title: Totally intracorporeal delta-shaped B-I anastomosis following laparoscopic distal gastrectomy using the Tri-Staple™ reloads on the manual Ultra handle: a prospective cohort study with historical controls.

text: BACKGROUND A delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy could be performed easily and sufficiently using only laparoscopic linear staplers. However, the restricted maneuverability and severe blurring of these staplers along with their limited hemostability induced strain. In this study, we determined the feasibility and safety of performing delta-shaped anastomosis using the Endo GIA™ Reloads with Tri-Staple™ Technology combined with Endo GIA™ Ultra Universal stapler (Tri-Staple) with a particular focus on short-term surgical outcomes. METHODS We performed a single-institutional prospective interventional study (UMIN 000008014). The Tri-Staple was prospectively used on 23 consecutive patients who underwent a curative totally laparoscopic Billroth I gastrectomy with delta-shaped anastomosis. These patients were matched with the 19 patients previously treated using the ENDOPATH(®) ETS Articulating Linear Cutters (ETS) on clinical and demographic characteristics. RESULTS There were no differences between the groups in anastomosis-related local complications, morbidity, non-anastomosis-related local complications, total systemic complications, and short-term outcomes with the exception of significantly reduced blood loss in the Tri-Staple group (ETS vs. Tri-Staple: 37 [10-306] vs. 15 [5-210] mL, p = 0.02). Intraoperative bleeding from the staple line was significantly reduced in the Tri-Staple group. The postoperative drain indwelling period (ETS vs. Tri-Staple, 6 [4-10] vs. 4 [2-43] days, p = 0.032), fasting period (5 [3-7] vs. 3 [3-24] days, p = 0.022), and hospital stay (14 [10-47] vs. 11 [6-58] days, p = 0.025) were significantly shorter in the Tri-Staple group. There was no mortality in this series. Acceleration assessed as indices of blurring of stapler tip might have a significant adverse influence on staple-line bleeding at stapling sites. CONCLUSION Totally laparoscopic Billroth I distal gastrectomy using Tri-Staple was feasible and safe with favorable short-term surgical outcomes. Reduced blurring while stapling may be a novel endpoint which newly developed stapling devices should target.


title: Viral quasispecies evolution.

text: Evolution of RNA viruses occurs through disequilibria of collections of closely related mutant spectra or mutant clouds termed viral quasispecies. Here we review the origin of the quasispecies concept and some biological implications of quasispecies dynamics. Two main aspects are addressed: (i) mutant clouds as reservoirs of phenotypic variants for virus adaptability and (ii) the internal interactions that are established within mutant spectra that render a virus ensemble the unit of selection. The understanding of viruses as quasispecies has led to new antiviral designs, such as lethal mutagenesis, whose aim is to drive viruses toward low fitness values with limited chances of fitness recovery. The impact of quasispecies for three salient human pathogens, human immunodeficiency virus and the hepatitis B and C viruses, is reviewed, with emphasis on antiviral treatment strategies. Finally, extensions of quasispecies to nonviral systems are briefly mentioned to emphasize the broad applicability of quasispecies theory.


title: Single-incision laparoscopic surgery using an articulating monopolar for juvenile cystic adenomyoma.

text: We demonstrate the feasibility of single-incision laparoscopic surgery (SILS) by using a novel monopolar cautery and a technique based on conventional multiport laparoscopic surgery in a patient with Juvenile cystic adenomyoma (JCA). A 20-year-old woman with severe dysmenorrhea, and a 3-cm uterine lesion was diagnosed with JCA. 70 cm of absorbable string tied to the tumor parenchyma was used to extract the tumor. The ends of the strings were positioned extracorporeally and the intra-abdominal parts of the strings adjacent to the anchored tumor were grasped by a laparoscopic needle holder for clarifying the incision line surrounding the tumor. The lesion was completely excised using a single-use articulating hook with monopolar cautery, and the hysterotomy site was sutured using barbed string. No complications occurred intraoperatively, and dysmenorrhea had significantly improved three months after surgery. SILS for JCA is a feasible and minimally invasive surgery for women desiring esthetic benefit.


title: Endovascular Treatment of a Dissected Celiac Trunk Aneurysm Complicated with Consequent Pseudoaneurysm: Primary Treatment and Treatment Relapse after 5 Years.

text: We report on an asymptomatic 56-year-old male with incidental diagnosis of celiac trunk aneurysm, diagnosed during an ultrasound scan performed to control polycystic kidney disease. The CT scan revealed a 3.8 cm saccular aneurysm of the celiac artery dissected in the superior wall with a consequent 4.3 cm pseudoaneurysm; we adopted an endovascular approach to exclude the lesion by catheterizing the celiac trunk and positioning a vascular plug in the common hepatic artery and a covered stent in the splenic artery; finally we fulfilled the aneurysm sac with Onyx. 30-day control CT scan revealed procedural success. Five years later he came back to our department for an aneurysm relapse in the common hepatic artery. We performed a second endovascular approach with a superselective catheterization of the pancreaticoduodenal arcade in order to exclude the lesion with Onyx and microcoils. Nowadays the patient is in good clinical conditions. Endovascular approach is a valuable method to treat visceral aneurysms; however, long-term imaging follow-up is essential to monitor the risk of relapse.


title: Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease.

text: AIM Management of fistulating perianal Crohn's disease (fpCD) is a significant challenge for a colorectal surgeon. A recent survey of surgical practice in this condition showed variation in management approaches. As a result we set out to devise recommendations for practice for UK colorectal surgeons. METHOD Results from a national survey were used to devise a set of potential consensus statements. Consultant colorectal surgeons were invited to participate in the exercise via the previous survey and the mailing list of the professional society. Iterative voting was performed on each statement using a five-point Likert scale and electronic voting, with opportunity for discussion and refinement between each vote. Consensus was defined as > 80% agreement. RESULTS Seventeen surgeons and two patient representatives voted upon 51 statements. Consensus was achieved on 39 items. Participants advocated a patient-centred approach by a colorectal specialist, within strong multidisciplinary teamworking. The use of anti-TNFα therapy is advocated. Where definitive surgical techniques are considered they should be carefully selected to avoid adverse impact on function. Ano/rectovaginal fistulas should be managed by specialists in fistulating disease. Stoma or proctectomy could be discussed earlier in a patient's treatment pathway to improve choice, as they may improve quality of life. CONCLUSION This consensus provides principles and guidance for best practice in managing patients with fpCD.


title: Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass.

text: BACKGROUND Robotic surgery is a complex technology offering technical advantages over conventional methods. Still, clinical outcomes and financial issues have been subjects of debate. Several studies have demonstrated higher costs for robotic surgery when compared to laparoscopy or open surgery. However, other studies showed fewer costly anastomotic complications after robotic Roux-en-Y gastric bypass (RYGBP) when compared to laparoscopy. METHODS We collected data for our gastric bypass patients who underwent open, laparoscopic, or robotic surgery from June 1997 to July 2010. Demographic data, BMI, complications, mortality, intensive care unit stay, hospitalization, and operating room (OR) costs were analyzed and a cost projection completed. Sensitivity analyses were performed for varied leak rates during laparoscopy, number of robotic cases per month, number of additional staplers during robotic surgery, and varied OR times for robotic cases. RESULTS Nine-hundred ninety patients underwent gastric bypass surgery at the University Hospital Geneva from June 1997 to July 2010. There were 524 open, 323 laparoscopic, and 143 robotic cases. Significantly fewer anastomotic complications occurred after open and robotic RYGBP when compared to laparoscopy. OR material costs were slightly less for robotic surgery (USD 5,427) than for laparoscopy (USD 5,494), but more than for the open procedure (USD 2,251). Overall, robotic gastric bypass (USD 19,363) was cheaper when compared to laparoscopy (USD 21,697) and open surgery (USD 23,000). CONCLUSIONS Robotic RYGBP can be cost effective due to balancing greater robotic overhead costs with the savings associated with avoiding stapler use and costly anastomotic complications.


What the SWIFT and TREVO II trials tell us about the role of endovascular therapy for acute stroke.


title: The association of stroke severity with health-related quality of life in survivors of acute cerebrovascular disease and their informal caregivers during the first year post stroke: a survey study.

text: PURPOSE To describe the health-related quality of life (HRQoL) of caregivers and survivors of transient ischaemic attack (TIA) and stroke during one year post discharge in comparison to age- and sex-matched population norms; and to analyse the association of initial stroke severity, measured by a routinely used stroke-specific scale, on subsequent HRQoL of caregivers and survivors. METHODS Cohort of hospitalized patients with TIA and stroke discharged alive from a large university hospital in Norway, and their informal caregivers. Questionnaires at 3 and 12 months post discharge were filled out by caregivers (n = 320 and n = 326, respectively) and survivors (n = 368 and n = 383, respectively). Multivariable linear regression analyses tested associations between initial stroke severity (National Institutes of Health Stroke Scale, NIHSS) and HRQoL (EQ-5D-3L) in caregivers and survivors. RESULTS Caregivers of survivors with TIA or stroke did not report lower HRQoL than matched norms. There was some evidence of an association of the NIHSS with caregiver HRQoL at 3 months only (age-sex-adjusted coefficient - 0.01, p = 0.008), however, this was attenuated after additional adjustments. Survivors with stroke, but not TIA, reported lower HRQoL than population norms at both time points. There was a negative association between higher NIHSS scores and survivors' HRQoL; fully adjusted coefficient - 0.01 at both time points (p = 0.001). CONCLUSION The informal caregivers and survivors with TIA did not report lower than expected HRQoL. Increasing stroke severity was associated with decreasing HRQoL among survivors, but had limited predictive value among caregivers. Other factors may therefore be better indicators of 'at risk' caregivers.


title: Microvascular anatomy of spinal dural arteriovenous fistulas: arteriovenous connections and their relationships with the dura mater.

text: OBJECT The microvascular anatomy of spinal dural arteriovenous fistulas (AVFs), especially the relationships of the vessels with the dura mater, has yet to be angiographically demonstrated in detail and proven histologically. METHODS From January 2012 through April 2014, a total of 7 patients with spinal dural AVFs in the thoracic region underwent open microsurgical obliteration at Tokyo Metropolitan Neurological Hospital. The microvascular anatomy of spinal dural AVFs was comprehensively assessed by using advanced microangiography, including 3D computer graphics and intraoperative indocyanine green video angiography, and by histological findings. RESULTS The 2 microangiography techniques revealed the spatial course and in vivo blood flow of the meningeal vessels and their relationships with the dura mater in sufficient detail. The meningeal branch of the intercostal artery split into multiple meningeal vessels on the outer dural surface adjacent to the root sleeve. After crossing the dura mater to the inner dural surface, these vessels gathered and joined a single intradural draining vessel. On the inner dural surface, the single draining vessel was fed by the surrounding multiple meningeal vessels, which appeared to be caput medusae. Histological findings revealed that the structure of the meningeal branch of the intercostal artery corresponded to that of a normal artery. The structure of intradural draining vessels corresponded to that of a vein modified by retrograde arterial inflow. On the inner dural surface, more than 1 meningeal artery gathered and joined with the proximal radiculomedullary vein. CONCLUSIONS Spinal dural AVFs are located on the inner dural surface, where multiple direct AV connections between more than 1 meningeal feeding artery and a single proximal radiculomedullary vein occur at the site where the vein connects to the dura mater.


title: Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study.

text: BACKGROUND The endovascular treatment of middle cerebral artery (MCA) aneurysms with unfavorable anatomy (wide neck, unfavorable morphology) is frequently challenging. Flow disruption with the WEB is a potentially interesting endovascular treatment for this type of aneurysm. OBJECTIVE To report in a multicenter series the preliminary treatment experience of MCA aneurysms with flow disruption by the WEB. METHODS Thirty-three patients with 34 MCA aneurysms were treated with the WEB in 5 European centers. The ability to successfully deploy the WEB, procedure- and device-related adverse events, morbidity and mortality of the treatment, and short-term angiographic follow-up results were analyzed. RESULTS Most treated aneurysms were unruptured (85.3%) and were between 5 and 10 mm (85.3%) with a neck size ≥ 4 mm (88.2%). The treatment failed in 1 of the 34 aneurysms (2.9%) owing to a lack of appropriate device size. Treatment was performed exclusively with the WEB in 29 of 33 aneurysms (87.9%). Additional treatment (coiling and/or stenting) was used in 4 of 33 aneurysms (12.1%). Mortality of the treatment was 0.0% and morbidity was 3.1% (intraoperative rupture with modified Rankin Scale score of 3 at the 1-month follow-up). In short-term follow-up (range, 2-12 months), adequate occlusion (total occlusion or neck remnant) was observed in 83.3% of aneurysms. CONCLUSION WEB flow disruption seems to be a promising technique for the treatment of complex MCA aneurysms, particularly those with a wide neck or unfavorable dome-to-neck ratio.


title: Our Next Pandemic Ethics Challenge? Allocating "Normal" Health Care Services.

text: The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.


title: Pure transvaginal umbilical hernia repair.

text: BACKGROUND Transvaginal natural orifice transluminal endoscopic surgery (NOTES) procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain [1, 2]. Most transvaginal procedures are performed as hybrid procedures [3]. To our knowledge, this is the first video depiction of a pure transvaginal umbilical hernia repair in a human. METHODS This is a 38-year-old woman, body mass index 36.4 kg/m(2), with a symptomatic port site hernia in the umbilical region after a previous laparoscopic cholecystectomy. The patient was positioned in stirrups in a steep Trendelenburg position. Sterilization of vaginal cavity was performed with 10 % povidone-iodine solution. A 2 cm transverse incision at the posterior fornix was made, and a SILS port (Covidien, North Haven, CT) was introduced. One 12 mm trocar and two 5 mm trocars were placed through SILS port. Standard straight laparoscopic instruments were used. A 12 cm round Parietex mesh (Covidien) was placed in a specimen retrieval bag and deployed into the peritoneal cavity. The mesh was extracted, unfolded in the abdominal cavity, and circumferentially fixated to the abdominal wall with an AbsorbaTack device (Covidien). The colpotomy incision was closed with a running absorbable suture. RESULTS The procedure lasted 103 min and was performed on an outpatient basis. No intraoperative complications occurred. The patient was doing well and had no pain or recurrence at 2, 6, and 9 months' follow-up. CONCLUSIONS Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible and safe. This approach may improve cosmesis and decrease the risk of future ventral hernias. Potential cons may include a longer operative time, mesh infection, and risk of visceral injury with a pure transvaginal approach. As transvaginal surgery evolves, techniques and devices will become increasingly refined to tackle these challenges.


The Surgical Health Services Research Agenda for the COVID-19 Pandemic.


Gain-of-function research: unknown risks.


title: Genetic diversity of novel circular ssDNA viruses in bats in China.

text: Novel circular ssDNA genomes have recently been detected in animals and in the environment using metagenomic and high-throughput sequencing approaches. In this study, five full-length circular ssDNA genomes were recovered from bat faecal samples using inverse PCR with sequences designed based on circovirus-related sequences obtained from Solexa sequencing data derived from a random amplification method. These five sequences shared a similar genomic organization to circovirus or the recently proposed cyclovirus of the family Circoviridae. The newly obtained circovirus/cyclovirus-like genomes ranged from 1741 to 2177 bp, and each consisted of two major ORFs, ORF1 and ORF2, encoding putative replicase (Rep) and capsid (Cap) proteins, respectively. The potential stem-loop region was predicted in all five genomes, and three of them had the typical conserved nonanucleotide motif of cycloviruses. A set of primers targeting the conserved Rep region was designed and used to detect the prevalence of circovirus/cyclovirus sequences in individual bats. Among 199 samples tested, 47 were positive (23.6%) for the circovirus genome and two (1.0%) were positive for the cyclovirus genome. In total, 48 partial Rep sequences plus the five full-length genomes were obtained in this study. Detailed analysis indicated that these sequences are distantly related to known circovirus/cyclovirus genomes and may represent 22 novel species that belong to the family Circoviridae.


title: Exercise-Based Strategies to Prevent Muscle Injury in Elite Footballers: A Systematic Review and Best Evidence Synthesis.

text: BACKGROUND Exercise-based strategies are used to prevent muscle injuries in football and studies on different competitive-level populations may provide different results. OBJECTIVES To evaluate the effectiveness of exercise-based muscle injury prevention strategies in adult elite football. METHODS A systematic search was conducted in PubMed (MEDLINE), Web of Science, Cochrane Library, and SPORTDiscuss (EBSCO). We considered only elite adult (> 16 year-old) football players with no distinction for gender; the intervention to be any exercise/s performed with the target to prevent lower-limb muscle injuries; the comparison to be no injury prevention exercise undertaken; the outcome to be the number of injuries, injury incidence, and severity. We searched systematic reviews, randomized-controlled trials (RCTs), and non-randomized-controlled trials (NRCTs), limited for English language. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool, the Cochrane Collaboration's Tool for assessing risk of bias in RCTs, and the Risk of Bias in NRCTs of Interventions tool. RESULTS 15 studies were included. Three systematic reviews showed inconsistent results, with one supporting (high risk of bias) and two showing insufficient evidence (low risk of bias) to support exercise-based strategies to prevent muscle injuries in elite players. Five RCTs and seven NRCTs support eccentric exercise, proprioception exercises, and a multi-dimensional component to an injury prevention program; however, all were deemed to be at high/critical risk of bias. Only one RCT was found at low risk of bias and supported eccentric exercise for preventing groin problems. CONCLUSION We found limited scientific evidence to support exercise-based strategies to prevent muscle injury in elite footballers. TRIAL REGISTRATION NUMBER PROSPERO CRD42017077705.


title: Characteristics of missed or interval colorectal cancer and patient survival: a population-based study.

text: BACKGROUND & AIMS Colorectal cancers (CRCs) diagnosed within a few years after an index colonoscopy can arise from missed lesions or the development of a new tumor. We investigated the proportion, characteristics, and factors that predict interval CRCs that develop within 6-60 months of colonoscopy. METHODS We performed a population-based cohort study of Utah residents who underwent colonoscopy examinations from 1995 through 2009 at Intermountain Healthcare or the University of Utah Health System, which provide care to more than 85% of state residents. Colonoscopy results were linked with cancer histories from the Utah Population Database to identify patients who underwent colonoscopy 6-60 months before a diagnosis of CRC (interval cancer). Logistic regression was performed to identify risk factors associated with interval cancers. RESULTS Of 126,851 patients who underwent colonoscopies, 2659 were diagnosed with CRC; 6% of these CRCs (159 of 2659) developed within 6 to 60 months of a colonoscopy. Sex and age were not associated with interval CRCs. A higher percentage of patients with interval CRC were found to have adenomas at their index colonoscopy (57.2%), compared with patients found to have CRC detected at colonoscopy (36%) or patients who did not develop cancer (26%) (P < .001). Interval CRCs tended to be earlier-stage tumors than those detected at index colonoscopy, and to be proximally located (odds ratio, 2.24; P < .001). Patients with interval CRC were more likely to have a family history of CRC (odds ratio, 2.27; P = .008) and had a lower risk of death than patients found to have CRC at their index colonoscopy (hazard ratio, 0.63; P < .001). CONCLUSIONS In a population-based study in Utah, 6% of all patients with CRC had interval cancers (cancer that developed within 6 to 60 months of a colonoscopy). Interval CRCs were associated with the proximal colon, earlier-stage cancer, lower risk of death, higher rate of adenoma, and family history of CRC. These findings indicate that interval colorectal tumors may arise as the result of distinct biologic features and/or suboptimal management of polyps at colonoscopy.


title: The free descending branch muscle-sparing latissimus dorsi flap: vascular anatomy and clinical applications.

text: BACKGROUND Increasing focus on reducing morbidity from latissimus dorsi flaps has led to the evolution of muscle-sparing variants and perforator-based flaps. This study aimed to investigate the vascular anatomy of the muscle-sparing variant and to describe its application as a free flap based on the descending branch of the thoracodorsal artery. METHODS Twelve fresh cadavers underwent anatomical dissection and angiographic injection studies of the thoracodorsal arterial system. The musculocutaneous territories of the descending and transverse branches to the latissimus dorsi muscle were identified and assessed using three-dimensional reconstruction software of computed tomography imaging results. In the clinical study, five patients underwent reconstruction of a variety of defects using the free descending branch muscle-sparing latissimus dorsi flap. RESULTS Three- and four-dimensional (computed tomography) angiography demonstrated perfusion of the latissimus dorsi muscle by the transverse and descending branches, with overlap of vascular territories via cross-linking vessels. The descending branch supplied a slightly greater cutaneous area overlying the muscle, although differences between both branches were not significant (p = 0.76). In the clinical study, the free muscle-sparing latissimus dorsi flap provided excellent coverage with no flap complications or seroma. CONCLUSIONS The free muscle-sparing latissimus dorsi flap based on the descending branch of the thoracodorsal artery is a viable reconstructive option. Significant collateral flow between vessels allows for larger flap harvest than would be expected. The flap is technically simple to harvest, provides a large perfusion area, and is a reliable variant of the full latissimus dorsi flap. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.


Metabolic Surgery for Type 2 Diabetes: Changing the Landscape of Diabetes Care.


title: Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection following standardization--a preliminary study.

text: BACKGROUND Laparoscopy-assisted distal gastrectomy (LADG) with standard D2 dissection is a complex procedure usually performed only by experienced surgeons, and the feasibility of this procedure still remains unclear. METHOD Patients who underwent LADG at the Cancer Institute Hospital between April 2006 and October 2008 were recruited for this study. Early surgical outcomes were compared between patients who underwent complete D2 dissection (complete D2 group; n = 42) and those who underwent D1 + beta dissection (D1 + beta group; n = 179) to determine the feasibility of laparoscopic D2 lymph node dissection. RESULTS In complete D2 group, the operation time was longer (253 +/- 10 vs 224 +/- 4 min; P = 0.005), and the number of retrieved lymph nodes was larger (41 +/- 2 vs 35 +/- 1; P = 0.002) compared with those in D1 + beta group. The other early surgical outcomes monitored for the two groups were not different between groups. CONCLUSIONS LADG with complete D2 lymph node dissection can be performed safely if the procedure is standardized and an experienced laparoscopic surgeon performs the surgery. To be accepted as a standard treatment for advanced gastric cancer, well-designed prospective trial is necessary.


title: Viscosity of iodinated contrast agents during renal excretion.

text: OBJECTIVE Modern iodinated non-ionic contrast agents (CAs) can be classified based on their molecular structure into monomeric and dimeric CAs and have at comparable iodine concentrations a different viscosity and osmolality. During their renal excretion, CAs are concentrated in the renal tubuli which might enhance the viscosity difference between monomeric and dimeric CAs. The viscosity of a CA might have an underestimated importance for renal safety, as suggested by recent publications. In this study, we investigated the viscosities of CAs at the concentrations expected to be present in renal tubules. This concentration process was simulated in vitro using dialysis. Furthermore, we investigated urine viscosity and urine flow in rodents after administration of several non-ionic monomeric and dimeric CAs. MATERIALS AND METHODS To estimate the viscosity of the CAs in vivo, we performed an in vitro dialysis of monomeric and dimeric CAs at various physiological osmolalities of the renal tubulus (290, 400, 500, 700 and 1000 mOsm/kg H2O). Following the dialysis, the iodine concentrations and the viscosities of the CAs were determined. Furthermore, to investigate the concentration process in vivo, we measured the urine viscosity and the urine flow in Han Wister rats after the administration of Iopromide, Iohexol, Ioversol, Iomeprol, Iodixanol, and Iosimenol at comparable iodine concentrations. As a control, saline was injected at the same volume. RESULTS In vitro dialysis of the dimeric CA increased the iodine concentration and strongly increased the viscosity at all tested osmolalities. In contrast, for the monomeric agents an increase in concentration and viscosity was observed only at 700 as well 1000 mOsm/kg H2O but to a lesser extent. In summary, dialysis strongly enhanced the viscosity differences between the non-ionic monomeric and dimeric CAs. The administration of dimeric CAs leads to a strong increase in urine viscosity; this was not observed for the monomeric CAs. In contrast, a significantly higher urine flow was measured after the administration of the monomeric CAs as compared to the dimeric CAs. CONCLUSION We demonstrated that the viscosity differences between monomeric and dimeric CAs are strongly enhanced due to a concentration process of the CAs upon increasing osmolalities, a process which is likely to take place in a similar manner in the tubular system. This result suggests that the viscosity of the dimeric agents increases dramatically in vivo and gives a plausible explanation for measured enhancement of urine viscosity upon dimeric CA administration. On the other hand, the higher osmolality of the monomeric agents causes an osmodiuresis, indicated by a higher urine flow, which leads to a faster elimination of the CAs from the kidney.


title: Urologic surgery in a safe hospital during the COVID-19 pandemic scenario.

text: The COVID-19 pandemic induced a global emergency that overwhelmed most hospitals around the world. Access to Hospitals has been restricted to selective oncological and urgent patients to minimize surgeries requiring Intensive Care Unit care. All other kind of non- urgent and benign surgeries have been rescheduled. The burden of oncological and urgent cases on the healthcare system has increased. We have been asked to become the referral center for major oncological and urgent urological surgeries, increasing our surgical volume. Through meticulous hospital protocols on PPE, use of nasopharyngeal swabs, controlled hospital access and the prompt management of suspected/positive cases, we were able to perform 31% more urological surgical procedures during the COVID-19 pandemic compared to the same period in 2019. We observed a 72% increase in oncological surgical procedures and 150% in urgent procedures. Our experience shows how the management of oncological and urgent cases can be maintained during unexpected, global emergencies, such as COVID-19.


title: Design of polymeric nanoparticles for biomedical delivery applications.

text: Polymeric nanoparticles-based therapeutics show great promise in the treatment of a wide range of diseases, due to the flexibility in which their structures can be modified, with intricate definition over their compositions, structures and properties. Advances in polymerization chemistries and the application of reactive, efficient and orthogonal chemical modification reactions have enabled the engineering of multifunctional polymeric nanoparticles with precise control over the architectures of the individual polymer components, to direct their assembly and subsequent transformations into nanoparticles of selective overall shapes, sizes, internal morphologies, external surface charges and functionalizations. In addition, incorporation of certain functionalities can modulate the responsiveness of these nanostructures to specific stimuli through the use of remote activation. Furthermore, they can be equipped with smart components to allow their delivery beyond certain biological barriers, such as skin, mucus, blood, extracellular matrix, cellular and subcellular organelles. This tutorial review highlights the importance of well-defined chemistries, with detailed ties to specific biological hurdles and opportunities, in the design of nanostructures for various biomedical delivery applications.


title: Keeping Patients With Cancer Exercising in the Age of COVID-19.

text: The novel 2019 coronavirus disease (COVID-19) pandemic is a global public health emergency. To date, physical distancing and good personal hygiene have been the only effective measures to limit spread. The pandemic has altered routine cancer care, including allied health and supportive care interventions. Clinicians must adapt and find ways to continue to deliver optimal patient care at this time. The prescription of exercise to people with cancer has been demonstrated to have meaningful benefits for both physical and mental health and quality of life, and may even enhance survival. Such exercise interventions provide the largest benefit to patients when delivered in a supervised, group, clinic-based setting. In the age of COVID-19, group-based exercise in communal facilities presents risks for both aerosol and surface transmission of the virus among people exercising, necessitating a pivot from the usual methods of exercise delivery to home-based exercise programs. In this article, we discuss the challenges that need to be overcome in moving to a home-based program for patients with cancer while maintaining the benefits of targeted and high-fidelity exercise medicine. We provide practical recommendations for how home-based exercise can be supported and nurtured by qualified exercise professionals who treat people living with cancer, as well as pointing to resources that are available online to assist practitioners. Despite the challenges faced during this pandemic, we believe that it is important for people to continue to benefit from exercise in a safe environment with the support of exercise specialists.


title: 18F-FDG PET as novel imaging biomarker for disease progression after ablation therapy in colorectal liver metastases.

text: PURPOSE Recurrent disease following thermal ablation therapy is a frequently reported problem. Preoperative identification of patients with high risk of recurrent disease might enable individualized treatment based on patients' risk profile. The aim of the present work was to investigate the role of metabolic parameters derived from the pre-ablation 18F-FDG PET/CT as imaging biomarkers for recurrent disease in patients with colorectal liver metastases (CLM). METHODS Included in this retrospective study were all consecutive patients with CLM treated with percutaneous or open thermal ablation therapy who had a pre-treatment baseline 18F-FDG PET/CT available. Multivariable cox regression for survival analysis was performed using different models for the metabolic parameters (SULpeak, SULmean, SULmax, partial volume corrected SULmean (cSULmean), and total lesion glycolysis (TLG)) corrected for tumour and procedure characteristics. The study endpoints were defined as local tumour progression free survival (LTP-FS), new intrahepatic recurrence free survival (NHR-FS) and extrahepatic recurrence free survival (EHR-FS). Clinical and imaging follow-up data was used as the reference standard. RESULTS Fifty-four patients with 90 lesions were selected. Univariable cox regression analysis resulted in eight models. Multivariable analysis revealed that after adjusting for lesion size and the approach of the procedure, none of the metabolic parameters were associated with LTP-FS or EHR-FS. Percutaneous approach was significantly associated with a shorter LTP-FS. It was demonstrated that lower values of SULpeak, SULmax, SULmean , and cSULmean are associated with a significant better NHR-FS, independent of the lesion size and number and prior chemotherapy. CONCLUSION We found no association between the metabolic parameters on pre-ablation 18F-FDG PET/CT and the LTP-FS. However, low values of the metabolic parameters were significantly associated with improved NHR-FS. The clinical implication of these findings might be the identification of high-risk patients who might benefit most from adjuvant or combined treatment strategies.


Collaboration in TB and COVID-19 control in Moscow.


title: First case report of single port video-assisted thoracoscopic middle lobectomy for the treatment of pulmonary aspergilloma in a pediatric patient.

text: We present the case of an 11-year-old girl with pulmonary aspergilloma secondary to a hematologic disease successfully treated with a single port video-assisted thoracoscopic lobectomy. This surgical procedure was not previously reported. We consider this approach to be a safe and appropriate procedure for lung resection, in children or adults requiring minimal intervention and early recovery.


title: Uncertainty and agreement regarding the role of flow diversion in the management of difficult aneurysms.

text: BACKGROUND AND PURPOSE The role of flow diversion in the management of aneurysms remains unknown. We sought to evaluate the community agreement regarding indications for flow diversion. MATERIALS AND METHODS A portfolio of 35 difficult aneurysm cases was sent to 40 clinicians with varying backgrounds and experience. Responders were asked whether they considered flow diversion a treatment option, whether other options were possible, whether recruitment in a randomized trial would be considered, and to select their final choice. Agreement was studied by using κ statistics. RESULTS Decisions for flow diversion were more frequent (n = 300, 39%) than decisions to coil (n = 163, 21.2%), to observe (n = 121, 15.7%), to occlude the parent vessel (n = 102, 13.2%), or to clip (n = 66, 8.6%). Sidewall aneurysm morphology was associated with flow diversion as the final choice (P = .001). Interjudge agreement was fair at best (κ <0.3) for all cases and all judges, despite high certainty levels (range, 7.2-8.9 ± 2.0 on a 0-10 scale). Agreement was no better within specialties or with more experience. All patients were judged to have other treatment options. Judges were willing to offer trial participation in 417 of 741 (56.3%) scenarios, more frequently when the aneurysm was sidewall (P = .001) or in the anterior circulation (P = .028). CONCLUSIONS Individuals did not agree regarding the indications for flow diversion. There is sufficient uncertainty to justify trials designed to protect patients from the potential risks of premature adoption of an innovation.


Novel Coronavirus 2019 (Sars-CoV2): a global emergency that needs new approaches?


Clinical Correlation of Anatomical Location of Nonthrombotic Iliac Vein Lesion.


title: Saphenous vein graft near-infrared spectroscopy imaging insights from the lipid core plaque association with clinical events near-infrared spectroscopy (ORACLE-NIRS) registry.

text: OBJECTIVES We sought to examine near-infrared spectroscopy (NIRS) imaging findings of aortocoronary saphenous vein grafts (SVGs). BACKGROUND SVGs are prone to develop atherosclerosis similar to native coronary arteries. They have received little study using NIRS. METHODS We examined the clinical characteristics and imaging findings from 43 patients who underwent NIRS imaging of 45 SVGs at our institution between 2009 and 2016. RESULTS The mean patient age was 67 ± 7 years and 98% were men, with high prevalence of diabetes mellitus (56%), hypertension (95%), and dyslipidemia (95%). Mean SVG age was 7 ± 7 years, mean SVG lipid core burden index (LCBI) was 53 ± 60 and mean maxLCBI4 mm was 194 ± 234. Twelve SVGs (27%) had lipid core plaques (2 yellow blocks on the block chemogram), with a higher prevalence in SVGs older than 5 years (46% vs. 5%, P = 0.002). Older SVG age was associated with higher LCBI (r = 0.480, P < 0.001) and higher maxLCBI4 mm (r = 0.567, P < 0.001). On univariate analysis, greater annual total cholesterol exposure was associated with higher SVG LCBI (r = 0.30, P = 0.042) and annual LDL-cholesterol and triglyceride exposure were associated with higher SVG maxLCBI4 mm (LDL-C: r = 0.41, P = 0.020; triglycerides: r = 0.36, P = 0.043). On multivariate analysis, the only independent predictor of SVG LCBI and maxLCBI4mm was SVG age. SVG percutaneous coronary intervention was performed in 63% of the patients. An embolic protection device was used in 96% of SVG PCIs. Periprocedural myocardial infarction occurred in one patient. CONCLUSIONS Older SVG age and greater lipid exposure are associated with higher SVG lipid burden. © 2016 Wiley Periodicals, Inc.


Open for outbreaks.


The effect of suturing on force for dislodgement of tracheostomy tubes: medial versus lateral sutures.


title: RIG-I-Mediated STING Upregulation Restricts Herpes Simplex Virus 1 Infection.

text: UNLABELLED STING has emerged in recent years as a key player in orchestrating innate immune responses to cytosolic DNA and RNA derived from pathogens. However, the regulation of STING still remains poorly defined. In the present study, we investigated the mechanism of the regulation of STING expression in relation to the RIG-I pathway. Our data show that signaling through RIG-I induces STING expression at both the transcriptional and protein levels in various cell types. STING induction by the RIG-I agonist 5'triphosphorylated RNA (5'pppRNA) was recognized to be a delayed event resulting from an autocrine/paracrine mechanism. Indeed, cotreatment with tumor necrosis factor alpha and type I/II interferon was found to have a synergistic effect on the regulation of STING expression and could be potently decreased by impairing NF-κB and/or STAT1/2 signaling. STING induction significantly contributed to sustainment of the immune signaling cascade following 5'pppRNA treatment. Physiologically, this cross talk between the RNA- and DNA-sensing pathways allowed 5'pppRNA to efficiently block infection by herpes simplex virus 1 (HSV-1) both in vitro and in vivo in a STING-dependent fashion. These observations demonstrate that STING induction by RIG-I signaling through the NF-κB and STAT1/2 cascades is essential for RIG-I agonist-mediated HSV-1 restriction. IMPORTANCE The innate immune system represents the first line of defense against invading pathogens. The dysregulation of this system can result in failure to combat pathogens, inflammation, and autoimmune diseases. Thus, precise regulation at each level of the innate immune system is crucial. Recently, a number of studies have established STING to be a central molecule in the innate immune response to cytosolic DNA and RNA derived from pathogens. Here, we describe the regulation of STING via RIG-I-mediated innate immune sensing. We found that STING is synergistically induced via proinflammatory and antiviral cytokine cascades. In addition, we show that in vivo protection against herpes simplex virus 1 (HSV-1) by a RIG-I agonist required STING. Our study provides new insights into the cross talk between DNA and RNA pathogen-sensing systems via the control of STING.


title: Simple technique for single incision transumbilical laparoscopic appendectomy.

text: INTRODUCTION Acute appendicitis is one of the most commonly encountered surgical problems in everyday practice. With the recent increase in popularity of single incision laparoscopic surgery (SILS), several techniques for SILS appendectomy have already been described. We herein describe our own simplified technique for single incision transumbilical laparoscopic appendectomy. MATERIALS AND METHODS From December 2008 to August 2009, a total of 26 patients consented for single incision laparoscopic appendectomy for acute appendicitis. Preoperative, intraoperative and postoperative data were collected. RESULTS Our technique was successful in 19 out of 26 (73.1%) patients, while seven patients required the placement of additional trocars. None of the patients needed conversion to an open approach. Mean OR time was 45.9 min. The mean length of stay was 1.1 day. Only one patient had developed postoperative umbilical wound infection. CONCLUSION Our technique for single incision laparoscopic transumbilical appendectomy is safe feasible, and reproducible. Prospective randomized studies comparing the single incision laparoscopic approach with its conventional multiport counterpart are necessary to confirm the conclusions of our early experience.


title: Full-thickness skin grafts for surgical defects of the nasal ala - a comprehensive review, approach and outcomes of 186 cases over 9 years.

text: BACKGROUND Skin cancers of the nasal ala are commonly encountered in dermatological surgery. Various techniques have been described to reconstruct surgical defects of the ala, including melolabial transposition flaps, interpolated melolabial flaps, bilobed and trilobed transposition flaps, island pedicle flaps and spiral flaps. Full-thickness skin grafts have received little attention in the reconstructive literature. OBJECTIVES We present our experience with full-thickness skin grafts for the reconstruction of partial thickness defects of the nasal ala in the largest series to date. METHODS A retrospective analysis of the Mohs micrographic surgery database over a 9-year period was performed. All cases of full-thickness skin grafts for reconstruction of the nasal ala were identified. Defect location, size and any postoperative complications were noted. All patients were reviewed at the time of suture removal, at 3 and 6 weeks postoperatively and at 1 year. RESULTS There were 186 cases in total in 181 patients (88 men and 93 women). Their ages ranged from 31 to 88 years with a mean of 65 years (median 66). Defect size varied from 0·3 × 0·4 cm to 2·0 × 2·7 cm, with the average defect size measuring 1·0-1·2 cm in diameter. Thirty-six per cent (67 of 186) of cases underwent postoperative dermabrasion, and 8% (14 of 186) received postoperative intralesional triamcinolone. The incidence of graft failure and infection was low. Good-to-excellent cosmetic results were seen in all patients and postoperative complications were uncommon and minor. CONCLUSIONS The use of full-thickness skin grafts for defects of the nasal ala is a simple and versatile reconstructive option with excellent functional and aesthetic outcomes.


title: Parenting Interventions in Pediatric Primary Care: A Systematic Review.

text: CONTEXT More than 4 decades of research indicate that parenting interventions are effective at preventing and treating mental, emotional, and behavioral disorders in children and adolescents. Pediatric primary care is a viable setting for delivery of these interventions. OBJECTIVE Previous meta-analyses have shown that behavioral interventions in primary care can improve clinical outcomes, but few reviews have been focused specifically on the implementation of parenting interventions in primary care. We aimed to fill this gap. DATA SOURCES We reviewed 6532 unique peer-reviewed articles published in PubMed, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo. STUDY SELECTION Articles were included if at least part of the intervention was delivered in or through primary care; parenting was targeted; and child-specific mental, emotional, and behavioral health outcomes were reported. DATA EXTRACTION Articles were reviewed in Covidence by 2 trained coders, with a third coder arbitrating discrepancies. RESULTS In our review of 40 studies, most studies were coded as a primary. Few researchers collected implementation outcomes, particularly those at the service delivery system level. LIMITATIONS Including only published articles could have resulted in underrepresentation of implementation-related data. CONCLUSIONS Parenting interventions delivered and implemented with fidelity in pediatric primary care could result in positive and equitable impacts on mental, emotional, and behavioral health outcomes for both parents and their children. Future research on the implementation strategies that can support adoption and sustained delivery of parenting interventions in primary care is needed if the field is to achieve population-level impact.


title: Traumatic fragmented medial coronoid process in a Chihuahua.

text: Fragmented medial coronoid process (FMCP) is a disease process that has not previously been reported in toy-breed dogs. This report describes a presumptive case of FMCP in a 14-month-old Chihuahua that was presented for evaluation approximately four weeks following acute onset of moderate lameness in the left forelimb. Definitive diagnosis of a fragmented medial coronoid process was based upon computed tomography (CT) scan. A CT scan also demonstrated moderate joint incongruity in the affected elbow. Surgical removal of the fragment and subtotal coronoidectomy were performed via a medial arthrotomy. An ulnar ostectomy was also performed to address joint incongruity. Histology of specimens removed at surgery did not demonstrate evidence of microdamage as characteristic of FMCP in large breed dogs, and instead, suggested that the fracture was acute and traumatic in nature. Rapid return to function was observed following surgery.


Ebola, physicians in training, and the duty to treat.


Bronchointerstitial pneumonia in Scottish cattle.


title: Tracheostomy care: the role of the nurse before, during and after insertion.

text: A tracheostomy is a surgical procedure that involves creating an opening and inserting a tube in the trachea to enable air transit from the external atmosphere to the lungs. The insertion of a tracheostomy is a common procedure used to wean patients from mechanical ventilation and to manage patients with upper respiratory tract complications. Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has resulted in many patients requiring a tracheostomy as part of respiratory management. The two most commonly used tracheostomy insertion procedures are the open surgical tracheostomy and the percutaneous dilatation tracheostomy, both of which are associated with a range of complications. This article outlines the indications, benefits and complications of tracheostomy insertion, as well as the various types of tracheostomy tube that may be used. It also explains the role of the nurse in caring for patients before, during and after tracheostomy insertion, including the management of tracheostomy-related complications and emergencies.


title: A cost comparison of laparoscopic and open colon surgery in a publicly funded academic institution.

text: BACKGROUND The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution. METHODS Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann-Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost. RESULTS There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost. CONCLUSIONS Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.


Finding motivation while working from home as a PhD student during the coronavirus pandemic.


COVID-19 Infection: Perioperative Implications: Reply.


title: Effect of syringe and aggregate filter administration on survival of transfused autologous fresh feline red blood cells.

text: OBJECTIVE To assess the effect of transfusion using a syringe and microaggregate filter on short-term survival and circulating half-life of autologous feline RBCs. DESIGN Prospective, internally controlled, observational study. SETTING A University Teaching Hospital ANIMALS Six apparently healthy, owned cats. INTERVENTIONS Blood collection by jugular venipuncture. Transfusion with labeled, autologous, fresh RBCs. MEASUREMENTS AND MAIN RESULTS Anticoagulated whole blood (35 mL/cat) was collected in 2 equal aliquots. RBCs were washed and labeled at 2 different biotin densities, before suspension in autologous plasma. Labeled RBCs were then transfused using 2 methods, gravity flow and pump delivery using a 20 mL syringe and 18 μm microaggregate filter. Whole blood samples were collected from each cat at 2-hour intervals for 12 hours following completion of the transfusions. Additional samples were collected at weekly intervals up to 6 weeks to assess circulating half-life of the transfused cells. Cell survival was assessed via flow cytometry. The proportion of transfused cells remaining in each of the 2 populations was measured. Biotinylated RBCs were readily detected in all cats over the 6-week sampling period. There was a significant decrease in both populations of labeled cells over the 6-week period (P < 0.01), as expected. There was no difference in probability that the RBCs would survive up to 12 hours immediately following transfusion, and no significant difference in survival between the 2 groups over 6 weeks. The average half-life of all labeled cells was approximately 23 days. CONCLUSIONS We conclude that, in contrast to findings from dogs, transfusion of autologous feline RBCs using a syringe + aggregate filter method does not significantly impact short- or long-term survival of the transfused cells.


title: Impact of Anemia on Platelet Reactivity and Ischemic and Bleeding Risk: From the Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents Study.

text: Anemic patients remain at increased risk of ischemic and bleeding events. Whether the effects of hemoglobin levels on thrombotic and bleeding risk are independent of platelet reactivity on clopidogrel, however, remains unknown. Patients from the Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents study were categorized by the presence of anemia at baseline, defined according the World Health Organization criteria. Platelet reactivity was measured with VerifyNow assay; high platelet reactivity (HPR) on clopidogrel was defined as platelet reactive units value >208. Of 8,413 patients included in the study cohort, 1,816 (21.6%) had anemia. HPR was more prevalent in patients with anemia (58.3% vs 38.4%; p <0.001), an association that persisted after multivariate adjustment (adjusted odds ratio: 2.04; 95% confidence interval [CI]: 1.82 to 2.29; p <0.0001). Patients with anemia had higher 2-year rates of major adverse cardiac events (9.5% vs 5.6%; p <0.0001), major bleeding (11.8% vs 7.7%; p <0.0001), and all-cause mortality (4.0% vs 1.4%; p <0.0001); however, after adjustment for baseline clinical confounders, including HPR, anemia was no longer significantly associated with major adverse cardiac events but was still independently associated with all-cause mortality (adjusted HR 1.61, 95% CI 1.23 to 2.12; p <0.0001) and major bleeding (adjusted HR 1.42, 95% CI 1.20 to 1.68; p <0.0001). The effect of HPR on clinical outcomes was uniform according to anemia status, without evidence of interaction. In conclusion, anemia independently correlated with HPR. After percutaneous coronary intervention with drug-eluting stents, anemia at baseline was significantly associated with higher 2-year hemorrhagic and mortality risk; conversely, its association with ischemic risk was attenuated after multivariate adjustment, including HPR.


title: Endoscopic closure of gastrointestinal leaks.

text: Surgery has been the mainstay of therapy in patients with gastrointestinal perforations. This paradigm started to shift with the development of techniques for endoscopic closure of gastrointestinal perforations. A detailed review of the literature on this subject, along with a commentary on practical aspects in the management of patients with gastrointestinal leaks, is provided here.


title: Association between incisional surgical site infection and the type of skin closure after stoma closure.

text: PURPOSE This study was performed to investigate the effect of subcuticular sutures on the incidence of incisional surgical site infection (SSI) after closure of a diverting stoma. METHODS The study was carried out as a retrospective analysis of prospectively collected data from 51 patients who underwent closure of diverting stoma following resections of lower rectal cancer between January 2008 and December 2008. This study attempted to determine whether there was an association between the type of skin closure and the incidence of incisional SSI. Moreover, risk factors for incisional SSI after closure of diverting stoma were identified using a multivariate analysis. RESULTS An incisional SSI occurred in 12 of the 51 patients (23.5%). The rate of incisional SSI with subcuticular sutures was 11.1% (3/27) in comparison to 37.5% (9/24) with transdermal suture and skin stapler. A subcuticular skin closure was the only favorable factor that was significantly associated with a lower incidence of incisional SSI (odds ratio: 0.19; 95% confidence interval: 0.04-0.92). CONCLUSIONS A subcuticular skin closure has a protective effect against incisional SSI after closure of diverting stoma. A larger study is necessary to further define the role of subcuticular suture on the prevention of incisional SSI in cases of gastrointestinal surgery.


title: Stent-Assisted Coiling of 501 Wide-Necked Intracranial Aneurysms: A Single-Center 8-Year Experience.

text: BACKGROUND Stent-assisted coiling has expanded the treatment of complex wide-necked intracranial aneurysms. We present our experience with stent-assisted coiling, with an emphasis on procedure-related neurologic complications and the incidence of angiographic recurrence. METHODS A total of 480 patients with 501 aneurysms who were treated with stent-assisted coiling between January 2007 and December 2014 were reviewed retrospectively. Baseline characteristics, procedure-related complications, angiographic follow-up results, and clinical outcomes were statistically analyzed. RESULTS Among the 480 patients, 423 (88%) were treated electively and 57 (11%) were treated in the context of subarachnoid hemorrhage. There were 22 (4.58%) overall procedure-related complications, which caused death in 4 patients (0.83%) and morbidity in 4 patients (0.83%). In a logistic regression analysis, the complications differed significantly among the patients with hypertension (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.09-7.48; P = 0.03), patients with aneurysms treated with coiling before stenting (OR, 3.07; 95% CI, 1.07-8.81; P = 0.04), and patients treated with multiple stents (OR, 4.96; 95% CI, 1.02-24.07; P = 0.04). Angiographic follow-up was available for 396 patients (83.4%) for a mean of 13 months. The rates of recanalization and retreatment were 13.9% and 3.5%, respectively. In a logistic analysis, larger aneurysm size and initial incomplete aneurysm occlusion were predictors of recanalization. Clinical follow-up was available for 406 patients (85.6%) for a mean of 44.8 months, and 399 patients (98.3%) achieved a Glasgow Outcome Scale score of 5. CONCLUSIONS Stent-assisted coiling appears to be a safe and effective option for treating complex wide-necked aneurysms. Higher complication rates are associated with coiling before stenting, use of multiple stents, and hypertension. Stent delivery before coil deployment reduces the risk of procedural complications. Larger aneurysm size and initial incomplete occlusion are associated with aneurysm recanalization.


title: Urban green spaces and cancer: a protocol for a scoping review.

text: INTRODUCTION Green space in the built environment is an important topic on the health agenda today. Studies have shown that access to green spaces is associated with better mental and physical health, yet green spaces can also be detrimental to health if they are not managed appropriately. Despite the increasing interest in urban green spaces, little research has so far been conducted into the links between green spaces and cancer. OBJECTIVE The purpose of this scoping review is therefore to map the literature available on the types of relationship between urban green spaces and cancer. METHOD AND ANALYSIS We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 guideline to report the protocol. To conduct this scoping review, we will use a structured search strategy based on controlled vocabulary and relevant key terms related to green space, urban space and cancer. We will search MEDLINE (PubMed), GreenFILE (EBSCOhost), Cumulative Index to Nursing and Allied Health Literature (EBSCOhost) and ScienceDirect as electronic database as well as hand-search publications for grey literature. This review will therefore provide evidence on this current topic, one which could have practical implications for policy-makers involved in choices which are more conducive to healthy living. ETHICS AND DISSEMINATION No primary data will be collected since all data that will be presented in this review are based on published articles and publicly available documents, and therefore ethics committee approval is not a requirement. The findings of this review will be presented at workshops and conferences, and will be submitted for publication in a peer-reviewed journal.


title: The 1918 influenza pandemic: lessons for 2009 and the future.

text: The 1918 to 1919 H1N1 influenza pandemic is among the most deadly events in recorded human history, having killed an estimated 50 to 100 million persons. Recent H5N1 avian influenza epizootics associated with sporadic human fatalities have heightened concern that a new influenza pandemic, one at least as lethal as that of 1918, could be developing. In early 2009, a novel pandemic H1N1 influenza virus appeared, but it has not exhibited unusually high pathogenicity. Nevertheless, because this virus spreads globally, some scientists predict that mutations will increase its lethality. Therefore, to accurately predict, plan, and respond to current and future influenza pandemics, we must first better-understand the events and experiences of 1918. Although the entire genome of the 1918 influenza virus has been sequenced, many questions about the pandemic it caused remain unanswered. In this review, we discuss the origin of the 1918 pandemic influenza virus, the pandemic's unusual epidemiologic features and the causes and demographic patterns of fatality, and how this information should impact our response to the current 2009 H1N1 pandemic and future pandemics. After 92 yrs of research, fundamental questions about influenza pandemics remain unanswered. Thus, we must remain vigilant and use the knowledge we have gained from 1918 and other influenza pandemics to direct targeted research and pandemic influenza preparedness planning, emphasizing prevention, containment, and treatment.


title: Recommendations for Designing, Conducting and Reporting Observational Studies in Homeopathy.

text: BACKGROUND Randomized placebo-controlled trials are considered to be the gold standard in clinical research and have the highest importance in the hierarchical system of evidence-based medicine. However, from the viewpoint of decision makers, due to lower external validity, practical results of efficacy research are often not in line with the huge investments made over decades. METHOD We conducted a narrative review. With a special focus on homeopathy, we give an overview on cohort, comparative cohort, case-control and cross-sectional study designs and explain guidelines and tools that help to improve the quality of observational studies, such as the STROBE Statement, RECORD, GRACE and ENCePP Guide. RESULTS Within the conventional medical research field, two types of arguments have been employed in favor of observational studies. First, observational studies allow for a more generalizable and robust estimation of effects in clinical practice, and if cohorts are large enough, there is no over-estimation of effect sizes, as is often feared. We argue that observational research is needed to balance the current over-emphasis on internal validity at the expense of external validity. Thus, observational research can be considered an important research tool to describe "real-world" care settings and can assist with the design and inform the results of randomised controlled trails. CONCLUSIONS We present recommendations for designing, conducting and reporting observational studies in homeopathy and provide recommendations to complement the STROBE Statement for homeopathic observational studies.


title: Classification of cavernous internal carotid artery tortuosity: a predictor of procedural complexity in Pipeline embolization.

text: BACKGROUND Flow diverters are increasingly used for the treatment of intracranial aneurysms. Understanding cavernous internal carotid artery (cICA) tortuosity may help to predict procedural complexities of deploying flow diverters. METHODS Pipeline embolization device (PED) neurointerventions for ICA aneurysms proximal to the ICA termination were reviewed. Cavernous ICA tortuosity was measured as a ratio D/AP, where D=height difference of the anterior and posterior genus, AP=sum of the angles of the anterior (A) and posterior (P) genus. Four types of cICA tortuosity were proposed. An analysis of variance regression and Fisher's exact test were performed to analyze differences among the types. RESULTS Cavernous ICA tortuosity was categorized into minimal (type I, n=28), moderate (type II-III, n=29), and severe (type IV, n=26). The groups were comparable for patient age (mean ± SEM years, type I: 55.6±10.4, II-III: 56.4±14.4, IV: 55±12.8) and aneurysm size (mean±SEM mm, type I: 6.25±3.5, II-III: 7.6±4.9, IV: 9.11±4.9). Analysis of variance demonstrated significant differences in procedural fluoroscopy time (mean ± SEM min, type I: 29.8±8.4, II-III: 44.9±34.1, IV: 52.6±17.2, p<0.005) and mean ± SEM D/AP (type I: 0.008±0.0008, II-III: 0.141±0.07, IV: 0.482±0.365, p<0.0001). Procedural complexity was also statistically significant (p<0.005) with 4%, 28%, and 35% of cases in types I, II-III, and IV, respectively, requiring intraprocedural PED removal or balloon post-processing of the implanted PED. CONCLUSIONS We propose a classification system for cICA tortuosity based on measurements of the anterior and posterior genu geometry. This classification correlates strongly with markers of PED procedural complexity and may be helpful in pre-procedure prognostication.


title: Prognostic Value of Lymph Node Yield and Density in Head and Neck Malignancies.

text: Objective Studies have suggested that the lymph node yield and lymph node density from selective or elective neck dissections are predictive of patient outcomes and may be used for patient counseling, treatment planning, or quality measurement. Our objective was to systematically review the literature and conduct a meta-analysis of studies that investigated the prognostic significance of lymph node yield and/or lymph node density after neck dissection for patients with head and neck cancer. Data Sources The Ovid/Medline, Ovid/Embase, and NLM PubMed databases were systematically searched on January 23, 2017, for articles published between January 1, 1946, and January 23, 2017. Review Methods We reviewed English-language original research that included survival analysis of patients undergoing neck dissection for a head and neck malignancy stratified by lymph node yield and/or lymph node density. Study data were extracted by 2 independent researchers (S.C. and M.O.). We utilized the DerSimonian and Laird random effects model to account for heterogeneity of studies. Results Our search yielded 350 nonduplicate articles, with 23 studies included in the final synthesis. Pooled results demonstrated that increased lymph node yield was associated with a significant improvement in survival (hazard ratio, 0.833; 95% CI, 0.790-0.879). Additionally, we found that increased lymph node density was associated with poorer survival (hazard ratio, 1.916; 95% CI, 1.637-2.241). Conclusions Increased nodal yield portends improved outcomes and may be a valuable quality indicator for neck dissections, while increased lymph node density is associated with diminished survival and may be used for postsurgical counseling and planning for adjuvant therapy.


title: Analysis of fat graft metabolic adaptation and vascularization using positron emission tomography-computed tomographic imaging.

text: BACKGROUND Fat tissue transfer is commonly used for different soft-tissue defects in surgery. The immediate result of these operations is often good, but the long-term result is unfortunately unpredictable. The authors used an experimental model to evaluate the vascularization, survival, and metabolic changes after free fat transfer and the impact of proangiogenic therapy on these processes. METHODS Fat was collected from the mouse epididymal region and placed into the subcutaneous tissue of the forehead. Fat grafts were treated with proangiogenic vascular endothelial growth factor (VEGF)-A (n = 9) or the control vector (n = 9). Metabolic activity and fat graft volume were investigated by positron emission tomography-computed tomography at 4 weeks and at 12 weeks. Histologic analysis was performed at 12 weeks. RESULTS The glucose metabolism (fluorodeoxyglucose uptake) of the transferred epididymal fat was higher than in the epididymal fat before transplantation in both study groups (VEGF-A and control) and resembled that of normal subcutaneous fat. VEGF-A therapy enhanced the survival and capillary density of the transferred fat after surgery. CONCLUSIONS Transfer of the metabolically inactive (epididymal) fat into a new environment modulated the metabolic activity of the fat grafts to resemble the situation in the recipient site. These novel findings support the clinical use of free fat grafts in various anatomical regions and tissue types. Proangiogenic VEGF-A therapy enhanced the vascularization and survival of the free fat grafts.


title: Probabilistic reconstruction of measles transmission clusters from routinely collected surveillance data.

text: Pockets of susceptibility resulting from spatial or social heterogeneity in vaccine coverage can drive measles outbreaks, as cases imported into such pockets are likely to cause further transmission and lead to large transmission clusters. Characterizing the dynamics of transmission is essential for identifying which individuals and regions might be most at risk. As data from detailed contact-tracing investigations are not available in many settings, we developed an R package called o2geosocial to reconstruct the transmission clusters and the importation status of the cases from their age, location, genotype and onset date. We compared our inferred cluster size distributions to 737 transmission clusters identified through detailed contact-tracing in the USA between 2001 and 2016. We were able to reconstruct the importation status of the cases and found good agreement between the inferred and reference clusters. The results were improved when the contact-tracing investigations were used to set the importation status before running the model. Spatial heterogeneity in vaccine coverage is difficult to measure directly. Our approach was able to highlight areas with potential for local transmission using a minimal number of variables and could be applied to assess the intensity of ongoing transmission in a region.


title: Prevalence and molecular characterisation of Giardia duodenalis in calves with diarrhoea.

text: The aim of this study was to investigate the prevalence of Giardia duodenalis in diarrhoeal faeces from calves that were reared in Korea using PCR and ELISA. Diarrhoeal faecal samples were collected from 590 calves (<3 months old) throughout the country from November 2013 through March 2015. Data were analysed according to the region of collection, season, and type of diarrhoea. Of the 590 collected faecal samples, 77 (13.1 per cent) and 78 (13.2 per cent; true prevalence 9.1 per cent) tested positive by PCR and ELISA, respectively. The results from both testing methods were in agreement in 501 (84.9 per cent) samples, with a κ value of 0.34, which suggests fair agreement. The PCR results showed a higher prevalence in summer and in cases of haemorrhagic diarrhoea (P<0.05), while the ELISA results showed a lower prevalence in cases of pasty diarrhoea (P<0.05). Phylogenetic analysis of the β-giardin gene sequences of G duodenalis showed that the sequences detected in this study belonged to assemblage E, which is specific to cattle and livestock. The higher prevalence of giardiasis in calves with haemorrhagic diarrhoea found in this study differed from previous studies. Therefore, researchers and veterinarians should be aware of the possible involvement of giardiasis in haemorrhagic diarrhoea.


title: [Protecting Medical Professionals from Infection During the Coronavirus Pandemic: Overnight Implementation of Virtual Medical Boards].

text: BACKGROUND For medical professionals in hospitals, it is nearly impossible to abide by the rules of social distancing to prevent coronavirus transmission. In order to avoid unnecessary contact between medical staff, virtual medical boards were implemented. METHODS Technical requirements for virtual boards were established overnight. Standard web cams and one license for a licensed provider of virtual boards were acquired. Most of the other technical gear required was readily available. Frequent and typical errors during the virtual boards were recorded and analyzed. RESULTS Virtual boards provided the means for adequate patient care in spite of social distancing among the medical staff. Over a period of 4 weeks, 956 face-to-face contacts were avoided. Most errors occurred during first-time participation and concerned audio transmission. By muting the microphone of inactive participants, most of these errors could be avoided. CONCLUSIONS Virtual boards for medical staff can be implemented with minimal effort und standard technical gear to slow down the transmission of coronavirus among medical professionals in the hospital setting.


title: Simultaneous resection of colorectal cancer and liver metastases in the right lobe using pure laparoscopic surgery.

text: It is now common to resect colorectal cancer by laparoscopic surgery. Hepatectomy has become a standard treatment for patients with colorectal cancer with resectable liver metastases. The resection of liver tumors can now be done partly by laparoscopic surgery. However, metastatic tumors in the right lobe are often difficult to resect laparoscopically. Furthermore, simultaneous resection of the colorectum and liver may also be difficult. In this study, we evaluated a new method to resect both colorectal cancer and liver metastases in the right lobe by laparoscopic surgery. Two cases are presented that underwent total laparoscopic resection of a right lobe tumor, associated with laparoscopic colorectal resection. The metastatic tumor in the right lobe was first resected in the left hemi-prone position. Then, the colorectal cancer was resected in the lithotomy position. The method for resecting the right lobe liver tumor and colorectal cancer was safe and feasible. The mean duration of surgery was 443.5 min, and the mean blood loss was 158 mL. The postoperative course was uneventful. In selected patients, laparoscopic hepatectomy for right lobe synchronous metastatic tumors can be safely performed simultaneously with colorectal surgery.


Successful Treatment of Topical Imiquimod-resistant Basal Cell Carcinoma by Electronic X-ray Brachytherapy.


title: Imaging of epidermal growth factor receptor expression in head and neck cancer with SPECT/CT and 111In-labeled cetuximab-F(ab')2.

text: UNLABELLED Combined treatment of advanced head and neck squamous cell carcinomas (HNSCC) with radiotherapy and the epidermal growth factor receptor (EGFR) inhibitor cetuximab improves clinical outcome in comparison to radiotherapy alone but is effective only in a few cases. To select those patients most likely to benefit from EGFR inhibition, it can be advantageous to quantify the tumor EGFR status before and possibly during therapy. The aim of this study was to develop and characterize the (111)In-cetuximab-F(ab')2 tracer to image EGFR targeting in vivo. METHODS The affinity and internalization kinetics of (111)In-cetuximab-F(ab')2 were determined in vitro. The optimal protein-fragment dose for imaging was determined in nude mice with a subcutaneous head and neck carcinoma model (FaDu). Mice with FaDu tumors were imaged using ultra-high-resolution SPECT with (111)In-cetuximab-F(ab')2 or (111)In-cetuximab IgG at 4, 24, 48, and 168 h after injection. Tumor tracer uptake was determined on micro-SPECT and autoradiography images of tumor sections. Immunohistochemical staining was used to analyze EGFR expression in the tumor. RESULTS In vitro, more than 50% of (111)In-cetuximab-F(ab')2 was internalized into FaDu cells within 24 h. The half maximal inhibitory concentration (IC50) of (111)In-cetuximab-F(ab')2 and (111)In-cetuximab was similar: 0.42 ± 0.16 nM versus 0.28 ± 0.14 nM, respectively. The protein dose-escalation study showed that the highest uptake of (111)In-cetuximab-F(ab')2 in tumors was obtained at doses of 10 μg/mouse or less (13.5 ± 5.2 percentage injected dose per gram [%ID/g]). Tumor uptake of (111)In-cetuximab was significantly higher (26.9 ± 3.3 %ID/g, P < 0.01). However, because of rapid blood clearance, tumor-to-blood ratios at 24 h after injection were significantly higher for (111)In-cetuximab-F(ab')2 (31.4 ± 3.8 vs. 1.7 ± 0.2, respectively; P < 0.001). The intratumoral distribution of (111)In-cetuximab-F(ab')2 correlated well with the immunohistochemical distribution of EGFR (r = 0.64 ± 0.06, P < 0.0001). micro-SPECT images of (111)In-cetuximab-F(ab')2 clearly showed preferential uptake in the tumor from 4 h onward, with superior tumor-to-background contrast at 24 h, compared with (111)In-cetuximab (107.0 ± 17.0 vs. 69.7 ± 3.9, respectively; P < 0.05). CONCLUSION (111)In-cetuximab-F(ab')2 displays higher tumor-to-blood ratios early after injection than (111)In-cetuximab in an HNSCC model, making it more suitable for EGFR visualization and potentially for selecting patients for treatment with EGFR inhibitors.


title: [Effects of novel coronavirus therapeutic drugs on cardiovascular system].

text: 2019新型冠状病毒（2019-nCoV）所引发的疫情已升级为全球大流行，并造成巨大损失，其传播力强、致病力较高，目前尚无治疗新型冠状病毒肺炎（COVID-19）的特效药物。国内外众多研究机构正在研发治疗COVID-19相关药物，并取得了一定的进展。相当一部分2019-nCoV感染患者合并基础疾病，尤其是心血管疾病，这部分患者更易进展为重症和危重症，其的治疗策略更需要优化。该文系统地介绍了目前临床上治疗COVID-19的主要药物，重点复习了这些药物对心血管系统的影响，以期为COVID-19患者的临床药物治疗提供参考。.


title: Whole-body vibration induces distinct reflex patterns in human soleus muscle.

text: The neuronal mechanisms underlying whole body vibration (WBV)-induced muscular reflex (WBV-IMR) are not well understood. To define a possible pathway for WBV-IMR, this study investigated the effects of WBV amplitude on WBV-IMR latency by surface electromyography analysis of the soleus muscle in human adult volunteers. The tendon (T) reflex was also induced to evaluate the level of presynaptic Ia inhibition during WBV. WBV-IMR latency was shorter when induced by low- as compared to medium- or high-amplitude WBV (33.9±5.3msvs. 43.8±3.6 and 44.1±4.2ms, respectively). There was no difference in latencies between T-reflex elicited before WBV (33.8±2.4ms) and WBV-IMR induced by low-amplitude WBV. Presynaptic Ia inhibition was absent during low-amplitude WBV but was present during medium- and high-amplitude WBV. Consequently, WBV induces short- or long-latency reflexes depending on the vibration amplitude. During low-amplitude WBV, muscle spindle activation may induce the short- but not the long-latency WBV-IMR. Furthermore, unlike the higher amplitude WBV, low-amplitude WBV does not induce presynaptic inhibition at the Ia synaptic terminals.


title: Health Beliefs of Wearing Facemasks for Influenza A/H1N1 Prevention: A Qualitative Investigation of Hong Kong Older Adults.

text: Although vaccination is the first-line strategy controlling and preventing influenza A/H1N1 for older adults, personal protective measures, such as wearing facemasks, are also important preventive behaviors to reduce the risk of becoming infected with influenza A/H1N1 during a pandemic. In the current study, we aimed to explore the belief-related psychological factors of wearing facemasks for influenza A/H1N1 prevention in a sample of Hong Kong older adults. Community-dwelling Chinese adults (N = 137) aged between 65 and 80 years (Mage = 75.10; SDage = 6.49) participated in semistructured interviews. Data were analyzed using theoretical thematic analysis and identified themes were matched deductively within the belief-based processes of the health belief model. Results revealed beliefs that underpinned 4 general dimensions of facemask wearing: (1) perceived susceptibility and seriousness of influenza A/H1N1 pandemic (e.g., influenza A/H1N1 as contagious and lethal), (2) modifying factors (e.g., social responsibility to prevent influenza), (3) cues to action (e.g., seeing others doing it), and (4) perceived benefits and barriers (e.g., protects oneself and others, difficult to breathe). Future interventions can target these beliefs to improve facemask wearing of older adults and, thus, curb preventable infection rates during an influenza A/H1N1 pandemic.


title: Cost Effectiveness of Stapled Haemorrhoidopexy and Traditional Excisional Surgery for the Treatment of Haemorrhoidal Disease.

text: OBJECTIVE Our objective was to compare the cost effectiveness of stapled haemorrhoidopexy (SH) and traditional haemorrhoidectomy (TH) in the treatment of grade II-IV haemorrhoidal disease from the perspective of the UK national health service. METHODS An economic evaluation was conducted alongside an open, two-arm, parallel-group, pragmatic, multicentre, randomised controlled trial conducted in several hospitals in the UK. Patients were randomised into either SH or TH surgery between January 2011 and August 2014 and were followed up for 24 months. Intervention and subsequent resource use data were collected using case review forms and questionnaires. Benefits were collected using the EQ-5D-3L (EuroQoL-five dimensions-three levels) instrument. The primary economic outcome was incremental cost measured in pounds (£), year 2016 values, relative to the incremental benefit, which was estimated using quality-adjusted life-years (QALYs). Cost and benefits accrued in the second year were discounted at 3.5%. The base-case analysis was based on imputed data. Uncertainty was explored using univariate sensitivity analyses. RESULTS Participants (n = 777) were randomised to SH (n = 389) or TH (n = 388). The mean cost of SH was £337 (95% confidence interval [CI] 251-423) higher than that of TH and the mean QALYs were -0.070 (95% CI -0.127 to -0.011) lower than for TH. The base-case cost-utility analysis indicated that SH has zero probability of being cost effective at both the £20,000 and the £30,000 threshold. Results from the sensitivity analyses were similar to those from the base-case analysis. CONCLUSIONS The evidence suggests that, on average, the total mean costs over the 24-month follow-up period were significantly higher for the SH arm than for the TH arm. The QALYs were also, on average, significantly lower for the SH arm. These results were supported by the sensitivity analyses. Therefore, in terms of cost effectiveness, TH is a superior surgical treatment for the management of grade II-IV haemorrhoids when compared with SH.


title: Strategic Approach to the Splenic Artery in Laparoscopic Spleen-preserving Distal Pancreatectomy.

text: BACKGROUND Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) is an ideal procedure in selected patients with benign or low-grade malignant tumors in the body/tail of the pancreas. We describe our procedure and experience with splenic vessel-preserving LSPDP (SVP-LSPDP) in a retrospective case series. METHODS Six consecutive patients underwent SVP-LSPDP from January 2011 to September 2013. We evaluated the courses of the splenic artery by preoperative computed tomography and applied an individualized approach (the superior approach or inferior approach) to the splenic artery. RESULTS All of the operations were successful. The median surgical duration was 249 minutes. The median blood loss was 0 mL. Pathologic examination revealed 4 cases of insulinoma, 1 case of solid pseudopapillary tumor, and 1 case of pancreatic metastasis from renal carcinoma. CONCLUSIONS In performing SVP-LSPDP, it is effective to make a strategic choice between 2 different approaches according to the course of splenic artery.


title: Combined use of N-acetylcysteine and Liberase improves the viability and metabolic function of human hepatocytes isolated from human liver.

text: BACKGROUND AIMS Successful hepatocyte isolation is critical for continued development of cellular transplantation. However, most tissue available for research is from diseased liver, and the results of hepatocyte isolation from such tissue are inferior compared with normal tissue. Liberase and N-acetylcysteine (NAC) have been shown separately to improve viability of isolated hepatocytes. This study aims to determine the effect of Liberase and NAC in combination on human hepatocyte isolation from normal and diseased liver tissues. METHODS Hepatocytes were isolated from 30 liver specimens through the use of a standard collagenase digestion technique (original protocol) and another 30 with the addition of NAC and standard collagenase substituted by Liberase (new protocol). Viability and success, defined as maintenance of cell adhesion and morphology for 48 hours, were assessed. Metabolic function was assessed by means of albumin and urea synthesis. RESULTS Baseline factors were similar for both groups. The delay to tissue processing was slightly shorter in the new protocol group (median, 2 versus 4 hours; P = 0.007). The success rate improved from 12 of 30 (40.0%) to 21 of 30 (70.0%) with the use of the new protocol (P = 0.037), and median viable cell yield increased from 7.3 × 10(4) to 28.3 × 10(4) cells/g tissue (P = 0.003). After adjusting for delay, success rate (P = 0.014) and viable cell yield/g tissue (P = 0.001) remained significantly improved. Albumin and urea synthesis were similar or superior in the new protocol group. CONCLUSIONS NAC and Liberase improve the success of hepatocyte isolation, with a significantly higher yield of viable cells. The use of these agents may improve the availability of hepatocytes for transplantation and laboratory research.


Don't forget our dual public health crises.


title: Randomized Comparison of Paclitaxel-Eluting Balloon and Stenting Versus Plain Balloon Plus Stenting Versus Directional Atherectomy for Femoral Artery Disease (ISAR-STATH).

text: BACKGROUND Atherosclerosis in the superficial femoral artery is common in patients suffering from peripheral artery disease. Paclitaxel-eluting balloon (PEB) angioplasty, stenting, and directional atherectomy (DA) have provided new options for the treatment of superficial femoral artery disease; however, the comparative efficacy of these interventional strategies remains uncertain. METHODS One hundred and fifty-five patients with symptomatic peripheral artery disease due to de novo superficial femoral artery stenotic or occlusive lesions were randomized to treatment with plain balloon angioplasty (BA) followed by PEB angioplasty and stenting (n=48), BA and stenting (n=52), or DA with distal protection and bailout stenting (n=55). The primary end point of the study was percentage diameter stenosis after 6 months measured by angiography. Other end points included target lesion revascularization, thrombosis, ipsilateral amputation, binary restenosis, and all-cause mortality at 6 and 24 months. RESULTS Baseline and lesion characteristics were comparable in all groups with a mean lesion length of 65.9±46.8 mm and 56% total occlusions. At 6 months angiography, the percent diameter stenosis was significantly lower in patients treated by PEB angioplasty and stenting (34±31%) as compared with BA angioplasty and stenting (56±29%, P=0.009) or DA (55±29%, P=0.007). Similarly, binary restenosis was significantly lower after treatment with PEB and stenting as compared with BA and stenting or DA. Clinical follow-up at 24 months revealed a lower risk for target lesion revascularization after PEB angioplasty and stenting as compared with BA and stenting or DA. We found no difference in terms of target lesion thrombosis and mortality among groups, and no patient underwent amputation. CONCLUSIONS Treatment of de novo superficial femoral artery lesions with PEB angioplasty and stenting is superior to BA angioplasty and stenting or DA in terms of angiographic diameter stenosis at 6 months and target lesion revascularization at 24 months. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00986752.


title: Feeling validated yet? A scoping review of the use of consumer-targeted wearable and mobile technology to measure and improve sleep.

text: The objectives of this review were to evaluate the use of consumer-targeted wearable and mobile sleep monitoring technology, identify gaps in the literature and determine the potential for use in behavioral interventions. We undertook a scoping review of studies conducted in adult populations using consumer-targeted wearable technology or mobile devices designed to measure and/or improve sleep. After screening for inclusion/exclusion criteria, data were extracted from the articles by two co-authors. Articles included in the search were using wearable or mobile technology to estimate or evaluate sleep, published in English and conducted in adult populations. Our search returned 3897 articles and 43 met our inclusion criteria. Results indicated that the majority of studies focused on validating technology to measure sleep (n = 23) or were observational studies (n = 10). Few studies were used to identify sleep disorders (n = 2), evaluate response to interventions (n = 3) or deliver interventions (n = 5). In conclusion, the use of consumer-targeted wearable and mobile sleep monitoring technology has largely focused on validation of devices and applications compared with polysomnography (PSG) but opportunities exist for observational research and for delivery of behavioral interventions. Multidisciplinary research is needed to determine the uses of these technologies in interventions as well as the use in more diverse populations including sleep disorders and other patient populations.


title: Adverse reactions of dimethyl sulfoxide in humans: a systematic review.

text: Background: Dimethyl sulfoxide (DMSO) has been used for medical treatment and as a pharmacological agent in humans since the 1960s. Today, DMSO is used mostly for cryopreservation of stem cells, treatment of interstitial cystitis, and as a penetrating vehicle for various drugs. Many adverse reactions have been described in relation to the use of DMSO, but to our knowledge, no overview of the existing literature has been made. Our aim was to conduct a systematic review describing the adverse reactions observed in humans in relation to the use of DMSO. Methods: This systematic review was reported according to the PRISMA-harms (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines. The primary outcome was any adverse reactions occurring in humans in relation to the use of DMSO. We included all original studies that reported adverse events due to the administration of DMSO, and that had a population of five or more. Results: We included a total of 109 studies. Gastrointestinal and skin reactions were the commonest reported adverse reactions to DMSO. Most reactions were transient without need for intervention. A relationship between the dose of DMSO given and the occurrence of adverse reactions was seen. Conclusions: DMSO may cause a variety of adverse reactions that are mostly transient and mild. The dose of DMSO plays an important role in the occurrence of adverse reactions. DMSO seems to be safe to use in small doses. Registration: PROSPERO CRD42018096117.


title: Notes from the Field: Concerns of Health-Related Higher Education Students in Brazil Pertaining to Distance Learning During the Coronavirus Pandemic.

text: This survey aimed to assess the concerns of students of health-related higher education in Brazil regarding distance learning during the coronavirus pandemic. A Google Forms anonymous questionnaire was sent by WhatsApp Messenger to students at a private university. Seven hundred and four students answered the questionnaire (566 female, 138 male, mean age = 23.09 years), reflecting approximately a third of the students in health-related disciplines. Students reported feeling anxious due to the pandemic. Most of the students agreed with having the ability to continue education through distance learning, but relatively few of them enjoyed it. Also, students were concerned that learning of clinical material and professional training would be impaired, and they were afraid of failing the year of education. Health-related higher education private institutions in Brazil should focus on reassessing and prioritizing their policies and protocols and include a detailed plan for the future.


title: Interventional management of acute ischemic stroke: a systematic review.

text: OPINION STATEMENT Historically, acute ischemic stroke (AIS) trials defined syndromes according to acute clinical presentation and post-ictus parenchymal imaging. With improvements in real-time arterial imaging, modern AIS treatment demands a structural approach based upon the level of cerebrovascular occlusion. The poor concordance of presenting National Institute of Health Stroke Scale (NIHSS) with vessel occlusion in recent trials bespeaks the need for an anatomic perspective. Specifically, patients with large-vessel occlusion (LVO) represent a distinct entity with a poorer prognosis than general AIS patients. Ongoing clinical trials and therapeutic strategies must recognize the varied natural history of AIS patients. Endovascular therapy offers promise in patients with the most severe strokes.


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title: Attempt to Harvest a Sufficient Number of Mononuclear Cells in an Appropriate Blood Product Volume By Modification of the Default Apheresis Setting.

text: To harvest for T cell therapy, a 1.6-fold higher number of CD3+ T cells was collected with MNC mode (N = 10) compared with Auto PBSC mode (N = 5) in COBE Spectra cell separator, but the blood product volume was increased by 3.5-fold. For therapeutic angiogenesis therapy, apheresis was initially performed using Auto PBSC mode (N = 4) to fine tune the blood product volume to omit cell concentration, but the collected number of mononuclear cells was lower than expected. However, an increase of the harvest cycle number from 3.8 ± 0.5 to 7.4 ± 2.0 cycles (N = 19) resulted in a 2.1-fold higher number of collected mononuclear cells (8.7 ± 4.1 × 109 vs. 4.1 ± 1.0 × 109 cells, P < 0.05). The increase in blood product volume by this modification appeared to be lower than that expected with MNC mode. These data show that optimal harvesting can be achieved by modification of default collection settings.


title: Single access laparoscopic splenectomy.

text: BACKGROUND Laparoscopic splenectomy has been performed in a standard fashion with 4 to 5 trocars since the early 1990s. Single access laparoscopy has recently gained interest, but single access laparoscopic splenectomy has not been reported to date. It has the possible benefits of less pain, faster recovery, better cosmesis, with theoretically similar costs to that of traditional trocars. METHODS A case is presented and the surgical technique of single access laparoscopic splenectomy is detailed. RESULTS The patient is an otherwise healthy 24-year-old male with medically refractory idiopathic thrombocytopenic purpura and a platelet count of 15 000. A splenectomy was performed using a single incision laparoscopic technique. The patient was placed in a right lateral decubitus position, and a 2.5-cm left upper quadrant incision was made. A multi-instrument flexible single incision port was used that held 3 trocars. A standard splenectomy was performed through this port. A linear stapler was used to transect the splenic hilum. The procedure time was just over 2 hours. The patient did well, was happy with his incision, and was discharged with a platelet count of 108 000. CONCLUSIONS Single access laparoscopic splenectomy is feasible in select patients and may provide a less painful, better cosmetic result.