples collected from CAP patients. We compared the results to those obtained with the liquid chip-based Luminex xTAG Respiratory Viral Panel (RVP) Fast Kit (for viruses) and the agarose gel-based Seegene PneumoBacter ACE Detection Kit (for atypical bacteria). All positive samples were further verified by the Sanger sequencing method. The sensitivity, specificity, positive predictive value, and negative predictive value of CEMP were 97.31%, 100%, 100%, and 99.85%, respectively. CEMP provides a rapid and accurate method for the high-throughput detection of pathogens in patients with CAP.


title: Evaluation of surgical performance during laparoscopic incisional hernia repair: a multicenter study.

text: BACKGROUND Laparoscopic incisional hernia repair (LIHR) is a common procedure requiring advanced laparoscopic skills. This study aimed to develop a procedure-specific tool to assess the performance of LIHR and to evaluate its reliability and validity. METHODS The Global Operative Assessment of Laparoscopic Skills-Incisional Hernia (GOALS-IH) is a 7-item global rating scale developed by experts to evaluate the steps of LIHR (placement of trocars, adhesiolysis, estimation of mesh size and shape, mesh orientation and positioning, mesh fixation, knowledge and autonomy in use of instruments, overall competence), each rated on a 5-point Likert scale. During LIHR, 13 attending surgeons and fellows experienced in minimally invasive surgery (MIS) and 19 novice surgeons (postgraduate years [PGYs], 3-5) were evaluated at four teaching hospitals by the attending surgeon, a trained observer, and self-assessment using GOALS-IH, and by a previously validated 5-item general laparoscopic rating scale (GOALS). Interrater reliability was assessed by intraclass correlation (ICC), and internal consistency of rating items was assessed by Cronbach's alpha. Known-groups construct validity was assessed by using the t-test and by correlating of the number of self-reported LIHR cases with the total score. Concurrent validity was assessed by correlating the GOALS-IH score with the GOALS general rating scale. Data are presented as mean and 95% confidence interval (CI). RESULTS Interrater reliability for the total GOALS-IH score was 0.79 (95% CI, 0.60-0.89) between observers and attending surgeons, 0.81 (95% CI, 0.58-0.92) between participants and attending surgeons, and 0.89 (95% CI, 0.76-0.96) between participants and observers. Internal consistency was high (Cronbach's alpha, 0.93). Experienced surgeons performed significantly better than novices as assessed by GOALS-IH (31; 95% CI, 29-33 vs. 21; 95% CI, 19-24; p < 0.01). Very good correlation was found between GOALS-IH and previous LIHR experience (r = 0.82; p < 0.01) and strong correlation between GOALS-IH and generic GOALS total scores (r = 0.90; p < 0.01). CONCLUSION Surgical performance during clinical LIHR can be assessed reliably using GOALS-IH. Results can be used to provide formative feedback to the surgeon and to identify steps of the operation that would benefit from specific educational interventions.


title: Transvaginal cholecystectomy learning curve.

text: BACKGROUND There are few surgeons in the United States, within private practice and academic centers, currently performing transvaginal cholecystectomies (TVC). The lack of exposure to TVC during residency or fellowship training, coupled with a poorly defined learning curve, further limits interested surgeons who want to apply this technique to their practice. This study describes the learning curve encountered during the introduction of TVC to our academic facility. METHODS This study is an analysis of consecutive TVCs performed between August 14, 2009 and August 3, 2012 at an academic center. The TVC patients were divided into sequential quartiles (n = 15/16). The learning curve outcome was measured as the operative time of TVC patients and compared to the operative time of female laparoscopic cholecystectomy (LC) patients performed during the same time period. RESULTS Sixty-one patients underwent a TVC with a mean age of 38 ± 12 years and mean BMI was 29 ± 6 kg/m(2). Sixty-seven female patients who underwent a LC with average age 41 ± 15 years and average BMI 33 ± 12 kg/m(2). The average operative time of LC patients and TVC patients was 48 ± 20 and 60 ± 17 min, respectively. Significant improvement in TVC operative times was seen between the first (n = 15 TVCs) and second quartiles (p = 0.04) and stayed relatively constant for third quartile, during which there was no statistically significant difference between the mean LC operative time for the second and third TVC quartiles CONCLUSIONS The learning curve of a fellowship-trained surgeon introducing TVC to their surgical repertoire, as measured by improved operative times, can be achieved with approximately 15 cases.


A Note to the JLD Community in Response to the Pandemic.


title: Combined infectious bronchitis virus Arkansas and Massachusetts serotype vaccination suppresses replication of Arkansas vaccine virus.

text: Polyvalent infectious bronchitis virus vaccination is common worldwide. The possibility of vaccine interference after simultaneous combined vaccination with Arkansas (Ark) and Massachusetts (Mass)-type vaccines was evaluated in an effort to explain the high prevalence of Ark-type infectious bronchitis virus in vaccinated chickens. Chickens ocularly vaccinated with combinations of Ark and Mass showed predominance of Mass vaccine virus before 9 days post-vaccination (DPV) in tears. Even when Mass and Ark vaccines were inoculated into separate eyes, Mass vaccine virus was able to outcompete Ark vaccine virus. Although Mass vaccine virus apparently had a replication advantage over Ark vaccine in ocular tissues, Ark vaccine virus appeared to have an advantage in spreading to and/or replicating in the trachea. When chickens vaccinated with Ark or Mass vaccine were housed together, Mass vaccine virus was able to spread to Ark-vaccinated chickens, but the Ark vaccine was not detected in Mass-vaccinated chickens. Only Mass vaccine was detected in tears of sentinel birds introduced into groups receiving both vaccines. Furthermore, Ark vaccine virus RNA was not detectable until 10 DPV in most tear samples from chickens vaccinated with both Ark and Mass vaccines at varying Ark vaccine doses, while high concentrations of Mass virus RNA were detectable at 3-7 DPV. In contrast, Ark vaccine virus replicated effectively early after vaccination in chickens vaccinated with Ark vaccine alone. The different replication dynamics of Ark and Mass viruses in chickens vaccinated with combined vaccines did not result in reduced protection against Ark challenge at 21 DPV. Further studies are needed to clarify if the viral interference detected determines differences in protection against challenge at other time points after vaccination.


Impact of Covid-19 on veterinary care.


title: Growing wealth and growing pains: child and adolescent psychiatry in Hong Kong, Malaysia and Singapore.

text: OBJECTIVE Several Asian regions have undergone a dramatic transformation, some becoming very affluent. This paper aims to ascertain how countries that are becoming wealthy have dealt with child and adolescent mental health issues. METHOD Population health status, child and adolescent mental health services, child psychiatry training, the number of child psychiatrists and related matters were examined in Hong Kong, Malaysia and Singapore. RESULTS Hong Kong, Malaysia and Singapore are ethnically, religiously, socially and politically very different. In spite of considerable wealth and a growing recognition that mental health problems in the young are increasing, they face similar problems--lack of access to treatment due to a dearth of services and a lack of child psychiatrists (2.5, 0.5 and 2.8 per million people, respectively). CONCLUSIONS Because the number of child psychiatrists is so small, their ability to provide services, advocate, train, maintain a professional identity, and deal with future crises is very limited. Other rapidly developing countries can learn from this experience and should take action early to prevent a similar outcome.


title: Robotic Single-Site® Sacrocolpopexy: First Report and Technique Using the Single-Site® Wristed Needle Driver.

text: The recently introduced da Vinci Single-Site® platform offers cosmetic benefits when compared with standard Multi-Site® robotic surgery. The innovative endowristed technology has increased the use of the da Vinci Single-Site® platform. The newly introduced Single-Site® Wristed Needle Driver has made it feasible to perform various surgeries that require multiple laparoscopic sutures and knot tying. Laparoscopic sacrocolpopexy is also a type of technically difficult surgery requiring multiple sutures, and there have been no reports of it being performed using the da Vinci Single-Site® platform. Thus, to the best of our knowledge, this is the first report of robotic single-site (RSS) sacrocolpopexy, and I found this procedure to be feasible and safe. All RSS procedures were completed successfully. The mean operative time was 122.17±22.54 minutes, and the mean blood loss was 66.67±45.02 mL. No operative or major postoperative complications occurred. Additional studies should be performed to assess the benefits of RSS sacrocolpopexy. I present the first six cases of da Vinci Single-Site® surgery in urogynecology and provide a detailed description of the technique.


Remdesivir for the Treatment of Covid-19 - Preliminary Report.


title: In vitro Antimicrobial Effects of Virus Block, Which Contains Multiple Polyoxometalate Compounds, and Hygienic Effects of Virus Block-Supplemented Moist Hand Towels.

text: BACKGROUND Historical evidence has verified the multifaceted antiviral efficacy of polyoxometalates (PMs). METHODS We carried out a study to investigate the antimicrobial effects of each of the 5 substances comprising virus block (VB): 3 PMs that have antibacterial and antiviral activity, an antibiotic agent, and an antibacterial agent. We also investigated the effectiveness of the addition of VB to moist hand towels in a study involving 120 volunteers. The time-dependent changes in metal ion concentrations in aqueous VB solution were analyzed using inductively coupled plasma atomic emission spectroscopy. RESULTS The metal elements in the aqueous VB solution remained stable for 12 weeks without undergoing time-dependent changes. DISCUSSION Further investigations were performed to study hand hygiene using moist hand towels in daily life settings. To this end, 120 volunteers provided 240 specimens that were used to investigate the presence of antibacterial compounds on the volunteers' hands before and after hand towel use. An aliquot of each specimen was suspended in phosphate-buffered saline and plated on agar media, and the number of colonies formed was counted. Normal bacterial flora found on the hands of the volunteers was investigated before and after the use of 4 different moist hand towels. CONCLUSIONS The effects of VB and PMs were superior to those of commercial moist hand towels, indicating that effective data were obtained that may be useful for the practical application of the tested items.


title: Symptomatic Very Delayed Parent Artery Occlusion After Flow Diversion Stent Embolization.

text: Flow diversion stents (FDSs) are constructed from high-density braided mesh, which alters intra-aneurysmal hemodynamics and leads to aneurysm occlusion by inducing thrombus formation. Although there are potential complications associated with FDS embolization, one of the serious complications is the parent artery occlusion due to the in-stent thrombosis. A 72-year-old woman with a symptomatic giant fusiform aneurysm in the cavernous segment of ICA underwent single-layer pipeline embolization device (PED) embolization. Six-month and 1-year follow-up conventional angiographies showed the residual blood flow in the aneurysm. Two-year follow-up MRI showed the aneurysm sac shrinkage and the antiplatelet therapy was discontinued. The patient suffered from symptomatic parent artery occlusion due to the in-stent thrombosis, 4 months after antiplatelet therapy discontinuation. The patient with the incompletely occluded aneurysm after PED embolization should be given long-term antiplatelet therapy because of the risk of delayed parent artery occlusion.


Critical paediatric COVID-19: varied presentations but good outcomes.


Lessons from a decade of emerging diseases: towards regional public health security.


title: Updated systematic review of exercise studies in breast cancer survivors: attention to the principles of exercise training.

text: OBJECTIVES To update our previous evaluation of the exercise interventions used in randomised controlled trials of breast cancer survivors in relation to (1) the application of the principles of exercise training in the exercise prescription; (2) the reporting of the components of the exercise prescription; and (3) the reporting of adherence of participants to the prescribed interventions. DESIGN Systematic review. DATA SOURCES The OVID Medline, Embase, CINAHL and SPORTDiscus electronic databases were searched from January 2010 to January 2017. ELIGIBILITY CRITERIA Randomised controlled trials of at least 4 weeks of aerobic and/or resistance exercise in women diagnosed with breast cancer, reporting on physical fitness or body composition outcomes. RESULTS Specificity was appropriately applied by 84%, progression by 29%, overload by 38% and initial values by 67% of newly identified studies. Reversibility was reported by 3% anddiminishing returns by 22% of newly identified studies. No studies reported all components of the exercise prescription in the methods, or adherence to the prescribed intervention in the results. Reporting of reversibility has increased from 2010, but no other improvements in reporting were noted from the previous review. SUMMARY/CONCLUSION No studies of exercise in women with breast cancer attended to all principles of exercise training, or reported all components of the exercise prescription in the methods, or adherence to the prescription in the results. Full reporting of the exercise prescribed and completed is essential for study replication in research and translating research findings into the community, and should be prioritised in future trials.


title: Beyond the Linguistic/Medical Anthropology Divide: Retooling Anthropology to Face COVID-19.

text: Differing analytics and ethnographic practices impede conversations between linguistic and medical anthropologists. Here I juxtapose articles in this special issue that use diverse ethnographic sites to rethink anthropological concepts of health, disease, care, the body, language, and communication in the light of the 2020 COVID-19 pandemic. I track how anthropologists and their interlocutors envision relations between ideologies, embedded modeling (or metacommunication), and ordinary pragmatics, particularly by projecting their actual or ideal consonance versus exploring how sounds, bodies, technologies, and practices emerge from disjunctures. Comparing H1N1 in 2009 and COVID-19 prompts reflection on why anthropologists must transcend this foundational divide to tackle pandemic complexities.


title: Treatment of post-traumatic carotid-cavernous fistulas using pipeline embolization device assistance.

text: This report describes two cases of post-traumatic, high flow carotid-cavernous fistulas that demonstrated residual shunting after initial embolization with coils and Onyx, and that were successfully closed with pipeline embolization devices. Following their combined endovascular treatments, the patients experienced clinical improvement of symptoms with durable obliteration of the fistulous communications.


title: Short term treatment results of local ablation with water-cooled microwave antenna for liver cancer: Comparison with radiofrequency ablation.

text: The aim of the present study was to evaluate the efficacy and safety of the new-generation percutaneous microwave ablation (MWA) compared with the radiofrequency ablation (RFA) system for the treatment of hepatocellular carcinoma (HCC). A retrospective study was conducted from January 2014 to February 2019. A total of 44 patients and 52 nodules (mean tumor size, 17.2±4.9 mm) were treated with MWA, and 55 patients and 70 nodules (mean tumor size, 17.7±6.4 mm) were treated with RFA. After 4 days of treatment, the direct effects of ablation were assessed using dynamic CT, and after discharge, a follow-up dynamic CT scan was performed every 3-4 months. Treatment efficacy, complications and local recurrence were recorded. For MWA and RFA, the average number of CT sessions were 1.05±0.23 and 1.28±0.54, respectively, and the mean ablation times were 5.0±2.0 and 8.1±4.8 min. Following MWA and RFA, the ablation ranges that were evaluated with the axial images were 31.9±5.5 and 33.3±9.0 mm, respectively, in the long-axis diameter and 27.6±5.3 and 23.4±6.8 mm, respectively, in the short-axis diameter. The flatness ratios of the ablation regions were 0.13±0.09 and 0.29±0.14 (axial image) and 0.11±0.07 and 0.28±0.14 (coronal image), respectively. The rates of complete tumor necrosis were comparable. The complication rates were 13.6% (MWA) and 14.5% (RFA), which were not significantly different. The cumulative local recurrence rates were not significantly different between the two methods (one-year recurrence rate, MWA: 6.91%, RFA: 5.17%). MWA was therefore indicated to be an effective treatment for HCC in respect to session number, treatment time and spherical ablation.


title: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in patients with previous lower abdominal surgery.

text: BACKGROUND We have performed laparoscopic totally extraperitoneal (TEP) repair for inguinal hernia repair for the last 20 years. We use two balloon dilators (sphere and kidney type) to dissect the preperitoneal space for the TEP repair. It may be difficult to obtain exposure in patients who previously underwent lower abdominal surgery, because of adhesions to the abdominal wall. We reviewed our experience with inguinal hernia repairs to retrospectively analyze factors that limit the laparoscopic TEP approach. METHODS From 2006 to 2016, 313 patients (281 men and 32 women) underwent laparoscopic TEP inguinal hernia repair at Yuki Hospital. The medical records of these patients were reviewed, and data for patients who previously underwent lower abdominal surgery were analyzed. RESULTS Eighty-four patients previously underwent lower abdominal surgery including appendectomy (N = 23), inguinal hernia repair [N = 45; including contralateral TEP repair (N = 26), ipsilateral anterior approach (N = 11)], and laparotomy with a lower abdominal midline incision (N = 22). TEP repair was successfully completed in 75 patients (75/84; 89%) and the procedure changed in nine patients to an anterior approach (N = 5), or transabdominal preperitoneal (TAPP) repair (N = 4). The reasons for changing the procedure included difficulty to develop the operative field (N = 5), violation of the integrity of the peritoneal envelope (N = 2), and intraoperative bleeding (N = 2). Seven patients had a contralateral inguinal hernia after TEP repair. CONCLUSION The majority of patients with an inguinal hernia and previous lower abdominal surgery underwent successful laparoscopic TEP repair. There is no need to avoid the laparoscopic TEP approach, even in patients with a history of previous lower abdominal surgery. However, patients after TEP repair of a contralateral inguinal hernia may be at increased risk for peritoneal injury and the approach may need to be changed.


title: Components of a hyperthermia clinic: recommendations for staffing, equipment, and treatment monitoring.

text: Like other technically sophisticated medical endeavours, a hyperthermia clinic relies on skilled staffing. Physicians, physicists and technologists perform multiple tasks to ensure properly functioning equipment, appropriate patient selection, and to plan and administer this treatment. This paper reviews the competencies and tasks that are used in a hyperthermia clinic.


title: Shortened penis post penile prosthesis implantation treated with subcutaneous soft silicone penile implant: case report.

text: Penile prosthesis surgery for erectile dysfunction has the highest satisfaction rates among all treatment options but is often associated with subjective and objective loss of penile length and girth following surgery. To present a novel technique using a subcutaneous soft silicone implant for reversal of penile shortening and narrowing after prosthesis surgery, with additional gains in overall penile length and girth. Nine patients were treated with the insertion of a subcutaneous soft silicone penile implant. All patients had previously reported a loss in penile length (0.5-2 cm), and seven of nine patients also reported a loss in penile girth (0.5-2.6 cm) after penile prosthesis surgery. During a follow-up period of 4-24 months, penile length and girth measurements showed a mean increase in length of 2.4 cm (±0.75 cm) and a mean increase in girth of 3.4 cm (±0.94 cm). The additional insertion of a subcutaneous soft silicone implant in patients with decreased penile length and girth after penile prosthesis surgery is an effective treatment option that provides reversal of lost penile length and girth.


Reply: Acellular dermal matrix in hand reconstruction.


title: Transformation of a large multi-speciality hospital into a dedicated COVID-19 centre during the coronavirus pandemic.

text: INTRODUCTION The article describes the process of converting a large multi-specialized hospital into one dedicated to COVID-19 patients, and present established standards of work organization in all the wards and training system of the medical and supporting staff. The several weeks pandemic of the COVID-19 disease has forced the healthcare systems of numerous countries to adjust their resources to the care of the growing number of COVID-19 patients. Managers were presented with the challenge of protecting the healthcare workers from transmission of the disease within medical institutions, and issues concerning the physical and psychological depletion of personnel. MATERIAL AND METHODS Based on analyses of the structure and work processes in Central Clinical Hospital (CCH) reconstructive strategic plan was developed. It included: division of existing wards into observation and isolation wards; installing locks; weekly plan for supplying personal protection equipment (PPE); designating new access to the hospital and communication routes; training of medical and supporting staff. The plan was implemented from the first days of conversion of the hospital. RESULTS The wards of the CCH were converted for observation and isolation, and each one was fitted with sanitary locks. There was a big improvement in the supply of PPE for the medical staff. Separation of the 'dirty' and 'clean' parts of the CCH were attained, and widespread intensive training not only protected personnel against infections, but also diminished unrest which was discernable at the beginning of conversion. CONCLUSIONS The transformation efforts will ultimately be appraised at the end of the epidemic, but the data looks encouraging. Two weeks after conversion, the testing of hospital Staff was started and by the end of April, 459 tests were had been conducted, of which only 11 were positive.


title: Aneurysm treatment with WEB in the cumulative population of two prospective, multicenter series: 3-year follow-up.

text: BACKGROUND WEB treatment is an endovascular approach for wide-neck bifurcation aneurysms that has demonstrated high safety and good efficacy in mid-term follow-up. While evaluating safety in the long term is important to determine if delayed adverse events occur affecting late morbidity and mortality, the most important point to evaluate is the long-term stability of aneurysm occlusion. The current analysis reports the 3-year clinical and anatomical results of WEB treatment in the combined population of two European trials (WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm Therapy) and WEBCAST-2). METHODS Aneurysm occlusion was evaluated using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant. RESULTS The safety population comprised 79 patients. The efficacy population comprised 61 aneurysms. Aneurysm locations were middle cerebral artery in 32/61 aneurysms (52.5%), anterior communicating artery in 13/61 (21.3%), basilar artery in 9/61 (14.8%), and internal carotid artery terminus in 7/61 (11.5%). No adverse events related to the device or procedure occurred between 2 and 3 years. At 3 years, complete occlusion was observed in 31/61 (50.8%) aneurysms, neck remnant in 20/61 (32.8%), and aneurysm remnant in 10/61 (16.4%). Between 1 year and 3 years, aneurysm occlusion was improved or stable in 53/61 (86.9%) aneurysms and worsened in 8/61 (13.1%). Worsening was mostly from complete occlusion to neck remnant in 6/61 (9.8%) aneurysms. The retreatment rate at 3 years was 11.4%. CONCLUSIONS This analysis confirms the high safety profile of WEB. Moreover, evidence demonstrates the great stability of aneurysm occlusion with adequate occlusion (complete occlusion or neck remnant) in 83.6% of aneurysms. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. WEBCAST and WEBCAST-2: Unique identifier: NCT01778322.


title: Effect of hypoxia-inducible factor-1alpha gene therapy on walking performance in patients with intermittent claudication.

text: BACKGROUND Hypoxia-inducible factor-1α (HIF-1α) is a transcriptional regulatory factor that orchestrates cellular responses to hypoxia. It increases collateral vessel growth and blood flow in models of hind-limb ischemia. This study tested whether intramuscular administration of Ad2/HIF-1α/VP16, an engineered recombinant type 2 adenovirus vector encoding constitutively active HIF-1α, improves walking time in patients with peripheral artery disease and intermittent claudication. METHODS AND RESULTS Two hundred eighty-nine patients with claudication were randomized in a double-blind manner to 1 of 3 doses of Ad2/HIF-1α/VP16 (2×10(9), 2×10(10), or 2×10(11) viral particles) or placebo, administered by 20 intramuscular injections to each leg. Graded treadmill tests were performed at baseline and then 3, 6, and 12 months after treatment. The primary end point was the change in peak walking time from baseline to 6 months. The secondary end point was change in claudication onset time, and tertiary end points included changes in ankle-brachial index and quality-of-life assessments. Median peak walking time increased by 0.82 minutes (interquartile range, -0.05-1.93 minutes) in the placebo group and by 0.82 minutes (interquartile range, -0.07-2.12 minutes), 0.28 minutes (interquartile range, -0.37-1.70 minutes), and 0.78 minutes (interquartile range, -0.02-2.10 minutes) in the HIF-1α 2×10(9), 2×10(10), and 2×10(11) viral particle groups, respectively (P=NS between placebo and each HIF-1α treatment group). There were no significant differences in claudication onset time, ankle-brachial index, or quality-of-life measurements between the placebo and each HIF-1α group. CONCLUSIONS Gene therapy with intramuscular administration of Ad2/HIF-1α/VP16 is not an effective treatment for patients with intermittent claudication. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00117650.


title: Robotic colorectal surgery for laparoscopic surgeons with limited experience: preliminary experiences for 40 consecutive cases at a single medical center.

text: BACKGROUND We present our preliminary experiences and results for forty consecutive patients with colorectal cancer (CRC) who were treated by robotic surgery. METHODS Between May 2013 and September 2014, forty patients with CRC received robotic surgery at a single institution. The clinicopathological features and perioperative parameters were retrospectively analyzed. RESULTS Of the 40 patients with CRC, 33 (82.5 %) had rectal cancers, and 22 (66.7 %) of those 33 patients also underwent pre-operative concurrent chemoradiotherapy (CCRT). The two most frequent surgical procedures were intersphincteric resection (ISR) with coloanal anastomosis (16/40, 40 %) and lower anterior resection (LAR) (15/40, 37.5 %). Among all 40 patients, the median time to first flatus passage was 2 days. The median time to soft diet resumption was 4 days. The median post operative hospital stay was 7 days. The overall complication rate was 20 % (8/40 patients), of which most of the complications were mild, although one laparotomy was required to check for post-operative bleeding. There was no 30-day hospital mortality, nor conversion to open surgery and laparoscopy. CONCLUSION We present our preliminary experiences of robotic colorectal surgery and demonstrate that robotic colorectal surgery is a safe and feasible surgery even when conducted by laparoscopic surgeons with limited experience.


title: Laparoscopic splenectomy: perioperative management, surgical technique, and results.

text: Since their introduction in the early 1990s, minimally invasive techniques have gained widespread acceptance because of the significant benefits that patients are able to experience. Some of these benefits include reduced postoperative pain, earlier return to normal activity, and improved cosmesis when compared with open surgery. For these reasons, since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has been increasingly utilized for a safe surgical removal of the spleen with nearly equivalent or superior short- and long-term outcomes when compared with the open approach. In this technical report, we aim to describe our preoperative and postoperative management of patients undergoing LS and to illustrate our preferred surgical technique, its rationale, and our results.


title: Edge Factors: Scientific Frontier Positions of Nations.

text: A key decision in scientific work is whether to build on novel or well-established ideas. Because exploiting new ideas is often harder than more conventional science, novel work can be especially dependent on interactions with colleagues, the training environment, and ready access to potential collaborators. Location may thus influence the tendency to pursue work that is close to the edge of the scientific frontier in the sense that it builds on recent ideas. We calculate for each nation its position relative to the edge of the scientific frontier by measuring its propensity to build on relatively new ideas in biomedical research. Text analysis of 20+ million publications shows that the United States and South Korea have the highest tendencies for novel science. China has become a leader in favoring newer ideas when working with basic science ideas and research tools, but is still slow to adopt new clinical ideas. Many locations remain far behind the leaders in terms of their tendency to work with novel ideas, indicating that the world is far from flat in this regard.


title: Reduction in cardiac mortality with bivalirudin in patients with and without major bleeding: The HORIZONS-AMI trial (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction).

text: OBJECTIVES The purpose of this study was to determine whether, in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), the reduction in cardiac mortality in those taking bivalirudin compared with unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor (UFH+GPI) can be fully attributed to reduced bleeding. BACKGROUND The association between hemorrhagic complications and mortality may explain the survival benefit with bivalirudin. METHODS A total of 3,602 STEMI patients undergoing primary PCI were randomized to bivalirudin versus UFH+GPI. Three-year cardiac mortality was analyzed in patients with and without major bleeding. RESULTS When compared with UFH+GPI, bivalirudin resulted in lower 3-year rates of major bleeding (6.9% vs. 10.5%, hazard ratio [HR]: 0.64 [95% confidence interval (CI): 0.51 to 0.80], p < 0.0001) and cardiac mortality (2.9% vs. 5.1%, HR: 0.56 [95% CI: 0.40 to 0.80], p = 0.001). Three-year cardiac mortality was reduced in bivalirudin-treated patients with major bleeding (20 fewer deaths with bivalirudin; 5.8% vs. 14.6%, p = 0.025) and without major bleeding (18 fewer deaths with bivalirudin; 2.6% vs. 3.8%, p = 0.048). In a fully-adjusted multivariable model accounting for major bleeding and other adverse events, bivalirudin was still associated with a 43% reduction in 3-year cardiac mortality (adjusted HR: 0.57 [95% CI: 0.39 to 0.83], p = 0.003). CONCLUSIONS Bivalirudin reduces cardiac mortality in patients with STEMI undergoing primary PCI, an effect that can only partly be attributed to prevention of bleeding. Further studies are required to identify the nonhematologic benefits of bivalirudin. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction; NCT00433966).


title: Serum levels of ferritin do not affect the prognosis of patients with hepatocellular carcinoma undergoing radiofrequency ablation.

text: BACKGROUND & AIMS Hepatic iron accumulation can accelerate liver injury in patients with various chronic liver diseases and lead to hepatocarcinogenesis. We elucidated the impact of serum levels of ferritin on the prognosis of hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) in a large cohort. METHODS We retrospectively analyzed 578 treatment-naïve HCC patients who underwent RFA. We divided our cohort into four groups by the quartile points of serum ferritin level: G1 (≤55 ng/mL, n = 148), G2 (56-130 ng/mL, n = 142), G3 (131-243 ng/mL, n = 144) and G4 (≥244 ng/mL, n = 144). We analyzed the recurrence and survival of patients using the Kaplan-Meier method. We also evaluated pathological iron deposition among patients with a solitary tumor smaller than 2 cm. RESULTS The cumulative rates of overall recurrence and survival at 5 years were 81.6% and 66.3%, respectively. The serum levels of ferritin were correlated with pathological iron deposition. There were no significant differences in recurrence and survival rates according to serum levels of ferritin and pathological hepatic iron deposition. CONCLUSIONS Serum levels of ferritin do not affect the prognosis of HCC patients undergoing RFA.


title: On-Pump Nonrobotic Total Endoscopic Coronary Artery Bypass Grafting: An Animal Study.

text: BACKGROUND Total endoscopic coronary artery bypass grafting (TECAB) is currently performed exclusively with the help of a telemanipulator. After extensive practice in a biomechanical model, the operation was performed as a nonrobotic approach in an animal study. METHODS Six large domestic pigs were anesthetized and intubated. Port access and endoscopic vision were used exclusively during the intrathoracic procedure. In five animals, an internal mammary artery was harvested, extracorporeal circulation was established via peripheral vessel access, and the ascending aorta occluded with an intraluminal balloon. In cardioplegic arrest, an anastomosis of internal mammary artery and left anterior descending coronary artery was performed with shortened 7-0 monofil thread running suture. As a terminal study, the animals were humanely killed and the quality of the anastomoses was checked. RESULTS After a steady learning curve, the fifth animal was operated on successfully and a satisfactory anastomosis was documented. CONCLUSION Despite demanding differences to humans as shape of thoracic cavity and size of peripheral access vessels, the viability of the nonrobotic TECAB concept was documented in a living animal model.


title: Effectiveness of telerehabilitation in the management of adults with stroke: A systematic review.

text: BACKGROUND Stroke is a leading cause of mortality and morbidity and access to timely rehabilitation can reduce morbidity and help patients to return to normal life. Telerehabilitation can deliver rehabilitation services with the use of technology to increase patient options, deliver services more efficiently and overcome geographical barriers to healthcare access. Despite its popularity, there is conflicting evidence for its effectiveness. Therefore, the aim of this systematic review was to update the current evidence base on the effectiveness of telerehabilitation for stroke. METHODS A systematic search of databases (Medline Ovid; Embase; Emcare; Scopus; The Cochrane Library; PEDro; OTSeeker) was conducted in April 2018 (updated in October 2018). This review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and methodology registered with PROSPERO (CRD42018090445). A modified McMaster critical appraisal tool for quantitative studies was used to assess the methodological quality of the included studies. Given the heterogeneity of the included studies, a descriptive synthesis was conducted. RESULTS Out of 1868 studies, 13 randomised controlled trials met the inclusion criteria. A diverse range of interventions were delivered through a variety of telerehabilitation systems and the effectiveness measured through a myriad of outcome measures. Summarised findings from the heterogeneous evidence base indicate that telerehabilitation may have a positive impact on a range of primary and secondary outcomes. However, despite these positive findings, the current evidence lacks clarity and uniformity in terms of intervention parameters and measurement of outcomes, which limits broader application of these results. DISCUSSION Telerehabilitation, as an alternate form of rehabilitation for people with stroke, shows potential. However, due to methodological and practical concerns, an unequivocal recommendation cannot be made. Findings from this review may inform future policies and practices regarding the use of telerehabilitation for stroke patients.


title: Solo surgeon single-port laparoscopic surgery with a homemade laparoscope-anchored instrument system in benign gynecologic diseases.

text: The objective of this study was to present the initial operative experience of solo surgeon single-port laparoscopic surgery (SPLS) in the laparoscopic treatment of benign gynecologic diseases and to investigate its feasibility and surgical outcomes. Using a novel homemade laparoscope-anchored instrument system that consisted of a laparoscopic instrument attached to a laparoscope and a glove-wound retractor umbilical port, we performed solo surgeon SPLS in 13 patients between March 2011 and June 2012. Intraoperative complications and postoperative surgical outcomes were determined. The primary operative procedures performed were unilateral salpingo-oophorectomy (n = 5), unilateral salpingectomy (n = 2), adhesiolysis (n = 1), and laparoscopically assisted vaginal hysterectomy (n = 5). Additional surgical procedures included additional adhesiolysis (n = 4) and ovarian drilling (n = 1).The primary indications for surgery were benign ovarian tumors (n = 5), ectopic pregnancy (n = 2), pelvic adhesion (infertility) (n = 1), and benign uterine tumors (n = 5). Solo surgeon SPLS was successfully accomplished in all procedures without a laparoscopic assistant. There were no intraoperative or postoperative complications. Our laparoscope-anchored instrument system obviates the need for an additional laparoscopic assistant and enables SPLS to be performed by a solo surgeon. The findings show that with our system, solo surgeon SPLS is a feasible and safe alternative technique for the treatment of benign gynecologic diseases in properly selected patients.


title: A new method of robot-assisted laparoscopic repair of perineal hernia after abdominoperineal resection: a case report.

text: INTRODUCTION Perineal hernia is a protrusion of the pelvic floor which contains intra-abdominal viscera. The occurrence of perineal hernia after abdominoperineal resection (APR) is rare, but it has been reported in recent years that the incidence of perineal hernia after rectal cancer surgery has increased. This has been attributed to a shift towards extralevator abdominoperineal resection, together with more frequent and long-term use of neoadjuvant therapy. PRESENTATION OF CASE Here, we report a patient with perineal hernia 5 years after APR surgery for rectal cancer. We decided to perform robot-assisted laparoscopic surgery on this patient using the da Vinci Surgical System. The perineal hernia was repaired by primary closure with the placement of a non-absorbable synthetic mesh as reinforcement for the pelvic floor. No complications occurred during the operation, and the patient was discharged on the third day after the operation. Clinical follow-up proceeded at the designated time intervals without difficulties. DISCUSSION The recurrence rates of perineal hernia are still very high, and due to poor view, suturing, and mesh placement in the deep pelvis, surgeons face many challenges. Many methods have been described, but there is still no consensus as to the optimal repair technique for perineal hernia. CONCLUSION Perineal hernias can be repaired with robot-assisted laparoscopy. Furthermore, compared with the open and laparoscopic methods, suturing and mesh placement are easier with the robot approach.


title: Side-to-end hypoglossal to facial anastomosis with transposition of the intratemporal facial nerve.

text: OBJECTIVE To describe results in a large series of patients using a recent variation of hypoglossal-facial nerve anastomosis (HFA) in which the intratemporal facial nerve segment is used, obviating the need for a sensory nerve "jump graft." STUDY DESIGN Retrospective chart review. SETTING Tertiary neurotologic referral center. PATIENTS Nineteen patients (12 female/7 male subjects) with facial paralysis because of posterior fossa surgery for tumor (n = 15), Bell's palsy (n = 1), facial neuroma (n = 1), hemangioma (n = 1), and trauma (n = 1) who underwent HFA from 1997 to 2011, with at least 1-year follow-up. Mean age at surgery is 47.4 years (range, 11.2-83 yr). Mean follow-up is 4.0 years. INTERVENTION Side-to-end hypoglossal to facial anastomosis with transposition of the intratemporal facial nerve (swingdown HFA). MAIN OUTCOME MEASURE House-Brackmann (H-B) facial nerve grade. RESULTS Seven patients (36.8%) achieved an H-B Grade III, 9 patients (47.4%) a grade IV, and 3 patients (15.8%) a grade V at last follow-up. No patients complained of dysphagia, dysarthria, or had evidence of oral incompetence. One patient complained of mild tongue weakness. Age at time of HFA (p ≤ 0.049, III younger than V) and time from facial nerve injury to HFA (p ≤ 0.02, III<IV and V) were significant factors for ultimate facial nerve outcome. All patients with an H-B III result had HFA within 6 months of injury. Other factors were not significant. CONCLUSION The HFA swingdown technique is a safe and effective method to restore facial nerve function in patients with facial paralysis and obviates the need for an interposition jump graft.


title: Generation of a protective T-cell response following coronavirus infection of the central nervous system is not dependent on IL-12/23 signaling.

text: The functional role of IL-12 and IL-23 in host defense and disease following viral infection of the CNS was determined. Instillation of mouse hepatitis virus (MHV, a positive-strand RNA virus) into the CNS of mice results in acute encephalitis followed by a chronic immune-mediated demyelinating disease. Antibody-mediated blocking of either IL-23 (anti-IL-23p19) or IL-12 and IL-23 (anti-IL-12/23p40) signaling did not mute T-cell trafficking into the CNS or antiviral effector responses and mice were able to control viral replication within the brain. Therapeutic administration of either anti-IL-23p19 or anti-IL-12/23p40 to mice with viral-induced demyelination did not attenuate T-cell or macrophage infiltration into the CNS nor improve clinical disease or diminish white matter damage. In contrast, treatment of mice with anti-IL-12/23p40 or anti-IL-23p19 resulted in inhibition of the autoimmune model of demyelination, experimental autoimmune encephalomyelitis (EAE). These data indicate that (1) IL-12 and IL-23 signaling are dispensable in generating a protective T-cell response following CNS infection with MHV, and (2) IL-12 and IL-23 do not contribute to demyelination in a model independent of autoimmune T-cell-mediated pathology. Therefore, therapeutic targeting of IL-12 and/or IL-23 for the treatment of autoimmune diseases may offer unique advantages by reducing disease severity without muting protective responses following viral infection.


title: Predictive patient-specific dosimetry and individualized dosing of pretargeted radioimmunotherapy in patients with advanced colorectal cancer.

text: PURPOSE Pretargeted radioimmunotherapy (PRIT) with bispecific antibodies (bsMAb) and a radiolabeled peptide reduces the radiation dose to normal tissues. Here we report the accuracy of an (111)In-labeled pretherapy test dose for personalized dosing of (177)Lu-labeled IMP288 following pretargeting with the anti-CEA × anti-hapten bsMAb, TF2, in patients with metastatic colorectal cancer (CRC). METHODS In 20 patients bone marrow absorbed doses (BMD) and doses to the kidneys were predicted based on blood samples and scintigrams acquired after (111)In-IMP288 injection for individualized dosing of PRIT with (177)Lu-IMP288. Different dose schedules were studied, varying the interval between the bsMAb and peptide administration (5 days vs. 1 day), increasing the bsMAb dose (75 mg vs. 150 mg), and lowering the peptide dose (100 μg vs. 25 μg). RESULTS TF2 and (111)In/(177)Lu-IMP288 clearance was highly variable. A strong correlation was observed between peptide residence times and individual TF2 blood concentrations at the time of peptide injection (Spearman's ρ = 0.94, P < 0.0001). PRIT with 7.4 GBq (177)Lu-IMP288 resulted in low radiation doses to normal tissues (BMD <0.5 Gy, kidney dose <3 Gy). Predicted (177)Lu-IMP288 BMD were in good agreement with the actual measured doses (mean ± SD difference -0.0026 ± 0.028 mGy/MBq). Hematological toxicity was mild in most patients, with only two (10 %) having grade 3-4 thrombocytopenia. A correlation was found between platelet toxicity and BMD (Spearman's ρ = 0.58, P = 0.008). No nonhematological toxicity was observed. CONCLUSION These results show that individual high activity doses in PRIT in patients with CEA-expressing CRC could be safely administered by predicting the radiation dose to red marrow and kidneys, based on dosimetric analysis of a test dose of TF2 and (111)In-IMP288.


title: Leukocytosis is common after total hip and knee arthroplasty.

text: BACKGROUND Postoperative infection is a potentially devastating complication after THA and TKA. In the early postoperative period, clinicians often find nonspecific indicators of infection. Although leukocytosis may be a sign of a developing infection in the early postoperative period, it may also be part of a normal surgical response. QUESTIONS AND PURPOSES: We determined (1) the natural history of white blood cell values after primary THA and TKA, (2) factors associated with early postoperative leukocytosis, and (3) the predictive value of white blood cell count for early postoperative periprosthetic joint infection. PATIENTS AND METHODS Using our institutional database, we identified all THA and TKA cases between January 2000 and December 2008. We determined the incidence of leukocytosis and characterized the natural history of postoperative white blood cell counts. We then investigated potential indicators of postoperative leukocytosis, including development of early periprosthetic infection. RESULTS The average postoperative white blood cell count increased to approximately 3 × 10(6) cells/μL over the first 2 postoperative days and then declined to a level slightly higher than the preoperative level by Postoperative Day 4. The incidence of postoperative leukocytosis for all patients was 38%. Factors associated with postoperative leukocytosis included TKA, bilateral procedures, older age, and higher modified Charlson Comorbidity Index. The sensitivity and specificity of white blood cell count for diagnosing early periprosthetic infection were 79% and 46%, respectively. CONCLUSIONS Postoperative leukocytosis is common after THA and TKA and represents a normal physiologic response to surgery. In the absence of abnormal clinical signs and symptoms, postoperative leukocytosis may not warrant further workup for infection. LEVEL OF EVIDENCE Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.


title: Utilization of Capsules for Negative Staining of Viral Samples within Biocontainment.

text: Transmission electron microscopy (TEM) is used to observe the ultrastructure of viruses and other microbial pathogens with nanometer resolution. Most biological materials do not contain dense elements capable of scattering electrons to create an image; therefore, a negative stain, which places dense heavy metal salts around the sample, is required. In order to visualize viruses in suspension under the TEM they must be applied to small grids coated with a transparent surface only nanometers thick. Due to their small size and fragility, these grids are difficult to handle and easily moved by air currents. The thin surface is easily damaged, leaving the sample difficult or impossible to image. Infectious viruses must be handled in a biosafety cabinet (BSC) and some require a biocontainment laboratory environment. Staining viruses in biosafety levels (BSL)-3 and -4 is especially challenging because these environments are more turbulent and technicians are required to wear personal protective equipment (PPE), which decreases dexterity. In this study, we evaluated a new device to assist in negative staining viruses in biocontainment. The device is a capsule that works as a specialized pipette tip. Once grids are loaded into the capsule, the user simply aspirates reagents into the capsule to deliver the virus and stains to the encapsulated grid, thus eliminating user handling of grids. Although this technique was designed specifically for use in BSL-3 or -4 biocontainment, it can ease sample preparation in any lab environment by enabling easy negative staining of virus. This same method can also be applied to prepare negative stained TEM specimens of nanoparticles, macromolecules and similar specimens.


title: The Emergence of COVID-19 in the U.S.: A Public Health and Political Communication Crisis.

text: The coronavirus public health crisis is also a political-communication and health-communication crisis. In this commentary, we describe the key communication-related phenomena and evidence of concerning effects manifested in the U.S. during the initial response to the pandemic. We outline the conditions of communication about coronavirus that contribute toward deleterious outcomes, including partisan cueing, conflicting science, downplayed threats, emotional arousal, fragmented media, and Trump's messaging. We suggest these have contributed toward divergent responses by media sources, partisan leaders, and the public alike, leading to different attitudes and beliefs as well as varying protective actions taken by members of the public to reduce their risk. In turn, these divergent communication phenomena will likely amplify geographic variation in and inequities in COVID-19 disease outcomes. We conclude with some suggestions for future research, particularly surrounding communication about health inequity and strategies for reducing partisan divergence in views of public health issues in the future.


title: Improving outcomes after laparoscopic appendectomy: a population-based, 12-year trend analysis of 7446 patients.

text: OBJECTIVE Laparoscopic appendectomy for acute appendicitis has become increasingly used over the past decade. The objective of this trend analysis is to assess whether clinical outcomes after laparoscopic appendectomy have improved over the past 12 years. METHODS This analysis is based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. All patients undergoing emergency laparoscopic appendectomy for acute appendicitis from 1995 to 2006 were included. The following outcomes were assessed for each of the 12 years: conversion rates, intraoperative complications, surgical postoperative complications, general postoperative complications, rate of reoperations, and length of hospital stay. Unadjusted and risk-adjusted multivariable analyses were performed. Statistical significance was set at a level of P < 0.05. All statistical tests were 2-sided. RESULTS Data from 7446 patients undergoing laparoscopic appendectomy for acute appendicitis were prospectively collected. Over the period of observation, the conversion rate decreased significantly from 2.2% to 1.2% (P(trend)< 0.001), as did intraoperative complications (from 3.1% to 0.7%; P(trend)< 0.001), surgical postoperative complications (from 6.1% to 1.9%; P(trend)< 0.001), general postoperative complications (from 4.9% to 1.5%; P(trend)< 0.001), and rates of reoperations (from 3.4% to 0.7%; P(trend)< 0.001). Average postoperative length of hospital stay also significantly decreased from 4.9 to 3.5 days (P(trend)< 0.001). CONCLUSIONS Our investigation provides compelling evidence that intraoperative complications, surgical and general postoperative complications, conversion rates, rates of reoperations, and average length of hospital stay have significantly decreased over the past decade in patients undergoing surgery for acute appendicitis. The present trend analysis is the first one in the literature encompassing more than a decade and reporting clinical outcomes after laparoscopic appendectomy for acute appendicitis, which represents an important quality control.


title: Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity.

text: IMPORTANCE Severe obesity (body mass index [BMI] ≥35) is associated with a broad range of health risks. Bariatric surgery induces weight loss and short-term health improvements, but little is known about long-term outcomes of these operations. OBJECTIVE To report 3-year change in weight and select health parameters after common bariatric surgical procedures. DESIGN AND SETTING The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. PARTICIPANTS AND EXPOSURE: Adults undergoing first-time bariatric surgical procedures as part of routine clinical care by participating surgeons were recruited between 2006 and 2009 and followed up until September 2012. Participants completed research assessments prior to surgery and 6 months, 12 months, and then annually after surgery. MAIN OUTCOMES AND MEASURES Three years after Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), we assessed percent weight change from baseline and the percentage of participants with diabetes achieving hemoglobin A1c levels less than 6.5% or fasting plasma glucose values less than 126 mg/dL without pharmacologic therapy. Dyslipidemia and hypertension resolution at 3 years was also assessed. RESULTS At baseline, participants (N = 2458) were 18 to 78 years old, 79% were women, median BMI was 45.9 (IQR, 41.7-51.5), and median weight was 129 kg (IQR, 115-147). For their first bariatric surgical procedure, 1738 participants underwent RYGB, 610 LAGB, and 110 other procedures. At baseline, 774 (33%) had diabetes, 1252 (63%) dyslipidemia, and 1601 (68%) hypertension. Three years after surgery, median actual weight loss for RYGB participants was 41 kg (IQR, 31-52), corresponding to a percentage of baseline weight lost of 31.5% (IQR, 24.6%-38.4%). For LAGB participants, actual weight loss was 20 kg (IQR, 10-29), corresponding to 15.9% (IQR, 7.9%-23.0%). The majority of weight loss was evident 1 year after surgery for both procedures. Five distinct weight change trajectory groups were identified for each procedure. Among participants who had diabetes at baseline, 216 RYGB participants (67.5%) and 28 LAGB participants (28.6%) experienced partial remission at 3 years. The incidence of diabetes was 0.9% after RYGB and 3.2% after LAGB. Dyslipidemia resolved in 237 RYGB participants (61.9%) and 39 LAGB participants (27.1%); remission of hypertension occurred in 269 RYGB participants (38.2%) and 43 LAGB participants (17.4%). CONCLUSIONS AND RELEVANCE Among participants with severe obesity, there was substantial weight loss 3 years after bariatric surgery, with the majority experiencing maximum weight change during the first year. However, there was variability in the amount and trajectories of weight loss and in diabetes, blood pressure, and lipid outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00465829.


Disruptive Effect of COVID-19 on Orthopaedic Daily Practice: A Cross-Sectional Survey.


title: Safety of Intraventricular rt-PA for Pan-Ventricular IVH Caused by a Ruptured AVM: A Case Report.

text: Intraventricular recombinant tissue plasminogen activator (IVT rt-PA) has improved outcomes for intraventricular hemorrhage (IVH). Patients with suspected or untreated arteriovenous malformations (AVMs) have been excluded from clinical trials. We present a patient with IVH secondary to a ruptured AVM safely treated with IVT rt-PA. A 48-year-old Hispanic male with a history of dermatomyositis presented to the emergency department with sudden left-sided weakness. En route to computed tomography (CT), he became lethargic. Computed tomography revealed extensive IVH with acute hydrocephalus, which was treated with the placement of external ventricular drain with clinical improvement. Computed tomography angiogram performed did not reveal AVM. Cerebral digital subtraction angiogram (DSA) was planned due to suspicion of AVM. Prior to DSA, patient became acutely lethargic. Computed tomography imaging revealed worsening hydrocephalus. External ventricular drain was noted to be draining. Repeat CT revealed improved hydrocephalus but with left lateral ventricle dilatation. Risks and benefits of IVT rt-PA were discussed with the family and a decision was made to treat. Three doses of 1 mg IVT rt-PA were administered with resolution of midline blood and lateral ventricular dilatation with clinical improvement. Digital subtraction angiogram revealed early draining vein on right internal carotid artery injection draining into the inferior sagittal sinus representing ruptured AVM without clear nidus. Repeat DSA with possible embolization was planned after discharge. In spite of additional in-hospital complications, the patient gradually improved and was ultimately discharged home. Our case supports the idea that the use of IVT rt-PA following an IVH caused by an underlying AVM could be further explored in carefully designed clinical trials.


title: Ulcerative Colitis: Shifting Sands.

text: Ulcerative colitis (UC) is a chronic inflammatory bowel disease associated with considerable disease burden. We review some current misconceptions about UC in adults with the aim of optimizing care for patients. Although UC and Crohn's disease (CD) are considered discrete diseases, distinctions between them are not always clear-cut and phenotypes may change over time. Patient management should take into account disease manifestations, disease severity and extent, and response to prior treatments. Although disease extent often defines severity, distal UC is not always less disabling than extensive disease as patients can progress to more extensive disease. In addition, severe proctitis can give rise to severe and debilitating symptoms, with a substantial impact on health-related quality of life. UC carries an increased risk of colorectal cancer (CRC) compared with CD; however, more recent data indicate a similar risk of CRC in CD with colonic involvement as with UC. Corticosteroids are widely used to induce remission in UC, and prolonged use of steroids in patients with UC is common, but corticosteroid-free maintenance of remission is an important therapeutic goal. Although biologic therapies provide a valuable treatment option in UC, they are not clinically effective in all patients and are also associated with secondary loss of response.


title: Safety and location analysis of transumbilical endoscopic submucosal dissection with single-basin lymph node dissection in the upper gastric body: a porcine model.

text: BACKGROUND In our previous study, transumbilical endoscopic submucosal dissection (TU-ESD) was revealed to be feasible, but delayed gastric perforation was observed in 30% of ESD sites. In this study, we aimed to verify locations at which it is feasible to perform TU-ESD in the upper gastric body and to demonstrate the safety of TU-ESD in single-basin lymph node dissection (SBLND). METHODS In vitro, TU-ESD was performed at three lesion sites (anterior wall, AW; posterior wall, PW; and lesser curvature, LC) in each porcine stomach using an EASIE-R tray (cases = 10). In vivo, TU-ESD was performed with SBLND in 9 pigs. Seven days after the operation, the pigs were sacrificed and examined. RESULTS In the in vitro feasibility study, the TU-ESD time was significantly faster in the PW group (5.9 ± 2.0 min) than in the LC group (8.5 ± 1.5 min) (p < 0.05) in all 10 cases. In the in vivo survival study, TU-ESD with SBLND was successfully performed without any complications (N = 9). There were no cases of delayed perforation, and healing ulcers were found in all pigs 7 days after the operation. Ulcer size (5.2 ± 3.5 cm2) was approximately 36% smaller than that observed at the ESD operation site (8.1 ± 1.9 cm2) (p = 0.05). Epithelialization in the margin and healing of the gastric ulcers were confirmed by microscopy. CONCLUSIONS TU-ESD with SBLND is a feasible and safe method. The upper posterior gastric body could be the most feasible location for performing TU-ESD, perhaps because of the difference in the subcutaneous dissection time.


title: The 20 Most Important and Most Preventable Health Problems of China: A Delphi Consultation of Chinese Experts.

text: OBJECTIVES To identify the 20 most important and most preventable health problems that should be addressed in the next 20 years in China. METHODS In 2015, we applied a modified electronic Delphi technique to reach consensus from a panel of top Chinese health experts (n = 70), who were requested to identify 20 health problems that, in their judgment, were most important and preventable. We also compared the results with evidences from epidemiological studies on disease-specific mortalities and disability-adjusted life years. RESULTS Consensus was reached after the second-round survey. The final agreed-upon 20 most important and most preventable health problems included 9 noncommunicable diseases, 4 communicable diseases, 2 unhealthy behaviors, and 2 forms of environmental pollution, plus depression, road injury, and contamination of food with pesticides, antibiotics, and hormone residues. The results are supported by relevant epidemiological studies in China. CONCLUSIONS The 20 most important and most preventable health problems in China for the next 20 years, agreed upon by a panel of top Chinese health experts, should be taken into consideration in national policymaking.


Group urges going metric to head off dosing mistakes.


Covid-19: "Steady the front line! There is no retreat from here".


title: New aspects of the renin-angiotensin system: angiotensin-converting enzyme 2 - a potential target for treatment of hypertension and diabetic nephropathy.

text: PURPOSE OF REVIEW Whereas angiotensin-converting enzyme promotes the formation of angiotensin II, angiotensin-converting enzyme 2 promotes the degradation of angiotensin II to angiotensin-(1-7). We review recent studies dealing with angiotensin-converting enzyme 2 in kidney disease and hypertension, and discuss the potential therapeutic benefit of increasing angiotensin-converting enzyme 2 activity in the treatment of these diseases. RECENT FINDINGS In glomeruli from diabetic mice, angiotensin-converting enzyme 2 expression is downregulated, and pharmacological inhibition of angiotensin-converting enzyme 2 leads to worsening of albuminuria, increased mesangial matrix deposition and fibronectin expression. The deletion of the angiotensin-converting enzyme 2 gene in mice leads to worsening of angiotensin II-induced hypertension and has also been shown to cause glomerulosclerosis in aging male mice. SUMMARY Angiotensin-converting enzyme 2 is a key enzyme in the renin-angiotensin system that favors the degradation of angiotensin I and angiotensin II. Angiotensin-converting enzyme 2 inhibition by pharmacological means and by genetic deletion worsens kidney disease in diabetic mice. Strategies geared to increasing angiotensin-converting enzyme 2 activity may provide a novel therapeutic target within the renin-angiotensin system by enhancing angiotensin II degradation that may complement the current approach of inhibiting angiotensin II formation and action. Amplifying angiotensin-converting enzyme 2 activity may have a potential therapeutic role for kidney disease and hypertension.


title: Laparoscopic common bile duct exploration in patients with complicated cholecystitis: a safety and feasibility study.

text: BACKGROUND Laparoscopic cholecystectomy (LC) with common bile duct exploration (LCBDE) is nowadays a preferred one-stage treatment. However, the influence of complicated cholecystitis (CC) on LCBDE has rarely been addressed. In the present study we aimed to verify whether severe gallbladder inflammation would adversely affect the outcome of LCBDE. MATERIAL AND METHODS From 2008 to 2011, all patients undergoing LC and LCBDE at China Medical University Hospital were included. Patients were divided into two groups based on the severity of cholecystitis. Those with unstable hemodynamics and co-morbidities who were deemed unfit for general anesthesia were excluded. Patient demographics, surgical results, and outcome were compared between the groups. RESULTS During the study period, 117 patients diagnosed with cholecystitis were found to have common bile duct (CBD) stones and underwent LC + LCBDE. Of these 117 patients, 87 had uncomplicated cholecystitis (UC) and the remaining 30 patients had CC. There was no demographic difference between the groups, but for patients with CC there were marginally longer operative times (190 vs. 223 min, p = 0.141), more blood loss (10 vs. 150 ml, p < 0.05), and longer postoperative hospital stays (6 vs. 7 days, p < 0.05). The risk of developing major intraoperative complications was not greater for those with CC. Conversion to open cholecystectomy was necessary in a total of 12 cases (10 %) with an overall 1 % mortality rate. CONCLUSIONS Complicated cholecystitis was not a contraindication for LCBDE. Complete stone clearance can be achieved in a substantial number of cases with an acceptable complication rate. Further prospective randomized studies are required to validate its long-term safety.


title: Current tools for norovirus drug discovery.

text: INTRODUCTION Rapid transmission of norovirus often occurs due to its low infectious dosage, high genetic diversity and its short incubation time. The viruses cause acute gastroenteritis and may lead to death. Presently, no effective vaccine or selective drugs accepted by the United States Food and Drug Administration (FDA) are available for the treatment of norovirus. Advances in the development of norovirus replicon cell lines, GII.4-Sydney HuNoV strain human B cells, and murine and gnotobiotic pig norovirus models have facilitated the discovery of effective small molecule inhibitors in vitro and in vivo. AREAS COVERED This review gives a brief discussion of the biology and replication of norovirus before highlighting the discovery of anti-norovirus molecules. The article coverage includes: an overview of the current state of norovirus drug discovery, the targeting of the norovirus life cycle, the inhibition of structural and nonstructural proteins of norovirus such as proteases and polymerase, and the blockage of virus entry into host cells. Finally, anti-norovirus drugs in the clinical development stage are described. EXPERT OPINION The current approach for the counteraction of norovirus focuses on the inhibition of viral RNA polymerase, norovirus 3C-like protease and the structural proteins VP1 as well as the blockade of norovirus entry. Broad-spectrum anti-norovirus molecules, based on the inhibition of 3C-like protease, have been developed. Other host factors and ways to overcome the development of resistance through mutation are also being examined. A dual approach in targeting viral and host factors may lead to an effective counteraction of norovirus infection. Current successes in developing norovirus replicon harboring cells and norovirus infected human cells, as well as murine norovirus models and other animal models such as piglets have facilitated the discovery of effective drugs and helped our understanding of its mechanism of action.


Laparoscopic repair of an isolated congenital bilateral lumbar hernia in an infant.


title: Comparison of single-stapling and hemi-double-stapling methods for intracorporeal esophagojejunostomy using a circular stapler after totally laparoscopic total gastrectomy.

text: BACKGROUND Laparoscopic total gastrectomy is not widely performed because of the difficulty of esophagojejunal reconstruction. This study analyzed complication rates of two different methods for reconstruction by a circular stapler after totally laparoscopic total gastrectomy (TLTG). METHODS Between 2010 and 2014, clinical data of 19 patients who underwent TLTG for gastric adenocarcinoma were collected retrospectively. There were two methods to fix the anvil of a circular stapler into the distal esophagus: In the single-stapling technique (SST) group, Endo-PSI(II) was used for purse-suturing on the distal esophagus for reconstruction, and in the hemi-double-stapling technique (hemi-DST) group, the esophagus was cut by linear stapler with the entry hole of the anvil shaft opened after inserting the anvil tail. In both groups, surgical procedures were the same, except for the reconstruction. RESULTS All TLTGs were performed securely without mortality. Intracorporeal laparoscopic esophagojejunal anastomosis was performed successfully for all the patients. In the hemi-DST group, four patients experienced anastomotic stenosis, three of whom required endoscopic balloon dilation. In contrast, no stenosis was seen in the SST group (p = 0.033). CONCLUSIONS Anastomosis with SST is preferred to that with hemi-DST to minimize postoperative complications.


title: Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy.

text: BACKGROUND Gastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. OBJECTIVE Determine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SETTING University hospital, France, public practice. MATERIAL AND METHODS This study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. RESULTS A total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1-245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0-86). Uniform gastric shape was acquired after 30-32 SG procedures. CONCLUSION Routine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.


title: Predictive value of National Early Warning Score 2 (NEWS2) for intensive care unit admission in patients with SARS-CoV-2 infection.

text: Background: From January 2020, Coronavirus disease 19 (COVID-19) has rapidly spread all over the world. An early assessment of illness severity is important for the stratification of patients. We analysed the predictive value of National Early Warning Score 2 (NEWS2) for intensive care unit admission (ICU) in patients with Severe Acute Respiratory Syndrome- Coronavirus-2 (SARS-CoV-2) infection.Methods: Data of 71 patients with SARS-CoV-2 admitted from 1 March to 20 April 2020, to the Clinic of Infectious Diseases of Perugia Hospital, Italy, were retrospectively reviewed. NEWS2 at hospital admission, demographic, comorbidity and clinical data were collected. Univariate and multivariate analyses were performed to establish the correlation between each variable and ICU admission.Results: Among 68 patients included in the analysis, 27 were admitted to ICU. NEWS2 at hospital admission was a good predictor of ICU admission as shown by an area under the receiver-operating characteristic curve analysis of 0.90 (standard error 0.04; 95% confidence interval 0.82-0.97). In multivariate logistic regression analysis, NEWS2 was significantly related to ICU admission using thresholds of 5 and 7. No other clinical variables included in the model were significantly correlated with ICU admission.A NEWS2 threshold of 5 had higher sensitivity than a threshold of 7 (89% and 63%). Higher specificity, positive likelihood ratio and positive predictive value were found using a threshold of 7 than a threshold of 5.Conclusions: NEWS2 at hospital admission was a good predictor for ICU admission. Patients with severe COVID-19 were correctly and rapidly stratified.


title: Effects of methylprednisolone or immunoglobulin when added to standard treatment with intravenous azithromycin for refractory Mycoplasma pneumoniae pneumonia in children.

text: BACKGROUND The prevalence of Mycoplasma pneumoniae pneumonia has increased considerably in recent years. To evaluate the efficacy of combined treatment of azithromycin with intravenous immunoglo-bulin (IVIG) or methylprednisolone in children with refractory Mycoplasma pneumoniae pneumonia (RMPP). METHODS Children with RMPP were randomly allocated to group A [intravenous azithromycin (IA)+ methylprednisolone], group B (IA+IVIG) or group C (IA alone). Following a 7-day treatment, group C patients were randomly separated into two sub-groups: group C1 (IA+methylprednisolone) and group C2 (IA+IVIG). Temperature, respiratory symptoms and signs were examined. The average febrile period after treatment (F2), average total febrile period (F3), infiltration absorption, atelectasis resolution, pleural effusion disappearance were determined. The levels of C-reactive protein (CRP), D-dimer, and lactate dehydrogenase (LDH) were measured. RESULTS Seven days after enrollment, the average F2 after treatment of group A was the shortest. Compared with the control group C, the combined treatment group A and B showed higher rates of infiltration absorption, atelectasis resolution and pleural effusion disappearance, while lower levels of serum CRP, D-dimer and LDH. Fourteen days after enrollment, all children with combined therapy clinically improved, and presented better laboratory results. Group C1 showed shorter F3 and lower levels of CRP and LDH than those of group C2. Overall, group A showed the shortest F3, also has the lowest CRP and LDH. CONCLUSIONS Azithromycin with IVIG or methylprednisolone was better treatment for children with RMPP than azithromycin alone. IVIG treatment may be beneficial, especially when the efficacy of corticosteroids is insecure, thus could be considered as an alternative of primary therapeutic approaches.


title: Utility of feline coronavirus antibody tests.

text: Eight different tests for antibodies to feline coronavirus (FCoV) were evaluated for attributes that are important in situations in veterinary practice. We compared four indirect immunofluorescent antibody tests (IFAT), one enzyme-linked immunosorbent assay (ELISA) (FCoV Immunocomb; Biogal) and three rapid immunochromatographic (RIM) tests against a panel of samples designated by consensus as positive or negative. Specificity was 100% for all but the two IFATs based on transmissible gastroenteritis virus (TGEV), at 83.3% and 97.5%. The IFAT and ELISA tests were best for obtaining an antibody titre and for working in the presence of virus. The RIM tests were the best for obtaining a result quickly (10-15 mins); of these, the Speed F-Corona was the most sensitive, at 92.4%, followed by FASTest feline infectious peritonitis (FIP; 84.6%) and Anigen Rapid FCoV antibody test (64.1%). Sensitivity was 100% for the ELISA, one FCoV IFAT and one TGEV IFAT; and 98.2% for a second TGEV IFA and 96.1% for a second FCoV IFAT. All tests worked with effusions, even when only blood products were stipulated in the instruction manual. The ELISA and Anigen RIM tests were best for small quantities of sample. The most appropriate FCoV antibody test to use depends on the reason for testing: in excluding a diagnosis of FIP, sensitivity, specificity, small sample quantity, rapidity and ability to work in the presence of virus all matter. For FCoV screening, speed and sensitivity are important, and for FCoV elimination antibody titre is essential.


title: Robotic perineal radical prostatectomy and robotic pelvic lymph node dissection via a perineal approach: The Tugcu Bakirkoy Technique.

text: Objective To describe The Tugcu Bakirkoy robotic perineal radical prostatectomy and pelvic lymph node dissection technique, and present the results of seven patients. Material and methods We performed seven robotic perineal radical prostatectomy and pelvic lymph node dissection operation using Da Vinci Xi HD Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, USA) on single Gel-port platform. The operation is completed in 4 stages: stage 1 open perineal dissection and gel port placement, stage 2 robotic perineal radical prostatectomy, stage 3 robotic pelvic lymph node dissection, stage 4 vesico-urethral anastomosis. In addition to describing the operation technique step by step, we aimed to present the perioperative and postoperative findings of the seven patients who underwent The Tugcu Bakirkoy Technique. Results All operations were successfully completed without any complications in fully the robotic procedure by a single surgeon. Demographic data of the patients were as follows: Mean age (62.1±8 years), mean body mass index (28.2±0.7 kg/m2), mean prostate specific antigen value (10.7±3 ng/mL), and mean prostate volume (64.2±15.3 cc). Mean operative time (184.1±20.2 mins), blood loss (64.2±15.3 cc), hospitalization time (2.1±0.6 days), and time to withdrawal of the urethral catheter (7.8±0.8 days) were also estimated. According to the pathology results, lymph node metastasis was detected in 3 patients while the surgical margin was positive in one. Conclusion We demonstrated for the first time that a new The Tugcu Bakirkoy robotic perineal radical prostatectomy technique which was previously tested in a cadaveric model, can be safely applied for the first time in vivo, and presented our results. On the basis of this, for problems that can not be overcome by traditional methods, this method is a good alternative as a way out. In this regard, it is necessary to carry out advanced studies so that this method can be applied to daily practice.