title: [Minilaparoscopy with 5 mm optics and 3 mm trocars].

text: Minilaparoscopy was introduced already 20 years ago. In spite of reduced diameter, technical performance of modern trocars and instruments has improved substantially. While carrying out a minilaparoscopic procedure, the required position of the trocars and the surgical strategy remain the same. The most important step towards minilaparoscopy is reduction of the diameter of the laparoscopes from 10 to 5 mm. The 5 mm laparoscopes show high resolution and transport enough energy to properly illuminate the surgical field. Minilaparoscopic procedures help to improve cosmetic results and reduce postoperative pain, but postoperative complication rates are not affected. Use of one 5 mm trocar causes higher tissue tension than two 3 mm trocars and an additionally placed 3 mm trocar will not increase the complication rate. Therefore, a reduced risk of trocar hernia formation may be expected when a minilaparoscopic approach is used. Efficiency has been proven for minilaparoscopic cholecystectomy, appendectomy, and hernioplasty (TAPP/TEP) whereas overall available evidence across the literature remains poor. Further miniaturization is linked directly to video editing: physical limitations in classic optic systems have already been reached; therefore, reduction of optical chip systems could be a possible alternative.


title: Syncytia Induction by Clinical Isolates of Human Respiratory Syncytial Virus A.

text: OBJECTIVE Syncytia formation is the hallmark of the cytopathic effect caused by human respiratory syncytial virus (HRSV), which is the most important viral respiratory pathogen in children. This article reports methodological improvements in primary HRSV isolation and the importance of syncytia formation and mRNA levels of F protein for the progeny yield, using clinical isolates of HRSV. METHODS The A and B strains of HRSV were isolated in HEp-2 cell cultures from fresh and frozen nasopharyngeal aspirates. The formation of syncytia was evaluated using 2 different assays. Levels of F protein mRNA were quantified by real-time PCR while HRSV progeny titration was done by plaque assay. RESULTS HRSV was primarily isolated from 238 of 312 (90.7%) samples, and 13 of these (12 HRSV-A and 1 HRSV-B) were continuously passaged in vitro. The quantity and size of syncytia formed by 6 pure HRSV-A clinical isolates were different, as were the levels of F protein mRNA. CONCLUSION There is a direct correlation of quantities of syncytia and inoculum size, but not with mRNA levels of HRSV-A F protein. Importantly, levels of F protein mRNA were directly related to progeny production.


title: Association Between CT Angiogram Collaterals and CT Perfusion in the Interventional Management of Stroke III Trial.

text: BACKGROUND AND PURPOSE Collateral flow can determine ischemic core and tissue at risk. Using the Interventional Management of Stroke (IMS) III trial data, we explored the relationship between computed tomography angiogram (CTA) collateral status and CT perfusion (CTP) parameters. METHODS Baseline CTA collaterals were trichotomized as good, intermediate, and poor, and CTP studies were analyzed to quantify ischemic core, tissue at risk, and mismatch ratios. Kruskal-Wallis and Spearman tests were used to measure the strength of association and correlation between CTA collaterals and CTP parameters. RESULTS A total of 95 patients had diagnostic CTP studies in the IMS III trial. Of these, 53 patients had M1/M2 middle cerebral artery±intracranial internal carotid artery occlusion, where baseline CTA collateral grading was performed. CTA collaterals were associated with smaller CTP measured ischemic core volume (P=0.0078) and higher mismatch (P=0.0004). There was moderate negative correlation between collaterals and core (rs=-0.45; 95% confidence interval, -0.64 to -0.20) and moderate positive correlation between collaterals and mismatch (rs=0.53; 95% confidence interval, 0.29-0.71). CONCLUSION Better collaterals were associated with smaller ischemic core and higher mismatch in the IMS III trial. Collateral assessment and perfusion imaging identify the same biological construct about ischemic tissue sustenance.


title: Conventional versus virtual radiographs of the injured pelvis and acetabulum.

text: BACKGROUND Evaluation of the fractured pelvis or acetabulum requires both standard radiographic evaluation as well as computed tomography (CT) imaging. The standard anterior-posterior (AP), Judet, and inlet and outlet views can now be simulated using data acquired during CT, decreasing patient discomfort, radiation exposure, and cost to the healthcare system. The purpose of this study is to compare the image quality of conventional radiographic views of the traumatized pelvis to virtual radiographs created from pelvic CT scans. METHODS Five patients with acetabular fractures and ten patients with pelvic ring injuries were identified using the orthopedic trauma database at our institution. These fractures were evaluated with both conventional radiographs as well as virtual radiographs generated from a CT scan. A web-based survey was created to query overall image quality and visibility of relevant anatomic structures. This survey was then administered to members of the Orthopaedic Trauma Association (OTA). RESULTS Ninety-seven surgeons completed the acetabular fracture survey and 87 completed the pelvic fracture survey. Overall image quality was judged to be statistically superior for the virtual as compared to conventional images for acetabular fractures (3.15 vs. 2.98, p = 0.02), as well as pelvic ring injuries (2.21 vs. 1.45, p = 0.0001). Visibility ratings for each anatomic landmark were statistically superior with virtual images as well. DISCUSSION Virtual radiographs of pelvic and acetabular fractures offer superior image quality, improved comfort, decreased radiation exposure, and a more cost-effective alternative to conventional radiographs.


COVID-19 in Children: Initial Characterization of the Pediatric Disease.


title: Therapeutic targets and computational approaches on drug development for COVID-19.

text: World Health Organization declared coronavirus disease (COVID-19) caused by SARS coronavirus-2 (SARSCoV-2) as pandemic. Its outbreak started in China in Dec 2019 and rapidly spread across all over the world. SARS-CoV-2 infected more than 800,000 people and caused about 35,000 deaths so far and no approved drugs are available to treat COVID-19. Several investigations have been carried out to identify potent drugs to COVID-19 based on drug repurposing, potential novel compounds from ligand libraries, natural products, short peptides, and RNAseq analysis. This review is focused on three different aspects such as (i) targets for drug design (ii) computational methods to identify lead compounds and (iii) drugs for COVID-19. It also covers the latest literature on various hit molecules proposed by computational methods and experimental techniques.


title: How reliable is the "scratch test" versus the Weber test after tympanomastoid surgery?

text: OBJECTIVES To identify whether the scratch test can be used as an alternative to the Weber's test after tympanomastoid surgery. METHODS This twin-center prospective study assessed major tympanomastoid surgery patients over a 6-month period. Patients were assessed postoperatively on Day 0 or Day 1 of surgery using a standardized proforma. A Weber's test was performed using a 512-Hz tuning fork, placed midline on the forehead to assess the direction of sound localization. This was directly compared with a scratch test, by asking the patient the following while scratching the head bandage in the midline: "Can you hear this? And which side is loudest?" RESULTS Fifty-six patients were assessed in total. Sixteen mastoid explorations, 14 tympanoplasties, 18 combined approach tympanoplasties, and 8 other procedures were included, all of which had standard external auditory canal packing and head bandage. Assessment with Weber's test found 41 patients to have sound lateralizing to the operated ear. In comparison, 50 patients lateralized sound to the operated ear with the scratch test. Overall, Weber's test had a sensitivity of 73.2% and specificity of 100% compared with a sensitivity of 89.3% and specificity of 100% for the "Scratch Test." No patients had a dead ear after surgery. CONCLUSION The scratch test proved to be more accurate than traditional postoperative tuning fork assessment and provides a quick, accurate, and simple solution for when such equipment is unavailable.


title: The Use of Flow Diverting Stents to Treat Para-Ophthalmic Aneurysms.

text: BACKGROUND AND PURPOSE Few publications have dealt exclusively with the use of flow diverter stents for the treatment of para-ophthalmic aneurysms. We sought to determine the efficacy of flow diverting stents (FDSs) to treat aneurysms in this specific location. METHODS We retrospectively reviewed our database of prospectively collected information for all patients treated with flow diversion for an unruptured saccular para-ophthalmic aneurysm between September 2009 and January 2016. The aneurysm fundus size, neck size, number and type of FDS, complications, and follow-up data were recorded. RESULTS We identified 74 patients that matched our inclusion criteria. Of these patients, 18 patients were male (24.3%). The average fundus size was 4.8 mm, 11 aneurysms had previous coil occlusions and 63 were treated solely with flow diversion. At an initial angiographic follow-up (mean avg. 3.2 months), 71.8% of the aneurysms were occluded, and at the last follow-up (mean avg. 31.8 months), 88.9% of aneurysms were occluded. One patient suffered permanent morbidity (1.36%) secondary to interruption of the antiplatelet medication and another died (1.36%) secondary to in-stent thrombosis that was also due to an interruption in the antiplatelet medication. CONCLUSION Treatment of saccular para-ophthalmic aneurysms with FDS is feasible and carries a high degree of technical success with low complication rates and excellent rates of aneurysm exclusion.


Securing the Safety Net and Protecting Public Health During a Pandemic: Medicaid's Response to COVID-19.


title: Kras mutation is a marker of worse oncologic outcomes after percutaneous radiofrequency ablation of colorectal liver metastases.

text: BACKGROUND Kras mutation has been associated with shorter overall survival and time to disease recurrence after resection of colorectal liver metastases (CLM). This study evaluated the prognostic value of Kras mutation in patients with CLM treated by percutaneous radiofrequency ablation (RFA). METHODS This is an IRB waived retrospective analysis of the impact of KRAS mutation status on oncologic outcomes after CLM RFA. The endpoints were overall survival (OS), local tumor progression (LTP) rates, and incidence of new liver, lung, and peritoneal metastases. Survival times were calculated using Kaplan-Meier methodology from the time of RFA. RESULTS The study enrolled 97 patients. Kras exon 2 mutation was detected in 39% (38/97) of patients. On univariate analysis, Kras mutation (P=0.016) (HR: 1.8; 95% CI: 1.1 - 2.9) was a significant predictor of OS and retained significance on multivariate analysis. Kras mutation was a significant predictor of new liver metastases (P=0.037) (SHR: 2.0; CI: 1.0-3.7) and peritoneal metastases (P=0.015) (sHR: 3.0; 95% CI: 1.2-7.2) on multivariate analysis. Kras mutation was a significant predictor of LTP after RFA of CLM ablated with margins of 1-5 mm (P=0.018) (SHR: 3.0; 95% CI: 1.2-7.7) with an LTP rate of 80% (12/15) versus 41% (11/27) for wild type. CONCLUSION Kras mutation is a significant predictor of overall survival, new liver, and peritoneal metastases after RFA of CLM. A minimal radiographic ablation margin ≥ 6 mm is essential for local tumor control especially for mutant CLM.


title: Stability of Weakly Acidic Hypochlorous Acid Solution with Microbicidal Activity.

text: Hypochlorous acid (HOCl) solution (200 ppm, pH 6) was prepared and evaluated for their stabilities and microbicidal activities. We demonstrated that HOCl is unstable against ultraviolet (UV) light, sunshine, contact with air, and elevated temperature (≧25℃). Furthermore, in the HOCl solution, the presence of excess NH2- or CHO-containing organic compounds such as proteins and carbohydrates, or of inorganic ions such as NO2-, SO3-, PO3-, Fe2+, Cu2+, and CuS, resulted in the rapid consumption of HOCl by oxidation reactions, and significantly decreased the microbicidal activity of the HOCl solution against coliform bacteria and total viable cell count. Thus, production of stable HOCl solution requires formulation in pure water harboring concentrations as low as possible of various compounds and ions, as well as storage in dark and cool conditions (<10℃) to maintain the concentration of HOCl molecules and microbicidal activity.


title: The relationship between applied energy and ablation zone volume in patients with hepatocellular carcinoma and colorectal liver metastasis.

text: OBJECTIVES To study the ratio of ablation zone volume to applied energy in computed tomography (CT)-guided radiofrequency ablation (RFA) and microwave ablation (MWA) in patients with hepatocellular carcinoma (HCC) in a cirrhotic liver and in patients with colorectal liver metastasis (CRLM). METHODS In total, 90 liver tumors, 45 HCCs in a cirrhotic liver and 45 CRLMs were treated with RFA or with one of two MWA devices (MWA_A and MWA_B), resulting in 15 procedures for each tumor type, per device. Device settings were recorded and the applied energy was calculated. Ablation volumes were segmented on the contrast-enhanced CT scans obtained 1 week after the procedure. The ratio of ablation zone volume in milliliters to applied energy in kilojoules was determined for each procedure and compared between HCC (RHCC) and CRLM (RCRLM), stratified according to ablation device. RESULTS With RFA, RHCC and RCRLM were 0.22 mL/kJ (0.14-0.45 mL/kJ) and 0.15 mL/kJ (0.14-0.22 mL/kJ; p = 0.110), respectively. With MWA_A, RHCC was 0.81 (0.61-1.07 mL/kJ) and RCRLM was 0.43 (0.35-0.61 mL/kJ; p = 0.001). With MWA_B, RHCC was 0.67 (0.41-0.85 mL/kJ) and RCRLM was 0.43 (0.35-0.61 mL/kJ; p = 0.040). CONCLUSIONS With RFA, there was no significant difference in energy deposition ratio between tumor types. With both MWA devices, the ratios were higher for HCCs. Tailoring microwave ablation device protocols to tumor type might prevent incomplete ablations. KEY POINTS • HCCs and CRLMs respond differently to microwave ablation • For MWA, CRLMs required more energy to achieve a similar ablation volume • Tailoring ablation protocols to tumor type might prevent incomplete ablations.


title: Antimicrobial constituents from the tubers of Bletilla ochracea.

text: A new 2-(2-methylpropyl)butanedioic acid derivative, bletillin A ( 1), and a new bibenzyl, bletillin B ( 2), together with seventeen known compounds ( 3- 19), were isolated from the tubers of Bletilla ochracea Schltr. Their structures were established by detailed spectroscopic analyses. Phenanthrenes ( 12- 14) exhibited antibacterial activities against gram-positive bacteria Staphylococcus aureus, S. epidermidis, and Bacillus subtilis, with MIC values of 12.5-25 µg/mL.


title: Response to "The COVID-19 outbreak in Italy: initial implications for organ transplantation programs".

text: I read the article on the overall reduction of Solid Organ Transplantation (SOT) activity in Italy, with growing concerns as also the National Regulatory Bodies (NRB) of Spain and the UK report substantial reduction of activity in their bulletins; currently, in the UK only five Kidney TxC are still operational. Importantly, another study reported in the US restricted SOT, with more than 70% of US Transplant Centres (TxC) having suspended Living Donor Kidney Transplantation (LDKT).


title: [Epidemiological analysis on a family cluster of COVID-19].

text: Objective: To understand the possible transmission route of a family cluster of COVID-19 in Zhengzhou and the potential infectivity of COVID-19 in incubation period, and provide scientific evidence for the timely control of infectious source and curb the spread of the epidemic. Methods: Epidemiological investigation was conducted for a family cluster of COVID-19 (8 cases) with descriptive epidemiological method, and respiratory tract samples of the cases were collected for the nucleic acid detection of 2019-nCoV by RT-PCR. Results: Two primary cases, which occurred on 31 January and 1 February, 2020, respectively, had a common exposure history in Wuhan. The other six family members had onsets on 30 January, 31 January, 1 February (three cases) and 3 February, 2020. Conclusions: In this family cluster of COVID-19, six family members were infected through common family exposure to the 2 primary cases. Five secondary cases had onsets earlier than or on the same day as the primary cases, indicating that COVID-19 is contagious in incubation period, and the home isolation in the early phase of the epidemic might lead to the risk of family cluster of COVID-19.


title: Imparting commercial antimicrobial dressings with low-adherence to burn wounds.

text: The objective of our study was to decrease the wound adherence of commercial silver based wound dressings by depositing a non-adherent layer. Our hypothesis was that this non-adherent layer will lower the dressing's adherence to burn wounds without compromising the antimicrobial activity or increasing the cytotoxicity. A polyacrylamide (PAM) hydrogel layer was grafted on two commercial silver antimicrobial dressings (silver nanocrystal dressing (NC) and silver plated dressing (SP)) using a proprietary technique. The grafted PAM served as the non-adherent layer. Dressing adherence was measured with a previously published in vitro gelatin model using an Instron mechanical force testing instrument. The dressings were challenged with two clinically retrieved bacterial strains (Methicillin-resistant Staphylococcus aureus (MRSA) and multidrug resistant (MDR) Pseudomonas aeruginosa) with both a disk diffusion test, and a suspension antibacterial test. The cytotoxicity of samples to human neonatal fibroblast cells was evaluated with 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyltetrazolium bromide (MTT) assay. Both untreated dressings showed high peeling energy: 2070±453J/m(2) (NC) and 669±68J/m(2) (SP), that decreased to 158±119J/m(2) (NC) and 155±138J/m(2) (SP) with the PAM deposition. Addition of the PAM caused no significant difference in zone of inhibition (ZOI) (disk diffusion test) or antibacterial kinetics (suspension test) against both bacteria (p>0.05, n=6) in either dressing. Survival of fibroblasts was improved by the PAM grafting from 48±5% to 60±3% viable cells in the case of NC and from 55±8% to 61±4% viable cells in SP (p<0.05, n=12). It was concluded that PAM as a non-adherent layer significantly decreases the adherence of these two commercial antimicrobial dressings in an in vitro gelatin model while preserving their antimicrobial efficacy, and reducing their cytotoxicity.


Reinventing Behavioral Health During the COVID-19 Pandemic.


title: Comparison of vesicular stomatitis virus pseudotyped with the S proteins from a porcine and a human coronavirus.

text: The surface proteins S of severe acute respiratory syndrome coronavirus (SARS-CoV) and transmissible gastroenteritis virus (TGEV) were compared for their ability to mediate infection of viral pseudotypes based on vesicular stomatitis virus (VSV). The cell tropism of the respective pseudotypes corresponded to the tropism of the viruses from which the S protein was derived. Higher infectivity values were obtained with the SARS-CoV S protein than with the TGEV S protein. Differences were observed with respect to the importance of the cytoplasmic tail and the membrane anchor of the S proteins. In the case of the SARS-CoV S protein, truncation of the cytoplasmic tail resulted in increased infectivity. For the TGEV S protein, the inactivation of an intracellular retention signal in the cytoplasmic tail was required. Exchange of the membrane anchor of the S proteins led to a low infection efficiency. Our results indicate that related glycoproteins may show substantial differences in their ability to mediate pseudotype infection.


title: Discordant memory B cell and circulating anti-Env antibody responses in HIV-1 infection.

text: Long-lived memory B cells (B(Mem)) provide an archive of historic Ab responses. By contrast, circulating Abs typically decline once the immunogen is cleared. Consequently, circulating Abs can underestimate the nature of cognate humoral immunity. On the other hand, the B(Mem) pool should provide a comprehensive picture of Ab specificities that arise over the entire course of infection. To test this hypothesis, we compared circulating Ab and B(Mem) from natural virus suppressors who control HIV-1 without therapy and maintain a relatively intact immune system. We found high frequencies of B(Mem) specific for the conserved neutralizing CD4 induced or CD4 binding site epitopes of gp120, whereas low Ab titers to these determinants were detected in contemporaneous plasma. These data suggest that plasma Ab repertoires can underestimate the breadth of humoral immunity, and analyses of B(Mem) should be included in studies correlating Ab specificity with protective immunity to HIV-1.


title: The effect of Houttuynia cordata injection on pseudorabies herpesvirus (PrV) infection in vitro.

text: CONTEXT Pseudorabies herpesvirus (PrV) belongs to the Alphaherpesvirinae. Piglets infected with PrV die within a few days. Development of effective antiviral agents is one alternative or complementary method to prevent PrV infection. Houttuynia cordata Thunb. (Saururaceae), H. cordata, a traditional Chinese medicine, is often used to relieve lung abnormal symptoms, infectious disease, refractory hemoptysis and malignant pleural effusion in China. OBJECTIVE The present study aimed to investigate the effect of H. cordata injection on cell infection by PrV using Vero cells (a monkey kidney cell line) and swine testis cells (ST) as models. MATERIALS AND METHODS The infectivity of PrV was determined by plaque assays when H. cordata was applied to the virus, to the virus infected cells, and to the cells prior to infection. The genomic DNA copies post-drug treatment were confirmed by PCR and reverse transcription PCR. The cell apoptosis caused by the virus was analyzed. RESULTS H. cordata efficiently inhibited cell infection after incubating the drug with PrV. Nevertheless, H. cordata was more efficient in Vero cells than in ST cells in terms of its inhibitory effect. Low-dosage drug inhibited cell apoptosis induced by PrV; nevertheless, high-dosage drug alone resulted in cell apoptosis. DISCUSSION AND CONCLUSION H. cordata has a direct inhibitory activity against PrV in vitro. H. cordata may be used as an anti-PrV agent or combined with other anti-PrV agents. PrV infection induces cell apoptosis and H. cordata inhibits cell infection. The optimal administration dosage of H. cordata should be taken into account in the future, because high-dosage H. cordata alone causes cell apoptosis.


Providing cancer surgery in the COVID-19 crisis.


title: Unidirectional barbed suture versus continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study.

text: STUDY OBJECTIVE To estimate the effectiveness of unidirectional knotless barbed suture and continuous suture with intracorporeal knots in the repair of uterine wall defects during laparoscopic myomectomy. DESIGN Randomized clinical study (Canadian Task Force Classification I). SETTING Single-center study in a university hospital. PATIENTS This study enrolled 44 women who underwent laparoscopic myomectomy. INTERVENTIONS In accord with to the randomization, the uterine wall defects were closed either with a continuous suture with intracorporeal knots (group V) or a unidirectional knotless barbed suture (group L). MEASUREMENTS AND MAIN RESULTS The time required to suture the uterine wall defect was significantly lower in group L (11.5 ± 4.1 minutes) than in group V (17.4 ± 3.8 minutes; p <.001). However, no significant difference was observed in the operative time between the 2 study groups. The intraoperative blood loss was significantly lower in group L than in group V (p =.004). The degree of surgical difficulty was significantly lower in group L (3.7 ± 1.1) than in group V (6.1 ± 2.1; p <.001). CONCLUSION The unidirectional knotless barbed suture may facilitate the suture of uterine wall defects during laparoscopic myomectomy. When compared with continuous suture and intracorporeal knots, the barbed suture reduces the time required to suture the uterine wall defect and the intraoperative blood loss.


title: A critical appraisal of chronic kidney disease mineral and bone disorders clinical practice guidelines using the AGREE II instrument.

text: BACKGROUND Patients with chronic kidney disease mineral and bone disorders (CKD-MBD) suffer high rates of morbidity and mortality, in particular related to bone and cardiovascular outcomes. The management of CKD-MBD remains challenging. The objective of this systematic survey is to critically appraise clinical practice guidelines (CPGs) addressing CKD-MBD. METHODS/DESIGN Data sources included MEDLINE, EMBASE, the National Guideline Clearinghouse, Guideline International Network and Turning Research into Practice up to May 2016. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility and subsequently appraised the guidelines using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE). RESULTS Sixteen CPGs published from 2003 to 2015 addressing the diagnosis and management of CKD-MBD in adult patients (11 English, two Spanish, one Italian, one Portuguese and one Slovak) proved eligible. The National Institute for Health and Care Excellence guideline performed best with respect to AGREE II criteria; only three other CPGs warranted high scores on all domains. All other guidelines received scores of under 60% on one or more domains. Major discrepancies in recommendations were not, however, present, and we found no association between quality of CPGs which was not associated with resulting recommendations. CONCLUSIONS Most guidelines assessing CKD-MBD suffer from serious shortcomings using AGREE criteria although limitations with respect to AGREE criteria do not necessarily lead to inappropriate recommendations.


title: Serosurvey for Selected Viral Pathogens among Sympatric Species of the African Large Predator Guild in Northern Botswana.

text: The recent increase in the creation of transboundary protected areas and wildlife corridors between them lends importance to information on pathogen prevalence and transmission among wildlife species that will become connected. One such initiative is the Kavango Zambezi Transfrontier Conservation Area of which Botswana's Okavango Delta constitutes a major contribution for wildlife and ecosystems. Between 2008 and 2011, we collected serum samples from 14 lions ( Panthera leo ), four leopards ( Panthera pardus ), 19 spotted hyenas ( Crocuta crocuta ), and six cheetahs ( Acinonyx jubatus ) in the Okavango. Samples were tested for antibodies against canine distemper virus (CDV), feline panleukopenia virus, enteric coronavirus, feline calicivirus, feline herpesvirus (FHV-1), and feline immunodeficiency virus (FIV). Evidence of exposure to all of these pathogens was found, to varying degrees, in at least one of the species sampled. High antibody prevalence (>90%) was only found to FHV-1 and FIV in lions. Only hyenas (26%, 5/19) were positive for CDV antibody. Except for one case, all individuals displayed physical conditions consistent with normal health for ≥12 mo following sampling. Our results emphasize the need for a comprehensive, multispecies approach to disease monitoring and the development of coordinated management strategies for subpopulations likely to be connected in transboundary initiatives.


title: The PrEP Care Continuum Among Cisgender Women Who Sell Sex and/or Use Drugs Globally: A Systematic Review.

text: HIV prevalence among cisgender female sex workers (FSW) and/or women who use drugs (WWUD) is substantially higher compared to similarly aged women. Consistent with PRISMA guidelines, we conducted the first systematic review on the pre-exposure prophylaxis (PrEP) continuum among FSW and/or WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting a PrEP related result among FSW and/or WWUD aged 18 + ; peer-reviewed; and published in English between 2012 and 2018. Our search identified 1365 studies; 26 met eligibility requirements, across the following groups: FSW (n = 14), WWUD (n = 9) and FSW-WWUD (n = 3). Studies report on at least one PrEP outcome: awareness (n = 12), acceptability (n = 16), uptake (n = 4), and adherence (n = 8). Specific barriers span individual and structural levels and include challenges to daily adherence, cost, and stigma. Combining health services and long-acting PrEP formulas may facilitate better PrEP uptake and adherence. The limited number of studies indicates a need for more research.


title: The role of the COVID-19 pandemic as a risk factor for suicide: What is its impact on the public mental health state today?

text: The phenomenon of suicide is a much studied but still little-known issue. In this particular period of health emergency, quarantine and mandatory restrictions could play a role in the genesis of fatal events or suicide attempts not only in people at risk. However, this issue has not yet been adequately addressed in the literature. The influence of the global pandemic could change the way suicide cases are analyzed; in the future, it is necessary to reconsider and analyze the various risk groups by population but above all to evaluate new methods of intervention for avoiding the increase in fatal events related to the current emergency whose duration is still unknown. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Laryngeal tube use in out-of-hospital cardiac arrest by paramedics in Norway.

text: BACKGROUND Although there are numerous supraglottic airway alternatives to endotracheal intubation, it remains unclear which airway technique is optimal for use in prehospital cardiac arrests. We evaluated the use of the laryngeal tube (LT) as an airway management tool among adult out-of-hospital cardiac arrest (OHCA) patients treated by our ambulance services in the Haukeland and Innlandet hospital districts. METHODS Post-resuscitation forms and data concerning airway management in 347 adult OHCA victims were retrospectively assessed with regard to LT insertion success rates, ease and speed of insertion and insertion-related problems. RESULTS A total of 402 insertions were performed on 347 OHCA patients. Overall, LT insertion was successful in 85.3% of the patients, with a 74.4% first-attempt success rate. In the minority of patients (n = 46, 13.3%), the LT insertion time exceeded 30 seconds. Insertion-related problems were recorded in 52.7% of the patients. Lack of respiratory sounds on auscultation (n = 100, 28.8%), problematic initial tube positioning (n = 85, 24.5%), air leakage (n = 61, 17.6%), vomitus/aspiration (n = 44, 12.7%), and tube dislocation (n = 17, 4.9%) were the most common problems reported. Insertion difficulty was graded and documented for 95.4% of the patients, with the majority of insertions assessed as being "Easy" (62.5%) or "Intermediate" (24.8%). Only 8.1% of the insertions were considered to be "Difficult". CONCLUSIONS We found a high number of insertion related problems, indicating that supraglottic airway devices offering promising results in manikin studies may be less reliable in real-life resuscitations. Still, we consider the laryngeal tube to be an important alternative for airway management in prehospital cardiac arrest victims.


title: Bone Healing Properties of Autoclaved Autogenous Bone Grafts Incorporating Recombinant Human Bone Morphogenetic Protein-2 and Comparison of Two Delivery Systems in a Segmental Rabbit Radius Defect.

text: PURPOSE This study aims to validate the effect of autoclaved autogenous bone (AAB), incorporating Escherichia coli-derived recombinant human bone morphogenetic protein-2 (ErhBMP-2), on critical-sized, segmental radius defects in rabbits. Delivery systems using absorbable collagen sponge (ACS) and fibrin glue (FG) were also evaluated. METHODS Radius defects were made in 12 New Zealand white rabbits. After autoclaving, the resected bone was reinserted and fixed. The animals were classified into three groups: only AAB reinserted (group 1, control), and AAB and ErhBMP-2 inserted using an ACS (group 2) or FG (group 3) as a carrier. Animals were sacrificed six or 12 weeks after surgery. Specimens were evaluated using radiology and histology. RESULTS Micro-computed tomography images showed the best bony union in group 2 at six and 12 weeks after operation. Quantitative analysis showed all indices except trabecular thickness were the highest in group 2 and the lowest in group 1 at twelve weeks. Histologic results showed the greatest bony union between AAB and radial bone at twelve weeks, indicating the highest degree of engraftment. CONCLUSION ErhBMP-2 increases bony healing when applied on AAB graft sites. In addition, the ACS was reconfirmed as a useful delivery system for ErhBMP-2.


title: Electrocardiography of the normal domestic pet rabbit.

text: To establish a well-tolerated technique for recording electrocardiograms (ECGs) and a reference range for the normal pet rabbit ECG, 46 healthy pet rabbits were studied. The following reference ranges were calculated. Heart rate was 198 to 330 bpm. P waves had a duration of 0.01 to 0.05 seconds and an amplitude of 0.04 to 0.12 mV. The P-R interval was 0.04 to 0.08 seconds and the duration of the QRS complex was 0.02 to 0.06 seconds. The amplitude of the R wave was 0.03 to 0.39 mV. The Q-T interval was 0.08 to 0.16 seconds. The amplitude of the T wave was 0.05 to 0.17 mV. Mean electrical axis was found to be -43° to +80°. Evidence of variation due to breed or bodyweight was not found to be significant, except for a quadratic relationship between R wave amplitude and bodyweight. The ECG recording technique used in this study for pet rabbits was well tolerated and shown to be both reliable and repeatable.


title: Rate of Intensive Care Unit admission and outcomes among patients with coronavirus: A systematic review and Meta-analysis.

text: BACKGROUND The rate of ICU admission among patients with coronavirus varied from 3% to 100% and the mortality was as high as 86% of admitted patients. The objective of the systematic review was to investigate the rate of ICU admission, mortality, morbidity, and complications among patients with coronavirus. METHODS A comprehensive strategy was conducted in PubMed/Medline; Science direct and LILACS from December 2002 to May 2020 without language restriction. The Heterogeneity among the included studies was checked with forest plot, χ2 test, I2 test, and the p-values. All observational studies reporting rate of ICU admission, the prevalence of mortality and its determinants among ICU admitted patients with coronavirus were included and the rest were excluded. RESULT A total of 646 articles were identified from different databases and 50 articles were selected for evaluation. Thirty-seven Articles with 24983 participants were included. The rate of ICU admission was 32% (95% CI: 26 to 38, 37 studies and 32, 741 participants). The Meta-Analysis revealed that the pooled prevalence of mortality in patients with coronavirus disease in ICU was 39% (95% CI: 34 to 43, 37 studies and 24, 983 participants). CONCLUSION The Meta-Analysis revealed that approximately one-third of patients admitted to ICU with severe Coronavirus disease and more than thirty percent of patients admitted to ICU with a severe form of COVID-19 for better care died which warns the health care stakeholders to give attention to intensive care patients. REGISTRATION This Systematic review and Meta-Analysis was registered in Prospero international prospective register of systemic reviews (CRD42020177095) on April 9/2020.


title: Genomic medicine: a decade of successes, challenges, and opportunities.

text: Genomic medicine--an aspirational term 10 years ago--is gaining momentum across the entire clinical continuum from risk assessment in healthy individuals to genome-guided treatment in patients with complex diseases. We review the latest achievements in genome research and their impact on medicine, primarily in the past decade. In most cases, genomic medicine tools remain in the realm of research, but some tools are crossing over into clinical application, where they have the potential to markedly alter the clinical care of patients. In this State of the Art Review, we highlight notable examples including the use of next-generation sequencing in cancer pharmacogenomics, in the diagnosis of rare disorders, and in the tracking of infectious disease outbreaks. We also discuss progress in dissecting the molecular basis of common diseases, the role of the host microbiome, the identification of drug response biomarkers, and the repurposing of drugs. The significant challenges of implementing genomic medicine are examined, along with the innovative solutions being sought. These challenges include the difficulty in establishing clinical validity and utility of tests, how to increase awareness and promote their uptake by clinicians, a changing regulatory and coverage landscape, the need for education, and addressing the ethical aspects of genomics for patients and society. Finally, we consider the future of genomics in medicine and offer a glimpse of the forces shaping genomic medicine, such as fundamental shifts in how we define disease, how medicine is delivered to patients, and how consumers are managing their own health and affecting change.


Administration of end-of-life drugs by family caregivers during covid-19: opportunity for future home prescribing plans.


title: Physical interventions to interrupt or reduce the spread of respiratory viruses.

text: Viral epidemics or pandemics of acute respiratory infections, like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccination may be insufficient to prevent their spread. Therefore, a Cochrane systematic review evaluated effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.


title: Outcome of sleeve gastrectomy as a primary bariatric procedure.

text: BACKGROUND Sleeve gastrectomy is being performed increasingly in Europe. Data on long-term outcome would be helpful in defining the role of sleeve gastrectomy. The aim of this study was to evaluate the outcome of sleeve gastrectomy as a primary bariatric procedure. METHODS Medical charts of all patients who underwent a primary sleeve gastrectomy at the authors' institution between August 2006 and December 2012 were reviewed retrospectively using a prospective online data registry. For evolution of weight loss and co-morbidity, only patients with follow-up of at least 1 year were included. A subgroup analysis was done to compare patients with an intended stand-alone procedure and those with an intended two-stage procedure. RESULTS A total of 1041 primary sleeve gastrectomies were performed in the study period. Median duration of surgery was 47 min, and median hospital stay was 2 days. Intra-abdominal bleeding occurred in 27 patients (2·6 per cent) and staple-line leakage in 24 (2.3 per cent). Some 866 patients had at least 1 year of follow-up. Mean excess weight loss was 68.4 per cent after 1 year (P < 0.001) and 67.4 per cent after 2 years. Smaller groups of patients achieved a mean excess weight loss of 69.3 per cent (163 patients), 70.5 per cent (62) and 58.3 per cent (19) after 3, 4 and 5 years respectively. No difference in postoperative complications was found between the subgroups. Seventy-one (8.2 per cent) of 866 patients had a revision of the sleeve gastrectomy; reflux or dysphagia was the indication in 34 (48 per cent) of these patients. CONCLUSION Sleeve gastrectomy is a safe and effective bariatric procedure. Maximum weight loss was achieved after 4 years. Long-term results regarding weight loss and co-morbidities were satisfactory.


title: BiSpectral Index (BIS) monitoring may detect critical hypotension before automated non-invasive blood pressure (NIBP) measurement during general anaesthesia; a case report.

text: A patient undergoing general anaesthesia for neurosurgery exhibited an unexpected sudden decrease in the BiSpectral Index (BIS) value to near-zero. This prompted the detection of profound hypotension using non-invasive blood pressure (NIBP) measurement and expedited urgent assessment and treatment, with the patient making a full recovery. Widely regarded as a 'depth of anaesthesia' monitor, this case demonstrates the potential extra clinical benefit BIS may have in the detection of critical incidents such as anaphylaxis during general anaesthesia.


title: Effect of cross-linked and non-cross-linked acellular dermal matrices on the expression of mediators involved in wound healing and matrix remodeling.

text: BACKGROUND Molecular mechanisms that direct the extent of the foreign body reaction to implanted biological meshes and their subsequent incorporation are poorly understood. The purpose of this study was to compare the influence of non-cross-linked human dermis (AlloDerm) with that of cross-linked porcine dermis (Permacol) on the expression of genes critical for wound healing and tissue remodeling in a rat ventral hernia model. METHODS Full-thickness abdominal wall defects were repaired with AlloDerm, Permacol, or suture repair with no mesh (n = 10 rats per group). Explants were harvested 90 days after repair and divided for histologic, immunohistochemical, and gene expression analyses. Real-time quantitative polymerase chain reaction arrays were used to profile the expression of 84 wound healing-associated genes at the tissue/mesh interface. RESULTS Both meshes induced the differential expression (≥ 3-fold change relative to suture repair, p ≤ 0.01) of extracellular matrix components, remodeling enzymes, and inflammatory cytokines. Genes most markedly up-regulated included matrix metalloproteinase-9 (Permacol, 66-fold; AlloDerm, 19-fold) and chemokine (C-C motif) ligand 12 (Permacol, 24-fold; AlloDerm, 71-fold). Immunohistochemistry using antibodies against matrix metalloproteinase-9 and chemokine (C-C motif) ligand 12 confirmed differential expression at the protein level (p < 0.001). Histologically, AlloDerm demonstrated overall better remodeling characteristics than Permacol. CONCLUSIONS Permacol elicits increased protease expression and reduced cellular and vascular infiltration compared with AlloDerm 90 days after implantation, indicative of delayed remodeling induced by cross-linking. Increased understanding of the host response to implanted materials ultimately will enable the development of improved meshes with enhanced wound healing properties and fewer graft-related complications.


title: Comparison of pediatric radiation dose and vessel visibility on angiographic systems using piglets as a surrogate: antiscatter grid removal vs. lower detector air kerma settings with a grid - a preclinical investigation.

text: The purpose of this study was to reduce pediatric doses while maintaining or improv-ing image quality scores without removing the grid from X-ray beam. This study was approved by the Institutional Animal Care and Use Committee. Three piglets (5, 14, and 20 kg) were imaged using six different selectable detector air kerma (Kair) per frame values (100%, 70%, 50%, 35%, 25%, 17.5%) with and without the grid. Number of distal branches visualized with diagnostic confidence relative to the injected vessel defined image quality score. Five pediatric interventional radiologists evaluated all images. Image quality score and piglet Kair were statistically compared using analysis of variance and receiver operating curve analysis to define the preferred dose setting and use of grid for a visibility of 2nd and 3rd order vessel branches. Grid removal reduced both dose to subject and imaging quality by 26%. Third order branches could only be visualized with the grid present; 100% detector Kair was required for smallest pig, while 70% detector Kair was adequate for the two larger pigs. Second order branches could be visualized with grid at 17.5% detector Kair for all three pig sizes. Without the grid, 50%, 35%, and 35% detector Kair were required for smallest to largest pig, respectively. Grid removal reduces both dose and image quality score. Image quality scores can be maintained with less dose to subject with the grid in the beam as opposed to removed. Smaller anatomy requires more dose to the detector to achieve the same image quality score.


title: Dynamic profile and clinical implications of hematological parameters in hospitalized patients with coronavirus disease 2019.

text: Objectives As people across the world suffer from coronavirus disease 2019 (COVID-19), further studies are needed to facilitate evaluating the severity and prognosis of COVID-19 patients. In the study, we aimed to dissect the dynamic profile and clinical implications of hematological findings in hospitalized patients with COVID-19. Methods We retrospectively analyzed the hematological findings of 72 patients with COVID-19 admitted from January 21 to February 17, 2020. The final date of follow-up was March 20, 2020. Dynamic profile of vital hematological parameters in severe and non-severe patients was presented at different time points (day 1, 5, 7, 9, 11, 13, 15 after admission), and the correlation of hematological parameters with hospitalization time was indicated. Results Of 72 patients with COVID-19, lymphopenia and leukopenia occurred in 39 (54.2%) and 20 (27.8%) patients with COVID-19, respectively. Fifteen (20.8%) patients were defined as severe cases and 57 (79.2%) were non-severe cases. Compared to non-severe patients, leukocyte count, neutrophil count and neutrophil-to-lymphocyte ratio (NLR) were significantly higher, whereas lymphocyte count was declined in severe patients at each time point. A growing trend in platelet count was found in non-severe patients over the follow-up period. In addition, a positive correlation of NLR with hospitalization time was detected from day 5 after admission. Conclusions Dynamic changes in vital hematological parameters from severe and non-severe patients had been characterized in the course of hospitalization. During hospitalization, NLR was found to have certain relevance to the hospitalization days and a role in forecasting disease prognosis for patients with COVID-19.


title: A role for Ifit2 in restricting West Nile virus infection in the brain.

text: Previous studies have demonstrated that type I interferon (IFN-I) restricts West Nile virus (WNV) replication and pathogenesis in peripheral and central nervous system (CNS) tissues. However, the in vivo role of specific antiviral genes that are induced by IFN-I against WNV infection remains less well characterized. Here, using Ifit2(-/-) mice, we defined the antiviral function of the interferon-stimulated gene (ISG) Ifit2 in limiting infection and disease in vivo by a virulent North American strain of WNV. Compared to congenic wild-type controls, Ifit2(-/-) mice showed enhanced WNV infection in a tissue-restricted manner, with preferential replication in the CNS of animals lacking Ifit2. Virological analysis of cultured macrophages, dendritic cells, fibroblasts, cerebellar granule cell neurons, and cortical neurons revealed cell type-specific antiviral functions of Ifit2 against WNV. In comparison, small effects of Ifit2 were observed on the induction or magnitude of innate or adaptive immune responses. Our results suggest that Ifit2 restricts WNV infection and pathogenesis in different tissues in a cell type-specific manner.


title: The dissection room experience: A factor in the choice of organ and whole body donation--a Nigerian survey.

text: The psychosocial impact of human dissection on the lives of medical and health science students has been noted. To assess the impact of the dissection room experience on one's willingness to become a whole body and organ donor, the attitudes of 1,350 students and professionals from the medical, health, and non-health related disciplines to body and organ donation were studied. The participants were broken into categories according to degree of exposure to human dissection. Participants who were never exposed to the dissection experience showed more willingness to donate their bodies than those who were exposed. With the exception of the physiotherapy department, the students and professionals from the health science departments who were exposed to the dissection room but never engaged in dissection showed the most unwillingness to donate their bodies (P < 0.001). An unwillingness to donate oneself was noted as one of the negative impacts associated with exposure to the dissection room. Willingness to donate an organ correlated positively with the level of exposure to the dissection room (P < 0.001). Most of the reasons for unwillingness were traceable to negative perceptions of the dissection room as a result of poor and disrespectful management of the human cadavers.


title: Low- versus Standard-Dose Intravenous Alteplase in the Context of Bridging Therapy for Acute Ischemic Stroke: A Korean ENCHANTED Study.

text: BACKGROUND AND PURPOSE Following the positive results from recent trials on endovascular therapy (EVT), bridging therapy (intravenous alteplase plus EVT) is increasingly being used for the treatment of acute ischemic stroke. However, the optimal dose of intravenous alteplase remains unknown in centers where bridging therapy is actively performed. The optimal dose for eventual recanalization and positive clinical outcomes in patients receiving bridging therapy also remains unknown. METHODS In this prospective Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) sub-study, we explored the outcomes following treatment with two different doses (low- [0.6 mg/kg] or standard-dose [0.9 mg/kg]) of intravenous alteplase across 12 Korean centers where EVT is actively performed. The primary endpoint was a favorable outcome at 90 days (modified Rankin Scale scores 0 to 1). Secondary endpoints included symptomatic intracerebral hemorrhage (ICH) in all patients, and the recanalization rate and favorable outcome in patients who underwent cerebral angiography for EVT (ClinicalTrials.gov, number NCT01422616). RESULTS Of 351 patients, the primary outcome occurred in 46% of patients in both the standard-(80/173) and low-dose (81/178) groups (odds ratio [OR], 1.14; 95% confidence interval [CI], 0.72 to 1.81; P=0.582), although ICHs tended to occur more frequently in the standard-dose group (8% vs. 3%, P=0.056). Of the 67 patients who underwent cerebral angiography, there was no significant difference in favorable functional outcome between the standard- and low-dose groups (39% vs. 21%; OR, 2.39; 95% CI, 0.73 to 7.78; P=0.149). CONCLUSIONS There was no difference in functional outcome between the patients receiving different doses of alteplase in centers actively performing bridging therapy.


title: Single site laparoscopy for fertility preservation: a cohort study.

text: STUDY OBJECTIVE To compare operative and postoperative results of ovarian cortex retrieval by conventional laparoscopy (1cm umbilical site and 3 accessory 5-mm-reusable working ports) (HASS) versus single site laparoscopy (SSL). DESIGN Prospective cohort study. SETTING Fertility Preservation Programme at La Fe University Hospital-University of Valencia, Valencia, Spain, 2011 to 2012. Fertility Preservation Programme at La Fe University Hospital of Valencia, Valencia, Spain. PATIENTS Twenty-one patients with cancer (breast cancer: n = 17; Hodgkin's lymphoma: n = 3; and non-Hodgkin's lymphoma: n = 1). INTERVENTION Ovarian cortex retrieval either by conventional laparoscopy using an umbilical Hasson port and 3 accessory ports (HASS group: n = 11) or by SSL (SSL group: n = 10). MEASUREMENTS AND MAIN RESULTS Operative length, blood loss, postoperative pain (visual analog scale for pain at 6, 24, and 48 hours), need of additional analgesia, quality of life (European Quality of Life-5 Dimensions), cosmesis of the scar, and patient's self-perception were assessed at 24 and 48 hours and 3 months after surgery. Baseline characteristics were similar between groups. Estimated blood loss, operative length, and postoperative pain did not differ between groups. The start of chemotherapy was not delayed in either group, and cosmesis and image self-perception were also similar. CONCLUSION The SSL approach can be considered a safe option compared with the classic multisite approach.


title: How Risk Communication via Facebook and Twitter Shapes Behavioral Intentions: The Case of Fine Dust Pollution in South Korea.

text: Despite the importance of social network sites (SNSs) in addressing emerging public health risks, there is still a relative lack of studies examining the effects of risk communication via SNSs on risk perceptions and preventive behaviors. Based on message expression‒ and reception‒effects paradigms, this study aims to explore how expressing and receiving risk information shape preventive behavioral intentions via risk perceptions. Given the differential nature and functionality of SNSs, the present investigation also examines whether expressing and receiving risk information via two different types of SNSs-Facebook and Twitter-have different effects on risk perceptions and behavioral intentions. Analyzing survey data from 1,152 South Korean adults in the context of fine dust hazards, this study found that expressing and receiving risk information not only affected risk perceptions but also directly or indirectly influenced preventive behavioral intentions. In addition, the effects of expressing and receiving risk information were differentiated between SNS platforms, specifically Facebook and Twitter.


title: Age-specific infectious period shapes dynamics of pneumonia in bighorn sheep.

text: Superspreading, the phenomenon where a small proportion of individuals contribute disproportionately to new infections, has profound effects on disease dynamics. Superspreading can arise through variation in contacts, infectiousness or infectious periods. The latter has received little attention, yet it drives the dynamics of many diseases of critical public health, livestock health and conservation concern. Here, we present rare evidence of variation in infectious periods underlying a superspreading phenomenon in a free-ranging wildlife system. We detected persistent infections of Mycoplasma ovipneumoniae, the primary causative agent of pneumonia in bighorn sheep (Ovis canadensis), in a small number of older individuals that were homozygous at an immunologically relevant genetic locus. Interactions among age-structure, genetic composition and infectious periods may drive feedbacks in disease dynamics that determine the magnitude of population response to infection. Accordingly, variation in initial conditions may explain divergent population responses to infection that range from recovery to catastrophic decline and extirpation.


title: Laparoscopic spleen preserving distal pancreatectomy.

text: Minimal invasive surgery is growing rapidly in vast fields of abdominal surgery. Nowadays, due to the development of laparoscopic instruments and improvement of surgical technique, laparoscopic pancreas surgery is becoming more widely adopted. Laparoscopic distal pancreatectomy has now become a standard procedure for the benign or borderline malignant tumor located in body or tail of pancreas, but laparoscopic spleen and splenic vessel preserving distal pancreatectomy is still a technically demanded operation. In this multimedia article, we will demonstrate our technique of laparoscopic spleen and splenic vessel preserving distal pancreatectomy.


title: OpenSAFELY: factors associated with COVID-19 death in 17 million patients.

text: COVID-19 has rapidly affected mortality worldwide1. There is unprecedented urgency to understand who is most at risk of severe outcomes, requiring new approaches for timely analysis of large datasets. Working on behalf of NHS England, here we created OpenSAFELY: a secure health analytics platform covering 40% of all patients in England, holding patient data within the existing data centre of a major primary care electronic health records vendor. Primary care records of 17,278,392 adults were pseudonymously linked to 10,926 COVID-19-related deaths. COVID-19-related death was associated with: being male (hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.53-1.65); older age and deprivation (both with a strong gradient); diabetes; severe asthma; and various other medical conditions. Compared with people with white ethnicity, Black and South Asian people were at higher risk even after adjustment for other factors (HR 1.48, 1.30-1.69 and 1.44, 1.32-1.58, respectively). We have quantified a range of clinical risk factors for COVID-19-related death in the largest cohort study conducted by any country to date. OpenSAFELY is rapidly adding further patients' records; we will update and extend results regularly.


title: Crystal structure of HAb18G/CD147: implications for immunoglobulin superfamily homophilic adhesion.

text: CD147, a member of the immunoglobulin superfamily (IgSF), plays fundamental roles in intercellular interactions in numerous pathological and physiological processes. Importantly, our previous studies have demonstrated that HAb18G/CD147 is a novel hepatocellular carcinoma (HCC)-associated antigen, and HAb18G/CD147 stimulates adjacent fibroblasts and HCC cells to produce elevated levels of several matrix metalloproteinases, facilitating invasion and metastasis of HCC cells. In addition, HAb18G/CD147 has also been shown to be a novel universal cancer biomarker for diagnosis and prognostic assessment of a wide range of cancers. However, the structural basis underlying the multifunctional character of CD147 remains unresolved. We report here the crystal structure of the extracellular portion of HAb18G/CD147 at 2.8A resolution. The structure comprises an N-terminal IgC2 domain and a C-terminal IgI domain, which are connected by a 5-residue flexible linker. This unique C2-I domain organization is distinct from those of other IgSF members. Four homophilic dimers exist in the crystal and adopt C2-C2 and C2-I dimerization rather than V-V dimerization commonly found in other IgSF members. This type of homophilic association thus presents a novel model for homophilic interaction between C2 domains of IgSF members. Moreover, the crystal structure of HAb18G/CD147 provides a good structural explanation for the established multifunction of CD147 mediated by homo/hetero-oligomerizations and should represent a general architecture of other CD147 family members.


title: Remdesivir for 5 or 10 Days in Patients with Severe Covid-19.

text: BACKGROUND Remdesivir is an RNA polymerase inhibitor with potent antiviral activity in vitro and efficacy in animal models of coronavirus disease 2019 (Covid-19). METHODS We conducted a randomized, open-label, phase 3 trial involving hospitalized patients with confirmed SARS-CoV-2 infection, oxygen saturation of 94% or less while they were breathing ambient air, and radiologic evidence of pneumonia. Patients were randomly assigned in a 1:1 ratio to receive intravenous remdesivir for either 5 days or 10 days. All patients received 200 mg of remdesivir on day 1 and 100 mg once daily on subsequent days. The primary end point was clinical status on day 14, assessed on a 7-point ordinal scale. RESULTS In total, 397 patients underwent randomization and began treatment (200 patients for 5 days and 197 for 10 days). The median duration of treatment was 5 days (interquartile range, 5 to 5) in the 5-day group and 9 days (interquartile range, 5 to 10) in the 10-day group. At baseline, patients randomly assigned to the 10-day group had significantly worse clinical status than those assigned to the 5-day group (P = 0.02). By day 14, a clinical improvement of 2 points or more on the ordinal scale occurred in 64% of patients in the 5-day group and in 54% in the 10-day group. After adjustment for baseline clinical status, patients in the 10-day group had a distribution in clinical status at day 14 that was similar to that among patients in the 5-day group (P = 0.14). The most common adverse events were nausea (9% of patients), worsening respiratory failure (8%), elevated alanine aminotransferase level (7%), and constipation (7%). CONCLUSIONS In patients with severe Covid-19 not requiring mechanical ventilation, our trial did not show a significant difference between a 5-day course and a 10-day course of remdesivir. With no placebo control, however, the magnitude of benefit cannot be determined. (Funded by Gilead Sciences; GS-US-540-5773 ClinicalTrials.gov number, NCT04292899.).


title: Treatment of thyroid nodules with radiofrequency: a 1-year follow-up experience.

text: PURPOSE The aim of this study is to assess the effectiveness and safety of radiofrequency ablation (RFA) in debulking benign solid thyroid nodules. MATERIALS AND METHODS This is a retrospective review of 77 patients with predominantly solid thyroid nodules treated with RFA in a single center between 2013 and 2016. All patients declined or were not eligible for surgery. Benign proven thyroid nodules causing compressive symptoms and cosmetic concerns were considered for treatment. Nodule volume, thyroid nodule related compressive symptoms, cosmetic concerns and thyroid function were evaluated. RESULTS All patients underwent a single treatment session. Mean nodule volume decreased from 17.9 ± 15.6 mL at baseline to 5.2 ± 7.4 after 12 months with a volume reduction ratio (VRR) of 70.9% ± 20.8%. There were no identifiable factors predictive of response to RFA. Median cosmetic and symptom scores of the entire population decreased from 3 [2-4] and 3 [0-10] to 1 [1-3] (p < 0.001) and 0 [0-5] (p < 0.001), respectively. No major complications occurred and RFA did not affect thyroid function when normal. CONCLUSION RFA induces substantial volume reduction of predominantly solid thyroid nodules and improves compressive symptoms and cosmetic concerns. RFA does not impact normal thyroid function and has an acceptable safety profile.


title: Lung transplantation as therapeutic option in acute respiratory distress syndrome for COVID-19-related pulmonary fibrosis.

text: BACKGROUND Critical patients with the 2019 coronavirus disease (COVID-19), even those whose nucleic acid test results had turned negative and those receiving maximal medical support, have been noted to progress to irreversible fatal respiratory failure. Lung transplantation (LT) as the sole therapy for end-stage pulmonary fibrosis related to acute respiratory distress syndrome has been considered as the ultimate rescue therapy for these patients. METHODS From February 10 to March 10, 2020, three male patients were urgently assessed and listed for transplantation. After conducting a full ethical review and after obtaining assent from the family of the patients, we performed three LT procedures for COVID-19 patients with illness durations of >1 month and extremely high sequential organ failure assessment (SOFA) scores. RESULTS Two of the three recipients survived post-LT and started participating in a rehabilitation program. Pearls of the LT team collaboration and perioperative logistics were summarized and continually improved. The pathological results of the explanted lungs were concordant with the critical clinical manifestation, and provided insight towards better understanding of the disease. Government health affair systems, virology detection tools, and modern communication technology all play key roles towards the survival of the patients and their rehabilitation. CONCLUSIONS Lung transplantation can be performed in end-stage patients with respiratory failure due to COVID-19-related pulmonary fibrosis. If confirmed positive-turned-negative virology status without organ dysfunction, LT provided the final option for these patients to avoid certain death, with proper protection of transplant surgeons and medical staffs. By ensuring instant seamless care for both patients and medical teams, the goal of reducing the mortality rate and salvaging the lives of patients with COVID-19 can be attained.


title: Radiofrequency ablation in the management of Barrett's esophagus: present role and future perspective.

text: Esophageal adenocarcinoma is the most rapidly increasing gastrointestinal cancer. Barrett's esophagus has been identified as a precancerous condition and major risk factor for esophageal cancer. Radiofrequency ablation has been shown to be a highly efficient in promoting remission of intestinal metaplasia. This technology has seen widespread clinical use since 2005. Radiofrequency ablation is common with all other ablative techniques; the concern that sound oncological principles are not being adhered to, that is, appropriate pathological staging, followed by appropriate definitive therapy. Endoscopic mucosal excision techniques are technically demanding; however, they are more attractive from an oncological perspective. Future research endeavors focusing on facilitation of large population screening, the identification of high risk phenotypes, endoscopic mucosal resection techniques will combat the esophageal adenocarcinoma epidemic.


Communication, transparency key as Canada faces new coronavirus threat.


title: 40-4-40: educational and economic outcomes of a free, international surgical training event.

text: PURPOSE OF STUDY To demonstrate a model for delivery of an international surgical training event, and demonstrate its educational and economic outcomes. STUDY DESIGN The Association of Surgeons in Training (ASiT) ran a course series on 16 January 2016 across the UK and Ireland. A mandatory, self-reported, online questionnaire collected delegate feedback, using 5-point Likert Scales, and a NetPromoter feedback tool. Precourse and postcourse matched questionnaires were collected for 'Foundation Skills in Surgery' (FSS) courses. Paired economic analysis was performed. Statistical analysis was carried out using RStudio (V.3.1.1 Boston, Massachusetts, USA). RESULTS Forty courses were held across the UK and Ireland (65.0% technical, 35.0% non-technical), with 184 faculty members. Of 570 delegates, 529 fully completed the feedback survey (92.8% response rate); 56.5% were male. The median age was 26 years (range: 18-67 years). The mean overall course NetPromoter Score was 8.7 out of 10. On logistic regression high NetPromoter Score was associated with completing a Foundation Skills in Surgery course (R=0.44, OR: 1.49, p=0.025) and having clear learning outcomes (R=0.72, OR: 2.04, p=0.029) but not associated with specialty, course style or teaching style. For Foundation Skills in Surgery courses, delegates reported increased commitment to a career in surgery (p<0.001), confidence with basic surgical skills (p<0.001) and confidence with assisting in theatre (p<0.001). A comparable cost saving of £231,462.37 was calculated across the 40 courses. CONCLUSION The ASiT '40-4-40' event demonstrated the diversity and depth of surgical training, with 40 synchronous technical and non-technical courses, demonstrable educational benefit and a significant cost saving to surgical trainees.


title: Persistent Bleeding Following a Stapled Hemorrhoidopexy.

text: A stapled hemorrhoidopexy (SH) is widely used for treatment of patients with grades III and IV hemorrhoids. The SH is easy to perform, is associated with less pain and allows early return to normal activities. However, complications, whether severe or not, have been reported. Here, we present the case of a female patient with persistent bleeding after a SH. The bleeding was caused by the formation of granulation tissue at the stapler line, diagnosed with sigmoidoscopy, and successfully treated via transanal excision (TAE) under spinal anesthesia. The biopsy showed inflammatory granulation tissue. After the TAE, her symptom was completely gone.


What are the risks--hypothetical and observed--of recombination involving live vaccines and vaccine vectors based on nonsegmented negative-strain RNA viruses?


title: Trends in Pneumonia Mortality Rates and Hospitalizations by Organism, United States, 2002-2011(1).

text: Because the epidemiology of pneumonia is changing, we performed an updated, population-based analysis of hospitalization and case-fatality rates for pneumonia patients in the United States. From 2002 to 2011, hospitalization rates decreased significantly for pneumonia caused by pneumococcus and Haemophilus influenzae but increased significantly for Pseudomonas spp., Staphylococcus aureus, and influenza virus.


title: Genetic characterization of Betacoronavirus lineage C viruses in bats reveals marked sequence divergence in the spike protein of pipistrellus bat coronavirus HKU5 in Japanese pipistrelle: implications for the origin of the novel Middle East respiratory syndrome coronavirus.

text: While the novel Middle East respiratory syndrome coronavirus (MERS-CoV) is closely related to Tylonycteris bat CoV HKU4 (Ty-BatCoV HKU4) and Pipistrellus bat CoV HKU5 (Pi-BatCoV HKU5) in bats from Hong Kong, and other potential lineage C betacoronaviruses in bats from Africa, Europe, and America, its animal origin remains obscure. To better understand the role of bats in its origin, we examined the molecular epidemiology and evolution of lineage C betacoronaviruses among bats. Ty-BatCoV HKU4 and Pi-BatCoV HKU5 were detected in 29% and 25% of alimentary samples from lesser bamboo bat (Tylonycteris pachypus) and Japanese pipistrelle (Pipistrellus abramus), respectively. Sequencing of their RNA polymerase (RdRp), spike (S), and nucleocapsid (N) genes revealed that MERS-CoV is more closely related to Pi-BatCoV HKU5 in RdRp (92.1% to 92.3% amino acid [aa] identity) but is more closely related to Ty-BatCoV HKU4 in S (66.8% to 67.4% aa identity) and N (71.9% to 72.3% aa identity). Although both viruses were under purifying selection, the S of Pi-BatCoV HKU5 displayed marked sequence polymorphisms and more positively selected sites than that of Ty-BatCoV HKU4, suggesting that Pi-BatCoV HKU5 may generate variants to occupy new ecological niches along with its host in diverse habitats. Molecular clock analysis showed that they diverged from a common ancestor with MERS-CoV at least several centuries ago. Although MERS-CoV may have diverged from potential lineage C betacoronaviruses in European bats more recently, these bat viruses were unlikely to be the direct ancestor of MERS-CoV. Intensive surveillance for lineage C betaCoVs in Pipistrellus and related bats with diverse habitats and other animals in the Middle East may fill the evolutionary gap.


Ventilator discontinuation: why are we still weaning?


title: Human Brucellosis in Febrile Patients Seeking Treatment at Remote Hospitals, Northeastern Kenya, 2014-2015.

text: During 2014-2015, patients in northeastern Kenya were assessed for brucellosis and characteristics that might help clinicians identify brucellosis. Among 146 confirmed brucellosis patients, 29 (20%) had negative serologic tests. No clinical feature was a good indicator of infection, which was associated with animal contact and drinking raw milk.


title: B fibers are the best predictors of cardiac activity during Vagus nerve stimulation: Qing, vagal B fiber activation and cardiac effects.

text: Background Vagus nerve stimulation (VNS) is a promising therapy for many neurologic and psychiatric conditions. However, determining stimulus parameters for individual patients is a major challenge. The traditional method of titrating stimulus intensity based on patient perception produces highly variable responses. This study explores using the vagal response to measure stimulation dose and predict physiological effect. Clinicians are investigating the use of VNS for heart failure management, and this work aims to correlate cardiac measures with vagal fiber activity. Results By recording vagal activity during VNS in rats and using regression analysis, we found that cardiac activity across all animals was best correlated to the activation of a specific vagal fiber group. With conduction velocities ranging from 5 to 10 m/s, these fibers are classified as B fibers (using the Erlanger-Gasser system) and correspond to vagal parasympathetic efferents. Conclusions B fiber activation can serve as a standardized, objective measure of stimulus dose across all subjects. Tracking fiber activation provides a more systematic way to study the effects of VNS and in the future, may lead to a more consistent method of therapy delivery.


title: Replication-dependent downregulation of cellular angiotensin-converting enzyme 2 protein expression by human coronavirus NL63.

text: Like severe acute respiratory syndrome coronavirus (SARS-CoV), human coronavirus (HCoV)-NL63 employs angiotensin-converting enzyme 2 (ACE2) as a receptor for cellular entry. SARS-CoV infection causes robust downregulation of cellular ACE2 expression levels and it has been suggested that the SARS-CoV effect on ACE2 is involved in the severity of disease. We investigated whether cellular ACE2 downregulation occurs at optimal replication conditions of HCoV-NL63 infection. The expression of the homologue of ACE2, the ACE protein not used as a receptor by HCoV-NL63, was measured as a control. A specific decrease for ACE2 protein level was observed when HCoV-NL63 was cultured at 34 °C. Culturing the virus at the suboptimal temperature of 37 °C resulted in low replication of the virus and the effect on ACE2 expression was lost. We conclude that the decline of ACE2 expression is dependent on the efficiency of HCoV-NL63 replication, and that HCoV-NL63 and SARS-CoV both affect cellular ACE2 expression during infection.


title: Depth-dependent changes of obstruction patterns under increasing sedation during drug-induced sedation endoscopy: results of a German monocentric clinical trial.

text: PURPOSE Drug-induced sedation endoscopy (DISE) and simulated snoring (SimS) can locate the site of obstruction in patients with sleep-disordered breathing (SDB). There is clinical evidence for a change in collapsibility of the upper airway depending on the depth of sedation. So far, a dose-response relationship between sedation and collapsibility has not been demonstrated. METHODS DISE and SimS were performed in 60 consecutive patients with SDB under monitoring of depth of sedation by BiSpectral Index® (BIS). Initially, SimS was conducted followed by DISE using bolus application of propofol. Sedation was performed up to a sedation level representing slow wave sleep (BIS = 40). The collapsibility of the upper airway was documented at decreasing sedation levels by an identical pictogram classification. RESULTS For all levels and patterns of obstruction, a dose-dependent increase in the collapsibility of the upper airway was detected. A maximum collapsibility was achieved at sedation levels representing slow wave sleep. The collapsibility during SimS corresponded to light sleep stages and did not cover slow wave sleep. CONCLUSION A dose-dependent change of patterns of obstructions can be observed during DISE under BIS monitoring indicating sedation depth. The obtained patterns of obstruction during DISE and SimS should thus be interpreted with regard to the sedation depth.


title: Clinical and laboratory characteristics of severe fever with thrombocytopenia syndrome in Chinese patients.

text: Severe fever with thrombocytopenia syndrome (SFTS) associated with severe fever with thrombocytopenia syndrome virus (SFTSV) is an emerging infectious disease. 12 patients with severe fever with thrombocytopenia syndrome in our study were presented mainly with fever and severe malaise. The clinical manifestations typically became worse on the 6th or 7th day. The average fever time is 9.11 ± 1.54 days. Most of them had multiorgan dysfunction, and part of them had hemophagocytic lymphohistiocytosis histiocytosis (HLH). The characteristic laboratory findings in the early stage were the drop of white blood cells (WBC), platelets (PLT) and serum Ca++, while increase of aspartate amino transferase (AST), creatine kinase (CK), and lactate dehydrogenase (LDH). CD3+CD4+ were significantly decreased, while CD3-CD56+ were significantly increased, whereas CD3+CD8+ were constantly elevated throughout the disease course. Ten to 14 days after illness onset, symptoms were improved, accompanied by resolution of laboratory abnormalities. These results indicate that severe fever with thrombocytopenia syndrome has an acute onset and self-limited course. It is a systemic infection. The host immune response caused tissues and organs injury. The improvement of symptoms and laboratory tests is consistent with the elimination of the virus and recover of immune response. Further investigation should be done in order to better understand this disease and guide the clinical treatment.


title: Ipsilateral opposite-side aspiration in resistant pneumothorax after CT image guided lung biopsy: complementary role after simple needle aspiration.

text: BACKGROUND The goal of this study was to evaluate the efficacy of ipsilateral opposite-side aspiration, a new method to overcome resistant pneumothorax after failure of a simple aspiration. The patient position is reversed (from prone to supine or vice versa) and the aspiration repeated. METHODS Between January 1, 2010, and April 3, 2012, 129 consecutive, CT image-guided, percutaneous needle biopsies of lung nodules were performed in 127 patients (75 men, 52 women; mean age, 67.8 years; range, 26-88 years). Two patients underwent repeated biopsies. The mean lesion diameter was 38 mm (range, 8-110 mm). Core biopsy and fine-needle aspiration (FNA) were performed in 126 procedures; in three cases, only FNA was performed. In the cases with symptomatic minimal pneumothorax and in all patients with pneumothorax > 10 mm, immediate, simple, manual aspiration was performed. Ipsilateral opposite-side aspiration was performed when simple aspiration failed. RESULTS Among 129 CT image-guided biopsies, pneumothorax was detected by CT scan in 54 (42%); 51 (39%) were detected during the biopsy. Delayed pneumothorax occurred in two patients (1.55%). Manual aspiration to treat pneumothorax was performed in 27 of 129 procedures (21%). Simple aspiration was successful in 20 of these 27 cases (74%). Ipsilateral opposite-side aspiration was accomplished in the remaining seven cases (26%) and was successful in six cases (86%). Two of 129 procedures (1.55%) required chest tube placement. CONCLUSIONS Immediate, simple, percutaneous aspiration of iatrogenic pneumothorax was successful in 74% of patients needing treatment. Our proposed new method of ipsilateral opposite-side aspiration offers a solution for patients who remain with resistant pneumothorax after simple aspiration.


title: Surgical treatment of extracranial arteriovenous malformations after multiple embolizations: outcomes in a series of 31 patients.

text: BACKGROUND Surgical resection after embolization is the most accepted approach to treating arteriovenous malformations. The authors analyzed the outcome of surgically treated patients and how surgical resection was influenced by multiple embolizations. METHODS Thirty-one patients were included from January of 2000 to December of 2012. The mean patient age was 24.9 years. Anatomical involvement, definition of limits, functional impairment, number of embolizations, type of resection, reconstruction method, blood transfusion, and hospital stay were evaluated. Morbidity, mortality, and regrowth rates and need for additional procedures were evaluated. RESULTS Lesions were preferentially located at the orbits, cheeks, and lips. The number of embolizations per patient increased with lesion complexity. In 22 cases, total excision was accomplished, and in nine, subtotal resections were performed to favor function. After multiple embolizations, better lesion identification was observed. Primary closure was performed in 20 cases, local flaps were performed in seven cases, axial flaps were performed in two patients, and free flaps were performed in two cases. There were no deaths. Regrowth rates were influenced by limits between arteriovenous malformations and surrounding tissues (15.8 percent of cases with precise limits versus 58.3 percent of lesions with imprecise limits; p = 0.021) and by type of resection (18.2 percent of cases after total resection versus 66.7 percent after subtotal resections; p = 0.015). CONCLUSIONS Multiple therapeutic embolizations seem to increase safety in the treatment of arteriovenous vascular malformations and suggest an additional positive effect besides bleeding control. Preoperative definition of limits and establishment of conditions for total resection are critical to determine management and risk of regrowth. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.


title: Application of 2-DE for studying the variation of blood proteome.

text: 2D electrophoresis (2-DE) is still a widely used proteomic method despite the availability of high-throughput approaches for protein identification. However, a literature survey only revealed a relatively small number of 2-DE-based studies of human blood proteome. We critically reviewed comparative 2-DE-based proteomic studies, in which groups of patients under examination involved more than ten individuals. Limitation on the number of samples is explained by the requirement to take into account the individual variation of blood proteome. The scanty amount of statistical data on quantitative variations of normal blood proteome may be one of the reasons for the poor applicability of proteomic biomarkers in clinical diagnostics.


title: Correction: Cuscuta seeds: Diversity and evolution, value for systematics/identification and exploration of allometric relationships.

text: [This corrects the article DOI: 10.1371/journal.pone.0234627.].


title: Enhanced X-ray absorption for micro-CT analysis of low density polymers.

text: X-ray microtomography (micro-CT), one of the most resourceful instruments for high resolution 3D analysis, can provide qualitative and quantitative accurate structural and compositional information for a broad range of materials. Yet its contribution to the field of biopolymeric materials science is often limited by low imaging contrast due to scarce X-ray attenuation features, particularly for sponges and foam-like structures. This limitation can be overcome to some extent by adjusting the working parameters of micro-CT equipment. However, such approach also facilitates noise and artefacts, and solving the signal-to-noise trade-off has been always problematic. Searching for alternatives turns one's attention towards the improvement of X-ray attenuation features. While several studies report the use of contrast agents for biological materials, studies to integrate multiple micro-CT approaches for biopolymers were not conducted so far. This method paper is thus aimed to serve as a platform for micro-CT analysis of low X-ray absorptive polymers. Here, several contrast enhancing artifices were developed and trialled on gelatin and poly(vinyl alcohol) biopolymer composites (GP). Accordingly, GP were modified with iodine, barium, silver-based chemicals and hexa(methyl disilazane) by two different methods, i.e. addition of high atomic number chemicals during materials synthesis and post-synthesis staining, respectively. Consequently, cross-sectional scanning electron microscopy emerged as complementary characterization, aimed to confirm the reproducibility of samples morphological features. The most versatile methods were barium chloride additive incorporation and iodine staining coupled with hexa(methyl disilazane) chemical drying. Both methods significantly improved the X-ray absorbance of our polymeric samples, providing better contrast of micro-CT tomograms.


title: Extending the indication for robot-assisted retroperitoneal partial nephrectomy to antero-lateral renal tumors.

text: BACKGROUND Robot-assisted retroperitoneal partial nephrectomy (RARPN) is typically employed for posterior renal tumors. This work aimed to extend the indication of RARPN to patients with selected antero-lateral renal tumor. METHODS Patients who underwent RARPN between December 2013 and September 2015 at the authors' institution were enrolled. Two intersecting lines were drawn on an axial CT image to define the medial/lateral nature of anterior renal tumors. Patients with antero-lateral tumor and posterior tumor were compared. RESULTS Antero-lateral tumors constituted 56.1% (32/57) of the total cases. The perioperative outcomes between the two groups were comparable. Although the operation time was longer for the antero-lateral tumor group, it did not show statistical significance. No cases had positive margins. There was one case of Clavien-Dindo grade IIIa complication in the antero-lateral tumor group. CONCLUSIONS RARPN is a safe and effective procedure not only for posterior renal tumors but also for carefully selected antero-lateral renal tumors. Copyright © 2016 John Wiley & Sons, Ltd.


title: Robotic anterior resection in a patient with situs inversus: is it merely a mirror image of everything?

text: Situs inversus (SI) is a rare condition involving transposition of internal organs. In performing minimally invasive surgeries for these patients, exact mirror image of the usual technique may not be easily achieved, especially for right-handed surgeons. We describe a case of robotic anterior resection in a patient with rectal cancer and SI, illustrating the technique and how robotic system facilitates the procedure. A 59-year-old gentleman presented with altered bowel habit. Colonoscopy showed an obstructing tumour at 10 cm from the anal verge. Computed tomography did not show distant metastasis, but revealed the diagnosis of SI. Intraoperative laparoscopy revealed peritoneal metastasis. Total robotic, single docking, anterior resection was performed to palliate his obstructive symptoms. The operation lasted for 3 h and 24 min. Blood loss was 100 ml. There were no intraoperative or postoperative complications. The patient was discharged on day four. The final pathology was T3N2M1.


title: Managing the coronavirus pandemic in Portugal: A step-by-step adjustment of health and social services.

text: This article presents an overview of what has been done in Portugal to curb the spread of coronavirus disease 2019 (COVID-19), regarding public health actions, mental health implications, and measures taken or recommended to prevent the harmful effects of the pandemic. Because Portugal has been pointed out as a case of success in managing the COVID-19 pandemic, this report offers opportunities to build on the experience gained, which may positively influence other countries, especially those that are still deeply affected by the COVID-19 pandemic. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients With Suspected Infection: A Systematic Review and Meta-analysis.

text: Background The quick Sequential Organ Failure Assessment (qSOFA) has been proposed for prediction of mortality in patients with suspected infection. Purpose To summarize and compare the prognostic accuracy of qSOFA and the systemic inflammatory response syndrome (SIRS) criteria for prediction of mortality in adult patients with suspected infection. Data Sources Four databases from inception through November 2017. Study Selection English-language studies using qSOFA for prediction of mortality (in-hospital, 28-day, or 30-day) in adult patients with suspected infection in the intensive care unit (ICU), emergency department (ED), or hospital wards. Data Extraction Two investigators independently extracted data and assessed study quality using standard criteria. Data Synthesis Thirty-eight studies were included (n = 385 333). qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to 69.4%) and a pooled specificity of 72.0% (CI, 63.4% to 79.2%) for mortality. The SIRS criteria were associated with a pooled sensitivity of 88.1% (CI, 82.3% to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%). The pooled sensitivity of qSOFA was higher in the ICU population (87.2% [CI, 75.8% to 93.7%]) than the non-ICU population (51.2% [CI, 43.6% to 58.7%]). The pooled specificity of qSOFA was higher in the non-ICU population (79.6% [CI, 73.3% to 84.7%]) than the ICU population (33.3% [CI, 23.8% to 44.4%]). Limitation Potential risk of bias in included studies due to qSOFA interpretation and patient selection. Conclusion qSOFA had poor sensitivity and moderate specificity for short-term mortality. The SIRS criteria had sensitivity superior to that of qSOFA, supporting their use for screening of patients and as a prompt for treatment initiation. Primary Funding Source Canadian Association of Emergency Physicians. (PROSPERO: CRD42017075964).


title: Clinical trials and the COVID-19 pandemic.

text: "...but why think? Why not try the experiment?..." John Hunter (1728-1793), in a letter to Edward Jenner. August 2nd, 1775. When Galen of Pergamum (2nd c. A.D.), physician, philosopher and experimentalist, sought to ascertain the therapeutic properties of Theriac, an antidote of repute against poisons, he resorted to an experiment. Theriac or Theriaca was a compound drug, containing in some versions used in antiquity numerous components; Galen's own composition included over 70 ingredients! One of its uses was as an antidote against snakebites, a frequent peril for the Roman armies marching on in sandals. Galen spent most of his life in Rome and was elevated to Imperial Physician at the court of Marcus Aurelius, who apparently took daily doses of Theriac, which among other components included opium. Describing the experiment to his friend Pison, Galen wrote, "as I could not possibly conduct a trial on humans, I experimented on roosters" For his experiment, Galen, studied two groups of roosters, but he doesn't tell us how many animals he included in each category. Both groups were exposed to poisonous snakebites. All roosters who were fed with theriac prior to exposure to viper bites survived, whereas in the second group that had not received prophylactic Theriac, all roosters died. Not only is Galen's methodology remarkable, preceding the modern randomised trial by eighteen centuries, but more importantly, it is notable for his ethical stance at a time when sensitivities about human rights, prevalent in our times, were largely absent in societies of widespread slavery. For example, Mithridates VI (132-63 BC), the King of Pontus who is credited with the first use of Theriac, tested its efficacy on criminals and slaves. For his experiment Galen used the random allocation of treatment, today's prospective randomised clinical trial, implemented in the evaluation of novel therapies, widely used internationally, particularly in cancer research! This experimental method used for ascertaining the efficacy of new drugs became established after the second half of the 20th century and is now firmly entrenched as a research tool. On the other hand, the retrieval of information from observational studies or non-randomised series is considered scientifically inferior and is often dismissed or ignored as irrelevant or anecdotal. Such is the compulsion for the randomised study that in the midst of the COVID-19 pandemic, respected physicians and scientists appeared in the media hesitant to recommend the use of protective facial masks, as there was no evidence of benefit for their use from prospective randomised studies in the general population! Logic had no place in the argument! COVID-19, caused by the SARS-CoV-2 new corona virus, brought to the fore the randomised trial, as well as, the ethical dilemmas that surround the allocation of treatment at random, in the face of a devastating pandemic. Anthony Fauci, distinguished infectious diseases expert and an adviser to the President of the USA, at a recent briefing from the Situation Room of the White House, endorsed categorically and unreservedly the randomised trial for the evaluation of drugs potentially effective against SARS-CoV-2, in patients afflicted with COVID-19. A few days later on April 8th, 2020, Professor Sotiris Tsiodras, scientific advisor to the Greek Government for COVID-19 and an expert on infectious diseases, when asked by a journalist about chloroquine, he responded, "Antony Fauci is correct. Nevertheless, we give the drug to everyone, that is, not half of the patients will receive it, and the other half will not". If we accept that the randomised trial represents the unique, impregnable method of evaluating new treatments-several clinicians dispute this dogma. -the question arises how will treatments be allocated to patients? According to the Declaration of Helsinki participation of a subject in a clinical trial requires their explicit written consent. Will, a potentially hypoxic patient rapidly deteriorating, be able to understand what is being asked of them, and will that patient be in a position to provide consent? And if that patient refuses to be randomised, what are the options? Is it his/her right to request the active treatment that a fellow patient is receiving in the next bed? Although the Declaration of Helsinki allows the option of no treatment or even placebo, where no known treatment is available for a certain condition, such as COVID-19, it also emphasizes that "while the primary purpose of medical research is to generate new knowledge, this goal can never take precedence over the rights and interests of individual research subjects". Consider now the physicians and nurses on the first line of the battle against the pandemic; to the enormous pressures and risks that they experience daily, they may have to endure the added psychological burden of the randomised trial, knowing that half of their patients are receiving the promising drug, whilst the other half are denied the chance of potential benefit. When during the Medical Research Council's randomized trial of streptomycin, one senior physician contracted tuberculosis, the Medical Research Council obtained supplies for him outside the trial. In this brief instance of medical history, the equipoise, the scientific imperative, all arguments and other justifications for providing treatment at random, were thrown out of the window in favour of the human factor! Why is randomization necessary? Because-it is presumed-the process of randomising subjects, protects the study from the selective inclusion of patients with favourable characteristics, thus inadvertently allowing or facilitating a falsely favourable result for the drug or treatment under investigation. However, the process of randomising patients does not necessarily result in the randomisation of the characteristics of their disease. Exactly because of this, at the end of a randomised study, even if the prognostic variables are evenly represented and balanced in the strata, further confirmation of the result is sought with a statistical multifactorial analysis. Such multifactorial analyses can also be applied to a non-randomised group of patients engaged in the trial of a new drug. Since the middle of the 20th century a generation of physicians have been trained to dismiss, or are incapable of evaluating the validity of a treatment beyond the established etiquette of the randomised study. This, some have argued, constitutes intellectual indolence, it is not scientific robustness. Pandits foresee that the world will be different after the end of this pandemic. Perhaps human ingenuity will seek new investigative methods that will render the randomised clinical trial obsolete, both, on methodological and ethical grounds. Until then and even if we have to accept the scientific supremacy of the randomised study in the evaluation of novel therapies, the ethical considerations in the unprecedented circumstances of a relentless pandemic demand a more humane approach, befitting the beneficent precepts of the Hippocratic tradition.


title: Quality of life assessment scales in polio survivors: a scoping review.

text: BACKGROUND Quality of life evaluation is essential to explore the effect of paralytic polio on the daily life experience of the polio survivor. Researchers have employed a range of assessment instruments to evaluate quality of life among polio survivors. Hence, to select the appropriate scale, it is crucial to compare the contents and psychometric properties of these instruments. PURPOSE This scoping review explores quality of life instruments that are used in polio literature and analyzes their contents and psychometric properties using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria. METHOD Using the Arksey and O'Malley framework, we conducted a literature search in the following electronic databases Medline, CINAHL, Web of Science, Embase, and Google Scholar to identify relevant studies that focused on quality of life of polio survivors. Of the 88 articles that qualify for full-text screening, 34 studies met our inclusion criteria. Two independent reviewers extracted data from the selected studies via Covidence, a reference manager that allows for blinding of reviews. RESULTS Most of the instruments included in this review are generic, self-reported, and multidimensional. Despite having mostly adequate psychometric properties, these properties were not evaluated in polio survivors. CONCLUSION The information provided in this review could be used to guide instrument selection and identify the need to develop a new tool or to adapt a pre-existing scale for measuring quality of life among polio survivors.