title: Is there any relationship between quality of life and the level of sympathectomy in primary palmar hyperhidrosis? Single-center experience.

text: BACKGROUND The discussions at the surgical levels (sympathectomy levels) about endoscopic thoracic sympathectomy (ETS) method, which is applied in hyperhidrosis treatment in the present day and acknowledged as the golden treatment method, continue. Mainly, most of the studies evaluates postoperative early period results. Our aim in this study is to compare the long-term quality of life depending on the different surgical levels (sympathectomy levels) and evaluate the postoperative complications. METHODS 165 patients operated due to palmar hyperhidrosis between January 2012 and July 2017 were evaluated. Sympathectomy was performed either by clipping or cauterization and sympathetic nerves included were T2-4, T3-4, or T3 levels. Data were retrospectively reviewed for complications, factors affecting the postoperative quality of life. RESULTS Ninety of the patients were male (54.5%) and 75 (45.5%) were female. The level of ganglion block was T2-T4 in 62 patients (37.6%), T3-T4 in 46 patients (27.9%), and T3 in 57 patients (34.5%). Early complications were observed in 27 patients (16.4%). Compensatory hyperhidrosis (CH) was observed in 62 patients (37.6%). There was a significant difference in the postoperative quality of life according to ETS level (p < 0.001). Patients who underwent T2-T4 sympathectomy had a lower quality of life than patients who underwent isolated T3 or T3-T4 sympathectomy. CONCLUSION Based on our results, we recommend performing lower level resections to increase the long-term quality of life in palmar hyperhidrosis patients. The lower risk of CH and comparable quality of life suggest that T3 sympathectomy is more effective.


title: Obesity and COVID-19: Oro-Naso-Sensory Perception.

text: Through a recent upsurge of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, the clinical assessment of most of the coronavirus disease 19 (COVID-19) patients clearly presents a health condition with the loss of oro-naso-sensory (ONS) perception, responsible for the detection of flavor and savor. These changes include anosmia and dysgeusia. In some cases, these clinical manifestations appear even before the general flu-like symptoms, e.g., sore throat, thoracic oppression and fever. There is no direct report available on the loss of these chemical senses in obese COVID-19 patients. Interestingly, obesity has been shown to be associated with low ONS cues. These alterations in obese subjects are due to obesity-induced altered expression of olfacto-taste receptors. Besides, obesity may further aggravate the SARS-CoV-2 infection, as this pathology is associated with a high degree of inflammation/immunosuppression and reduced protection against viral infections. Hence, obesity represents a great risk factor for SARS-CoV-2 infection, as it may hide the viral-associated altered ONS symptoms, thus leading to a high mortality rate in these subjects.


title: Diaphragmatic and pericardial reconstruction after surgery for malignant pleural mesothelioma.

text: Extrapleural pneumonectomy (EPP) and pleurectomy-decortication (P/D) are both recognised surgical procedures for selected cases affected by malignant pleural mesothelioma (MPM). Surgical techniques have ameliorated over the last years, remaining the complete macroscopic resection of the disease the main surgical principle. EPP is defined as an en-bloc resection of the visceral pleura, parietal pleura, pericardium and diaphragm alongside the pneumonectomy. The thoracic domain of the International Association for Study of Lung Cancer (IASLC) recently clarified the, previously confused, surgical terminology. "Extended P/D" is considered as parietal and visceral pleurectomy, diaphragmatic and pericardial resection with the purpose to remove all macroscopic disease. The term "radical" was replaced by "extended" to underline that this procedure does not have oncologic radicality aims. Both operations above are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. The technical aspects of resection and reconstruction are described and the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.


title: D-dimer and mortality in COVID-19: a self-fulfilling prophecy or a pathophysiological clue?

text: The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a global phenomenon has presented clinicians around the world with multiple challenges. Thromboembolic events are recognised complications of viral infection, but the diagnosis of an acute pulmonary thrombotic complication in the context of coronavirus disease 2019 (COVID-19) can be challenging because of the similarities of presentation, logistical considerations of diagnosis in a patient isolated for infection control reasons and the effects of cognitive errors in diagnostic reasoning. We present the case of a patient who was diagnosed with a pulmonary thrombotic complication during inpatient care for COVID-19. The haemostasis parameters we observed, including increased levels of von Willebrand factor and factor VIII, point towards a relevant involvement of endothelial cells in patients with severe COVID-19. We suggest that it is possible to hypothesise a spectrum of secondarily acquired, prothrombotic coagulopathy mediated by the endothelial interaction with SARS-CoV-2 as a cause of mortality in a subset of patients with a complicated clinical course of COVID-19. We support the recommendation of thromboembolic chemoprophylaxis for inpatients with COVID-19 as a very minimum in the absence of strict contraindications, while recognising that pulmonary thrombotic complications can occur under standard thromboprophylaxis. We suggest that higher, possibly therapeutic levels of anticoagulation might be mandatory for a further subset of patients with COVID-19 where a discrepant evolution of C-reactive protein and D-dimer is observed. Therapeutic levels of anticoagulation are obligatory where new evidence of a macrovascular thrombotic complication has been documented. More research to delineate the macro- and microvascular thrombotic complications of COVID-19, and the therapeutic implications for this patient group is required.


title: Energetic stress: The reciprocal relationship between energy availability and the stress response.

text: The worldwide epidemic of metabolic syndromes and the recognized burden of mental health disorders have driven increased research into the relationship between the two. A maladaptive stress response is implicated in both mental health disorders and metabolic disorders, implicating the hypothalamic-pituitary-adrenal (HPA) axis as a key mediator of this relationship. This review explores how an altered energetic state, such as hyper- or hypoglycemia, as may be manifested in obesity or diabetes, affects the stress response and the HPA axis in particular. We propose that changes in energetic state or energetic demands can result in "energetic stress" that can, if prolonged, lead to a dysfunctional stress response. In this review, we summarize the role of the hypothalamus in modulating energy homeostasis and then briefly discuss the relationship between metabolism and stress-induced activation of the HPA axis. Next, we examine seven mechanisms whereby energetic stress interacts with neuroendocrine stress response systems, including by glucocorticoid signaling both within and beyond the HPA axis; by nutrient-induced changes in glucocorticoid signaling; by impacting the sympathetic nervous system; through changes in other neuroendocrine factors; by inducing inflammatory changes; and by altering the gut-brain axis. Recognizing these effects of energetic stress can drive novel therapies and prevention strategies for mental health disorders, including dietary intervention, probiotics, and even fecal transplant.


title: Selecting an appropriate surgical treatment instead of carotid artery stenting alone according to the patient's risk factors contributes to reduced perioperative complications in patients with internal carotid stenosis: a single institutional retrospective analysis.

text: This retrospective study was aimed to compare the perioperative complications for internal carotid artery stenosis (ICS) in a Japanese single institute between the use of carotid artery stenting (CAS) alone or the use of an appropriate individualized treatment method allowing either carotid endarterectomy (CEA) or CAS based on patient risk factors. Based on the policy at our hospital, only CAS was performed on patients (n = 33) between January 2005 and November 2009. From December 2009 to December 2012, either CEA or CAS (tailored treatment) was selected for patients (n = 61) based on individual patient risk factors. CEA was considered the first-line treatment in all cases. In high-risk CEA cases, CAS was performed instead (n = 11), whereas in low-risk CEA cases, CEA was performed (n = 19). Further, in moderate-risk CEA cases based on own criteria, CAS was considered first, whereas for high-risk CAS cases, CEA was performed (n = 17). For low-risk CAS cases, CAS was performed (n = 9). Perioperative clinical complications (any stroke, myocardial infarction, or death within 30 days) were compared between both periods. Significantly reduced perioperative complications were observed during the tailored period (4/61 sites, 6.6%) as compared with the CAS period (8/33 sites, 24.2%) [Fisher's exact test p = 0.022; odds ratio, 4.56 (CAS/tailored); 95% confidence interval, 1.26-16.5]. Selecting an appropriate individualized treatment method according to patient risk factors, as opposed to adhering to a single treatment approach such as CAS, may contribute to improved overall outcomes in patients with ICS.


title: The Diabetes Surgery Summit consensus conference: recommendations for the evaluation and use of gastrointestinal surgery to treat type 2 diabetes mellitus.

text: OBJECTIVES To develop guidelines for the use of gastrointestinal surgery to treat type 2 diabetes and to craft an agenda for further research. BACKGROUND Increasing evidence demonstrates that bariatric surgery can dramatically ameliorate type 2 diabetes. Not surprisingly, gastrointestinal operations are now being used throughout the world to treat diabetes in association with obesity, and increasingly, for diabetes alone. However, the role for surgery in diabetes treatment is not clearly defined and there are neither clear guidelines for these practices nor sufficient plans for clinical trials to evaluate the risks and benefits of such "diabetes surgery." METHODS A multidisciplinary group of 50 voting delegates from around the world gathered in Rome, Italy for the first International Conference on Gastrointestinal Surgery to Treat Type 2 Diabetes--(the "Diabetes Surgery Summit"). During the meeting, available scientific evidence was examined and critiqued by the entire group to assess the strength of evidence and to draft consensus statements. Through an iterative process, draft statements were then serially discussed, debated, edited, reassessed, and finally presented for formal voting. After the Rome meeting, statements that achieved consensus were summarized and distributed to all voting delegates for further input and final approval. These statements were then formally critiqued by representatives of several sientific societies at the 1st World Congress on Interventional Therapies for T2DM (New York, Sept 2008). Input from this discussion was used to generate the current position statement. RESULTS A Diabetes Surgery Summit (DSS) Position Statement consists of recommendations for clinical and research issues, as well as general concepts and definitions in diabetes surgery. The DSS recognizes the legitimacy of surgical approaches to treat diabetes in carefully selected patients. For example, gastric bypass was deemed a reasonable treatment option for patients with poorly controlled diabetes and a body mass index > or =30 kg/m. Clinical trials to investigate the exact role of surgery in patients with less severe obesity and diabetes are considered a priority. Furthermore, investigations on the mechanisms of surgical control of diabetes are strongly encouraged, as they may help advance the understanding of diabetes pathophysiology. CONCLUSIONS The DSS consensus document embodies the foundations of "diabetes surgery," and represents a timely attempt by leading scholars to improve access to surgical options supported by sound evidence, while also preventing harm from inappropriate use of unproven procedures.


title: Physical activity participation and the risk of chronic diseases among South Asian adults: protocol for a systematic review and meta-analysis.

text: BACKGROUND Chronic diseases contribute to about half of the adult disease burden in the South Asian region. Meanwhile, physical activity levels are declining despite the global evidence of its role in the prevention of chronic diseases. While there are a plethora of systematic reviews on the effects of physical activity on chronic diseases, there has not yet been a synthesis of the evidence concerning the nature of this relationship among people living in South Asian countries incorporating multiple chronic diseases and a focus on physical activity domains. The aim of this protocol is to describe the rationale and methods for a systematic review of published research to identify the association between physical activity and selected chronic diseases and their markers and analysis of the strength of association with a focus on physical activity domains among South Asian adults 40 years and older. METHODS Nine electronic databases including Medline, PsycINFO, Embase, CENTRAL, CINAHL Plus, AgeLine, SPORTDiscus, Scopus and Web of Science will be systematically searched for papers reporting the association between physical activity and selected chronic diseases (type 2 diabetes mellitus, breast cancer, colorectal cancer, coronary heart disease, stroke, vascular diseases and musculoskeletal diseases (osteoarthritis, osteoporosis, back and neck pain)) and their markers using predefined search terms. Searches will be limited to peer-reviewed, English language papers with a quantitative design. In addition, a manual search of references of relevant systematic reviews as well as citations and references of eligible studies will also be carried out. The methodological appraisal will be performed using the National Institutes of Health quality assessment checklist for observational studies and the Effective Public Health Practice Project quality assessment tool for intervention studies. The overall quality of evidence for the study outcomes across the study designs will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. The review results will be presented in the form of narrative synthesis, and a random effects meta-analysis is planned depending on the nature of included studies and available data. DISCUSSION This review will summarise the strength of the association between physical activity and selected chronic diseases and their markers among South Asian adults 40 years or older. The findings will provide an evidence base to guide public health policy and interventions in the South Asian region and to inform future research to address the rising burden of chronic diseases. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018096505.


Remembering the "pan" in "pandemic": considering the impact of global resource disparity on a duty to treat.


title: Debate: #Together despite the distance.

text: The pandemic COVID-19 (SARS-CoV-2) has had a major global impact on the healthcare systems worldwide as they deal with the surge of critically ill persons. Additionally, the preventative measure of stay-at-home orders and closure of nonessential businesses has caused the disruption of entire communities. The child/youth mental health workforce bears the additional burden of the disruption of the systems-based practice crucial to the successful provision of mental health services. Major sources of stress for the workforce include: (a) a threat to the worker's personal/family health and life (traumatic injury), (b) a loss of colleagues or threat to professional mastery and identity (grief injury), (c) an inner conflict between ones' values and aspirations and what they are able to accomplish in their work (moral injury), and (d) fatigue, simply feeling worn out by the relentless work and need, without time for rest and recovery (fatigue injury). The rapid transformation of the in-person to virtual practice by the implementation of telehealth/telephonic sessions has eroded the boundary between personal/professional life and created a new Zoom fatigue.


title: Intraperitoneal temperature and desiccation during endoscopic surgery. Intraoperative humidification and cooling of the peritoneal cavity can reduce adhesions.

text: This study was conducted to document quantitatively the intraperitoneal temperature and desiccation during laparoscopic surgery. The temperature, relative humidity, and flow rate were measured in vitro and during laparoscopic surgery, at the entrance and at the exit of the abdomen. This permitted us to calculate desiccation for various flow rates using either dry CO(2) or CO(2) humidified with 100% relative humidity at any preset temperature between 25 and 37°C. The study showed that desiccation, both in vitro and in vivo, varies as expected with the flow rates and relative humidity while intraperitoneal temperature varies mainly with desiccation. Temperature regulation of bowels is specific and drops to the intraperitoneal temperature without affecting core body temperature. With a modified humidifier, desiccation could be eliminated while maintaining the intraperitoneal temperature between 31 to 32°C.


title: Waffle Y technique: pCONus for tandem bifurcation aneurysms of the middle cerebral artery.

text: Broad based bifurcation aneurysms are challenging. Various endovascular techniques aim at stabilizing the coil package in the aneurysm. Among these, the waffle cone technique provides a viable alternative to Y stenting in selected cases, incorporating a less complex delivery, and the reduced inherent risk of a single stenting procedure compared with the use of two stents in Y configuration. Unlike conventional stents, the distal end of the new pCONus device opens like a blossoming flower inside of the aneurysm to facilitate the waffle cone technique. In a case with tandem unruptured broad based middle cerebral artery bifurcation aneurysms, the complex anatomical challenge was resolved by a unique combination of both techniques: two pCONus deployed in Y configuration, offering stable neck coverage for coiling both aneurysms. The angiographic results with complete occlusion of both aneurysms and the uneventful clinical course at 90 days with continued daily administration of dual antiplatelet therapy are encouraging.


SECURE-Psoriasis: A de-identified registry of psoriasis patients diagnosed with COVID-19.


title: A prospective study comparing three-port video-assisted thoracoscopy with the single-incision laparoscopic surgery (SILS) port and instruments for the video thoracoscopic approach: a pilot study.

text: BACKGROUND Single-incision laparoscopic surgery (SILS) has proved its advantages in several procedures, mainly a shorter hospital stay, improved aesthetic results, and less postoperative pain. The authors have used this approach for several thoracic surgical procedures. METHODS This prospective study compared 20 cases between standard three-port video-assisted thoracic surgery (VATS) and the single-incision approach using a standard abdominal SILS system. In both groups, postsurgical analgesia was provided with 15 ml of bupivacaine 0.5% at 3 h intervals via a paravertebral catheter. The hospital length of stay and chest drain duration (in hours) were recorded as well as postoperative pain using an analogic visual pain scale (AVPS). A telephone survey was conducted for all the outpatients. The Mann-Whitney U test was used for statistical analysis. RESULTS This study of 20 procedures included 11 lung biopsies, 6 pneumothorax procedures, 2 mediastinic cystectomies, and 1 catamenial pneumothorax procedure. No statistically significant difference was reported in hospital length of stay or chest drain duration between the two groups. However, postoperative pain at 24 h was significantly less in the SILS group (AVPS, 4.40) than in the VATS group (AVPS, 6.20) (p = 0.035). The SILS group reported two minor surgical wound complications and one catamenial pneumothorax recurrence that did not require drainage. The VATS group reported one case of skin rash with no identifiable cause. CONCLUSIONS The use of the SILS port in thoracic surgery results in less postoperative pain. This is related to the port's protective effect over the periostium and the intercostal nerve, relieving them of direct contact with surgical instruments. However, the findings showed a higher incidence of surgical wound complications with the SILS port, which can be attributed to increased pressure on the skin and soft tissues surrounding the port and to the fact that this same incision was used for chest drain placement, thus increasing the risk for complications.


title: Human Parainfluenza Virus Type 3 Infections in Patients with Hematopoietic Stem Cell Transplants: the Mode of Nosocomial Infections and Prognosis.

text: There have been a few prospective and comprehensive surveillance studies on the respiratory viral infections (RVIs) among patients undergoing hematopoietic stem cell transplantation (HSCT). A 2-year prospective cohort surveillance study of symptomatic and asymptomatic RVIs was performed in hospitalized HSCT patients. Oropharyngeal (OP) swab samples were serially collected each week from 1 week before and up to 100 days after HSCT and were tested for virus isolation with cell culture-based viral isolation (CC-based VI) and a multiplex PCR (MPCR). A total of 2,747 OP swab samples were collected from 250 HSCT patients (268 HSCT procedures). Among these patients, 79 had RVIs (CC-based VI, n = 63; MPCR, n = 17). The parainfluenza virus type 3 (PIV3) accounted for 71% (57/80) of the cases of RVIs. Some PIV3 infections were asymptomatic and involved a longer virus-shedding period. The PIV3 was often cultured from samples taken before the onset of a respiratory disease. The PIV3 infections were attributed to the transmission of nosocomial infections. PIV3 infections before engraftment will more likely result in the development of lower respiratory tract infections and worse outcomes. A real-time monitoring of respiratory viral infections in the HSCT ward among patients with or without respiratory symptoms is required for the prevention of nosocomial RVIs, especially of PIV3 infections.


title: Use of Quantitative Morphological and Functional Features for Assessment of Axillary Lymph Node in Breast Dynamic Contrast-Enhanced Magnetic Resonance Imaging.

text: Background Axillary lymph-node assessment is considered one of the most important prognostic factors concerning breast cancer survival. Objective We investigated the discriminative power of morphological and functional features in assessing the axillary lymph node. Methods We retrospectively analysed data from 52 consecutive patients who undergone DCE-MRI and were diagnosed with primary breast carcinoma: 94 lymph nodes were identified. Per each lymph node, we extracted morphological features: circularity, compactness, convexity, curvature, elongation, diameter, eccentricity, irregularity, radial length, entropy, rectangularity, roughness, smoothness, sphericity, spiculation, surface, and volume. Moreover, we extracted functional features: time to peak (TTP), maximum signal difference (MSD), wash-in intercept (WII), wash-out intercept (WOI), wash-in slope (WIS), wash-out slope (WOS), area under gadolinium curve (AUGC), area under wash-in (AUWI), and area under wash-out (AUWO). Selection of important features in predicting metastasis has been done by means of receiver operating characteristic (ROC) analysis. Performance of linear discriminant analysis was analysed. Results All morphological features but circularity showed a significant difference between median values of metastatic lymph nodes group and nonmetastatic lymph nodes group. All dynamic parameters except for MSD and WOS showed a statistically significant difference between median values of metastatic lymph nodes group and nonmetastatic lymph nodes group. Best results for discrimination of metastatic and nonmetastatic lymph nodes were obtained by AUGC (accuracy 75.8%), WIS (accuracy 71.0%), WOS (accuracy 71.0%), and AUCWO (accuracy 72.6%) for dynamic features and by compactness (accuracy 82.3%), curvature (accuracy 71.0%), radial length (accuracy 71.0%), roughness (accuracy 74.2%), smoothness (accuracy 77.2%), and speculation (accuracy 72.6%) for morphological features. Linear combination of all morphological and/or of all dynamic features did not increase accuracy in metastatic lymph nodes discrimination. Conclusions Compactness as morphological feature and area under time-intensity curve as dynamic feature were the best parameters in identifying metastatic lymph nodes on breast MRI.


title: Availability of researcher-led eHealth tools for pain assessment and management: barriers, facilitators, costs, and design.

text: INTRODUCTION Numerous eHealth tools for pain assessment and management have been developed and evaluated with promising results regarding psychometric properties, efficacy, and effectiveness. Although considerable resources are spent on developing and evaluating these tools with the aim of increasing access to care, current evidence suggests they are not made available to end users, reducing their impact and creating potential research waste. METHODS This study consisted of 2 components: (1) a systematic review of eHealth tools for pediatric pain assessment and/or management published in the past 10 years, and (2) an online survey, completed by the authors of identified tools, of tool availability, perceived barriers or facilitators to availability, grant funding used, and a validated measure of user-centeredness of the design process (UCD-11). RESULTS Ninety articles (0.86% of citations screened) describing 53 tools met inclusion criteria. Twenty-six survey responses were completed (49.06%), 13 of which (50.00%) described available tools. Commonly endorsed facilitators of tool availability included researchers' beliefs in tool benefits to the target population and research community; barriers included lack of infrastructure and time. The average cost of each unavailable tool was $314,425.31 USD ($3,144,253.06 USD total, n = 10). Authors of available tools were more likely to have followed user-centered design principles and reported higher total funding. CONCLUSION Systemic changes to academic and funding structures could better support eHealth tool availability and may reduce potential for research waste. User-centered design and implementation science methods could improve the availability of eHealth tools and should be further explored in future studies.


title: Systematic review of surveillance systems and methods for early detection of exotic, new and re-emerging diseases in animal populations.

text: In this globalized world, the spread of new, exotic and re-emerging diseases has become one of the most important threats to animal production and public health. This systematic review analyses conventional and novel early detection methods applied to surveillance. In all, 125 scientific documents were considered for this study. Exotic (n = 49) and re-emerging (n = 27) diseases constituted the most frequently represented health threats. In addition, the majority of studies were related to zoonoses (n = 66). The approaches found in the review could be divided in surveillance modalities, both active (n = 23) and passive (n = 5); and tools and methodologies that support surveillance activities (n = 57). Combinations of surveillance modalities and tools (n = 40) were also found. Risk-based approaches were very common (n = 60), especially in the papers describing tools and methodologies (n = 50). The main applications, benefits and limitations of each approach were extracted from the papers. This information will be very useful for informing the development of tools to facilitate the design of cost-effective surveillance strategies. Thus, the current literature review provides key information about the advantages, disadvantages, limitations and potential application of methodologies for the early detection of new, exotic and re-emerging diseases.


title: Comparison of VivaSight double-lumen tube with a conventional double-lumen tube in adult patients undergoing video-assisted thoracoscopic surgery.

text: The efficiency of a double-lumen tube depends on its position in the airways, which can be verified by fibreoptic bronchoscopy. The VivaSight DL is a single-use double-lumen tube with a camera embedded in the tube's right side. The view from the camera appears continuously on a monitor. In this prospective study of 71 adult patients, we compared intubation times using either the VivaSight DL or a conventional double-lumen tube. Median (IQR [range]) duration of intubation with visual confirmation of tube position was significantly reduced using the VivaSight DL compared with the conventional double-lumen tube (51 (42-60 [35-118]) s vs 264 (233-325 [160-490]) s, respectively, p < 0.0001). None of the patients allocated to the VivaSight DL required fibreoptic bronchoscopy during intubation or surgery. The VivaSight DL enables significantly more rapid intubation compared with the conventional double-lumen tube.


title: Clinical and radiological features of novel coronavirus pneumonia.

text: Recently, COVID-19 has spread in more than 100 countries and regions around the world, raising grave global concerns. COVID-19 transmits mainly through respiratory droplets and close contacts, causing cluster infections. The symptoms are dominantly fever, fatigue, and dry cough, and can be complicated with tiredness, sore throat, and headache. A few of patients have symptoms such as stuffy nose, runny nose, and diarrhea. The severe disease can progress rapidly into the acute respiratory distress syndrome (ARDS). Reverse transcription polymerase chain reaction (RT-PCR) and Next-generation sequencing (NGS) are the gold standard for diagnosing COVID-19. Chest imaging is used for cross validation. Chest CT is highly recommended as the preferred imaging diagnosis method for COVID-19 due to its high density and high spatial resolution. The common CT manifestation of COVID-19 includes multiple segmental ground glass opacities (GGOs) distributed dominantly in extrapulmonary/subpleural zones and along bronchovascular bundles with crazy paving sign and interlobular septal thickening and consolidation. Pleural effusion or mediastinal lymphadenopathy is rarely seen. In CT imaging, COVID-19 manifests differently in its various stages including the early stage, the progression (consolidation), and the absorption. In its early stage, it manifests as scattered flaky GGOs in various sizes, dominated by peripheral pulmonary zone/subpleural distributions. In the progression state, GGOs increase in number and/or size, and lung consolidations may become visible. The main manifestation in the absorption stage is interstitial change of both lungs, such as fibrous cords and reticular opacities. Differentiation between COVID-19 pneumonia and other viral pneumonias are also analyzed. Thus, CT examination can help reduce false negatives of nucleic acid tests.


title: The role of percutaneous embolization techniques in the management of dural sinus malformations with atypical angioarchitecture in neonates: report of 2 cases.

text: Dural sinus malformations (DSMs) are rare congenital malformations that can be midline or lateral in location. Midline DSMs have been reported to have a worse prognosis than lateral DSMs and have traditionally been more difficult to manage. The authors report 2 unusual manifestations of midline DSMs and their management with percutaneous transfontanelle embolization. The first patient (Case 1) presented at 21 days of life with a large midline DSM and multiple highflow dural and pial arteriovenous shunts. The child developed congestive cardiac failure and venous congestion with intracranial hemorrhage and seizures within a few weeks. The second patient (Case 2) presented with a large midline DSM found on prenatal imaging that was determined to be a purely venous malformation on postnatal evaluation. This large malformation resulted in consumptive coagulopathy and apneic episodes from brainstem compression. The patient in Case 1 was treated initially with endovascular embolization and eventually with curative percutaneous-transfontanelle embolization. The patient in Case 2 was treated with percutaneous transfontanelle embolization in combination with posterior fossa decompression and cranial expansion surgery.


Andrew soldan, veterinary director of the APHA, responds.


A case series of a pav+ weaning protocol in an acute care environment demonstrating an absence of weaning failure.


title: Thyroid function analysis in 50 patients with COVID-19: a retrospective study.

text: BACKGROUND Since the outbreak of the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019, it has affected over 200 countries, areas, or territories in six continents. At present, whether COVID-19 has an effect on thyroid function is unclear. The aim of this study was to evaluate thyroid function in patients with COVID-19. METHODS Clinical manifestations, laboratory results, and chest computed tomography scans were retrospectively reviewed for 50 patients with laboratory-confirmed COVID-19 without a history of thyroid disease who underwent thyroid function testing during their course of COVID-19 infection and after recovery. They were admitted to the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China, between January and March 2020. Healthy participants who underwent routine physical checkups and non-COVID-19 pneumonia patients with a similar degree of severity during the same period were included in the study as the control group. Thyroid hormone and thyroid stimulating hormone (TSH) levels were analyzed and compared between the COVID-19 and control groups. RESULTS TSH lower than the normal range was present in 56% (28/50) of the patients with COVID-19. The levels of TSH and serum total triiodothyronine (TT3) of the patients with COVID-19 were significantly lower than those of the healthy control group and non-COVID-19 pneumonia patients. The more severe the COVID-19, the lower the TSH and TT3 levels were, with statistical significance (p < 0.001). The degree of the decreases in TSH and TT3 levels was positive correlated with the severity of the disease. The total thyroxine (TT4) level of the patients with COVID-19 was not significantly different from the control group. All the patients did not receive thyroid hormone replacement therapy. After recovery, no significant differences in TSH, TT3, TT4, free triiodothyronine (FT3), and free thyroxine (FT4) levels were found between the COVID-19 and control groups. CONCLUSIONS The changes in serum TSH and TT3 may be important manifestations of the courses of COVID-19.


"Social Media Misinformation"-An Epidemic within the COVID-19 Pandemic.


The Strategy for Return to Work after the COVID-19 Pandemic on Small and Medium-sized Enterprises.


title: Immune-Checkpoint Inhibitors for Cancer Therapy in the COVID-19 Era.

text: The potential immune intersection between COVID-19 disease and cancer therapy raises important practical clinical questions and highlights multiple scientific gaps to be filled. Among available therapeutic approaches to consider, checkpoint inhibitors (ICI) seem to require major attention as they may act at the cross-road between cancer treatment and COVID-19 disease, due to their profound immunomodulatory activity. Based on available literature evidences, we suggest guidance to consider for treating physicians, and propose areas of clinical and pre-clinical investigation. Comprehensively, though with the necessary caution, ICI therapy seems to remain a suitable therapeutic option for cancer patients during the COVID-19 pandemic.


title: Rotavirus antagonizes cellular antiviral responses by inhibiting the nuclear accumulation of STAT1, STAT2, and NF-kappaB.

text: A vital arm of the innate immune response to viral infection is the induction and subsequent antiviral effects of interferon (IFN). Rotavirus reduces type I IFN induction in infected cells by the degradation of IFN regulatory factors. Here, we show that the monkey rotavirus RRV and human rotavirus Wa also block gene expression induced by type I and II IFNs through a mechanism allowing signal transducer and activator of transcription 1 (STAT1) and STAT2 activation but preventing their nuclear accumulation. In infected cells, this may allow rotavirus to block the antiviral actions of IFN produced early in infection or by activated immune cells. As the intracellular expression of rotavirus nonstructural proteins NSP1, NSP3, and NSP4 individually did not inhibit IFN-stimulated gene expression, their involvement in this process is unlikely. RRV and Wa rotaviruses also prevented the tumor necrosis factor alpha-stimulated nuclear accumulation of NF-kappaB and NF-kappaB-driven gene expression. In addition, NF-kappaB was activated by rotavirus infection, confirming earlier findings by others. As NF-kappaB is important for the induction of IFN and other cytokines during viral infection, this suggests that rotavirus prevents cellular transcription as a means to evade host responses. To our knowledge, this is the first report of the use of this strategy by a double-stranded RNA virus.


title: Congenital cytomegalovirus infection.

text: Congenital cytomegalovirus (CMV) infection is a serious health problem. The obstacles for limiting this infection are the lack of public awareness on this issue, especially owing to the asymptomatic nature of CMV infections, the inefficacy of therapy, and the unsuccessful vaccine trials to date. It is therefore important to organize the current data to estimate the results and to report that the development of a vaccine against CMV must be of the highest priority.


title: Comparison of endovascular treatment versus conservative medical treatment in patients with acute basilar artery occlusion.

text: INTRODUCTION Basilar artery occlusion (BAO) causes mortality up to 90%. METHODS A total of 99 patients with BAO received either endovascular (endovascular mechanical recanalization and/or intra-arterial with optional intravenous thrombolysis [IVT] as bridging concept) or conservative medical treatment (IVT and/or medical oral therapy). Outcome parameters were measured in accordance with the thrombolysis in cerebral infarction (TICI), National Institutes of Health Stroke Scale (NIHSS), and modified Rankin Scale (mRS) scores. RESULTS In all, 78% underwent endovascular and 22% conservative medical treatment. The NIHSS at admission was 20 in both the groups. Postprocedurally, 36% (95% confidence interval: 26%-48%) of the endovascular group and 9% (21%-64%) of the conservative group reached TICI 3 (P = .017). In all, 30% of the endovascular group and 9% of the conservative group were documented with TICI 2b (P = .057). At 90 days follow-up, 45% (31%-60%) of the endovascular-treated patientsand no patient (0%-25%) of the conservative-treated group reached mRS ≤2 (P = .012). CONCLUSION Endovascular treatment of BAO provides a better chance to survive this severe condition with good clinical outcome.


title: Evaluation of the severe acute respiratory syndrome (SARS) surveillance system, with emphasis on influenza, Brazil, 2014-2016.

text: OBJECTIVE to evaluate attributes of the severe acute respiratory syndrome (SARS) surveillance system in Brazil, 2014-2016. METHOD this was an evaluation study conducted according to United States Centers for Disease Control and Prevention guidelines. Data from the Influenza Web information system notified for the period 2014-2016 were used. The simplicity, completeness, inconsistency, timeliness, acceptability, representativeness, positive predictive value (PPV) of the SARS case definition attributes and usefulness were evaluated. RESULTS a simple structure was found with good completeness (100% for required variables; >95% for optional variables); low inconsistency (3.2%); lack of timeliness (68.2%); low acceptability (average of 70.4%); representative of the territory (capable of analyzing risk groups); high PPV (29.1%); useful (fulfils system objectives). CONCLUSION the attributes evaluated indicate that the system is capable of providing complete, representative and useful information about influenza, adequate for guiding national health responses.


COVID-19: Not a Simple Public Health Emergency.


title: A Parallelized Pumpless Artificial Placenta System Significantly Prolonged Survival Time in a Preterm Lamb Model.

text: An artificial placenta (AP) is an arterio-venous extracorporeal life support system that is connected to the fetal circulation via the umbilical vasculature. Previously, we published an article describing a pumpless AP system with a small priming volume. We subsequently developed a parallelized system, hypothesizing that the reduced circuit resistance conveyed by this modification would enable healthy fetal survival time to be prolonged. We conducted experiments using a premature lamb model to test this hypothesis. As a result, the fetal survival period was significantly prolonged (60.4 ± 3.8 vs. 18.2 ± 3.2 h, P < 0.01), and circuit resistance and minimal blood lactate levels were significantly lower in the parallel circuit group, compared with our previous single circuit group. Fetal physiological parameters remained stable until the conclusion of the experiments. In summary, parallelization of the AP system was associated with reduced circuit resistance and lactate levels and allowed preterm lamb fetuses to survive for a significantly longer period when compared with previous studies.


title: Relaxation matters: comparison of in-vitro vasodilatory role of botulinum toxin-A and papaverine in human radial artery grafts.

text: BACKGROUND Radial artery (RA) is widely used in coronary artery bypass (CABG) surgery and the prevention of spasm is crucial for graft patency. Botulinum toxin A (BTX-A) and B are commonly used for aesthetic reasons and neuromuscular disorders. They are proven to raise blood flow and increase survival of ischemic skin flaps. In this study we evaluated and compared the vasodilator effects of BTX-A and papaverine on human RA grafts. METHODS After resting 60 min in isolated organ baths, human RA grafts were examined. Contraction responses for different doses of serotonin (5-HT) and endothelin-1 (ET-1) were evaluated as a percent of maximum contraction response elicited by 80 mM potassium chloride (KCl). The inhibitory effects of BTX-A and papaverine on contraction responses taken at the 0th hour were compared with the 1st and 2nd hour responses. Inhibitory effects of BTX-A and papaverine against the contractile agent were evaluated by comparing the results of the first and last (0th and 2nd hour) application. RESULTS In low concentrations, when we compared the effects of BTX-A (10- 8 M) and papaverine (10- 6 M) on 5-HT, papaverine was found to be more effective at both the 0th and 2nd hour (p < 0.05). Both BTX-A and papaverine inhibited the maximum contractile effect of ET-1 to the same extent at the 0th hour; but, the inhibitory effect of BTX-A was significantly stronger at the 2nd hour (p < 0.05). In high concentrations, when we compared the effects of BTX-A (10- 6 M) and papaverine (10- 4 M) on 5-HT, papaverine showed stronger inhibition (p < 0.05), whereas both agents had similar action of inhibition on ET-1 mediated maximum contraction responses. CONCLUSION BTX-A inhibits both ET-1 and 5-HT induced contractions and its effectiveness does not decrease over time as observed with papaverine. This study is the first in the literature using human RA for prevention of vasospasm by BTX-A.


title: Emerging Foodborne and Agriculture-Related Viruses.

text: Viruses rapidly evolve and can emerge in unpredictable ways. Transmission pathways by which foodborne viruses may enter human populations and evolutionary mechanisms by which viruses can become virulent are discussed in this chapter. A majority of viruses emerge from zoonotic animal reservoirs, often by adapting and infecting intermediate hosts, such as domestic animals and livestock. Viruses that are known foodborne threats include hepatitis E virus, tick-borne encephalitis virus, enteroviruses, adenovirus, and astroviruses, among others. Viruses may potentially evolve and emerge as a result of modern agricultural practices which can concentrate livestock and bring them into contact with wild animals. Examples of viruses that have emerged in this manner are influenza, coronaviruses such as severe acute respiratory syndrome and Middle East respiratory syndrome, and the Nipah virus. The role of bats, bush meat, rodents, pigs, cattle, and poultry as reservoirs from which infectious pathogenic viruses emerge are discussed.


title: A Model for COVID-19 Prediction in Iran Based on China Parameters.

text: BACKGROUND The rapid spread of COVID-19 virus from China to other countries and outbreaks of disease require an epidemiological analysis of the disease in the shortest time and an increased awareness of effective interventions. The purpose of this study was to estimate the COVID-19 epidemic in Iran based on the SIR model. The results of the analysis of the epidemiological data of Iran from January 22 to March 24, 2020 were investigated and prediction was made until April 15, 2020. METHODS By estimating the three parameters of time-dependent transmission rate, time-dependent recovery rate, and timedependent death rate from Covid-19 outbreak in China, and using the number of Covid-19 infections in Iran, we predicted the number of patients for the next month in Iran. Each of these parameters was estimated using GAM models. All analyses were conducted in R software using the mgcv package. RESULTS Based on our predictions of Iran about 29000 people will be infected from March 25 to April 15, 2020. On average, 1292 people with COVID-19 are expected to be infected daily in Iran. The epidemic peaks within 3 days (March 25 to March 27, 2020) and reaches its highest point on March 25, 2020 with 1715 infected cases. CONCLUSION The most important point is to emphasize the timing of the epidemic peak, hospital readiness, government measures and public readiness to reduce social contact.


title: Risk assessment as a guide for the prevention of the many faces of venous thromboembolism.

text: BACKGROUND Approximately 900,000 cases of deep vein thrombosis and pulmonary embolism occur annually in the United States, and one-third lead to the patient's death. A variety of surgical factors contribute to Virchow's triad of venous stasis, vascular injury, and hypercoagulability, including intraoperative venous distension and microvascular endothelial damage. Patients also may have individual risk factors such as a history of thromboembolism, cancer, advanced age, or a genetic trait linked to hypercoagulation. This article discusses recent trends in the development and validation of venous thromboembolism risk scores, including the results of a large validation study. DATA SOURCES A Medline literature search was performed to identify original studies. CONCLUSIONS Venous thromboembolism risk scores have been developed for groups of patients based on a few broad risk categories, but a more accurate, individualized risk score can be obtained using a recently validated risk scoring system, which can be used to determine the type and length of prophylaxis to administer. Further studies are under way to refine this system.


title: Panel report: best practices for the surgical treatment of obesity.

text: BACKGROUND Bariatric surgery is a rapidly growing field. Advances in surgical technologies and techniques have raised concerns about patient safety. Bariatric surgeons and programs are under increased scrutiny from regulatory agencies, insurers, and public health officials to provide high quality and safe care for bariatric patients at all phases of care. METHODS During the 2009 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on patient safety and best practices in bariatric surgery. The following article is a summary of this panel presentation. RESULTS AND CONCLUSIONS Weight loss surgery is a field that is evolving and adapting to multiple external pressures. Safety concerns along with increasing public scrutiny have led to a systematic approach to defining best practices, creating standards of care, and identifying mechanisms to ensure that patients consistently receive the best and most effective care possible. In many ways, bariatric surgery and multidisciplinary bariatric surgery programs may serve as a model for other programs and surgical specialties in the near future.


title: Temporal Change of SARS-CoV-2 in Clinical Specimens of COVID-19 Pneumonia Patients.

text: The quality and type of specimen collection affect the sensitivity of real-time reverse transcriptase-PCR (rRT-PCR) for the diagnosis of SARS-CoV-2. In this report, the course over time of rRT-PCR for SARS-CoV-2 in 26 clinical specimens collected from the upper (nasopharyngeal and throat swabs) and lower (sputum) respiratory tracts of COVID-19 cases with pneumonia was investigated along with the clinical course. The preliminary results revealed that higher SARS-CoV-2 RNA concentration and longer time for detection make self-collected sputum a preferable specimen for the diagnosis and follow-up of COVID-19 pneumonia. Self-collection of sputum can minimize the risk of unnecessary exposure to healthcare workers, preserve the shortage of personal protective equipment, and limit viral transmission to the environment.


COVID-19 in the Pediatric Population.


title: Chronic fatigue syndrome following infections in adolescents.

text: PURPOSE OF REVIEW To review the recent epidemiology, pathophysiology, and treatment of postinfectious chronic fatigue syndrome (CFS) in adolescents. RECENT FINDINGS Thirteen percent of adolescents (mainly women) met the criteria for CFS 6 months following infectious mononucleosis; the figure was 7% at 12 months and 4% at 24 months. Peak work capacity, activity level, orthostatic intolerance, salivary cortisol, and natural killer cell number and function were similar between adolescents with CFS following infectious mononucleosis and recovered controls. Autonomic system, oxygen consumption, peak oxygen pulse, psychological and cytokine network differences were documented between those who recovered and those who did not. SUMMARY The prognosis of CFS is better in adolescents than in adults. Activity level, exercise tolerance, and orthostatic testing could not distinguish patients with CFS from adolescents who have recovered from infectious mononucleosis (controls), while certain cytokine network analyses, life stress factors, and autonomic symptoms could.


title: The impact of age on outcomes of elderly ED patients ventilated due to community acquired pneumonia.

text: OBJECTIVES There is no consensus on whether mechanical ventilation should be initiated for advanced age with community-acquired pneumonia (CAP). This study investigated the effects of age on the outcomes of mechanical ventilation in the emergency department (ED) for advanced age with CAP. METHODS We retrospectively investigated the medical records of advanced age (age, ≥65 years) with CAP who required mechanical ventilation in the ED of our hospital between January 2006 and December 2012. The patients were divided into 65 to 74, 75 to 84, and 85 years or older age groups. The following outcomes were measured: number of patients weaned from mechanical ventilation, in-hospital mortality, ventilator-free days, and intensive care unit days. Multiple logistic regression analysis was used to identify risk factors associated with mortality and weaning from mechanical ventilation. RESULTS Seventy-one patients (mean age, 79.5 years) were included. The overall in-hospital mortality rate was 43.7%. No significant differences were observed among the 3 groups with regard to weaning from mechanical ventilation (P=.59), in-hospital mortality (P=.90), ventilator-free days (P=.83), or intensive care unit days (P=.12). Age was not significantly associated with weaning from mechanical ventilation or in-hospital mortality among advanced age. Diabetes mellitus was an independent factor for weaning from mechanical ventilation (P=.048) and was relatively associated with mortality (P=.051). CONCLUSIONS Age, in itself, may not be a factor limiting the initiation of mechanical ventilation in the ED in advanced age with CAP. Further studies should determine appropriate indications for mechanical ventilation in the ED for these patients.


title: The frequency response of cerebral autoregulation.

text: The frequency-response of pressure autoregulation is not well delineated; therefore, the optimal frequency of arterial blood pressure (ABP) modulation for measuring autoregulation is unknown. We hypothesized that cerebrovascular autoregulation is band-limited and delineated by a cutoff frequency for which ABP variations induce cerebrovascular reactivity. Neonatal swine (n = 8) were anesthetized using constant minute ventilation while positive end-expiratory pressure (PEEP) was modulated between 6 and 0.75 cycles/min (min(-1)). The animals were hemorrhaged until ABP was below the lower limit of autoregulation (LLA), and PEEP modulations were repeated. Vascular reactivity was quantified at each frequency according to the phase lag between ABP and intracranial pressure (ICP) above and below the LLA. Phase differences between ABP and ICP were small for frequencies of >2 min(-1), with no ability to differentiate cerebrovascular reactivity between ABPs above or below the LLA. For frequencies of <2 min(-1), ABP and intracranial pressure (ICP) showed phase shift when measured above LLA and no phase shift when measured below LLA [above vs. below LLA at 1 min(-1): 156° (139-174°) vs. 30° (22-50°); P < 0.001 by two-way ANOVA for both frequency and state of autoregulation]. Data taken above LLA fit a Butterworth high-pass filter model with a cutoff frequency at 1.8 min(-1) (95% confidence interval: 1.5-2.2). Cerebrovascular reactivity occurs for sustained ABP changes lasting 30 s or longer. The ability to distinguish intact and impaired autoregulation was maximized by a 60-s wave (1 min(-1)), which was 100% sensitive and 100% specific in this model.


title: Remote FLS testing in the real world: ready for "prime time".

text: INTRODUCTION Maintaining the existing FLS test centers requires considerable investment in human and financial resources. It can also be particularly challenging for those outside of North America to become certified due to the limited number of international test centers. Preliminary work suggests that it is possible to reliably score the FLS manual skills component remotely using low-cost videoconferencing technology. Significant work remains to ensure that testing procedures adhere to standards defined by SAGES for this approach to be considered equivalent to standard on-site testing. OBJECTIVE To validate the integrity and validity of the FLS manual skills examination administered remotely in a real-world environment according to FLS testing protocols and to evaluate participants' experience with the setting. METHODS Individuals with various levels of training from the University of Toronto completed a pre- and a post-test questionnaire. Participants presented to one of the two FLS testing rooms available for the study, each connected via Skype to a separate room with a FLS proctor who administered and scored the test remotely (RP). An on-site proctor (OP) was present in the room as a control. An invigilator was also present in the testing room to follow directions from the RP and ensure the integrity of test materials. RESULTS Twenty-one participants were recruited, and 20 completed the test. There was no significant difference between scores by RP and OP. Interrater reliability between the RP and OP was excellent. One critical error was missed by the RP, but this would not have affected the test outcome. Participants reported being highly satisfied. CONCLUSION We demonstrate that proctors located remotely can administer the FLS skills test in a secure and reliable fashion, with excellent interrater reliability compared to an on-site proctor. Remote proctoring of the FLS examination could become a strategy to increase certification rates while containing costs.


Sex hormones signal why virus hits men harder.


title: The possible impact of COVID-19 on colorectal surgery in Italy.

text: The COVID-19 outbreak in Italy is stopping access to elective benign disease treatment and changing the approach to malignant disease as well as the outpatients care of those patients treated for colorectal cancer. The lack of knowledge about the possible implications of the spread of the infection during surgery could extend to infect surgeons, surgery nurses and also the anesthesiologists, the results will become evident in the long term. The surgical approach may change going towards less invasive procedures to minimize the aerosolized biological fluids, this approach could reduce the access to first level hospitals changing the entire health care system in the future.


COVID-19 with abdominal symptoms and acute abdominal pain: a guide to identification for general practice.


Covid-19: now is not the time to judge the UK's response.


title: Liquid-injection for preperitoneal dissection of transabdominal preperitoneal (TAPP) inguinal [corrected] hernia repair.

text: BACKGROUND The creation of an adequate peritoneal flap during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair, while avoiding injuring surrounding structures can be technically challenging. Liquid infiltration of the preperitoneal space can help facilitate dissection and avoid inadvertent injuries. We describe a novel technique for TAPP inguinal hernia repair using liquid-injection for preperitoneal [corrected] dissection and report our initial experience. METHODS TAPP inguinal hernia repair using a liquid-injection technique during preperitoneal dissection was performed by a single surgical resident without prior TAPP repair experience from July 2013 to January 2014. After trocar placement, 60 mL of 0.3 % lidocaine with 1:300,000 dilution of epinephrine was injected percutaneously using a blunt needle under laparoscopic visualization into the preperitoneal space to assist with the dissection and parietalization of the vas deferens, spermatic vessels, and epigastric vessels. The initial peritoneal incision is performed at the lateral side of the inguinal canal, followed by blunt dissection of the preperitoneal space. RESULTS Eleven patients (median age: 69; 8 male) with a total of 12 inguinal hernias underwent a TAPP repair using a liquid-injection preperitoneal dissection technique. Ten patients had unilateral hernias (4 indirect, 6 direct), and one patient had bilateral direct hernias. The median operative time, median injection time, and median dissection time were 116, 3.5, and 42 min, respectively. Estimated blood loss was less than 10 mL for all cases. No intraoperative injuries, conversions to open repair, or 30-day postoperative complications occurred. There were no hernia recurrences after a median follow-up of 143 days. CONCLUSION Our preliminary experience suggests that liquid-injection to assist preperitoneal dissection during TAPP inguinal hernia repair appears to be safe and feasible. This novel method facilitates the dissection of spermatic cord structures, and can be used to minimize trauma to surrounding structures, especially when performed by trainees with limited operative experience.


Research reporting standards for percutaneous thermal ablation of lung neoplasms.


New paradigms in the treatment of small bowel obstruction.


Measles outbreak at an international airport: a Hong Kong perspective.


What is the role of a dermatologist in the battle against COVID-19? The experience from a hospital on the frontline in Milan.


Advancing biomedical and health informatics knowledge through reviews of existing research.


Bovine coronavirus suspected in the deaths of housed calves.


title: Radiofrequency Ablation for the Treatment of Hepatocellular Carcinoma in Patients with Transjugular Intrahepatic Portosystemic Shunts.

text: PURPOSE To assess radiofrequency (RF) ablation efficacy, as well as the patency of transjugular intrahepatic portosystemic shunts (TIPSs), in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS Retrospective database review of patients with pre-existing TIPS undergoing RF ablation of HCC was conducted over a 159-month period ending in November 2013. TIPS patency pre- and post-RF ablation was assessed by ultrasound, angiography, and/or contrast-enhanced CT or MRI. Patient demographics and immediate post-RF ablation outcomes and complications were also reviewed. RESULTS 19 patients with 21 lesions undergoing 25 RF ablation sessions were included. Child-Pugh class A, B, and C scores were seen in 1, 13, and 5 patients, respectively. Eleven patients (58 %) ultimately underwent liver transplantation. Immediate technical success was seen in all ablation sessions without residual tumor enhancement (100 %). No patients (0 %) suffered liver failure within 1 month of ablation. Pre-ablation TIPS patency was demonstrated in 22/25 sessions (88 %). Of 22 cases with patent TIPS prior to ablation, post-ablation patency was demonstrated in 22/22 (100 %) at immediate post-ablation imaging and in 21/22 (95 %) at last follow-up (1 patient was incidentally noted to have occlusion 31 months later). No immediate complications were observed. CONCLUSION Ablation efficacy was similar to the cited literature values for patients without TIPS. Furthermore, TIPS patency was preserved in the majority of cases. Patients with both portal hypertension and HCC are not uncommonly encountered, and a pre-existing TIPS does not appear to be a definite contraindication for RF ablation.


title: Lessons learned and concepts formed from study of the pathogenesis of the two negative-strand viruses lymphocytic choriomeningitis and influenza.

text: Viruses have unique lifestyles. To describe the pathogenesis and significance of viral infection in terms of host responses, resultant injury, and therapy, we focused on two RNA viruses: lymphocytic choriomeningitis (LCMV) and influenza (Flu). Many of the currently established concepts and consequences about viruses and immunologic tolerance, virus-induced immunosuppression, virus-induced autoimmunity, immune complex disease, and virus-lymphocyte and virus-dendritic cell interactions evolved through studies of LCMV in its natural murine host. Similarly, the mechanisms, aftermath, and treatment of persistent RNA viruses emerged, in large part, from research on LCMV. Analysis of acute influenza virus infections uncovered the prominent direct role that cytokine storm plays in the pathogenesis, morbidity, and mortality from this disease. Cytokine storm of influenza virus infection is initiated via a pulmonary endothelial cell amplification loop involving IFN-producing cells and virus-infected pulmonary epithelial cells. Importantly, the cytokine storm is chemically treatable with specific agonist therapy directed to the sphingosphine 1 phosphate receptor 1, which is located on pulmonary endothelial cells, pointing to the endothelial cells as the gatekeepers of this hyperaggressive host immune response.


title: Treatment of fungal pyelonephritis and ureterolithiasis with a subcutaneous ureteral bypass system and systemic antifungal medication in a cat.

text: Purpose We describe a case of ureteral obstruction and fungal pyelonephritis in a cat. The case was managed successfully with a subcutaneous ureteral bypass (SUB) device and systemic antifungal medication. Case summary A 9-year-old, male, neutered, domestic shorthair cat was referred for severe azotemia, ureteral obstruction, and sonographically identified progressive pyelectasia of the left kidney. A SUB device was placed. Cytology of the left kidney subsequently identified fungal organisms, and the cat responded clinically to treatment with fluconazole and supportive care. The cat survived for 11 months with intermittent fluconazole treatment. Conclusion Fungal pyelonephritis should be considered as a possible concurrent diagnosis in cats with ureteral obstruction. The successful clinical outcome in this case suggests that treatment with SUB placement, antifungal medication, and supportive care could be an effective treatment strategy.


title: Prediction of Stroke Onset Is Improved by Relative Fluid-Attenuated Inversion Recovery and Perfusion Imaging Compared to the Visual Diffusion-Weighted Imaging/Fluid-Attenuated Inversion Recovery Mismatch.

text: BACKGROUND AND PURPOSE Acute stroke patients with unknown time of symptom onset are ineligible for thrombolysis. The diffusion-weighted imaging and fluid-attenuated inversion recovery (FLAIR) mismatch is a reasonable predictor of stroke within 4.5 hours of symptom onset, and its clinical usefulness in selecting patients for thrombolysis is currently being investigated. The accuracy of the visual mismatch rating is moderate, and we hypothesized that the predictive value of stroke onset within 4.5 hours could be improved by including various clinical and imaging parameters. METHODS In this study, 141 patients in whom magnetic resonance imaging was obtained within 9 hours after symptom onset were included. Relative FLAIR signal intensity was calculated in the region of nonreperfused core. Mean Tmax was calculated in the total region with Tmax >6 s. Mean relative FLAIR, mean Tmax, lesion volume with Tmax >6 s, age, site of arterial stenosis, core volume, and location of infarct were analyzed by logistic regression to predict stroke onset time before or after 4.5 hours. RESULTS Receiver-operating characteristic curve analysis revealed an area under the curve of 0.68 (95% confidence interval 0.59-0.78) for the visual diffusion-weighted imaging/FLAIR mismatch, thereby correctly classifying 69% of patients with an onset time before or after 4.5 hours. Age, relative FLAIR, and Tmax increased the accuracy significantly (P<0.01) to an area under the curve of 0.82 (95% confidence interval 0.74-0.89). This new predictive model correctly categorized 77% of patients according to stroke onset before versus after 4.5 hours. CONCLUSIONS In patients with unknown stroke onset, the accuracy of predicting time from symptom onset within 4.5 hours is improved by obtaining relative FLAIR and perfusion imaging.


title: Detection of novel gammaherpesviruses from fruit bats in Indonesia.

text: Bats are an important natural reservoir of zoonotic viral pathogens. We previously isolated an alphaherpesvirus in fruit bats in Indonesia, and here establish the presence of viruses belonging to other taxa of the family Herpesviridae. We screened the same fruit bat population with pan-herpesvirus PCR and discovered 68 sequences of novel gammaherpesvirus, designated 'megabat gammaherpesvirus' (MgGHV). A phylogenetic analysis of approximately 3.4 kbp of continuous MgGHV sequences encompassing the glycoprotein B gene and DNA polymerase gene revealed that the MgGHV sequences are distinct from those of other reported gammaherpesviruses. Further analysis suggested the existence of co-infections of herpesviruses in Indonesian fruit bats. Our findings extend our understanding of the infectious cycles of herpesviruses in bats in Indonesia and the phylogenetic diversity of the gammaherpesviruses.


Cognitive behaviour therapy for health anxiety.


COVID-19 Pandemic: Negative-pressure tent during atomization of local anesthetic for awake fibreoptic intubation.


title: Laparoscopic Mesh Repair of Bilateral Obturator Hernias Post-Peritoneal Dialysis.

text: Abdominal wall hernias are prevalent in patients undergoing peritoneal dialysis (PD). Obturator hernias, first described by Arnaud de Ronsil in 1724, are an uncommon type of hernia where intra-abdominal contents protrude through the obturator foramen. The following case highlights a rare presentation of bilateral obturator hernias with right femoral and inguinal hernia in an 82-year-old woman post-PD. This patient presented with 5 months of bilateral thigh pain and swelling and was found to only have a right-sided obturator hernia on computer tomography (CT) scan. Intraoperatively, bilateral obturator hernias were found along with right inguinal and femoral hernias, which were all repaired laparoscopically with polypropylene mesh. Postoperatively, the patient developed a self-limiting port site hematoma and resumed PD 1 month post-surgery. Due to the high morbidity and mortality from obturator hernias, prompt diagnosis and treatment are imperative. Compared with open hernia repair, laparoscopic hernia repairs are associated with quicker return to usual activities and less persisting pain and numbness. This case portrays that laparoscopic approach to bilateral obturator hernias can be considered in patients post-PD.


title: Identification of heat shock protein 10 within the equine embryo, endometrium, and maternal peripheral blood mononuclear cells.

text: Early pregnancy factor has been identified as a 10-kDa extracellular homolog of heat shock protein 10 (Hsp10). Hsp10 has been detected during early pregnancy in serum of mice, sheep, pigs, horses, cows, and humans by the rosette inhibition test. Hsp10 has also been associated with several neoplastic and autoimmune diseases. The goal of the present study was to determine if Hsp10 could be detected in the early equine embryo through the use of immunohistochemistry and quantitative real-time PCR. Additionally, analysis of systemically harvested peripheral blood mononuclear cells (PBMCs) from both pregnant and nonpregnant mares was evaluated to determine expression levels of HSP10. Embryos were collected from Quarter Horse mares by uterine lavage at either 8 or 25 days after ovulation. Collection and separation of PBMCs occurred on Day 8 for both pregnant and nonpregnant mares. Immunohistochemistry revealed cytoplasmic localization of HSP10 throughout the single layer of ectodermal cells forming the trophoblast in Day-8 embryos. Day-25 embryos demonstrated intense localization focally along the apical border of ectodermal cells forming the trophoblast layer of the developing chorion. There was no nuclear staining in either embryonic population. Quantitative real-time PCR detected the presence of mRNA for HSP10 in both 8- and 25-day equine embryos. Day-25 embryos exhibited an elevated degree of expression (P = 0.006) compared with the 8-day embryos for HSP10. Endometrial samples did not display any significant difference in degree of expression for HSP10 (P = 0.10). Finally, PBMCs from pregnant mares demonstrated elevated (P = 0.03) expression of HSP10 compared to the nonpregnant mares on Day 8 of the estrous cycle. This study confirmed the presence of HSP10 protein and mRNA expression of HSP10 in equine embryos at two maturation stages. Additionally, the presence of increased gene expression within PBMCs of pregnant mares suggests communication, possibly leading to necessary immunomodulatory effects between the embryo and mare.


title: The Change of Endotracheal Tube Cuff Pressure During Laparoscopic Surgery.

text: Background We evaluated the endotracheal tube cuff pressure (Pcuff) changes during pneumoperitoneum for laparoscopic cholecystectomy and the correlations between body mass index (BMI), pneumoperitoneum time, and Pcuff changes. Methods Total 60 patients undergoing laparoscopic cholecystectomy were allocated to either a study group (BMI ≥ 25 kg/m2) or a control group (BMI < 25 kg/m2). The endotracheal intubation was performed with a high-volume low-pressure cuffed oral endotracheal tube. A manometer was connected to the pilot balloon using a 3-way stopcock and the cuff was inflated. The change in Pcuff was defined as the difference between the pressure just before intra-abdominal CO2 insufflation and the pressure before CO2 desufflation. Results Pcuff increased to 5.3 ± 3.6 cmH2O in the study group and 5.7 ± 5.4 cmH2O in the control group. There was no significant difference between two groups. While BMI was not correlated with change in Pcuff (r = 0.022, p = 0.867), there was a significant correlation between change in Pcuff and the duration of pneumoperitoneum (r = 0.309, p = 0.016). Conclusion The change in Pcuff was not affected by BMI and was significantly correlated with pneumoperitoneum time. We recommend regular measurement and adjustment of Pcuff during laparoscopic surgery.


Seven tips to manage your mental health and well-being during the COVID-19 outbreak.


title: Gut-brain actions underlying comorbid anxiety and depression associated with inflammatory bowel disease.

text: IntroductionInflammatory bowel disease (IBD) is a chronic relapsing and remitting disorder characterised by inflammation of the gastrointestinal tract. There is a growing consensus that IBD is associated with anxiety- and depression-related symptoms. Psychological symptoms appear to be more prevalent during active disease states with no difference in prevalence between Crohn's disease and ulcerative colitis. Behavioural disturbances including anxiety- and depression-like symptoms have also been observed in animal models of IBD. RESULTS The likely mechanisms underlying the association are discussed with particular reference to communication between the gut and brain. The close bidirectional relationship known as the gut-brain axis includes neural, hormonal and immune communication links. Evidence is provided for a number of interacting factors including activation of the inflammatory response system in the brain, the hypothalamic-pituitary-adrenal axis, and brain areas implicated in altered behaviours, changes in blood brain barrier integrity, and an emerging role for gut microbiota and response to probiotics in IBD.DiscussionThe impact of psychological stress in models of IBD remains somewhat conflicted, however, it is weighted in favour of stress or early stressful life events as risk factors in the development of IBD, stress-induced exacerbation of inflammation and relapse. CONCLUSION It is recommended that patients with IBD be screened for psychological disturbance and treated accordingly as intervention can improve quality of life and may reduce relapse rates.


Prioritizing systemic therapies for genitourinary malignancies: Canadian recommendations during the COVID-19 pandemic.


title: Mechanisms by which ambient humidity may affect viruses in aerosols.

text: Many airborne viruses have been shown to be sensitive to ambient humidity, yet the mechanisms responsible for this phenomenon remain elusive. We review multiple hypotheses, including water activity, surface inactivation, and salt toxicity, that may account for the association between humidity and viability of viruses in aerosols. We assess the evidence and limitations for each hypothesis based on findings from virology, aerosol science, chemistry, and physics. In addition, we hypothesize that changes in pH within the aerosol that are induced by evaporation may trigger conformational changes of the surface glycoproteins of enveloped viruses and subsequently compromise their infectivity. This hypothesis may explain the differing responses of enveloped viruses to humidity. The precise mechanisms underlying the relationship remain largely unverified, and attaining a complete understanding of them will require an interdisciplinary approach.


title: Endemic and emerging acute virus infections in Indonesia: an overview of the past decade and implications for the future.

text: Being the largest archipelago country in the world, with a tropical climate and a unique flora and fauna, Indonesia habitats one of the most diverse biome in the world. These characteristics make Indonesia a popular travel destination, with tourism numbers increasing yearly. These characteristics also facilitate the transmission of zoonosis and provide ideal living and breading circumstances for arthropods, known vectors for viral diseases. A review of the past 10 years of literature, reports of the Ministry of Health, Republic of Indonesia and ProMED-mail shows a significant increase in dengue infection incidence. Furthermore, chikungunya, Japanese encephalitis and rabies are proven to be endemic in Indonesia. The combination of cohort studies, governmental data and ProMED-mail reveals an integrated overview for those working in travel medicine and public health, focusing on both endemic and emerging acute virus infections. This review summarizes the epidemiology of acute virus infections in Indonesia, including outbreak reports, as well as public health response measurements and their potential or efficacy. Knowledge about human behaviour, animal reservoirs, climate factors, environment and their role in emerging virus infection are discussed. We aim to support public health authorities and health care policy makers in a One Health approach.


title: Are co-infections with COVID-19 and Influenza low or underreported? An observational study examining current published literature including three new unpublished cases.

text: As the COVID-19 pandemic continues, one major point of uncertainty is the impact this novel pathogen will have during the upcoming 2020-2021 flu season. While the influenza virus is a known contributor to human morbidity and mortality, the question of how a coinfection between COVID-19 and influenza might manifest is of utmost concern. The aim of this study was to review the limited cases of COVID-19/influenza coinfection currently available in the literature, along with cases in the community of El Paso, Texas, to determine whether any patterns of clinical presentation and morbidity emerged. An international review of the literature was conducted. Six published articles describing COVID-19/influenza coinfection were identified, with a total of thirteen patients described therein. Three additional patients were identified from the El Paso, Texas data. The most common presenting symptoms were fever and cough. The most common laboratory findings were elevated C-reactive protein and lymphocytopenia. Thirteen patients presented with viral pneumonia findings on CT, and nine had findings of ground-glass opacity. Finally, complications were reported in six patients, with most common complication being acute respiratory distress syndrome (ARDS). The results of the review indicate that, due to the similarity in presentation between COVID-19 and influenza, further analysis will be required to understand the effects of coinfection on morbidity and mortality. However, the limited number of coinfection cases in the literature indicates that the implementation of COVID-19 control measures may continue to play a role in limiting the spread of these human respiratory pathogens. This article is protected by copyright. All rights reserved.


title: Carotid artery stenting outcomes: do they correlate with antiplatelet response assays?

text: OBJECTIVE Limited data exist regarding the use of antiplatelet response assays during neuroendovascular intervention. We report outcomes after carotid artery stenting (CAS) based on aspirin and P2Y12 assays. METHODS We retrospectively identified patients who had aspirin and P2Y12 assays at the time of stenting. Aspirin (325 mg) and clopidogrel (75 mg) were started 7-10 days pre-intervention. If not possible, aspirin (650 mg) and clopidogrel (600 mg) loading doses were given pre-intervention. Assays were checked on postoperative day 0/1. Outcomes included neurological ischemic sequela at 30 days, 1 and 2 years, as well as 30 day death/hemorrhage/myocardial infarction. RESULTS 449 patients were included. Mean P2Y12 reaction unit (PRU) values were higher in patients with an ipsilateral ischemic event (stroke/transient ischemic attack (TIA)) or stroke (alone) at 1 and 2 years than in patients with no events: ischemic event versus no event at 1 year, 252 vs 202 (p=0.008); stroke versus no stroke at 1 year, 252 versus 203(p=0.029); ischemic event versus no event at 2 years, 244 vs 203 (p=0.047); stroke versus no stroke at 2 years, 243 versus 203 (p=0.082). Ischemic event free survival (stroke/TIA, p=0.0268) and overall survival (p=0.0291) post-CAS were longer in patients with PRU ≤198 compared with an initial threshold of PRU ≤237. Mean PRU values were higher in patients who died from all causes at 30 days than in survivors (p=0.031). No correlation was found between lower PRU values and hemorrhage. Aspirin reaction units did not correlate with outcome. CONCLUSIONS PRU ≤198 may be associated with a lower incidence of ischemic neurological sequela and death post-CAS. Prospective studies are needed to validate the relationship between antiplatelet assays and outcomes post-CAS.


title: Malignant external otitis: Factors predicting patient outcomes.

text: OBJECTIVE Malignant external otitis (MEO) is an aggressive infection, primarily affecting elderly diabetic patients. It begins in the external ear canal and spreads to adjacent structures. This study investigated the clinical characteristics of patients diagnosed and treated for MEO and analyzed factors affecting patient outcomes. STUDY DESIGN Historical cohort. SETTING Tertiary medical center. METHODS Medical records of all patients diagnosed and treated for MEO from 1990 to 2013, were retrospectively reviewed. Clinical features, laboratory, imaging and outcomes were analyzed. RESULTS 88 patients were included, mean age was 73±11.5years, 61 (69%) were male. Of these, 75% had diabetes. Mean follow-up was 60months. The most common presenting symptoms were otalgia (89%), external ear canal edema (86%) and otorrhea (84%). Pseudomonas aeruginosa was isolated in 61% of ear cultures. All patients were treated with antibiotics, 22% had surgery and 8% hyperbaric oxygen. Overall survival rate was 38% in 5years, with disease specific mortality 14%. DM, facial nerve palsy, positive CT scan and age above 70 were found to correlate and predict disease-specific mortality. CONCLUSIONS MEO carries a grave prognosis. The presence of two or more of the following features, DM, facial nerve palsy, positive CT scan and age above 70, predicts poor outcome, and highlights the need for prolonged, vigorous treatment.


title: Guillain-Barré Syndrome as a Neurological Complication of Novel COVID-19 Infection: A Case Report and Review of the Literature.

text: INTRODUCTION The novel coronavirus (COVID-19) is a global pandemic. Although the main clinical manifestation of COVID-19 is respiratory involvement, there is evidence suggesting the neuroinvasive potential of COVID-19. There are limited reports of neurological complications of COVID-19 infection in the literature. Herein, we aim to describe 2 members of a family affected by COVID-19, presenting with ascending paresthesia with the final diagnosis of Guillain-Barré syndrome. CASE REPORT A 38-year-old man presented with a history of ascending paresthesia and bilateral facial droop since 5 days before admission. The medical history was positive for flu-like symptoms affecting all the members of his family. The neurological examination was notable for bilateral peripheral facial paralysis, generalized areflexia, and derceased sensation in distal limbs. The cerebrospinal fluid analysis revealed an albuminocytologic dissociation. In addition, the electromyography-nerve conduction study findings were suggestive of acute axonal-demyelinating polyneuropathy. Meanwhile the patient was treated with a diagnosis of Guillain-Barré syndrome, his 14-year-old daughter presented with a history of progressive paresthesia and weakness. Similar to her father, the paraclinical evaluations were consistent with Guillain-Barré syndrome. Taking into account clinical findings and the outbreak of COVID-19, the suspicion of COVID-19 was proposed. Eventually, on the basis of throat swab samples stand on polymerase chain reaction, the patients were diagnosed with COVID-19. CONCLUSION Our cases revealed the familial occurrence of Guillain-Barré syndrome after COVID-19 infection. The authors emphasize neurological complications of COVID-19.


title: [Impact of the COVID-19 pandemic on admissions for acute coronary syndrome: review of the literature and single-center experience].

text: During the early phase of the lockdown following the COVID-19 pandemic, an alarm on the impact on cardiology admissions for cardiac causes, particularly in the field of acute coronary syndromes (ACS), has emerged. In order to evaluate this trend, we analyzed the literature data published since the beginning of the COVID-19 pandemic to date, in addition to our intensive cardiac care unit (ICCU) experience. This analysis showed (i) a reduction of the overall ICCU admissions up to 50%; (ii) a 40-50% reduction of ACS admissions, greater for non-ST-elevation myocardial infarction (NSTEMI) than for ST-elevation myocardial infarction (STEMI); (iii) a reduction greater than 50% of coronary angiography and percutaneous coronary angioplasty; (iv) a higher time delay of STEMI; and (v) a higher number of ICCU admissions for non-primarily cardiac problems. In conclusion, the lockdown imposed due to the spread of COVID-19 infection has led to a change in the number and type of cardiology admissions. It seems therefore necessary that patients, especially for time-dependent diseases such as ACS, continue to refer to hospital care; that contemporary standard of care for acute cardiac disease should be guaranteed, and that intensivist cardiologists acquire specific skills for the treatment of patients with clinical conditions normally treated by other specialists.


title: Preparedness for Coronavirus Disease in Hospitals of Nepal: A Nationwide Survey.

text: INTRODUCTION Coronavirus disease pandemic has affected large number of people globally and has continued to spread. Preparedness of individual nations and the hospitals is important to effectively deal with the surge of cases. We aimed to obtain nation wide data from Nepal, about hospital preparedness for COVID-19. METHODS Online questionnaire was prepared in accordance with the Center for Disease Control recommendations to assess preparedness of hospitals for COVID-19. The questionnaire was circulated to the over 800 doctors across the nation, who are the life members of six medical societies. RESULTS We obtained 131 completed responses from all seven provinces. Majority of respondents had anaesthesiology as the primary specialty. Only 52 (39.7%) participants mentioned that their hospital had policy to receive suspected or proven cases with COVID-19. Presence of isolation ward was mentioned by 83 (63.4%) respondents, with only 9 (6.9%)mentioning the presence of airborne isolation. Supply of personal protective equipment (PPE) was inadequate as per 124 (94.7%) respondents. Critical care services for COVID-19 patients were possible only in hospitals of 42 (32.1%)respondents. RT-polymerase chain reaction could be performed only in the hospital of 6 (4.6%) respondents. CONCLUSIONS It is apparent that most of the hospitals are not well prepared for management of patients with COVID-19. Resource allocation and policy making should be aimed to enhance national preparedness for the pandemic.


title: The Experience of people with rheumatoid arthritis living with fatigue: a qualitative metasynthesis.

text: OBJECTIVES To identify, appraise and synthesise qualitative studies on the experience of living with rheumatoid arthritis (RA)-related fatigue. METHODS We conducted a qualitative metasynthesis encompassing a systematic literature search in February 2017, for studies published in the past 15 years, in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, SveMed, PsychINFO and Web of Science. To be included, the studies had to report the experience of living with fatigue among adults with RA. The analysis and synthesis followed Malterud's systematic text condensation. RESULTS Eight qualitative articles were included, based on 212 people with RA (69% women) and aged between 20 and 83 years old. The synthesis resulted in the overall theme 'A vicious circle of an unpredictable symptom'. In addition, the synthesis derived four subthemes: 'being alone with fatigue'; 'time as a challenge'; 'language as a tool for increased understanding' and 'strategies to manage fatigue'. Fatigue affects all areas of everyday life for people with RA. They strive to plan and prioritise, pace, relax and rest. Furthermore, they try to make use of a variety of words and metaphors to explain to other people that they experience that RA-related fatigue is different from normal tiredness. Despite this, people with RA-related fatigue experience feeling alone with their symptom and they develop their own strategies to manage fatigue in their everyday life. CONCLUSIONS The unpredictability of RA-related fatigue is dominant, pervasive and is experienced as a vicious circle, which can be described in relation to its physical, cognitive, emotional and social impact. It is important for health professionals to acknowledge and address the impact of fatigue on the patients' everyday lives. Support from health professionals to manage fatigue and develop strategies to increase physical activity and maintain work is important for people with RA-related fatigue.


title: Ifit2 deficiency results in uncontrolled neurotropic coronavirus replication and enhanced encephalitis via impaired alpha/beta interferon induction in macrophages.

text: Type I interferons (IFN-α/β) limit viral dissemination prior to the emergence of adaptive immune responses through the concerted action of interferon-stimulated genes (ISGs). Although IFN-α/β induction by coronaviruses is modest, it effectively limits viral spread within the central nervous system (CNS) and protects against mortality. The protective roles of specific ISGs against the mouse hepatitis virus (MHV) members of the coronaviruses are largely unknown. This study demonstrates a protective role of the ISG Ifit2 in encephalitis induced by the dual hepato- and neurotropic MHV-A59. Contrasting the mild encephalitis and 100% survival of MHV-A59-infected wild-type (wt) mice, nearly 60% of infected Ifit2(-/-) mice exhibited severe encephalitis and succumbed between 6 and 8 days postinfection. Increased clinical disease in Ifit2(-/-) mice coincided with higher viral loads and enhanced viral spread throughout the CNS parenchyma. Ifit2(-/-) mice also expressed significantly reduced IFN-α/β and downstream ISG mRNAs Ifit1, Isg15, and Pkr, while expression of proinflammatory cytokines and chemokines was only modestly affected in the CNS. Impaired IFN-α/β induction in the absence of Ifit2 was confirmed by ex vivo mRNA analysis of microglia and macrophages, the prominent cell types producing IFN-α/β following MHV CNS infection. Furthermore, both IFN-α/β mRNA and protein production were significantly reduced in MHV-infected Ifit2(-/-) relative to wt bone marrow-derived macrophages. Collectively, the data implicate Ifit2 as a positive regulator of IFN-α/β expression, rather than direct antiviral mediator, during MHV-induced encephalitis.


title: DuraSeal as a spacer to reduce rectal doses in low-dose rate brachytherapy for prostate cancer.

text: The purpose of this study was to evaluate the utility of off-label use of DuraSeal polyethylene glycol (PEG) gel in low-dose rate (LDR) prostate brachytherapy seed implantation to reduce rectal doses. Diluted DuraSeal was easy to use and, in spite of a clearance effect, useful in decreasing D₂cc rectal doses.


title: What role do viruses play in nosocomial pneumonia?

text: PURPOSE OF THE REVIEW Viruses are an increasingly recognized cause of community-acquired pneumonia (CAP), but their exact role in nosocomial pneumonia is still debated. This review focuses on the role of viruses as a cause of nosocomial pneumonia. RECENT FINDINGS Respiratory viruses may be responsible for healthcare-associated pneumonia, because affected patients and those with CAP have the same risk factors for viral disease. In mechanically ventilated patients, viruses belonging to the Herpesviridae family, namely herpes simplex virus (HSV) and cytomegalovirus, can be reactivated and cause bronchopneumonitis or ventilator-associated pneumonia, respectively. Recent results confirmed the high rate of HSV reactivation in the distal airways of mechanically ventilated patients, and that patients with high virus loads (>10(5) copies/ml of bronchoalveolar lavage fluid) have poorer outcomes than those with low or no virus load. However, the responsibility of mimivirus, initially described as a possible cause of pneumonia, was not confirmed for nosocomial pneumonia. SUMMARY Respiratory viruses are mainly responsible for CAP, but they may also cause healthcare-associated pneumonia. HSV bronchopneumonitis and cytomegalovirus pneumonia are not rare diseases, and patients with Herpesviridae lung infections have worse prognoses than those without. Whether or not those Herpesviridae infections are responsible for true morbidity or morbidity remains to be determined.


title: Successful treatment of refractory complete separation of an esophagojejunal anastomosis after laparoscopic total gastrectomy: a case report.

text: BACKGROUND Anastomotic leakage after total gastrectomy occurs despite improvements in surgical techniques and patient management. Although many cases of dehiscence can be managed non-operatively, major leakage requires a second surgery and can potentially lead to death. Therefore, accurate and immediate diagnosis and treatment are essential. CASE PRESENTATION In this report, we describe a 66-year-old Japanese man who was diagnosed with a complete separation of an esophagojejunal anastomosis after laparoscopic total gastrectomy with oral contrast radiography using Gastrografin®. The severe complication was successfully treated by re-anastomosis after two emergency drainage surgeries. After the second surgery, the esophageal end formed a fistula with the jejunum, but balloon dilation failed to open the fistula. Therefore, oral ingestion and conservative treatment were considered unsuitable, and we performed esophagojejunal re-anastomosis 7 months after the first surgery. At a follow-up examination 2 years after re-anastomosis, the patient weighed 47 kg, and his ingestion had recovered to 80% of that before surgery. CONCLUSIONS Complete separation of an esophagojejunal anastomosis is a rare but severe complication of total gastrectomy. Therefore, we consider that once separation is diagnosed, aggressive and urgent re-operation and effective drainage are useful. Moreover, it is necessary to take great care to minimize the operative morbidity associated with esophagojejunal anastomosis.


title: Preliminary surgical results of single-incision transumbilical laparoscopic bariatric surgery.

text: BACKGROUND Recently, single-incision laparoscopic surgery (SILS) has been used for bariatric procedures, and this surgery is considered a type of minimally invasive surgery. When SILS is performed via the transumbilical route, the resultant abdominal wound is hidden and the cosmetic outcome is better. However, because of the small angle of manipulation and difficulty in liver traction, this technique is not used to perform complex bariatric surgery. In this prospective study, we used our novel technique, which involves the use of a liver-suspension tape and umbilicoplasty of an omega-shaped incision (omega umbilicoplasty), to perform laparoscopic bariatric surgery via the single-incision transumbilical (SITU) approach. We then assessed the safety and effectiveness of our surgical technique. METHODS We started performing and developing this technique from December 2008. Until July 2009, 40 consecutive patients underwent 40 bariatric procedures: two adjustable gastric band placements, six sleeve gastrectomies, and 32 Roux-en-Y gastric bypass operations, including five cases where concomitant cholecystectomy was performed. RESULTS The mean operation time was 93.4 min and the mean duration of postoperative hospitalization was 1.15 days. No perioperative or postoperative complications or deaths occurred. Most patients were very satisfied with the cosmetic outcomes. CONCLUSION Our technique can be safely and effectively used for SITU laparoscopic bariatric surgery. This technique will soon be used for advanced abdominal surgeries besides bariatric ones.


title: Discovery of a novel nidovirus in cattle with respiratory disease.

text: The family Coronaviridae represents a diverse group of vertebrate RNA viruses, all with genomes greater than 26,000 nt. Here, we report the discovery and genetic characterization of a novel virus present in cattle with respiratory disease. Phylogenetic characterization of this virus revealed that it clusters within the subfamily Torovirinae, in the family Coronaviridae. The complete genome consists of only 20,261 nt and represents the smallest reported coronavirus genome. We identified seven ORFs, including the canonical nidovirus ORF1a and ORF1b. Analysis of polyprotein 1ab revealed that this virus, tentatively named bovine nidovirus (BoNV), shares the highest homology with the recently described python-borne nidoviruses and contains several conserved nidovirus motifs, but does not encode the NendoU or O-MT domains that are present in other viruses within the family Coronaviridae. In concert with its reduced genome, the atypical domain architecture indicates that this virus represents a unique lineage within the order Nidovirales.


The use of FRED® to reduce intraoperative spectacle fogging.