title: Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients.

text: Background and Purpose- Sustained successful reperfusion is an important prognostic factor for good clinical outcome in acute ischemic stroke. We aimed to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies within a prospective cohort. Methods- A total of 711 stroke patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b/3) followed with magnetic resonance or computed tomographic angiography at 24 to 48 hours were included. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. Results are displayed as adjusted odds ratio (aOR) and 95% CI. Improvement in accuracy of additional imaging findings on angiography control runs after the intervention was evaluated by area under the curve. Results- Early reocclusion was observed in 16 of 711 successfully reperfused patients (2.3%; 95% CI, 1.1-3.3; median delay: 20 hours). Suggestive predictors were higher platelets on admission (aOR, 1.01; 95% CI, 1.01-1.02), prestroke functional dependence (aOR, 7.12; 95% CI, 1.49-34.03), and stroke of undetermined or other specified pathogenesis in the TOAST classification (aOR, 7.19; 95% CI, 1.10-47.05 and aOR, 36.50; 95% CI, 4.47-298.11, respectively). When implementing residual embolic fragments or stenosis at the thrombectomy site into the logistic regression model, discrimination between patients with and without reocclusion improved significantly (area under the curve, 0.955 versus 0.854; P=0.023). Early reocclusion was an independent predictor of unfavorable outcome at 90 days (aOR for modified Rankin Scale ≤2, 0.13; 95% CI, 0.03-0.57). Conclusions- Early reocclusion within 48 hours after successful mechanical thrombectomy is rare but associated with poor outcome. Patients with high platelets on admission and residual embolic fragments or stenosis at the thrombectomy site are at high risk for reocclusion, which may be prevented or corrected after carefully re-evaluating the last angiographic run.


title: Emerging, evolving, and established infectious diseases and interventions.

text: Planning, implementing, and evaluating interventions against infectious diseases depend on the nature of the infectious disease; the availability of intervention measures; and logistical, economic, and political constraints. Infectious diseases and vaccine- or drug-based interventions can be loosely categorized by the degree to which the infectious disease and the intervention are well established. Pertussis, polio, and measles are three examples of long-known infectious diseases for which global vaccination has dramatically reduced the public health burden. Pertussis vaccination was introduced in the 1940s, polio vaccination in the 1950s, and measles vaccination in the 1960s, nearly eliminating these diseases in many places.


title: Network Properties in Transitions of Consciousness during Propofol-induced Sedation.

text: Reliable electroencephalography (EEG) signatures of transitions between consciousness and unconsciousness under anaesthesia have not yet been identified. Herein we examined network changes using graph theoretical analysis of high-density EEG during patient-titrated propofol-induced sedation. Responsiveness was used as a surrogate for consciousness. We divided the data into five states: baseline, transition into unresponsiveness, unresponsiveness, transition into responsiveness, and recovery. Power spectral analysis showed that delta power increased from responsiveness to unresponsiveness. In unresponsiveness, delta waves propagated from frontal to parietal regions as a traveling wave. Local increases in delta connectivity were evident in parietal but not frontal regions. Graph theory analysis showed that increased local efficiency could differentiate the levels of responsiveness. Interestingly, during transitions of responsive states, increased beta connectivity was noted relative to consciousness and unconsciousness, again with increased local efficiency. Abrupt network changes are evident in the transitions in responsiveness, with increased beta band power/connectivity marking transitions between responsive states, while the delta power/connectivity changes were consistent with the fading of consciousness using its surrogate responsiveness. These results provide novel insights into the neural correlates of these behavioural transitions and EEG signatures for monitoring the levels of consciousness under sedation.


What's in a name? Issues to consider when naming Mendelian disorders.


title: Digital health and the COVID-19 epidemic: an assessment framework for apps from an epidemiological and legal perspective.

text: As COVID-19 spreads across the globe, crowdsourced digital technology harbours the potential to improve surveillance and epidemic control, primarily through increased information coverage, higher information speed, fast case tracking and improved proximity tracing. Targeting those aims, COVID-19-related smartphone and web-based health applications are continuously emerging, leading to a multitude of options, raising ethical and legal challenges and potentially overwhelming end users. Building on an existing trustworthiness checklist for digital health applications, we searched the literature and developed a framework to guide the assessment of smartphone and web-based applications that aim to contribute to controlling the current epidemic or mitigating its effects. It further integrates epidemiological subject knowledge and a legal analysis, outlining the mechanisms through which new applications can support the fight against COVID-19. The resulting framework includes 40 questions across 8 domains on “purpose”, “usability”, “information accuracy”, “organisational attributes / reputation”, “transparency”, “privacy” and “user control / self-determination”. All questions should be primarily answerable from publicly available data, as provided by application manufacturers. The framework aims to guide end users in choosing a transparent, safe and valuable application and suggests a set of information items that developers ideally make available to allow a balanced judgement and facilitate the trustworthiness of their products.


title: Incidental detection of asymptomatic migration of Hem-o-lok clip into the bladder after laparoscopic radical prostatectomy.

text: Hem-o-lok clips have been widely used in laparoscopic or robot-assisted surgery. We report a case of an incidentally discovered Hem-o-lok migration into the bladder after laparoscopic radical prostatectomy. The patient was a 75-year-old man with localized prostate cancer who underwent laparoscopic radical prostatectomy in July 2009. At 3 postoperative years, follow-up ultrasonography revealed a small round mass in the bladder. No lower urinary tract symptoms were reported, and urinalysis results had never indicated hematuria or pyuria. Cystoscopy revealed a Hem-o-lok clip in the bladder, near the vesicourethral anastomotic site. We could not remove it with forceps in the outpatient clinic, so we performed the procedure again under general anesthesia and successfully removed the Hem-o-lok clip. To our knowledge, this is the first report of an asymptomatic Hem-o-lok migration into the bladder.


title: Single- versus multiple-port thoracoscopic lobectomy for lung cancer: a propensity-matched study†.

text: OBJECTIVES In this retrospective study, we aimed to compare single-port (SP) and multiport (MP) video-assisted thoracoscopic surgery (VATS) for the surgical resection of non-small-cell lung cancer (NSCLC). METHODS Between October 2013 and October 2014, a total of 411 consecutive NSCLC patients who underwent VATS lobectomy in the Department of Thoracic Surgery, Zhongshan Hospital of Fudan University, were enrolled. Propensity-matched analysis, incorporating preoperative clinical features, was used to compare the perioperative outcomes and analyse the safety and efficacy between SP and MP VATS lobectomies for NSCLCs. RESULTS There were 115 patients in the SP group, and 296 patients in the MP group from October 2013 to October 2014. Propensity matching produced 100 pairs in this retrospective study. During the operation, the lobectomy took less time in the SP than in the MP (65.7 ± 14.8 vs 81.3 ± 13.6, P < 0.001) group, while the duration of lymphadenectomy was longer in the SP group (29.6 ± 16.7 vs 17.4 ± 13.3, P < 0.001). The total operation duration, the volume of estimated blood loss (55.1 ± 9.0 ml vs 58.7 ± 7.1 ml, P = 0.22) and the length of postoperative hospital stay (4.7 ± 1.2 days vs 5.3 ± 1.4 days, P = 0.05) were similar between the two groups. Postoperatively, SP and MP groups showed similar results in terms of morbidity and mortality. CONCLUSIONS In comparison with conventional VATS, SP VATS lobectomy showed better safety and efficacy in the surgical resection of NSCLCs. Further studies based on larger populations and better methodology are required to determine its further benefits towards patients.


title: The Preoperative Prognostic Nutritional Index for the Prediction of Outcomes in Patients with Early-Stage Ovarian Clear Cell Carcinoma.

text: The prognostic nutritional index (PNI), which reflects preoperative malnutrition, is useful for predicting the incidence of postoperative complications and has been reported in recent years to predict the long-term prognosis of various malignancies. The purpose of this study was to clarify the significance of PNI as a prognostic factor for early-stage clear cell ovarian carcinoma. A total of 82 patients with stage I-II (FIGO 2014) ovarian clear cell carcinoma undergoing primary surgery at our hospital from January 2005 to December 2017 were enrolled. PNI was calculated using the formula: 10 × serum albumin (g/ dL) + 0.005 × peripheral blood lymphocyte count (/mm3). Preoperative PNI exhibited relatively high area under the curve value (0.709) for 5 year survival, and the optimal cutoff value was 46.5. The overall survival was significantly shorter in the PNI-low group than in the PNI-high group. Multivariate analysis showed that high PNI was a significant independent prognostic factor for favorable prognosis (hazard ratio = 0.102, p = 0.010). There was no significant difference in recurrence-free survival between the two groups (p = 0.220), but the postrecurrence survival was significantly longer in the PNI-high group than in the PNI-low group (p = 0.0383). The preoperative PNI was a useful predictor of prognosis, even in early-stage ovarian clear cell carcinoma.


title: NLR: A Cost-effective Nomogram to Guide Therapeutic Interventions in COVID-19.

text: COVID-19 exhibits a non-yet elucidated heterogeneity dominated by mild form of the illness. Nevertheless, mortality is frequent among patients with a delayed innate immune response that suddenly exacerbates during the second week after admission leading to a lethal over inflammation. Therefore, this rapid and unpredictable deterioration requires timely prediction of COVID-19 refractoriness and critical illness. The two biomarkers readily available in routine laboratories, blood lymphocytes and neutrophil counts, are expected to provide an accurate clinical tool to incline reasonable medication and care because lymphopenia marks immune exhaustion while neutrophilia demonstrates the immunological exuberation. Meanwhile, combining the two parameters as a Neutrophil-to-lymphocyte ratio (NLR) helps to constitute a powerful predictive and prognostic nomogram. This scoring tool allows clinicians to stratify COVID-19 severities on admission and guide early interventions to accelerate recovery and shorten the course of disease in order to alleviate the shortage of medical resources and reduce mortality.


title: Obesity and Higher Risk for Severe Complications of Covid-19: What to do when the two pandemics meet.

text: The coronavirus disease 2019 (COVID-19) pandemic has spread around the globe, infecting more than ten million individuals, with more than 500,000 dead; about one half of the infected people have recovered. Despite this fact, a subgroup of individuals affected by COVID-19 is at greater risk of developing worse outcomes and experience a high rate of mortality. Data on the association between obesity and COVID-19 are growing; the available studies, have reported a high prevalence of overweight and obesity in patients experiencing a severe COVID-19 course, with serious complications requiring hospitalization and admission to intensive care units. This paper attempts to highlight potential mechanisms behind the greater vulnerability to COVID-19 of individuals with obesity. The presence of uncontrolled chronic obesity-related comorbidities, particularly pulmonary diseases, can present a primary fertile soil for respiratory tract infection. Combined with immune system impairments, such as alteration in the T-cell proliferation and macrophage differentiation, and the high pro-inflammatory cytokine production by the adipose organ, this may worsen the general condition toward a systemic diffusion of infection. Prevention remains the first line of intervention in these patients that can be achieved by adhering to social distancing and adopting hygiene precautions, combined with a healthy lifestyle. Patients with obesity require preferential access dedicated to primary care services to ensure they are regularly taking their medications for the treatment of any concurrent chronic diseases. Finally, their physicians must promptly manage any medical signs or symptoms in the case of suspected severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) infection to prevent the risk of severe outcomes.


title: Molecular characterization of infectious bronchitis virus isolates from Russia and neighbouring countries: identification of intertypic recombination in the S1 gene.

text: Infectious bronchitis virus (IBV) isolates recovered in Russia, Ukraine, and Kazakhstan between 2007 and 2010 were subjected to molecular characterization and compared with those isolated a decade ago. The IBV genome was detected in 202 out of 605 field samples from chickens with various clinical signs. Partial sequencing of the S1 gene revealed 153 vaccine strains and 49 field isolates of several genetic groups. Massachusetts, 793/B and D274 remained the predominant IBV genotypes along with QX, whereas B1648, Italy-02, Arkansas and variants accounted for about 12% of the total number. Three IBVs contained recombinant S1 gene sequences comprising genome fragments of QX-type field isolates and vaccine strains H120 (UKR/02/2009) or 4/91 (RF/03/2010), and vaccine strains H120 and D274 (RF/01/2010). The results of the present study showed a significant decline in prevalence of variant IBVs and a further spread of QX-type isolates in commercial chicken flocks in Russia as compared with the 1998 to 2002 data.


Editorial: Clinical trial design in the era of COVID-19.


title: Prevalence and predictors of medication non-adherence among patients with multimorbidity: A systematic review protocol.

text: Introduction: Patients with multimorbidity are expected to adhere to complex medication regimens in order to manage their multiple chronic conditions. It has been reported the likelihood of adherence decreases as patients are prescribed more medications. Much medication adherence research to date is dominated by a single-disease focus, which is at odds with the rising prevalence of multimorbidity and may artificially underestimate the complexity of managing chronic illness. This review aims to describe the prevalence of medication non-adherence among patients with multimorbidity, and to identify potential predictors of non-adherence in this population. Methods: A systematic review will be conducted and reported according to PRISMA guidelines. PubMed, EMBASE, CINAHL and PsycINFO will be searched using a predefined search strategy from 2009-2019. Quantitative studies will be considered eligible for review if prevalence of medication non-adherence among adults with two or more chronic conditions is reported. Studies will be included in the review if available in English full text. Titles and abstracts will be screened by single review, with 20% of screening cross-checked by a second reviewer. Full-text articles will be screened by two independent reviewers, noting reasons for exclusions. Data extraction will be performed using a predefined extraction form. Quality and risk of bias assessment will be conducted using criteria for observational studies outlined by Sanderson et al. (2007). A narrative synthesis and, if feasible, meta-analysis will be conducted. Discussion: By exploring medication non-adherence from a multimorbidity perspective, the review aims to inform an evidence base for intervention development which accounts for the rising prevalence of patients with multiple chronic conditions. Study registration: The systematic review is prospectively registered in PROSPERO ( CRD42019133849); registered on 12 June 2019.


title: Analysis of neuron-specific enolase and S100B as biomarkers of cognitive decline following surgery in older people.

text: BACKGROUND/AIMS Post-operative cognitive decline is frequent in older individuals following major surgery; however, biomarkers of this decline are less clearly defined. METHODS Sixty-eight participants over the age of 60 provided blood samples at baseline and 24 h post-surgery. Cognitive decline was measured at baseline and 52 weeks post-surgery using the Cambridge Assessment for Mental Disorder in the Elderly, section B (CAMCOG) score. Plasma levels of neuron-specific enolase (NSE) and S100B were measured by ELISA. RESULTS Baseline NSE and the change in NSE levels between baseline and 24 h were correlated with the change in CAMCOG score between baseline and 52 weeks. CONCLUSION NSE concentrations may be a useful predictor of individuals at risk of more severe long-term cognitive decline.


title: Flexibility of Finger Activation Patterns Elicited through Non-invasive Multi-Electrode Nerve Stimulation.

text: The inability to effectively activate and control skeletal muscles is a common impairment following a variety of neurological conditions or injuries. One common approach to restoring or augmenting this impairment is the use of external electrical stimulation of the muscles, called functional electrical stimulation (FES). Typically targeted directly at the anatomical muscle belly, existing methodologies often involve high current amplitudes, limited superficial muscle activation, and early onset of muscle fatigue. We have recently explored the capabilities of a non-invasive peripheral nerve stimulation method for the dexterous control of finger and hand muscles. Further development of our stimulation system has enabled us to manually search across a variety of stimulation locations with increased consistency and efficiency. This study examined the preliminary results in two subjects of an automated stimulation system which can rapidly characterize a large combination of stimulation electrodes. Our preliminary findings suggested that the stimulation grid was able to produce a number of clustered EMG activities and finger forces. This robust ability to flexibly generate different grasp patterns demonstrates the promise of the methodology in future applications for FES and rehabilitation.


title: Pediatric Microlaryngoscopy and Bronchoscopy in the COVID-19 Era.

text: Importance As an aerosol-generating procedure, traditional pediatric microlaryngoscopy and bronchoscopy techniques must be adapted in order to reduce the risk of transmission of severe acute respiratory syndrome coronavirus 2. Objective To describe a modified technique for pediatric microlaryngoscopy and bronchoscopy for use in the COVID-19 era and present a case series of patients for whom the technique has been used. Design, Setting, and Participants Observational case series of pediatric patients undergoing emergency or urgent airway procedures performed at a tertiary pediatric otolaryngology department in Australia. Procedures were completed between March 23 and April 9, 2020, with a median (range) follow-up of 24.5 (11-28) days. Exposures Modified technique for microlaryngoscopy and bronchoscopy, minimizing aerosolization of respiratory tract secretions. Main Outcomes and Measures The main outcome was the feasibility of technique, which was measured by ability to perform microlaryngoscopy and bronchoscopy with comparable success to the usual technique (ie, adequate examination of the patient for diagnostic procedures and ability to perform interventional procedures). Results The technique was used successfully in 8 patients (median [range] age, 160 days [27 days to 2 years 6 months]); 5 patients were male, and 3 were female. Intervention was performed on 6 patients; 2 balloon dilations for subglottic stenosis, 2 injections of hyaluronic acid for type 1 clefts, and 2 cold-steel supraglottoplasties. No adverse events occurred. Conclusions and Relevance In this case series, feasibility of a modified technique for pediatric microlaryngoscopy and bronchoscopy was demonstrated. By reconsidering the surgical approach in light of specific COVID-19 infection risks, this technique may be associated with reduced spread of aerosolized respiratory secretions perioperatively and intraoperatively, but the technique and patient outcomes require further study.


title: Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective.

text: The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making.


Diabetes and COVID-19.


title: Endotracheal tube cuff--small important part of a big issue.

text: Many of the complications related to prolonged ventilation are related to inappropriate handling of endotracheal tube (ETT) cuff. This article reviews the possible complications associated with the ETT cuff, and the landmark development made in that field. The article challenges the present paradigm of cuff use and reviews the current clinical practice in that area.


title: Pharmacokinetics and pharmacodynamics of propofol: changes in patients with frontal brain tumours.

text: Background Models of propofol pharmacokinetics and pharmacodynamics developed in patients without brain pathology are widely used for target-controlled infusion (TCI) during brain tumour excision operations. The goal of this study was to determine if the presence of a frontal brain tumour influences propofol pharmacokinetics and pharmacodynamics and existing PK-PD model performance. Methods Twenty patients with a frontal brain tumour and 20 control patients received a propofol infusion to achieve an induction-emergence-induction anaesthetic sequence. Propofol plasma concentration was measured every 4 min and at each transition of the conscious state. Bispectral index (BIS) values were continuously recorded. We used non-linear mixed-effects modelling to analyse the effects of the presence of a brain tumour on the pharmacokinetics and pharmacodynamics of propofol. Subsequently we calculated the predictive performance of Marsh, Schnider, and Eleveld models in terms of median prediction error (MdPE) and median absolute prediction error (MdAPE). Results Patients with brain tumours showed 40% higher propofol clearance than control patients. Performance of the Schnider model (MdPEpk -20.0%, MdAPEpk 23.4%) and Eleveld volunteer model (MdPEpk -8.58%, MdAPEpk 21.6%) were good. The Marsh model performed less well (MdPEpk -14.3%, MdAPEpk 41.4%), as did the Eleveld patient model (MdPEpk -30.8%, MdAPEpk 32.1%). Conclusions Brain tumours might alter the pharmacokinetics of propofol. Caution should be exerted when using propofol TCI in patients with frontal brain tumours due to higher clearance. Trial registry number NCT01060631.


title: Corridor-based endonasal endoscopic surgery for pediatric skull base pathology with detailed radioanatomic measurements.

text: BACKGROUND Pediatric anatomy is more restricted, and the propagation of endonasal endoscopic approaches in the pediatric population has been limited. OBJECTIVE To demonstrate the feasibility of the endonasal endoscopic approach in a variety of age groups and to perform measurements of the corridors and spaces available for surgery as a guide for case selection. METHODS Only patients <18 years were included. The choice of operative corridor/approach is described in relation to pathological entity and location. Preoperative/postoperative visual fields and endocrine panels, extent of resection, as well as postoperative long-term complications are described. Prospective magnetic resonance image-based anatomic measurements of key distances were performed to determine age-dependent surgical indications and limitations. RESULTS Forty purely endoscopic procedures were performed in 33 pediatric patients (5-18 years of age) harboring a variety of skull base lesions, from benign tumors to congenital malformations. For the 20 patients in whom gross total resection was the intended goal of surgery, gross total resection was attained in 15 (75%). There were 2 infections (5%) and no cerebrospinal fluid leaks. Significant improvement was shown in 58.3% of patients with visual deficits. Hormone overproduction resolved in 75% of patients, while preoperative hormone insufficiency only improved in 29.2%. Wider intercarotid distance at the superior clivus (P = .01) and shorter nare-dens working distance (P = .001) predicted improved outcomes and fewer postoperative complications. CONCLUSION Endonasal endoscopic skull base approaches are viable in the pediatric population, they are not impeded by sphenoid sinus aeration, and they have minimal risk of cerebrospinal fluid leak and meningitis. Outcomes and complications can be predicted based on specific radio anatomical skull base measurements rather than age.


title: Hospital Variation in Functional Recovery After Stroke.

text: BACKGROUND Functional status is a key patient-centric outcome, but there are little data on whether functional recovery post-stroke varies among hospitals. This study examined the distribution of functional status 3 months after stroke, determined whether these outcomes vary among hospitals, and identified hospital characteristics associated with better (or worse) functional outcomes. METHODS AND RESULTS Observational analysis of the AVAIL study (Adherence Evaluation After Ischemic Stroke-Longitudinal) included 2083 ischemic stroke patients enrolled from 82 US hospitals participating in Get With The Guidelines-Stroke and AVAIL. The primary outcome was dependence or death at 3 months (modified Rankin Scale [mRS] score of 3-6). Secondary outcomes included functional dependence (mRS score of 3-5), disabled (mRS score of 2-5), and mRS evaluated as a continuous score. By 3 months post-discharge, 36.5% of patients were functionally dependent or dead. Rates of dependence or death varied widely by discharging hospitals (range: 0%-67%). After risk adjustment, patients had lower rates of 3-month dependence or death when treated at teaching hospitals (odds ratio, 0.72; 95% confidence interval, 0.54-0.96) and certified primary stroke centers (odds ratio, 0.69; 95% confidence interval, 0.53-0.91). In contrast, a composite measure of hospital-level adherence to acute stroke care performance metrics, stroke volume, and bed size was not associated with downstream patient functional status. Findings were robust across mRS end points and sensitivity analyses. CONCLUSIONS One third of acute ischemic stroke patients were functionally dependent or dead 3 months postacute stroke; functional recovery rates varied considerably among hospitals, supporting the need to better determine which care processes can maximize functional outcomes.


title: Changing attitudes and improving skills: demonstrating the value of the SAGES flexible endoscopy course for fellows.

text: BACKGROUND The purpose of this study was to examine the effectiveness of the SAGES flexible endoscopy course in improving fellows' attitudes, confidence, and skills related to implementing endoscopy in practice. METHODS Fellows participated in a 2-day course consisting of case presentations, expert panels, and hands-on laboratory training. Before and after the course, fellows completed a questionnaire assessing demographics, experiences in residency, practice plans, plans to implement flexible endoscopy in practice, and level of confidence performing 15 endoscopic procedures. Half of the fellows were randomly assigned to complete pre- and post-skills testing using a previously validated endoscopic targeting model. RESULTS Fifty-four fellows (90 %; age 33.5 ± 2.8; 58 % male) completed the pre- and post-questionnaire. All MIS fellowship types were represented. Almost half (48 %) reported none or very little flexible endoscopy in their current fellowship. The average prior case volume among those completing an ACGME-approved residency (42/54) was 76 upper and 75 lower endoscopies with one-third reporting no experience in therapeutic EGD (33 %) or polypectomy (31 %). Intentions to implement flexible endoscopy in practice significantly improved after the course overall (3.72 ± .85-3.92 ± .69, p < 0.05; 1 = never; 5 = very frequently). Prior to the course, 39 % of fellows reported plans to use endoscopy in practice "occasionally" or "rarely." After, this decreased to 28 with 72 % planning to implement "frequently" or "very frequently." Mean levels of confidence performing all 15 endoscopic tasks improved significantly after the course. Skills performance for the 27 fellows improved significantly as well; participants decreased their time to perform the targeting task by 40 % (222.3 ± 119.8-133.0 ± 70.1 s; p < 0.001) and decreased errors by 49 % (2.9 ± 1.7-1.5 ± 1.5; p < 0.001). CONCLUSIONS These results indicate that the SAGES flexible endoscopy course increases fellow confidence to implement endoscopic techniques, expands the ways in which they plan to include endoscopy in practice, and enhances their endoscopic skills.


title: Antenatal Corticosteroids for Pregnant Women at High Risk of Preterm Delivery with COVID-19 Infection: A Decision Analysis.

text: OBJECTIVE Antenatal corticosteroids given prior to preterm deliveries reduce the risk of adverse neonatal outcomes. However, steroid administration in the setting of a viral respiratory infection can worsen maternal outcomes. Therefore, the decision to administer corticosteroids must balance the neonatal benefits with the potential harm to the mother if she is infected with the novel coronavirus disease 2019 (COVID-19). This study aimed to determine the gestational ages for which administering antenatal corticosteroids to women at high risk of preterm labor with concurrent COVID-19 infection results in improved combined maternal and infant outcomes. STUDY DESIGN A decision-analytic model using TreeAge (2020) software was constructed for a theoretical cohort of hospitalized women with COVID-19 in the United States. All model inputs were derived from the literature. Outcomes included maternal intensive care unit (ICU) admission and death, along with infant outcomes of death, respiratory distress syndrome, intraventricular hemorrhage, and neurodevelopmental delay. Quality-adjusted life years (QALYs) were assessed from the maternal and infant perspectives. Sensitivity analyses were performed to determine if the results were robust over a range of assumptions. RESULTS In our theoretical cohort of 10,000 women delivering between 24 and 33 weeks of gestation with COVID-19, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths. Overall, we found that corticosteroid administration resulted in higher combined QALYs up to 31 weeks of gestation in all hospitalized patients, and up to 29 weeks of gestation in ICU patients. CONCLUSION Administration of antenatal corticosteroids at less than 32 weeks of gestation for hospitalized patients and less than 30 weeks of gestation for patients admitted to the ICU resulted in higher combined maternal and infant outcomes compared with expectant management for women at high risk of preterm birth with COVID-19 infection. These results can guide clinicians in their counseling and management of these pregnant women. KEY POINTS · Antenatal steroids reduce adverse neonatal outcomes.. · Steroids worsen maternal outcomes in COVID-19.. · Steroids given < 32 weeks result in improved outcomes..


title: Bacterial contamination of suction catheter tips during aortic valve replacement surgery: a prospective observational cohort study.

text: BACKGROUND Bacterial mediastinitis is a severe complication after open heart surgery. The infection causes prolonged hospitalization and an increased mortality risk. Observations from orthopaedic surgery showed that the suction catheter used during surgery is commonly contaminated with bacteria. The aim of this study was to describe the prevalence of suction catheter contamination in cardiac surgery and to study if suction time influences the contamination risk. METHODS Fifty suction catheter tips were collected during 25 aortic valve replacement operations. The suction tip was exchanged once during the operation (after aortotomy closure). The tips were subjected to bacterial contamination analysis. RESULTS In 20 of the 25 investigated cases (80%), bacterial contamination was detected on one or both tips. The tip used during the beginning of the operation showed bacterial contamination in 13/25 cases (52%) and the second tip in 12/25 (48%). In 5/25 cases (20%) both tips were contaminated. There was no association between bacterial contamination and suction time. Coagulase-negative staphylococcus was the most commonly detected microorganism. CONCLUSIONS The suction device should be considered as a potential source of bacterial contamination in cardiac surgery. The results suggest that the suction catheter should be replaced before key moments like valve implantation and sternal closure.


Do Right to Try Laws Undermine the FDA'S Authority? An Examination of the Consequences of Unlimited Access to Unapproved Drugs.


title: Provision of Psychotherapy during the COVID-19 Pandemic among Czech, German and Slovak Psychotherapists.

text: Psychotherapists around the world are facing an unprecedented situation with the outbreak of the novel coronavirus disease (COVID-19). To combat the rapid spread of the virus, direct contact with others has to be avoided when possible. Therefore, remote psychotherapy provides a valuable option to continue mental health care during the COVID-19 pandemic. The present study investigated the fear of psychotherapists to become infected with COVID-19 during psychotherapy in personal contact and assessed how the provision of psychotherapy changed due to the COVID-19 situation and whether there were differences with regard to country and gender. Psychotherapists from three European countries: Czech Republic (CZ, n = 112), Germany (DE, n = 130) and Slovakia (SK, n = 96), with on average 77.8% female participants, completed an online survey. Participants rated the fear of COVID-19 infection during face-to-face psychotherapy and reported the number of patients treated on average per week (in personal contact, via telephone, via internet) during the COVID-19 situation as well as (retrospectively) in the months before. Fear of COVID-19 infection was highest in SK and lowest in DE (p < 0.001) and was higher in female compared to male psychotherapists (p = 0.021). In all countries, the number of patients treated on average per week in personal contact decreased (p < 0.001) and remote psychotherapies increased (p < 0.001), with more patients being treated via internet than via telephone during the COVID-19 situation (p < 0.001). Furthermore, female psychotherapists treated less patients in personal contact (p = 0.036), while they treated more patients via telephone than their male colleagues (p = 0.015). Overall, the total number of patients treated did not differ during COVID-19 from the months before (p = 0.133) and psychotherapy in personal contact remained the most common treatment modality. Results imply that the supply of mental health care could be maintained during COVID-19 and that changes in the provision of psychotherapy vary among countries and gender.


title: Clinical negligence claims following the COVID-19 pandemic.

text: John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses how the Courts may view clinical negligence claims brought by families who have lost loved ones during the pandemic.


title: A direct aspiration first-pass technique vs stentriever thrombectomy in emergent large vessel intracranial occlusions.

text: OBJECTIVE Endovascular thrombectomy in patients with acute ischemic stroke caused by occlusion of the proximal anterior circulation arteries is superior to standard medical therapy. Stentriever thrombectomy with or without aspiration assistance was the predominant technique used in the 5 randomized controlled trials that demonstrated the superiority of endovascular thrombectomy. Other studies have highlighted the efficacy of a direct aspiration first-pass technique (ADAPT). METHODS To compare the angiographic and clinical outcomes of ADAPT versus stentriever thrombectomy in patients with emergent large vessel occlusions (ELVO) of the anterior intracranial circulation, the records of 134 patients who were treated between June 2012 and October 2015 were reviewed. RESULTS Within this cohort, 117 patients were eligible for evaluation. ADAPT was used in 47 patients, 20 (42.5%) of whom required rescue stentriever thrombectomy, and primary stentriever thrombectomy was performed in 70 patients. Patients in the ADAPT group were slightly younger than those in the stentriever group (63.5 vs 69.4 years; p = 0.04); however, there were no differences in the other baseline clinical or radiographic factors. Procedural time (54.0 vs 77.1 minutes; p < 0.01) and time to a Thrombolysis in Cerebral Infarction (TICI) scale score of 2b/3 recanalization (294.3 vs 346.7 minutes; p < 0.01) were significantly lower in patients undergoing ADAPT versus stentriever thrombectomy. The rates of TICI 2b/3 recanalization were similar between the ADAPT and stentriever groups (82.9% vs 71.4%; p = 0.19). There were no differences in the rates of symptomatic intracranial hemorrhage or procedural complications. The rates of good functional outcome (modified Rankin Scale Score 0-2) at 90 days were similar between the ADAPT and stentriever groups (48.9% vs 41.4%; p = 0.45), even when accounting for the subset of patients in the ADAPT group who required rescue stentriever thrombectomy. CONCLUSIONS The present study demonstrates that ADAPT and primary stentriever thrombectomy for acute ischemic stroke due to ELVO are equivalent with respect to the rates of TICI 2b/3 recanalization and 90-day mRS scores. Given the reduced procedural time and time to TICI 2b/3 recanalization with similar functional outcomes, an initial attempt at recanalization with ADAPT may be warranted prior to stentriever thrombectomy.


title: Current Status of Distal Embolization in Femoropopliteal Endovascular Interventions.

text: The application of advanced endovascular techniques in very complex femoropopliteal atherosclerotic lesions has shown to expose patients to a higher risk of distal embolization (DE). This complication can affect both the short- and long-term outcomes, leading to worsening ischemia, early minor/major amputation, and longer hospital stay. Recently, there has been an increasing body of evidence on pathophysiology and clinical-radiological management of DE that however has not been systematically addressed by guidelines. The aim of this review was to analyze the current evidence outlining definition and classification, risk assessment, prevention, and management strategies of DE in femoropopliteal endovascular interventions.


title: Continuous on-line glucose measurement by microdialysis in a central vein. A pilot study.

text: INTRODUCTION Tight glucose control in the ICU has been proven difficult with an increased risk for hypoglycaemic episodes. Also the variability of glucose may have an impact on morbidity. An accurate and feasible on-line/continuous measurement is therefore desired. In this study a central vein catheter with a microdialysis membrane in combination with an on-line analyzer for continuous monitoring of circulating glucose and lactate by the central route was tested. METHODS A total of 10 patients scheduled for major upper abdominal surgery were included in this observational prospective study at a university hospital. The patients received an extra central venous catheter with a microdialysis membrane placed in the right jugular vein. Continuous microdialysis measurement proceeded for 20 hours and on-line values were recorded every minute. Reference arterial plasma glucose and blood lactate samples were collected every hour. RESULTS Mean microdialysis-glucose during measurements was 9.8 ± 2.4 mmol/l.No statistical difference in the readings was seen using a single calibration compared to eighth hour calibration (P =0.09; t-test). There was a close agreement between the continuous reading and the reference plasma glucose values with an absolute difference of 0.6+0.8 mmol, or 6.8+9.3% and measurements showed high correlation to plasma readings (r = 0.92). The limit of agreement was 23.0%(1.94 mmol/l) compared to arterial plasma values with a line of equality close to zero.However, in a Clarke-Error Grid 93.3% of the values are in the A-area,and the remaining part in the B-area.Mean microdialysis-lactate was 1.3 ± 1.1 mmol/l. The measurements showed high correlation to the blood readings (r = 0.93). CONCLUSION Continuous on-line microdialysis glucose measurement in a central vein is a potential useful technique for continuous glucose monitoring in critically ill patients, but more improvements and testing are needed.


title: Leadership requirements for Lean versus servant leadership in health care: a systematic review of the literature.

text: As health care organizations face pressures to improve quality and efficiency while reducing costs, leaders are adopting management techniques and tools used in manufacturing and other industries, especially Lean. Successful Lean leaders appear to use a coaching leadership style that shares underlying principles with servant leadership. There is little information about specific similarities and differences between Lean and servant leaderships. We systematically reviewed the literature on Lean leadership, servant leadership, and health care and performed a comparative analysis of attributes using Russell and Stone's leadership framework. We found significant overlap between the two leadership styles, although there were notable differences in origins, philosophy, characteristics and behaviors, and tools. We conclude that both Lean and servant leaderships are promising models that can contribute to the delivery of patient-centered, high-value care. Servant leadership may provide the means to engage and develop employees to become successful Lean leaders in health care organizations.


title: The role of the skin microbiome in atopic dermatitis: a systematic review.

text: Dysbiosis is a hallmark of atopic dermatitis (AD). The composition of skin microbiome communities and the causality of dysbiosis in eczema have not been well established. The objective of this review is to describe the skin microbiome profile in AD and address whether there is a causal relationship between dysbiosis and AD. The protocol is registered in PROSPERO (CRD42016035813). We searched PubMed, Embase, Scopus and ClinicalTrials.gov for primary research studies applying culture-independent analysis on the microbiome on AD skin of humans and animal models. Two authors independently screened the full text of studies for eligibility and assessed risk of bias. Because of heterogeneity no quantitative synthesis was done. Of 5735 texts, 32 met the inclusion criteria (17 published: 11 human and six animal studies). The studies varied in quality and applied different methodology. The skin in AD had low bacterial diversity (lowest at dermatitis-involved sites) and three studies showed depletion of Malassezia spp. and high non-Malassezia fungal diversity. The relative abundance of Staphylococcus aureus and Staphylococcus epidermidis were elevated and other genera were reduced, including Propionibacterium. A mouse study indicated that dysbiosis is a driving factor in eczema pathogenesis. The data are not sufficiently robust for good characterization; however, dysbiosis in AD not only implicates Staphylococcus spp., but also microbes such as Propionibacterium and Malassezia. A causal role of dysbiosis in eczema in mice should encourage future studies to investigate if this also applies to humans. Other important aspects are temporal dynamics and the influence of methodology on microbiome data.


title: The Added Value of Partial Stomach-partitioning to a Conventional Gastrojejunostomy in the Treatment of Gastric Outlet Obstruction.

text: INTRODUCTION Poor results have been reported after conventional gastrojejunostomy (CGJ) as palliative surgical bypass treatment of gastric outlet obstruction (GOO). Partial stomach-partitioning gastrojejunostomy (PSPGJ) has been introduced as an alternative surgical treatment of GOO to reduce the risk of postoperative delayed gastric emptying (DGE). AIM The aim was to study PSPGJ as an alternative to CGJ in the treatment of GOO, with respect to DGE. PATIENTS AND METHODS A retrospective cohort study was completed in all patients who underwent a bypass of the duodenum via PSPGJ or CGJ due to GOO. Cases where concomitant biliary or bariatric procedures were performed were excluded. RESULTS Twenty-four patients met the inclusion criteria for the study; ten cases underwent PSPGJ and 14 CGJ. The incidence of DGE grade B-C was significantly lower in the PSPGJ group (0 %) compared with the CGJ group (42.9 %, p = 0.024). Oral nutrition only was recorded more often at follow-up in the PSPGJ group (9/9, 100 %) than in the CGJ group (4/13, 30.8 %) (p = 0.002). CONCLUSION PSPGJ seems to be followed by a lower rate of DGE compared to CGJ.


title: The renal microcirculation in sepsis.

text: Despite identification of several cellular mechanisms being thought to underlie the development of septic acute kidney injury (AKI), the pathophysiology of the occurrence of AKI is still poorly understood. It is clear, however, that instead of a single mechanism being responsible for its aetiology, an orchestra of cellular mechanisms failing is associated with AKI. The integrative physiological compartment where these mechanisms come together and exert their integrative deleterious action is the renal microcirculation (MC). This is why it is opportune to review the response of the renal MC to sepsis and discuss the determinants of its (dys)function and how it contributes to the pathogenesis of renal failure. A main determinant of adequate organ function is the adequate supply and utilization of oxygen at the microcirculatory and cellular level to perform organ function. The highly complex architecture of the renal microvasculature, the need to meet a high energy demand and the fact that the kidney is borderline ischaemic makes the kidney a highly vulnerable organ to hypoxaemic injury. Under normal, steady-state conditions, oxygen (O2) supply to the renal tissues is well regulated; however, under septic conditions the delicate balance of oxygen supply versus demand is disturbed due to renal microvasculature dysfunction. This dysfunction is largely due to the interaction of renal oxygen handling, nitric oxide metabolism and radical formation. Renal tissue oxygenation is highly heterogeneous not only between the cortex and medulla but also within these renal compartments. Integrative evaluation of the different determinants of tissue oxygen in sepsis models has identified the deterioration of microcirculatory oxygenation as a key component in the development AKI. It is becoming clear that resuscitation of the failing kidney needs to integratively correct the homeostasis between oxygen, and reactive oxygen and nitrogen species. Several experimental therapeutic modalities have been found to be effective in restoring microcirculatory oxygenation in parallel to improving renal function following septic AKI. However, these have to be verified in clinical studies. The development of clinical physiological biomarkers of AKI specifically aimed at the MC should form a valuable contribution to monitoring such new therapeutic modalities.


title: The Autophagy-Related Protein GABARAP Is Induced during Overwintering in the Bean Bug (Hemiptera: Alydidae).

text: In most insects dependent on food resources that deplete seasonally, mechanisms exist to protect against starvation. Insects overcome periods of food depletion using diapause-associated physiological mechanisms, such as increased energy resources in fat bodies and suppression of metabolism. Because autophagy supplies energy resources through the degradation of intracellular components, we hypothesized that it might be an additional strategy to combat starvation during overwintering. In this study, we measured the abundance of the proteins involved in the signaling pathway of autophagy during overwintering in adults of the bean bug Riptortus pedestris (Fabricius) (Hemiptera: Alydidae), which must withstand the periodic depletion of its host plants from late fall to early spring. Although the levels of gamma-aminobutyric acid receptor-associated protein (GABARAP) markedly increased after the cessation of food supply, AMP-activated protein kinase (AMPK) and target of rapamycin (TOR) were not found to be associated with food depletion. Thus, food depletion appears to induce autophagy independent of AMPK and TOR. The GABARAP levels significantly increased universally when the food supply ceased, irrespective of the diapause status of adults and low-temperature conditions. In overwintering diapause adults under seminatural conditions, the GABARAP levels significantly increased during early spring. Thus, autophagy appears to assist the survival of the bean bugs under natural conditions of food deficiency.


title: Electronic patient-generated health data to facilitate prevention and health promotion: a scoping review protocol.

text: INTRODUCTION Rapidly expanding digital innovations transform the perception, reception and provision of health services. Simultaneously, health system challenges underline the need for patient-centred, empowering and citizen-engaging care, which facilitates a focus on prevention and health promotion. Through enhanced patient-engagement, patient-provider interactions and reduced information gaps, electronic patient-generated health data (PGHD) may facilitate both patient-centeredness and preventive scare. Despite that, comprehensive knowledge syntheses on their utilisation for prevention and health promotion purposes are lacking. The review described in this protocol aims to fill that gap. METHODS AND ANALYSIS Our methodology is guided by Arksey and O' Malley's methodological framework for scoping reviews, as well as its advanced version by Levac, Colquhoun and O'Brien. Seven electronic databases will be systematically searched using predefined keywords. Key electronic journals will be hand searched, while reference lists of included documents and grey literature sources will be screened thoroughly. Two independent reviewers will complete study selection and data extraction. One of the team's senior research members will act as a third reviewer and make the final decision on disputed documents. We will include literature with a focus on electronic PGHD and linked to prevention and health promotion. Literature on prevention that is driven by existing discomfort or disability goes beyond the review's scope and will be excluded. Analysis will be narrative and guided by Shapiro et al's adapted framework on PGHD flow. ETHICS AND DISSEMINATION The scoping review described in this protocol aims to establish a baseline understanding of electronic PGHD generation, collection, communication, sharing, interpretation, utilisation, context and impact for preventive purposes. The chosen methodology is based on the use of publicly available information and does not require ethical approval. Review findings will be disseminated in digital health conferences and symposia. Results will be published and additionally shared with relevant local and national authorities.


title: Converging and diverging needs between patients and providers who are collecting and using patient-generated health data: an integrative review.

text: Objective This integrative review identifies convergent and divergent areas of need for collecting and using patient-generated health data (PGHD) identified by patients and providers (i.e., physicians, nurses, advanced practice nurses, physician assistants, and dietitians). Methods A systematic search of 9 scholarly databases targeted peer-reviewed studies published after 2010 that reported patients' and/or providers' needs for incorporating PGHD in clinical care. The studies were assessed for quality and bias with the Mixed-Methods Appraisal Tool. The results section of each article was coded to themes inductively developed to categorize patient and provider needs. Distinct claims were extracted and areas of convergence and divergence identified. Results Eleven studies met inclusion criteria. All had moderate to low risk of bias. Three themes (clinical, logistic, and technological needs), and 13 subthemes emerged. Forty-eight claims were extracted. Four were divergent and twenty were convergent. The remainder was discussed by only patients or only providers. Conclusion As momentum gains for integrating PGHD into clinical care, this analysis of primary source data is critical to understanding the requirements of the 2 groups directly involved in collection and use of PGHD.


Ethical issues in caring for patients with Ebola: implications for critical care nurses.


title: Conduit Vascular Evaluation is Associated with Reduction in Anastomotic Leak After Esophagectomy.

text: BACKGROUND Anastomotic leak following esophagectomy is associated with significant morbidity and mortality. A major factor determining anastomotic success is an adequate blood supply to the conduit. The aim of this study was to determine the impact of intraoperative evaluation of the conduit's vascular supply on anastomotic failure after esophagectomy. METHODS We retrospectively analyzed data from 90 consecutive patients undergoing esophagectomy with gastric conduit reconstruction. A change in surgical practice occurred after 60 cases were completed, when we introduced the use of intraoperative indocyanine green fluorescence angiography and Doppler examination to evaluate blood supply and assist in construction of the conduit. The leak rates before and after implementation of conduit vascular evaluation were compared. RESULTS After the introduction of intraoperative vascular evaluation of the gastric conduit, we noted a dramatic decrease in the rate of anastomotic leak from 20 % in the first 60 patients to 0 % in the succeeding 30 patients. CONCLUSIONS Intraoperative vascular evaluation with indocyanine green fluorescence imaging and Doppler examination of the gastric conduit used to assist reconstruction after esophagectomy allows for enhanced construction of the conduit that maximizes blood supply to the anastomosis. This change in practice was associated with a significant reduction in anastomotic leak rate.


title: Baylisascaris procyonis-Associated Meningoencephalitis in a Previously Healthy Adult, California, USA.

text: After severe neurocognitive decline developed in an otherwise healthy 63-year-old man, brain magnetic resonance imaging showed eosinophilic meningoencephalitis and enhancing lesions. The patient tested positive for antibodies to Baylisascaris spp. roundworms, was treated with albendazole and dexamethasone, and showed improvement after 3 months. Baylisascariasis should be considered for all patients with eosinophilic meningitis.


Neurology in the time of covid-19.


title: Reward related ventral striatal activity and differential response to sertraline versus placebo in depressed individuals.

text: Medications to treat major depressive disorder (MDD) are not equally effective across patients. Given that neural response to rewards is altered in MDD and given that reward-related circuitry is modulated by dopamine and serotonin, we examined, for the first time, whether reward-related neural activity moderated response to sertraline, an antidepressant medication that targets these neurotransmitters. A total of 222 unmedicated adults with MDD randomized to receive sertraline (n = 110) or placebo (n = 112) in the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study completed demographic and clinical assessments, and pretreatment functional magnetic resonance imaging while performing a reward task. We tested whether an index of reward system function in the ventral striatum (VS), a key reward circuitry region, moderated differential response to sertraline versus placebo, assessed with the Hamilton Rating Scale for Depression (HSRD) over 8 weeks. We observed a significant moderation effect of the reward index, reflecting the temporal dynamics of VS activity, on week-8 depression levels (Fs ≥ 9.67, ps ≤ 0.002). Specifically, VS responses that were abnormal with respect to predictions from reinforcement learning theory were associated with lower week-8 depression symptoms in the sertraline versus placebo arms. Thus, a more abnormal pattern of pretreatment VS dynamic response to reward expectancy (expected outcome value) and prediction error (difference between expected and actual outcome), likely reflecting serotonergic and dopaminergic deficits, was associated with better response to sertraline than placebo. Pretreatment measures of reward-related VS activity may serve as objective neural markers to advance efforts to personalize interventions by guiding individual-level choice of antidepressant treatment.


title: National cross-sectional survey to explore preparation to undertake aseptic technique in pre-registration nursing curricula in the United Kingdom.

text: BACKGROUND Aseptic technique is a core nursing skill. Sound preparation is required during pre-registration nursing education to enable student nurses to acquire the knowledge and skills necessary to prevent and control healthcare-associated infection and promote patient safety. Few studies have explored nursing students' education and training in aseptic technique. OBJECTIVES To investigate what, when and how pre-registration nursing students are taught aseptic technique and how they are assessed in undergraduate, pre-registration nursing programmes in the United Kingdom. DESIGN National cross-sectional survey exploring preparation to undertake aseptic technique in pre-registration nursing curricula in the United Kingdom. SETTING Universities providing undergraduate, pre-registration adult nursing programmes in the United Kingdom. PARTICIPANTS Nurse educators. METHODS Structured telephone interviews were conducted with nurse educators. Descriptive and inferential statistical data analyses were undertaken. RESULTS Response rate was 70% (n = 49/70). A variety of different learning and teaching methods were reported to be in use. Teaching in relation to aseptic technique took place in conjunction with teaching in relation to different clinical procedures rather than placing emphasis on the principles of asepsis per se and how to transfer them to different procedures and situations. Wide variation in teaching time; use of multiple guidelines; inaccuracy in the principles identified by educators as taught to students; and limited opportunity for regular, criteria based competency assessment were apparent across programmes. CONCLUSIONS Pre-registration preparation in relation to aseptic technique requires improvement. There is a need to develop a working definition of aseptic technique. The generalisability of these findings in other healthcare students needs to be explored.


title: TNF-alpha inhibitor adalimumab attenuates endotoxin induced cardiac damage in rats.

text: PURPOSE To investigate the effects of adalimumab pretreatment on the lipopolysaccharide-mediated myocardial injury. METHODS Twenty-eight Wistar rats were randomized into four groups (n=7). Control (C) group animals were injected once a day with intraperitoneal (i.p) 0.9 % saline for two days. In the Adalimumab (Ada) group, adalimumab was injected at a dose of 10 mg/kg/ day (i.p) for two days. Lipopolysaccharide (Lps) group rats were injected with a dose of 5 mg/kg (i.p) lipopolysaccharide. Lipopolysaccharide + Adalimumab (Lps+Ada) group rats received adalimumab before the administration of lipopolysaccharide. The animals were sacrificed 24 h after the last injection and blood samples were obtained for determination of biochemical cardiac injury markers and circulating levels of TNF-α and interleukin-6 (IL-6). Hearts were harvested for histological examination. RESULTS Endotoxin exposure resulted in significant increases in serum cardiac injury markers, serum cytokines and histological myocardial injury scores in the Lps group. The levels of circulating cytokines, cardiac injury markers and histological injury scores for myocardial necrosis, perivascular cell infiltration, and inflammation were significantly reduced in Lps+Ada as compared to Lps group (p<0.05). CONCLUSIONS Adalimumab pretreatment reduces endotoxin-induced myocardial damage in rats. This beneficial effect is thought to be related to the reduction of cytokine release.


title: Severe acute respiratory syndrome-associated coronavirus vaccines formulated with delta inulin adjuvants provide enhanced protection while ameliorating lung eosinophilic immunopathology.

text: UNLABELLED Although the severe acute respiratory syndrome-associated coronavirus (SARS-CoV) epidemic was controlled by nonvaccine measures, coronaviruses remain a major threat to human health. The design of optimal coronavirus vaccines therefore remains a priority. Such vaccines present major challenges: coronavirus immunity often wanes rapidly, individuals needing to be protected include the elderly, and vaccines may exacerbate rather than prevent coronavirus lung immunopathology. To address these issues, we compared in a murine model a range of recombinant spike protein or inactivated whole-virus vaccine candidates alone or adjuvanted with either alum, CpG, or Advax, a new delta inulin-based polysaccharide adjuvant. While all vaccines protected against lethal infection, addition of adjuvant significantly increased serum neutralizing-antibody titers and reduced lung virus titers on day 3 postchallenge. Whereas unadjuvanted or alum-formulated vaccines were associated with significantly increased lung eosinophilic immunopathology on day 6 postchallenge, this was not seen in mice immunized with vaccines formulated with delta inulin adjuvant. Protection against eosinophilic immunopathology by vaccines containing delta inulin adjuvants correlated better with enhanced T-cell gamma interferon (IFN-γ) recall responses rather than reduced interleukin-4 (IL-4) responses, suggesting that immunopathology predominantly reflects an inadequate vaccine-induced Th1 response. This study highlights the critical importance for development of effective and safe coronavirus vaccines of selection of adjuvants based on the ability to induce durable IFN-γ responses. IMPORTANCE Coronaviruses such as SARS-CoV and Middle East respiratory syndrome-associated coronavirus (MERS-CoV) cause high case fatality rates and remain major human public health threats, creating a need for effective vaccines. While coronavirus antigens that induce protective neutralizing antibodies have been identified, coronavirus vaccines present a unique problem in that immunized individuals when infected by virus can develop lung eosinophilic pathology, a problem that is further exacerbated by the formulation of SARS-CoV vaccines with alum adjuvants. This study shows that formulation of SARS-CoV spike protein or inactivated whole-virus vaccines with novel delta inulin-based polysaccharide adjuvants enhances neutralizing-antibody titers and protection against clinical disease but at the same time also protects against development of lung eosinophilic immunopathology. It also shows that immunity achieved with delta inulin adjuvants is long-lived, thereby overcoming the natural tendency for rapidly waning coronavirus immunity. Thus, delta inulin adjuvants may offer a unique ability to develop safer and more effective coronavirus vaccines.


title: Polyamines and Their Role in Virus Infection.

text: Polyamines are small, abundant, aliphatic molecules present in all mammalian cells. Within the context of the cell, they play a myriad of roles, from modulating nucleic acid conformation to promoting cellular proliferation and signaling. In addition, polyamines have emerged as important molecules in virus-host interactions. Many viruses have been shown to require polyamines for one or more aspects of their replication cycle, including DNA and RNA polymerization, nucleic acid packaging, and protein synthesis. Understanding the role of polyamines has become easier with the application of small-molecule inhibitors of polyamine synthesis and the use of interferon-induced regulators of polyamines. Here we review the diverse mechanisms in which viruses require polyamines and investigate blocking polyamine synthesis as a potential broad-spectrum antiviral approach.


title: Plague Masks: The Visual Emergence of Anti-Epidemic Personal Protection Equipment.

text: Often described as "masks" face-worn devices are employed as personal protection equipment by health workers and the general public and considered to be an indispensable technology against epidemics. Simultaneously, they are potent symbols of existential risk. Could these material and visual aspects be more than simply indexically connected? In this article, I examine these apparatuses through a historical anthropological approach of their invention during the 1910-11 Manchurian plague outbreak. Arguing that they should be taken seriously as masks, I demonstrate that their emergence was rooted in their configuration as transformative agents of medical reason.


title: Acute lung injury: a yellow card for engineered nanoparticles?

text: Application of nanomaterials in various diagnostic and therapeutic areas shows great promise. To translate nanotechnology into nanomedicine, it is important to understand any potential mechanisms of toxicity caused by nanomaterials, and to design approaches to mitigate any detrimental effects.


title: Immuno-informatics based approaches to identify CD8+ T cell epitopes within the Leishmania donovani 3-ectonucleotidase in cured visceral leishmaniasis subjects.

text: Leishmaniases are vector-borne diseases for which no vaccine exists. These diseases are caused by the Leishmania species complex. Activation of the CD8+ T cell is crucial for protection against intracellular pathogens, and peptide antigens are attractive strategies for the precise activation of CD8+ T in vaccine development against intracellular infections. The traditional approach to mine the epitopes is an arduous task. However, with the advent of immunoinformatics, in silico epitope prediction tools are available to expedite epitope identification. In this study, we employ different immunoinformatics tools to predict CD8+ T cell specific 9 mer epitopes presented by HLA-A*02 and HLA-B40 within the highly conserved 3'-ectonucleotidase of Leishmania donovani. We identify five promiscuous epitopes, which have no homologs in humans, theoretically cover 85% of the world's population and are highly conserved (100%) among Leishmania species. Presentation of selected peptides was confirmed by T2 cell line based HLA-stabilization assay, and three of them were found to be strong binders. The in vitro peptide stimulation of peripheral blood mononuclear cells (PBMC) from cured HLA-A02+ visceral leishmaniasis (VL) subjects produced significantly higher IFN-γ, IL-2 and IL-12 compared to no peptide control healthy subjects. Further, CD8+ cells from treated VL subjects produced significantly higher intracellular IFN-γ, lymphocyte proliferation and cytotoxic activity against selected peptides from the PBMCs of treated HLA-A02+ VL subjects. Thus, the CD8+ T cell specific epitopes shown in this study will speed up the development of polytope vaccines for leishmaniasis.


title: Primary laparoscopic cholecystectomy in patients with portal cavernoma and non-obstructive portal biliopathy: Two case reports.

text: A laparoscopic cholecystectomy can be technically challenging with co-existing portal hypertension, as commonly seen with cirrhosis of the liver. Extra hepatic portal vein obstruction (EHPVO) although less common, is a significant cause of portal hypertension in India. EHPVO has a unique clinical profile, which differentiates it from portal hypertension associated with cirrhosis of the liver. This impacts therapy in EHPVO algorithmically and operatively. We report two cases of symptomatic gall stones with portal cavernoma. Further evaluation revealed non-obstructive portal biliopathy. Both underwent a successful laparoscopic cholecystectomy. We highlight the importance of careful operative strategy, diligent haemostasis and the feasibility of performing a laparoscopic cholecystectomy in patients with symptomatic gall stones associated with a portal cavernoma.


title: Embolization of Intracranial Dural Arteriovenous Fistulas Using PHIL Liquid Embolic Agent in 26 Patients: A Multicenter Study.

text: BACKGROUND AND PURPOSE The introduction of liquid embolic agents has revolutionized endovascular approach to cranial vascular malformations. The aim of the study was to retrospectively assess the efficacy and safety of Precipitating Hydrophobic Injectable Liquid (PHIL), a new nonadhesive liquid embolic agent, in the treatment of patients with cranial dural arteriovenous fistulas. The primary end point was the rate of complete occlusion of dural arteriovenous fistulas. Secondary end points included the incidence of adverse events and clinical status at 3-month follow-up. MATERIALS AND METHODS This was a retrospective multicenter study. Twenty-six consecutive patients with dural arteriovenous fistulas (de novo or previously treated) treated by injection of PHIL only or with PHIL in combination with other embolization products (such as Onyx or detachable coils) were included in the study. Recruitment started in August 2014 and ended in September 2015. RESULTS Twenty-two (85%) patients were treated with PHIL only, with 3 patients treated with both PHIL and Onyx, and 1, with both PHIL and coils. Immediate complete angiographic occlusion was achieved in 20 (77%) patients. Of the 6 patients with residual fistulas, 3 were retreated with PHIL and 1 achieved angiographic cure. An adverse event was seen in 1 patient who developed worsening of preexisting ataxia due to acute thrombosis of the draining vein. CONCLUSIONS PHIL appears to be safe and effective for endovascular treatment of cranial dural arteriovenous fistulas. Short-term angiographic and clinical results are comparable with those of Onyx, with the added advantage of easier preparation and improved homogeneous cast visualization. The use of iodine as a radio-opacifier also produces considerably less artifacts on CT compared with tantalum-based embolic materials.


Rhinovirus infections in infants: is respiratory syncytial virus ready for the challenge?


title: Response to letter to the editor: radiological approaches to COVID-19 pneumonia.

text: This is a letter to response to "letter to the editor" about our review article entitled "Radiological approaches to COVID-19 pneumonia". Abstract is not required in this format.


title: Transumbilical multiple-port laparoscopic cholecystectomy using standard laparoscopic instruments.

text: INTRODUCTION As a complement to standard laparoscopy, single incision laparoscopic cholecystectomy (SILS) is gaining popularity. We report our technique and our initial experience with transumbilical multi-port laparoscopic cholecystectomy (TUMP-LC) without an access device, with standard laparoscopic instruments, and report the clinical outcomes. MATERIAL AND METHODS Twenty-five (23 F: 2 M) consecutive patients with symptomatic cholelithiasis were included. The surgical outcomes such as length of stay, complications and perioperative morbidity were analyzed. For evaluation of surgical stress preoperative and postoperative C-reactive protein (CRP) values at 6 h and 24 h were measured. Postoperative pain was evaluated using a standard 10-point visual analogue scale (VAS). RESULTS The mean duration of the surgery was 44.56 minutes (range, 18-110). Additional trocars were needed in two (8%) cases. Mean pain scores post-operatively at 4 h, 12 h and 24 h were 4 ± 1.19, 3.64 ± 1.03 and 2.24 ± 0.96, respectively (p < 0.0001). Plasma CRP values increased at 6 h and started to decrease at 24 h (p < 0.0001). None of the cases were converted to open surgery and no major complications occurred. DISCUSSION TUMP-LC using standard laparoscopic instrumentation without an access device is an effective alternative to standard four-incision laparoscopic cholecystectomy. Our technique maintains the principles of the conventional procedure and the instrumentation, but also improves the access.


title: Assessment of the incidence of chronic pain and discomfort after primary inguinal hernia repair.

text: BACKGROUND Chronic pain and discomfort is a notable complication after inguinal hernia repair. This study assesses the incidence and degree of chronic pain and discomfort after primary inguinal hernia repair performed in our hospital and aims to clarify its relationship to the type of mesh placement. MATERIALS AND METHODS A retrospective analysis was conducted of 334 patients (378 lesions) who underwent primary inguinal hernia using the Lichtenstein (onlay mesh), Ultrapro Plug (UPP; onlay plus plug mesh), modified Kugel Patch (onlay and underlay mesh), or laparoscopic transabdominal preperitoneal (TAPP; underlay mesh) procedure. Postoperative pain was assessed using a numerical rating scale at postoperative 2-3 wk, 3 mo, and 6 mo. Postoperative discomfort was assessed 6 mo afterward. RESULTS Questionnaire responses were received for 378 lesions (100%) after 2-3 wk, 229 (60.6%) after 3 mo, and 249 (65.9%) after 6 mo. The majority of chronic pain experienced was mild, and no patient suffered from severe pain. The level of pain tended to be less for the TAPP procedure than for other methods. Discomfort at rest was significantly less for TAPP versus Ultrapro Plug (P < 0.01), and discomfort with movement was significantly less for TAPP versus modified Kugel (P < 0.05). CONCLUSIONS Onlay mesh appears to be a risk factor in chronic pain and discomfort. The lower level of chronic pain and discomfort with underlay mesh placement is considered to result from the reduced risk of nerve damage in this procedure than in the onlay mesh placement procedure.


title: Mechanical thrombectomy using a combined CT/C-arm X-ray system.

text: BACKGROUND Mechanical thrombectomy (MT) using stent-retrievers has been proven to be a safe and effective treatment in acute ischemic stroke (AIS), particularly in large vessel occlusion. Other than patient characteristics, time to recanalization is the most important factor linked to outcome. MT is usually performed in a dedicated angiography suite using a floor- and/or ceiling-mounted biplane angiographic system. Here we report our first experience of MT with a new combined CT and mobile C-arm X-ray device setup. METHODS Patients with AIS underwent stroke imaging (non-contrast enhanced CT, CT perfusion, and CT angiography) using a commercially available 64-slice CT scanner which was modified for combined use with a C-arm system. In patients with large vessel occlusion, MT was conducted without further patient transfer within the CT imaging suite using a mobile C-arm X-ray device equipped with a 30×30 cm (12×12 inch), 1.5×1.5 k full-view flat detector which was positioned between the gantry and patient table. The safety and feasibility of this new system was assessed in preliminary patients. RESULTS Angiographic imaging quality of the mobile C-arm was feasible and satisfactory for diagnostic angiography and MT. Using this setup, time between stroke imaging and groin puncture (picture-to-puncture time) was reduced by up to 35 min (including time for preparation of the patient such as intubation). CONCLUSIONS MT using a combined CT/C-arm system is safe and feasible. The potential advantages, particularly time saving and ensuing improvement in patient outcome, need to be assessed in a larger study.


title: A large hepatic cyst with obstructive jaundice successfully treated with single-incision laparoscopic deroofing.

text: We herein present a case of hepatic cysts causing obstructive jaundice that was treated with single-incision laparoscopic deroofing. A 72-year-old female patient was referred to hospital due to a large hepatic cyst that compressed the intrahepatic bile ducts. The patient was scheduled to undergo single-incision laparoscopic deroofing. The EZ ACCESS(TM) oval type (Hakko Co. Ltd.) was placed at the umbilicus using a 25-mm incision with two 5-mm trocars. An additional 12-mm port was placed at the left epigastric region. We unroofed and excised the cyst wall using a vessel sealing system in liver segment 4. After surgery, the patient was found to be asymptomatic. The unroofed cysts were completely diminished. Notably, the remnant liver had fairly regenerated. The estimated regeneration volume of the normal liver was 153 cm(3). To prevent surgical complications, clinicians should perform adequate management and use of devices. To prevent postoperative recurrence of cysts, performing complete deroofing is essential. Single-incision laparoscopic deroofing contributes to improving the quality of life of patients and should be considered a standard treatment.


title: The characteristics of household food waste in Hong Kong and their implications for sewage quality and energy recovery.

text: Food waste (FW) is a worldwide environmental issue due to its huge production amount. FW separation from municipal solid waste followed by different treatment strategies has been widely accepted. Food waste disposer (FWD) is a promising approach to separate and collect household food waste (HFW), which has been widely applied in many countries. However, the feasibility of FWD application in many countries is still being debated due to the major concerns over the impact of FWD on the wastewater treatment plants. In order to investigate the feasibility of FWD application, FW characterization is a key work to be conducted in advance. Since the FW characteristics largely vary by region, reliable and representative FW characteristics in different countries should be investigated. To provide such information for further studies on FW management for Hong Kong, HFW was collected from Hong Kong typical households over one year and analyzed systemically in this study. The FW composition varied little from place to place or season to season, and the values observed were comparable with results reported from other countries and regions. Based on the reliable HFW characteristics obtained from one-year survey coupled with statistical analysis, simulated HFW for Hong Kong consisting of 50% fruits, 20% vegetables, 20% starchy food and 10% meat was proposed for future studies. On the other hand, the FWD treatment caused more than 50% of the biodegradable organic content in HFW to dissolve. With a ratio of 1 g food waste to 1 L sewage, total solids in the wastewater stream were predicted to increase by 73%, total chemical oxygen demand by 61%, soluble chemical oxygen demand by 110%, nitrogen by 6% and phosphorus by 16%. Theoretically, 22 million m3/year of additional methane could be generated if 50% of Hong Kong residential buildings equipped with FWD. That would certainly increase pollutant loading on the wastewater treatment plants, but also energy recovery potential.


title: Distributed Simulation in surgical training: an off-site feasibility study.

text: BACKGROUND Simulation offers recognised training benefits, but the cost of high-fidelity contextualised simulation is prohibitive and its accessibility limited to specialised Distributed Simulation centres. Distributed simulation (DS) is an innovative concept of low-cost, portable and high-fidelity contextualised simulation. However, it has previously only been trialled at a central London teaching hospital. AIMS (1) To explore the off-site feasibility of DS. (2) To determine the response of end-users to DS. METHODS A DS naive researcher recreated a standardised porcine laparoscopic cholecystectomy scenario at a District General Hospital using DS. A research diary detailed the logistical feasibility of the project, whilst mixed methods were used to determine the response of the 10 surgeons who completed the full-team simulation. RESULTS DS is feasible off-site with end-users comparing it favourably to their previous simulation experiences. Surgeons perceived DS as being most useful for building the operative confidence of juniors between learning the basics on a bench top model and before entering the operating theatre. CONCLUSIONS DS has the potential to provide high-fidelity contextualised simulation as an adjunct to, and not a replacement for, surgical training. Unlike other modalities, it is low cost and portable, thereby addressing concerns over affordability and accessibility.


title: A systematic approach to evaluate parameter consistency in the inlet stream of source separated biowaste composting facilities: A case study in Colombia.

text: Biowaste is commonly the largest fraction of municipal solid waste (MSW) in developing countries. Although composting is an effective method to treat source separated biowaste (SSB), there are certain limitations in terms of operation, partly due to insufficient control to the variability of SSB quality, which affects process kinetics and product quality. This study assesses the variability of the SSB physicochemical quality in a composting facility located in a small town of Colombia, in which SSB collection was performed twice a week. Likewise, the influence of the SSB physicochemical variability on the variability of compost parameters was assessed. Parametric and non-parametric tests (i.e. Student's t-test and the Mann-Whitney test) showed no significant differences in the quality parameters of SSB among collection days, and therefore, it was unnecessary to establish specific operation and maintenance regulations for each collection day. Significant variability was found in eight of the twelve quality parameters analyzed in the inlet stream, with corresponding coefficients of variation (CV) higher than 23%. The CVs for the eight parameters analyzed in the final compost (i.e. pH, moisture, total organic carbon, total nitrogen, C/N ratio, total phosphorus, total potassium and ash) ranged from 9.6% to 49.4%, with significant variations in five of those parameters (CV>20%). The above indicate that variability in the inlet stream can affect the variability of the end-product. Results suggest the need to consider variability of the inlet stream in the performance of composting facilities to achieve a compost of consistent quality.


Global payer.


title: COVID-19 Fatality Rate and Performed Swabs in Italy: a Misleading Perception.

text: BACKGROUND CoronaVirus Disease 2019 (COVID-19) fatality rate in Italy is controversial and is largely affecting discussion on the impact of containment measures that are straining the world's social and economic fabric, such as large-scale use of isolation and quarantine, closing borders, imposing limits on public gatherings, and implementing nationwide lockdowns. OBJECTIVE The scientific community, citizens, politicians and mass media are arguing over data that seem to suggest that Italy has a significantly higher number of COVID-19-related deaths than in the rest of the world. Moreover, Italian citizens have a misleading perception related to the number of actually performed swab tests. Citizens and mass media denounce that the coverage obtained by COVID-19 swab testing in Italy is not in line with other countries all over the world. METHODS In this paper, we try to clarify, with a set of statistical analysis conducted world-wide, both aspects by highlighting the actual numbers and by comparing them with the official data available. RESULTS The analysis clearly shows that the Italian COVID-19 fatality and mortality rate are in line with the official world scenario, and these findings are true also for the number of COVID-19 swabs performed in Italy and in Lombardy Region. CONCLUSIONS Up-to-date analysis of this type may simplify the understanding of the pandemic evolution. CLINICALTRIAL


title: Factors Influencing the Relationship Between the Functional Movement Screen and Injury Risk in Sporting Populations: A Systematic Review and Meta-analysis.

text: BACKGROUND Studies investigating the association between the Functional Movement Screen (FMS) and sports injury risk have reported mixed results across a range of athlete populations. OBJECTIVES The purpose of this systematic review was to identify whether athlete age, sex, sport type, injury definition and mechanism contribute to the variable findings. STUDY DESIGN Systematic review and meta-analysis. METHODS A systematic search was conducted in October 2018 using PubMed, EBSCOhost, Scopus, EmBase and Web of Science databases. Studies were included if they were peer reviewed and published in English language, included athletes from any competition level, performed the FMS at baseline to determine risk groups based on FMS composite score, asymmetry or pain, and prospectively observed injury incidence during training and competition. Study eligibility assessment and data extraction was performed by two reviewers. Random effects meta-analyses were used to determine odds ratio (OR), sensitivity and specificity with 95% confidence intervals. Sub-group analyses were based on athlete age, sex, sport type, injury definition, and injury mechanism. RESULTS Twenty-nine studies were included in the FMS composite score meta-analysis. There was a smaller effect for junior (OR = 1.03 [0.67-1.59]; p = 0.881) compared to senior athletes (OR = 1.80 [1.17-2.78]; p = 0.008) and for male (OR = 1.79 [1.08-2.96]; p = 0.024) compared to female (OR = 1.92 [0.43-8.56]; p = 0.392) athletes. FMS composite scores were most likely to be associated with increased injury risk in rugby (OR = 5.92 [1.67-20.92]; p = 0.006), and to a lesser extent American football (OR = 4.41 [0.94-20.61]; p = 0.059) and ice hockey (OR = 3.70 [0.89-15.42]; p = 0.072), compared to other sports. Specificity values were higher than sensitivity values for FMS composite score. Eleven studies were included in the FMS asymmetry meta-analysis with insufficient study numbers to generate sport type subgroups. There was a larger effect for senior (OR = 1.78 [1.16-2.73]; p = 0.008) compared to junior athletes (OR = 1.21 [0.75-1.96]; p = 0.432). Sensitivity values were higher than specificity values for FMS asymmetry. For all FMS outcomes, there were minimal differences across injury definitions and mechanisms. Only four studies provided information about FMS pain and injury risk. There was a smaller effect for senior athletes (OR = 1.28 [0.33-4.96]; p = 0.723) compared to junior athletes (OR = 1.71 [1.16-2.50]; p = 0.006). Specificity values were higher than sensitivity values for FMS pain. CONCLUSION Athlete age, sex and sport type explained some of the variable findings of FMS prospective injury-risk studies. FMS composite scores and asymmetry were more useful for estimating injury risk in senior compared to junior athletes. Effect sizes tended to be small except for FMS composite scores in rugby, ice hockey and American football athletes. PROTOCOL REGISTRATION CRD42018092916.


title: Evaluation of three real-time PCR assays for detection of Mycoplasma pneumoniae in an outbreak investigation.

text: We compared the performances of three recently optimized real-time PCR assays derived from distinct genomic regions of Mycoplasma pneumoniae during an outbreak. Comprehensive evaluation established that a newly described toxin gene represents a superior target for detecting M. pneumoniae DNA in clinical specimens, although use of multiple targets may increase testing confidence.


title: Prospective trial evaluating new circular and linear stapler devices for gastrointestinal anastomosis: preliminary data.

text: Several commercial models of stapler devices are available. This study evaluated the ease of use, effectiveness and safety of new commercial stapling devices for gastrointestinal anastomosis. A total of 11 patients (5 men) requiring surgical therapy for benign or malignant disease of the digestive tract were recruited between July and October 2006. Eleven patients were treated with KYGW circular stapler or KYFB linear stapler (Changzhou Kangdi Medical Stapler). In these patients, 14 staplers were used and 21 stapled sutures (16 linear, 5 circular) were performed. Number of anastomoses successfully completed, postoperative anastomotic fistula or dehiscence, days to take fluid and normal diet, length of hospital stay and anastomotic stenosis were recorded. A 10-point questionnaire enquiring about the instrument and anastomotic features was administered to surgeons immediately after the operation in the study group and in 10 control patients treated with standard CDH circular and SDH linear staples (Ethicon Endo-Surgery). Mean scores on the questionnaire for the experimental and control groups were good (>7.5) and did not significantly differ for handling, closing ease, bleeding, and overall satisfaction. No case of intra-abdominal sepsis, leakage or intestinal obstruction was recorded in the study group. In the 5 patients with colorectal anastomosis, the anastomotic lumen at 15 days was wide open and at 3 months there were no strictures. These new instruments are valuable for performing gastrointestinal anastomosis and are in conformity with clinical requirements; their use is simple and seems to be safe.


title: Comparison of the FilmArray Respiratory Panel and Prodesse real-time PCR assays for detection of respiratory pathogens.

text: We compared the diagnostic performance and overall respiratory pathogen detection rate of the premarket version of the FilmArray Respiratory Panel (RP) multiplex PCR assay (Idaho Technology, Inc., Salt Lake City, UT) with those of the Food and Drug Administration (FDA)-cleared Prodesse ProFlu+, ProFAST+, ProParaflu+, Pro hMPV+, and ProAdeno+ real-time PCR assays (Gen-Probe, San Diego, CA). The assays were performed on a panel of 192 nasopharyngeal-secretion specimens collected from 81 children under 1 year of age with upper respiratory tract symptoms. To resolve discordant results and confirm pathogens detected only by the larger FilmArray panel, we performed laboratory-developed real-time PCR assays. Among viruses detectable by both commercial assays (adenovirus, human metapneumovirus, influenza A virus, influenza B virus, parainfluenza viruses 1 to 3, and respiratory syncytial virus), the FilmArray and Prodesse assays showed good overall agreement (181/192 [94.3%]; kappa = 0.87; 95% CI, 0.79 to 0.94). FilmArray RP detected more parainfluenza viruses 1 and 3 than ProParaflu+ (18 versus 13) while ProAdeno+ detected more adenoviruses (11 versus 6), but these differences were not statistically significant. Additionally, FilmArray RP detected 138 pathogens (confirmed as true positives) not included in the Prodesse assays (rhinovirus [RV]/enterovirus [EV], 118; bocavirus, 8; coronavirus, 7; parainfluenza virus 4, 4; Mycoplasma pneumoniae, 1). FilmArray RP was cleared by the FDA following the completion of this study. The FDA-cleared version includes the following targets: adenovirus, coronaviruses HKU1 and NL63, human metapneumovirus (hMPV), influenza A virus (to type level only), influenza A H1 seasonal virus, influenza A H3 seasonal virus, influenza A virus H1-2009, influenza B virus, parainfluenza viruses 1 to 4, respiratory syncytial virus (RSV), and RV/EV (no differentiation). The larger panel in the FilmArray RP assay allowed the detection of additional respiratory pathogens compared to the Prodesse assays. In this population of young children with upper respiratory tract infection, RV/EV accounted for the majority of the additional pathogens detected by FilmArray RP.


title: The effects of backward adjustable thoracic support in wheelchair on spinal curvature and back muscle activation for elderly people.

text: OBJECTIVES To investigate the effects of backward adjustable thoracic support on spinal curvature and back muscle activation during wheelchair sitting. METHODS Twenty elderly people were recruited for this study. The backward adjustable thoracic support sitting posture was compared with the slumped, normal, and lumbar support sitting postures. Spinal curvatures (pelvic, lumbar, and thoracic angles) and muscle activations of 4 back muscles on both sides (maximal voluntary isometric contraction of the lumbar multifidus, lumbar erector spinae, iliocostalis lumborum pars thoracis, and thoracic erector spinae at T9) were measured and compared between the different sitting postures using one-way analysis of variance with repeated measures. RESULTS The backward adjustable thoracic support sitting posture showed a relatively neutral pelvic tilt (-0.32±4.80°) when compared with the slumped (22.84±5.27°) and lumbar support (-8.97±3.31°) sitting postures (P<0.001), and showed relatively higher lumbar lordosis (-23.38±6.50°) when compared with the slumped (14.77±7.83°), normal (0.44±7.47°), and lumbar support (-16.76±4.77°) sitting postures (P<0.05). It also showed relatively lower back muscle activity when compared with the normal and lumbar support sitting postures (P<0.05). CONCLUSIONS The backward adjustable thoracic support sitting concept was suggested because it maintains a more neutral pelvic tilt, higher lumbar lordosis, and lower back muscle activation, which may help maintain a better sitting posture and reduce the risk of back pain.


title: Inappropriate Nasopharyngeal Sampling for SARS-CoV-2 Detection Is a Relevant Cause of False-Negative Reports.

text: Reverse transcriptase polymerase chain reaction (RT-PCR) detection of SARS-CoV-2 mRNA on nasopharyngeal swab is the standard for diagnosing active COVID-19 disease in asymptomatic cases and in symptomatic patients without the typical radiologic findings. For the present COVID-19 outbreak in Italy, we describe 4 symptomatic patients with negative RT-PCR results at the first nasopharyngeal swab, which became positive when collected a few hours later by an otolaryngologist. All the patients showed nasal obstruction. The present report suggests that inadequate nasopharyngeal sampling performed by untrained operators in the presence of nasal obstruction can be a relevant case of false-negative findings at RT-PCR, with a clear negative impact on the efforts to contain the current outbreak.


Strategies shift as coronavirus pandemic looms.


title: The association between adverse childhood experiences and traumatic brain injury/concussion in adulthood: A scoping review protocol.

text: INTRODUCTION Exposure to adverse childhood experiences (ACEs) is a significant risk factor for physical and mental illnesses later in life. Concussion or traumatic brain injury is a challenging condition where preinjury factors may interact to affect recovery. The association between ACEs and traumatic brain injury/concussion is not well mapped in any previous reviews of the literature. Using a scoping review methodology, the research question that will be addressed is: what is known from the existing literature about the association between ACEs and traumatic brain injury/concussion in adults? METHODS AND ANALYSIS The methodological frameworks outlined by Arksey and O'Malley and Levac et al will be used. All original studies in English published since 2007 investigating ACEs and traumatic brain injury/concussion outcomes will be included with no limitations on study type. Literature search strategies will be developed using medical subject headings and text words related to ACEs and traumatic brain injury/concussions. Multiple electronic databases will be searched. Two independent reviewers will screen titles and abstracts for full-text review and full texts for final inclusion. Two independent reviewers will extract data on study characteristics for ACE exposure and traumatic brain injury/concussion outcomes. Extracted data will be summarised quantitatively using numerical counts and qualitatively using thematic analysis. DISSEMINATION This review will identify knowledge gaps on the associations between ACEs and traumatic brain injury/concussion and promote further research. Knowledge translation will occur throughout the review process with dissemination of project findings to stakeholders at the local, national and international levels.


title: A descriptive analysis of medical education in China.

text: A highly trained medical profession is vital to a country's economic development. With the development of a growing economy in China and the increasing impact of globalization, the recent outbreak of new infectious diseases including SARS and the lethal avian influenza have highlighted the importance of medicine and medical care. Ultimately, the health of the public depends on the quality of the medical education programmes. This article outlines the various educational policies in China, points out deficiencies in the medical education of China when compared to the American model of medical education and makes suggestions of changes that need to be made to Chinese medical education programmes.