title: Cocirculation of two distinct genetic and antigenic lineages of proposed influenza D virus in cattle.

text: UNLABELLED Viruses with approximately 50% homology to human influenza C virus (ICV) have recently been isolated from swine and cattle. The overall low homology to ICV, lack of antibody cross-reactivity to ICV in hemagglutination inhibition (HI) and agar gel immunodiffusion assays, and inability to productively reassort with ICV led to the proposal that these viruses represented a new genus of influenza virus, influenzavirus D (IDV). To further our understanding of the epidemiology of IDV, real-time reverse transcription-PCR was performed on a set of 208 samples from bovines with respiratory disease. Ten samples (4.8%) were positive and six viruses were successfully isolated in vitro. Phylogenetic analysis of full-genome sequences of these six new viruses and four previously reported viruses revealed two distinct cocirculating lineages represented by D/swine/Oklahoma/1334/2011 (D/OK) and D/bovine/Oklahoma/660/2013 (D/660), which frequently reassorted with one another. Antigenic analysis using the HI assay and lineage-representative D/OK and D/660 antiserum found up to an approximate 10-fold loss in cross-reactivity against heterologous clade antiserum. One isolate, D/bovine/Texas/3-13/2011 (D/3-13), clustered with the D/660 lineage, but also had high HI titers to heterologous (D/OK) clade antiserum. Molecular modeling of the hemagglutinin esterase fusion protein of D/3-13 identified a mutation at position 212 as a possible antigenic determinant responsible for the discrepant HI results. These results suggest that IDV is common in bovines with respiratory disease and that at least two genetic and antigenically distinct clades cocirculate. IMPORTANCE A novel bovine influenza virus was recently identified. Detailed genetic and antigenic studies led to the proposal that this virus represents a new genus of influenza, influenzavirus D (IDV). Here, we show that IDV is common in clinical samples of bovine respiratory disease complex (BRDC), with a prevalence similar to that of other established BRDC etiological agents. These results are in good agreement with the near-ubiquitous seroprevalence of IDV previously found. Phylogenetic analysis of complete genome sequences found evidence for two distinct cocirculating lineages of IDV which freely reassort. Significant antigenic differences, which generally agreed with the surface glycoprotein hemagglutinin esterase phylogeny, were observed between the two lineages. Based on these results, and on the ability of IDV to infect and transmit in multiple mammalian species, additional studies to determine the pathogenic potential of IDV are warranted.


title: Percutaneous Microwave Ablation of Histologically Proven T1 Renal Cell Carcinoma.

text: OBJECTIVES To assess the safety and efficacy of percutaneous microwave ablation (MWA) of histologically proven T1 renal cell carcinoma (RCC). METHODS We analysed patients with a histologically proven RCC (≤ 7 cm) treated by MWA from April 2012-April 2018. Primary and secondary efficacy, local tumour recurrence (LTR), morbidity and mortality were reported. Efficacy was defined as no residual tumour enhancement on follow-up imaging 1 month after the first ablation (primary efficacy) and after re-ablation(s) for residual disease (secondary efficacy). Adverse events (AE) were registered by the Clavien-Dindo classification and the common terminology criteria for AE. Univariable and multivariable logistic regression analyses were performed to investigate a relation among pre-treatment factors incomplete ablation and complications. RESULTS In 100 patients, a total of 108 RCCs (85 T1a and 23 T1b) were treated by MWA. Median size was 3.2 cm (IQR 2.4-4.0). Primary efficacy was 89% (95%CI 0.81-0.94) for T1a lesions and 52% (95%CI 0.31-0.73) for T1b lesions (p < 0.001). Fifteen lesions (7 T1a) were re-ablated for residual disease by MWA in one (n = 13) and two (n = 2, both T1b) sessions resulting in secondary efficacy rates of 99% (T1a) and 95% (T1b, p = 0.352). LTR occurred in four tumours (2 T1a, 2 T1b) after 10-60 months. Six (4%) AEs grade > 3-5 were observed (2 T1a, 4 T1b, p = 0.045). Multivariable analysis showed that mR.E.N.A.L. nephrometry was independently associated with incomplete ablation (p = 0.012). CONCLUSION Microwave ablation is safe and effective for T1a and T1b RCC lesions with a significantly lower primary efficacy for T1b lesions.


title: Tidal volume measurement error in pressure control modes of mechanical ventilation: A model study.

text: UNLABELLED Tidal volume (VT) measurement during pressure control (PC) ventilation with preset inspiratory time may produce errors due to patient inspiratory effort. We evaluated VT error in 3 common ICU ventilators. METHODS Simulated patient: 60kg adult with ARDS using IngMar Medical ASL 5000 having moderate inspiratory effort. Ventilators evaluated: Covidien PB 840, Maquet Servo-i, and Dräger Evita XL, PC breaths at preset inspiratory time (TI) 0.6-1.4s. VT error was defined as ventilator displayed VT minus the simulator displayed VT (mL/kg or % of true). RESULTS Relaxation of inspiratory effort caused flow reversal (exhalation) during TI, which led to VT error. For the PB 840, VT error was proportional to TI (maximum -2.0mL/kg, -19%). For the Servo-i, VT error was not related to TI (maximum error -0.2mL/kg or -1.2%). Volume error for Evita XL was not related to TI (maximum error was -0.7mL/kg or -6%). CONCLUSIONS Calculation of VT as the integral of flow over the preset inspiratory time rather than the period between zero crossings of flow may result in underestimation of both inhaled and exhaled volumes. The size of VT error can be large enough to potentially affect patient outcomes on some ventilators.


title: Resolution of cranial neuropathies following treatment of intracranial aneurysms with the Pipeline Embolization Device.

text: OBJECT Intracranial aneurysms, especially those of the cavernous segment of the internal carotid artery (ICA), can present with cranial nerve (CN) palsies. The Pipeline Embolization Device (PED) has demonstrated safety and efficacy in the treatment of cerebral aneurysms by flow diversion, but little data exist reporting the outcomes of cranial neuropathies following treatment with the device. METHODS The prospectively maintained Barrow Neurological Institute's endovascular database was reviewed for all patients treated with the PED after presenting with one or more CN palsies secondary to a cerebral aneurysm since May 2011. Patient charts and digital subtraction angiograms were reviewed to report clinical and angiographic outcomes. Only patients with clinical follow-up were included in the analysis. RESULTS A total of 127 patients were treated with the PED at the authors' institution after FDA approval. Twentytwo patients presented with cranial neuropathies, for initial inclusion in this study. Of these, 20 had sufficient followup for analysis. Cranial neuropathies included those of CN II, III, V, and VI, with presenting symptoms of diplopia, decreased visual acuity, and facial numbness and/or pain. Thirteen lesions were cavernous segment ICA aneurysms, whereas the remainder included supraclinoid and petrous segment ICA, posterior communicating artery, and basilar trunk aneurysms. At an average clinical follow-up of 9.55 months, 15 patients (75%) had resolution or significant improvement of their cranial neuropathies, and the remaining 5 had stable symptoms. Of the 18 patients with angiographic follow-up, 12 (66.7%) demonstrated complete obliteration or small neck residual, whereas 6 (33.3%) had residual lesion. Patients with complete or near-complete obliteration of their lesion were significantly more likely to demonstrate symptomatic improvement at follow-up (p = 0.009). Two patients with persistent symptoms were eventually treated with microsurgical bypass. Transient complications in this series included 6 (30%) extracranial hemorrhagic complications related to dual-antiplatelet therapy, all of which were managed medically. There was 1 delayed right ICA occlusion following retreatment that led to microsurgical bypass. CONCLUSIONS Intracranial aneurysms presenting with one or more CN palsies show a high rate of clinical improvement after treatment with the PED. Clinical outcomes must be weighed against the risks and challenges faced with flow diverters. Further research is warranted for patients whose symptoms do not respond optimally to device placement.


title: Analysis of coagulation parameters in patients with COVID-19 in Shanghai, China.

text: To investigate the characteristic of coagulation function in 303 patients with Coronavirus disease 2019 (COVID-19), we evaluated the correlation between coagulation function and disease status. We retrospectively analyzed 303 patients diagnosed with COVID-19 and evaluated the clinical data of 240 patients who were discharged. The coagulation function of the two groups (mild and severe) was compared. Compared with the mild group, majority of patients in the severe group were male (76.9% vs. 49.8%) and elderly (median age 65 vs. 50), and the proportion with chronic underlying diseases was higher (73.1% vs. 36.1%). There were 209 abnormalities (69.0%) of coagulation parameters in 303 patients admitted to hospital. Comparison of various indexes of coagulation function between the two groups in admission, the proportion of abnormal coagulation indicators in the severe group was higher than that in the mild group (100% vs. 66.1%). The median coagulation parameters in the severe group were higher than those in the mild group: international normalized ratio (1.04 vs. 1.01), prothrombin time (13.8 vs. 13.4) seconds, activated partial thromboplastin time (43.2 vs. 39.2) seconds, fibrinogen (4.74 vs. 4.33) g/L, fibrinogen degradation products (2.61 vs. 0.99) µg/mL, and D-dimer (1.04 vs. 0.43) µg/mL, the differences were statistically significant (p < 0.05). Coagulation dysfunction is common in patients with COVID-19, especially fibrinogen and D-dimer elevation, and the degree of elevation is related to the severity of the disease. As the disease recovers, fibrinogen and activated partial thromboplastin time also return to normal.


title: A protocol for an updated and expanded systematic mixed studies review of fear of cancer recurrence in families and caregivers of adults diagnosed with cancer.

text: BACKGROUND Fear of cancer recurrence (FCR) is reportedly common, persistent, associated with significant morbidity and often higher in cancer caregivers than cancer patients. This review will summarise empirical research on FCR to understand its prevalence, severity, correlates, course and impact in families and caregivers of adults diagnosed with cancer, and identify tested interventions that reduce its effects. METHODS This review will include peer-reviewed, empirical, qualitative and/or quantitative studies on fear, worry or concern of patients' cancer returning or progressing among adult family members or caregivers of the cancer patient. It will exclude records reporting no original empirical research on FCR. We will search CINAHL, Embase, PubMed, PsycINFO, ProQuest Dissertations and Theses GLOBAL from 1997 onwards. Pairs of reviewers will conduct independent screening, data extraction and risk of bias assessment. Risk of bias will be assessed with the Cochrane Risk of Bias tool for randomised studies, the Risk of Bias Assessment tool for Nonrandomized Studies and the questions for qualitative studies in the mixed methods appraisal tool. We will conduct a narrative synthesis of quantitative studies and a thematic synthesis of qualitative studies. DISCUSSION This review will provide further clarity on the prevalence and severity of FCR in families and caregivers and differences by caregiver and care recipient demographic and medical characteristics. Any intervention studies located may indicate therapies or treatments that could reduce FCR in families and caregivers. Findings are expected to provide guidance for individuals and organisations working to manage FCR in families and caregivers of those with cancer. SYSTEMATIC REVIEW REGISTRATION This protocol will be registered with PROSPERO after peer-review.


title: Respiratory viral detection and small airway inflammation in lung tissue of patients with stable, mild COPD.

text: BACKGROUND Viral respiratory tract infections are implicated in the pathogenesis of chronic obstructive pulmonary disease (COPD). In lung tissue specimens from patients with stable, mild COPD and from control smokers without airflow obstruction, we determined the prevalence and load of nucleic acid from common respiratory viruses and concomitant inflammation of small airways measuring less than 2-mm in diameter. METHODS Frozen lung tissue obtained from patients with stable, mild COPD (n = 20) and control subjects (n = 20) underwent real-time quantitative PCR (qPCR) for 13 respiratory viruses, and quantitative histology for inflammation of small airways. The two groups were compared for viral prevalence and load, and airway inflammation. The relationship between viral load and airway inflammatory cells was also analyzed. RESULTS Viral nucleic acid were detected in lung tissue of 18/40 (45.0%) of the individuals studied and included seven co-infections that were characterized by a "dominant virus" contributing to most of the total measured viral load. Lung tissue of COPD patients had a significantly higher prevalence of viral nucleic acid (particularly influenza A virus), and increased inflammation of small airways by macrophages and neutrophils versus controls. In qPCR-positive individuals, linear regression analysis showed a direct correlation between viral load and airway neutrophils, and between influenza A virus load and airway macrophages. CONCLUSION The lung tissue of patients with stable, mild COPD has a higher prevalence and load of respiratory viruses versus non-obstructed control subjects, and increased inflammation of small airways. Respiratory viruses may represent potential targets in COPD patient management.


title: The use of a fibrin glue with a low concentration of thrombin decreases seroma formation in postbariatric patients undergoing circular abdominoplasty.

text: BACKGROUND The serum collection under the abdominal flap is the most common complication after a lipo-abdominoplasty. The frequency of seroma increases further among obese patients, who have achieved massive weight loss after bariatric surgery. The purpose of this study is to demonstrate the effectiveness of fibrin glues with a low concentration of thrombin in reducing seroma formation after a lipo-abdominoplasty. METHODS Thirty patients, that had achieved a significant weight loss after an intervention of laparoscopic adjustable gastric banding (LAGB), underwent a circular lipo-abdominoplasty at our bariatric surgery department. Patients were divided into two groups of 15 subjects each: group A underwent traditional surgery; in group B, we applied a slow-clotting variant of fibrin glue (ARTISS, Baxter) under the abdominal flap. All subjects were evaluated clinically using an ultrasound device on postoperative day 15. We considered positive for seroma, those cases with a liquid collection greater than 20 cc. RESULTS The groups were homogeneous for age, BMI, male/female ratio, and diabetic or smoker patients. The mean hospital stay was significantly longer in group A than in group B. We found eight cases of serum collection >20 cc in group A and only one case in group B. Hematoma, umbilicus necrosis, and surgical site infection occurred in both groups, but overall complication rate was lower in group B. CONCLUSIONS The use of a fibrin glue with a low concentration of thrombin could be useful during wound closure and may decrease seroma formation in postbariatric patients undergoing lipo-abdominoplasty.


title: Cardiac arrest is a predictor of difficult tracheal intubation independent of operator experience in hospitalized patients.

text: BACKGROUND Placement of advanced airways has been associated with worsened neurologic outcome in survivors of out-of-hospital cardiac arrest. These findings have been attributed to factors such as inexperienced operators, prolonged intubation times and other airway related complications. As an initial step to examine outcomes of advanced airway placement during in-hospital cardiac arrest (IHCA), where immediate assistance and experienced operators are continuously available, we examined whether cardiopulmonary resuscitation efforts affect intubation difficulty. Additionally, we examined whether or not the use of videolaryngoscopy increases the odds of first attempt intubation success compared with traditional direct laryngoscopy. METHODS The study setting is a large urban university-affiliated teaching hospital where experienced airway managers are available to perform emergent intubation for any indication in any out-of-the-operating room location 24 hours a day, 7 days-a-week, 365 days-a-year. Intubations occurring in all adults >18 years-of-age who required emergent tracheal intubation outside of the operating room between January 1, 2008 and December 31, 2012 were examined retrospectively. Multivariate logistic regression was used to estimate the odds of difficult intubation during IHCA compared to other emergent non-IHCA indications with adjustment for a priori defined potential confounders (body mass index, operator experience, use of videolaryngoscopy versus direct laryngoscopy, and age). RESULTS In adjusted analyses, the odds of difficult intubation were higher when taking place during IHCA (OR=2.63; 95% CI 1.1-6.3, p=0.03) compared to other emergent indications. Use of video versus direct laryngoscopy for initial intubation attempts during IHCA, however, did not improve the odds of success (adjusted OR = 0.71; 95% CI 0.35-1.43, p = 0.33). CONCLUSIONS Difficult intubation is more likely when intubation takes place during IHCA compared to other emergent indications, even when experienced operators are available. Under these conditions, direct laryngoscopy (versus videolaryngoscopy) remains a reasonable first choice intubation technique.


title: Effect of palatal implants on continuous positive airway pressure and compliance.

text: OBJECTIVE Determine if the Pillar palatal implant system reduces continuous positive airway pressure (CPAP) pressure and improves patient compliance with CPAP therapy. STUDY DESIGN Randomized, double-blind, placebo-controlled study. SETTING Four geographically dispersed tertiary sleep disorder referral centers. METHODS Subjects with mild to moderate sleep apnea dissatisfied with CPAP because of pressure-related complaints were randomized to receive Pillar implants or a sham procedure performed in double-blind fashion. Active and sham groups were compared for changes in therapeutic CPAP pressures (primary outcome) with a 90-day follow-up sleep study and CPAP compliance (secondary outcome) with a 90-day smart card report. RESULTS Twenty-six subjects were randomized to Pillar implants and 25 to a sham implant procedure. There were no differences between groups with regard to demographics and baseline parameters. Both sham and active groups had reduced mean CPAP pressure (-1.1 vs -0.5 cm H(2)O) with no difference between groups (P = .32) at 90-day follow-up. In addition, there was no difference in average daily CPAP use between groups (P = .80). Both groups experienced improvements in Epworth sleepiness scores and Functional Outcome of Sleep Questionnaire scores at 90 days with no differences between groups. The active group reported significantly higher CPAP satisfaction scores than the sham group (P = .04). CONCLUSION Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance.


title: Bioactivity and potential health benefits of licorice.

text: Licorice is an herbal plant named for its unique sweet flavor. It is widely used in the food and tobacco industries as a sweetener. Licorice is also used in traditional Chinese medicine (TCM) and complementary medicine. Because the use of licorice has long been a part of TCM, the details of its therapeutic applications have been thoroughly established. In modern science, licorice is of interest because of its broad range of applications. Extracts of and compounds isolated from licorice have been well studied and biologically characterized. In this review, we discuss the nutraceutical and functional activities of licorice as well as those of the extracts of and the isolated compounds from licorice, including agents with anti-inflammatory activity, cell-protective abilities, and chemopreventive effects. The side effects of licorice are also enumerated. A comparison of the activities of licorice described by modern science and TCM is also presented, revealing the correspondence of certain characteristics.


title: Validation of predictors of adverse outcomes in hospital-acquired pneumonia in the ICU.

text: OBJECTIVE To validate a set of predictors of adverse outcomes in patients with ICU-acquired pneumonia in relation to clinically relevant assessment at 28 days. DESIGN Prospective, observational study. SETTING Six medical and surgical ICUs of a university hospital. PATIENTS Three hundred thirty-five patients with ICU-acquired pneumonia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Development of predictors of adverse outcomes was defined when at least one of the following criteria was present at an evaluation made 72-96 hours after starting treatment: no improvement of PaO2/FIO2, need for intubation due to pneumonia, persistence of fever or hypothermia with purulent respiratory secretions, greater than or equal to 50% increase in radiographic infiltrates, or occurrence of septic shock or multiple organ dysfunction syndrome. We also assessed the inflammatory response by different serum biomarkers. The presence of predictors of adverse outcomes was related to mortality and ventilator-free days at day 28. Sequential Organ Failure Assessment score was evaluated and related to mortality at day 28.One hundred eighty-four (55%) patients had at least one predictor of adverse outcomes. The 28-day mortality was higher for those with versus those without predictors of adverse outcomes (45% vs 19%, p<0.001), and ventilator-free days were lower (median [interquartile range], 0 [0-17] vs 22 [0-28]) for patients with versus patients without predictors of adverse outcomes (p<0.001). The lack of improvement of PaO2/FIO2 and lack of improvement in Sequential Organ Failure Assessment score from day 1 to day 5 were independently associated with 28-day mortality and fewer ventilator-free days. The marginal structural analysis showed an odds ratio of death 2.042 (95% CI, 1.01-4.13; p=0.047) in patients with predictors of adverse outcomes. Patients with predictors of adverse outcomes had higher serum inflammatory response accordingly to biomarkers evaluated. CONCLUSIONS The presence of any predictors of adverse outcomes was associated with mortality and decreased ventilator-free days at day 28. The lack of improvement in the PaO2/FIO2 and Sequential Organ Failure Assessment score was independently associated with mortality in the multivariate analysis.


title: Initial results of minimally invasive Ivor Lewis esophagectomy after induction chemoradiation (50.4 gy) for esophageal cancer.

text: OBJECTIVE Esophageal cancer patients receiving induction chemoradiation to 41 Gy randomized to minimally invasive (MIS) esophagectomy have fewer postoperative pulmonary complications compared with those who underwent open procedures. We evaluated the feasibility of MIS Ivor Lewis esophagectomy in patients treated with induction chemoradiation to 50.4 Gy. METHODS We retrospectively analyzed clinical data from 30 consecutive patients undergoing MIS Ivor Lewis esophagectomy after induction chemoradiation to a mean dose of 50.4 Gy by a single surgeon at a tertiary institution since 2010. Data collected included patient demographics, preoperative risk factors, neoadjuvant treatment modalities, histology, staging, operative factors, and perioperative complications. RESULTS The mean age of the patients was 61 ± 9.5 years, and 87% were men. The dominant histology was adenocarcinoma (90%), with most tumors (70%) located at the gastroesophageal junction. A total of 22 patients (73%) presented with dysphagia, but only 15 (50%) had associated weight loss (mean 12.2% total body mass). All patients had R0 resections; mean number of resected lymph nodes was 27.1 ± 11.4. Mean operating room time was 535 ± 120 minutes, with the last 10 operations 2 hours shorter than the preceding 20. Four patients (13.3%) had major complications. including 2 (6.7%) anastomotic leaks. There was no operative mortality. CONCLUSIONS Minimally invasive Ivor Lewis esophagectomy after chemoradiation to 50.4 Gy can be performed with decreased morbidity and mortality compared with historical series of open Ivor Lewis esophagectomy. Oncologic outcomes were acceptable as demonstrated by lymph node retrieval and complete resection rates. Operative time decreased significantly after 20 cases.


title: Diagnosis and management of pulmonary nodules.

text: There are an increased number of pulmonary nodules discovered on CT scan images in part due to those performed for lung cancer screening. Risk stratification and patient involvement is critical in determining management ranging from interval imaging to invasive biopsy or surgery. A definitive diagnosis requires tissue biopsy. The choice of a particular biopsy technique depends on the risks/benefits of the procedure, the diagnostic yield and local expertise. This review will focus on the evaluation and management of pulmonary nodules based on the Fleischner Society and American College of Chest Physician guidelines. There have been recent changes to both societies' recommendations for incidental detection of solid and subsolid nodules, risk stratification, imaging, minimally invasive diagnostic techniques and definitive surgical options.


title: Coil occlusion of wide-neck bifurcation aneurysms assisted by a novel intra- to extra-aneurysmatic neck-bridging device (pCONus): initial experience.

text: BACKGROUND AND PURPOSE The pCONus is a new stentlike self-expanding nitinol implant with 4 distal petals, which is fully retrievable and electrolytically detachable. The distal end is implanted inside the aneurysm at the neck. The shaft is anchored in the parent vessel. In selected wide-neck bifurcation aneurysms, the pCONus was used to assist coiling. The device was evaluated for its safety and efficacy. MATERIAL AND METHODS Twenty-eight patients with 28 wide-neck aneurysms (9 recently ruptured) were treated with pCONus-assisted coiling at the discretion of the operator. Other treatment options were considered but were discarded due to anticipated difficulties. Technical issues, immediate posttreatment angiographic findings, clinical outcome, and follow-up imaging were assessed. RESULTS There were 11 MCA, 7 anterior communicating artery, 1 posterior cerebral artery, 1 A2, and 8 basilar artery aneurysms. Insertion and deployment of the pCONus and subsequent coiling were possible in all cases. There were no clinically evident complications associated with the use of the device. Initial anatomic outcome showed 8 complete occlusions, 9 neck remnants, and 11 incomplete occlusions. Neurologic status remained unchanged at follow-up. Angiographic controls were obtained in 22 patients (mean, 7.5 months). Of these, 13 had complete occlusion, 9 showed improvement, and 7 were unchanged. Four died from SAH sequelae or other diseases, and 2 have not yet undergone follow-up. No intimal hyperplasia was observed. CONCLUSIONS The pCONus facilitates coil occlusion of unruptured and ruptured wide-neck bifurcation aneurysms. The device can be deployed safely. Coil retention is sufficient to protect the efferent vessels. So far, no intimal hyperplasia in the shaft has been observed.


title: Lower Extremity Near-infrared Spectroscopy After Popliteal Block For Orthopaedic Foot Surgery.

text: BACKGROUND Noninvasive measurement of cutaneous tissue oxygenation using near-infrared spectroscopy (NIRS) has become common in peri-operative care. Following institution of peripheral nerve blocks, neurovascular alterations in the blocked region have been described. OBJECTIVE The primary aim of this study encompassed the assessment of the influence of a popliteal block on changes in regional oxygen saturation (SrO2), and the location of most prominent changes. METHOD We conducted a prospective randomised controlled trial. Hundred twenty patients who received a popliteal block for foot surgery were included. Popliteal block was performed under echographic guidance. The patients were randomized in 3 groups according to the location of the SrO2 electrodes on the legs. Bilateral SrO2 measurements were performed simultaneously. SrO2 in the operated leg and in the control leg was measured at baseline and 1, 5, 10, 15, and 30 minutes after the perineural injection. We quantified the evolution in SrO2 by calculating over time the differences in SrO2 values between the operated and control leg (=ΔSrO2). RESULTS At 30 minutes, ΔSrO2 increased significantly (p<0.05) at the plantar side of the foot (11.3% ± 2.9%), above the ankle (4.9% ± 1.3%) and the popliteal fossa (3.6% ± 1.2%). CONCLUSION At 30 minutes after institution of the popliteal block, ΔSrO2 was most prominent at the plantar side of the foot as compared with measurement performed above the ankle or under the knee.


title: Evolving Management of COVID-19: A Multi-institutional Otolaryngology Perspective.

text: OBJECTIVE To provide evolving information on active protocols regarding inpatient, outpatient, procedural, and surgical case management taking place in otolaryngology practices in response to COVID-19. STUDY TYPE Cross-sectional multi-institutional survey. METHODS An online survey of 55 otolaryngology departments across North America. RESULTS As of March 25, 2020, almost all (n = 53 of 55, 96.3%) otolaryngology departments had canceled elective cases and were performing only urgent consults. Most residents continued to participate in operative cases (n = 45 of 49, 91.8%) and take call (n = 48 of 50, 96.0%). Of the respondents, 27 of 29 (93.1%) stated that they were deferring nonemergent tracheostomy procedures for the time being. The use of personal protective equipment followed a general trend of an increasing level of protection with an increased risk of the procedure; most (n = 49 of 54, 90.7%) incorporated N95 mask usage for bedside/clinic examinations with flexible laryngoscopy. Powered air-purifying respirators and N95 masks were used mainly for procedures involving the mucosal surfaces. DISCUSSION Due to the high viral density in the nasal cavity and nasopharynx of patients with COVID-19, basic examinations and common otolaryngology procedures place practitioners at high risk of exposure. Although there is variability in practice among otolaryngologists across North America in managing the COVID-19 outbreak, most are primarily seeing urgent ambulatory and inpatient consultations. Most are also incorporating personal protective equipment appropriate to the level of transmission across mucous membranes. IMPLICATIONS FOR PRACTICE In these rapidly evolving times, it is helpful to find solidarity and assurance among health care providers. Current data aimed to provide (1) perceived methods regarding the safe care of otolaryngology patients and (2) updated practice patterns at a national level.


Two cases of novel coronavirus are confirmed in France.


title: Coil embolization versus clipping for ruptured intracranial aneurysms: a meta-analysis of prospective controlled published studies.

text: BACKGROUND AND PURPOSE Coil embolization is an alternative to clipping for intracranial aneurysms. However, controversy exists regarding the best therapeutic strategy in patients with ruptured aneurysms, and there is great center- and country-related variability in the rates of clipping versus coiling. We performed a meta-analysis of prospective controlled trials of clipping versus coil embolization for ruptured aneurysms. MATERIALS AND METHODS We performed a search of the English literature for published prospective controlled trials comparing surgical clipping with endovascular coil embolization for ruptured intracranial aneurysms. Data were abstracted from the identified references. Outcomes of interest were the proportion of patients with a poor outcome at 1 year and episodes of rebleeding from the index treated aneurysm after the allocated treatment. RESULTS There were 3 prospective controlled trials eligible for inclusion. These studies enrolled 2723 patients. Meta-analysis of these studies showed that the rate of poor outcome at 1 year was significantly lower in patients allocated to coil embolization (risk ratio, 0.75; 95% confidence interval, 0.65-0.87). This relative effect is consistent with an absolute risk reduction of 7.8% and a number needed to treat of 13. The effect on mortality was not statistically different across the 2 treatments. Rebleeding rates within the first month were higher in patients allocated to endovascular coil embolization. CONCLUSIONS On the basis of the analysis of the 3 high-quality prospective controlled trials available, there is strong evidence to indicate that endovascular coil embolization is associated with better outcomes compared with surgical clipping in patients amenable to either therapeutic strategy.


title: Research in human resuscitation: what we learn from animals.

text: AIM It was not until the 18th century that scientists throughout Europe established humane societies to develop resuscitation techniques and to keep registries of successful and unsuccessful cases. Since then, the science and art of cardiopulmonary resuscitation have flourished, multiple international organizations were found, and guidelines are proposed every 5 years in an everlasting attempt to improve the outcome of cardiac arrest victims. The aim of this article is to present the role of animal models in resuscitation research. METHODS A comprehensive search in PubMed, CINAHL, Cochrane Library, and Scopus databases was performed. RESULTS Mice, rats, and swine have been established as experimental models for conducting resuscitation research. The choice of the animal model is not a simple task, as there are multiple parameters that have to be considered when designing an experiment. CONCLUSION Animal models are used extensively in resuscitation research and possess a central role in the effort towards a better understanding of the underlying mechanisms. However, experimental results should always be cautiously extrapolated in humans.


Accountability to Population Health in the COVID-19 Pandemic: Designing Health Care Delivery Within a Social Responsibility Framework.


title: Internal Hernias and Nonclosure of Mesenteric Defects During Laparoscopic Roux-en-Y Gastric Bypass.

text: BACKGROUND Internal hernias have been described after laparoscopic Roux-en-Y gastric bypass (LRYGB) as a major problem. Thus, many routinely close defects during LRYGB. In our technique, we do not close any defects. We hypothesize that not closing the defects would not cause a significant internal hernia rate diagnosed during reoperations. METHODS Patients who were reoperated after LRYGB were included in this study. Only patients who had a laparoscopic or open exploration focused on inspecting for internal hernias are reported here. The LRYGB technique that was utilized included an antecolic, antegastric gastrojejunostomy, minimal division of the small bowel mesentery, a long jejunojejunostomy performed with three staple lines, adequate division of the omentum, and placement of the jejunojejunostomy above the colon in the left upper quadrant. RESULTS There were a total of 387 patients who had LRYGB from 2002 to 2007 utilizing this particular technique. Fifty-four patients had a reoperation at an average of 24 (Range: 1-60) months postoperatively. The procedures were abdominoplasty, cholecystectomy, diagnostic laparoscopy, and lysis of adhesions. While two patients had a defect present, no patient had an internal hernia despite aggressive attempts to diagnose one. CONCLUSIONS Internals hernias are not common after our particular method of LRYGB. Before adopting and advocating routine closure, surgeons should consider the surgical technique and the true associated incidence of internal hernias. We do not recommend routine closure of these defects with our technique.


title: Temporal changes in urinary excretion of liver-type fatty acid binding protein (L-FABP) in acute kidney injury model of domestic cats: a preliminary study.

text: Liver-type fatty acid-binding protein (L-FABP) is a biomarker for the early detection of renal diseases in humans. It is secreted along with cytotoxic oxidation products from proximal tubular epithelial cells under conditions of ischemia and/or oxidative stress. This study examined urinary L-FABP excretion under renal ischemia in feline acute kidney injury (AKI) model. L-FABP excretion increased immediately after renal ischemia/reperfusion, despite the absence of obvious structural damage to the kidneys, in the two AKI model cats studied. L-FABP was detected in the renal tubular lumen immediately after renal ischemia/reperfusion in the two cats, but not in a sham surgery cat. These results suggested that high L-FABP excretion is a pathophysiological response associated with antioxidant defense in proximal tubules with renal ischemia and/or oxidative stress in a feline model.


title: STAT2 and IRF9: Beyond ISGF3.

text: Cytokine signaling is mediated by the combinatorial usage of seven STAT proteins that form homo- or heterodimers involved in the regulation of specific transcriptional programs. Among STATs, STAT2 is classically known to dimerize with STAT1 and together with IRF9 forms the ISGF3 transcription factor complex that has long been considered a hallmark of activation by type I and type III interferons. However, accumulating evidence reveal distinct facets of STAT2 and IRF9 activity mediated by the segregation in alternative STAT1-independent complexes/pathways that are thought to trigger different transcriptional programs. The goal of this review is to summarize our current knowledge of the stimuli, regulatory mechanisms, and function of these alternative pathways.


Adapt(ed) to repair - TH2 immune responses in the bladder promote recurrent infections.


title: Pneumothorax in a dog caused by necrotizing pneumonia secondary to heatstroke.

text: OBJECTIVE To describe the clinical course, diagnostic findings, medical and surgical treatments, and outcome in a dog with spontaneous pneumothorax secondary to necrotizing pneumonia thought to be a delayed complication of heatstroke. CASE SUMMARY A 1.5-year-old Labrador Retriever developed spontaneous pneumothorax 12 days after an episode of exertional heat stroke. Computed tomography was performed and showed bilateral pneumothorax and multifocal pulmonary consolidation, especially at the lung periphery. A median sternotomy was performed, and multifocal, well-demarcated areas of consolidated pulmonary tissue with purple discoloration were identified and resected from the right middle, right caudal, and accessory lung lobes. Histologic examination of the resected pulmonary tissue indicated necrotizing pneumonia, and bacteriologic culture of the tissue resulted in growth of Pseudomonas aeruginosa. Examination of tissue from a pectoral muscle biopsy performed at this time showed necrotizing myopathy. The dog was discharged 7 days after surgery and made a full recovery. NEW OR UNIQUE INFORMATION PROVIDED This case report describes pneumothorax and multifocal necrotizing pneumonia as a delayed complication of heatstroke, and provides the first description of the computed tomography appearance of histologically confirmed necrotizing pneumonia in a dog. Multifocal necrotizing pneumonia with or without pneumothorax should be considered in dogs that develop respiratory distress following severe systemic illness.


Establishment and Management of Mechanical Circulatory Support During the COVID-19 Pandemic.


Priorities for the US Health Community Responding to COVID-19.


title: Venous collateral drainage patterns predict clinical worsening in dural venous sinus thrombosis.

text: BACKGROUND Dural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. The condition of approximately 23% of patients with DVST will worsen after initial presentation, as a result of restricted venous outflow and venous hypertension, but early identification of this subset is challenging. A venous collateral scale (VCS) that grades alternative drainage routes may improve prediction of clinical deterioration. OBJECTIVE To examine the ability of the VCS system to accurately identify patients with DVST who will experience clinical worsening, based on their imaging at presentation. METHODS From our institutional database, we identified patients with DVST on dedicated venous imaging between January 2010 and July 2016. A VCS was created and calculated from venous imaging at presentation by two reviewers blinded to subsequent data. RESULTS The 27 patients who met the inclusion criteria for this study had a median age of 42 years and 14 (52%) were female. Initial symptoms included headache without hemorrhage in 30% and focal deficit in 30%. Transverse sinus occlusion was present in 70% and superior sagittal sinus occlusion in 41%. VCS was 0 in 11%, 1 in 37%, and 2 in 52%. A lower VCS was significantly associated with clinical worsening both from time of initial symptom onset (77% vs 29%, VCS 0-1 vs 2, p<0.05) and during hospitalization (62% vs 0%, VCS 0-1 vs 2, p<0.01). In multivariate analysis, VCS but no other presenting features was significantly associated with in-hospital worsening (OR=2, p<0.01). CONCLUSIONS The type and quality of venous collaterals influence outcome in DVST. VCS helps to identify patients whose condition is likely to deteriorate and may need additional aggressive interventions.


title: Acetabular cup revision combined with tensor facia lata reconstruction for management of massive abductor avulsion after failed total hip arthroplasty.

text: We report on 17 patients with massive abductor avulsions after total hip arthroplasty (THA) treated with medialization of the acetabular component and tensor fascia lata (TFL) reconstruction. All patients had severe limp, positive Trendelenburg sign, and avulsion of the abductor insertion confirmed on MRI. Mean age was 69 years (range, 50-83 years), and mean follow-up period was 36 months (range, 18-78 months). After surgery, 9 patients had no limp (47%), 8 patients had a mild limp, and abductor power improved from mean 2.5/5 to mean 3.8 (P < 0.0001). At latest follow-up, the Harris Hip Score was excellent in 6 hips (37%), good in 7 (43%) hips, and fair or poor in 3 (23%). Two patients with mild limp were not satisfied with their procedure.


title: Sequence-independent VIDISCA-454 technique to discover new viruses in canine livers.

text: In many mammals, viruses cause hepatitis. Despite many efforts a specific virus responsible for canine idiopathic hepatitis has not been identified. The discovery of a viral etiology in canine hepatitis will promote the development of specific drugs and vaccines for the treatment of idiopathic hepatitis in dogs. The objective of this study was the application of the sequence-independent Virus Discovery cDNA-amplified fragment length polymorphism (VIDISCA) technique combined with high through-put sequencing on a Roche-454 sequencer to identify unknown viruses. Liver tissue of a dog with idiopathic acute hepatitis was cultured on a canine liver cell line and the cell culture medium was submitted to the VIDISCA-454 technique. Without prior knowledge of the viral species involved, this technique identified Canine adenovirus type 1 (CAV-1) as the infecting agent. This demonstrates the power of VIDISCA-454 to identify viruses, independent of preliminary information about the genomic sequence. Consequently, the strategy of propagation in this cell line followed by the VIDISCA-454 technique is valuable to identify the viral etiology of idiopathic hepatitis in dogs.


PFO: "Please Figure Out," or Now "Potentially Figured Out?".


Commentary: Exploring the transmission of COVID-19 through the ocular surface.


title: Protocol for a systematic review of health promotion interventions for African Americans delivered in US barbershops and hair salons.

text: INTRODUCTION African American adults are disproportionately burdened by chronic diseases, particularly at younger ages. Developing culturally appropriate interventions is paramount to closing the gap in these health inequities. The purpose of this systematic review is to critically evaluate health promotion interventions for African Americans delivered in two environments that are frequented by this population: barbershops and hair salons. Characteristics of effective interventions will be identified and evidence for the effectiveness of these interventions will be provided. Results of this review will inform future health promotion efforts for African Americans particularly focused on the leading health inequities in obesity-related chronic diseases: cardiovascular disease, cancer and type 2 diabetes. METHODS AND ANALYSIS Subject headings and keywords will be used to search for synonyms of 'barbershops,' 'hair salons' and 'African Americans' to identify all relevant articles (from inception onwards) in the following databases: Academic Search Ultimate, Cumulative Index of Nursing and Allied Health Literature, Embase, PsycINFO, PubMed, Web of Science (Science Citation Index and Social Sciences Citation Index) and ProQuest Dissertations. Experimental and quasi-experimental studies for adult (>18 years) African Americans delivered in barbershops and hair salons will be included. Eligible interventions will include risk reduction/management of obesity-related chronic disease: cardiovascular disease, cancer and type 2 diabetes. Two reviewers will independently screen, select and extract data and a third will mediate disagreements. The methodological quality (or risk of bias) of individual studies will be appraised using the Effective Public Health Practice Project Quality Assessment Tool. Quality and content of the evidence will be narratively synthesised. ETHICS AND DISSEMINATION Since this is a protocol for a systematic review, ethical approval is not required. Findings from the review will be widely disseminated through conference presentations, peer-reviewed publications and traditional and social media outlets.


title: Mechanical thrombectomy for acute ischemic stroke with cerebral microbleeds.

text: BACKGROUND The influence of cerebral microbleeds (CMBs) on post-thrombolytic hemorrhagic transformation (HT) in patients with acute ischemic stroke remains controversial. OBJECTIVE To investigate the association of CMBs with HT and clinical outcomes among patients with large-vessel occlusion strokes treated with mechanical thrombectomy. METHODS We analyzed patients with acute stroke treated with Merci Retriever, Penumbra system or stent-retriever devices. CMBs were identified on pretreatment T2-weighted, gradient-recall echo MRI. We analyzed the association of the presence, burden, and distribution of CMBs with HT, procedural complications, in-hospital mortality, and clinical outcome. RESULTS CMBs were detected in 37 (18.0%) of 206 patients. Seventy-three foci of microbleeds were identified. Fourteen patients (6.8%) had ≥2 CMBs, only 1 patient had ≥5 CMBs. Strictly lobar CMBs were found in 12 patients, strictly deep CMBs in 12 patients, strictly infratentorial CMBs in 2 patients, and mixed CMBs in 11 patients. There were no significant differences between patients with CMBs and those without CMBs in the rates of overall HT (37.8% vs 45.6%), parenchymal hematoma (16.2% vs 19.5%), procedure-related vessel perforation (5.4% vs 7.1%), in-hospital mortality (16.2% vs 18.3%), and modified Rankin Scale score 0-3 at discharge. CMBs were not independently associated with HT or in-hospital mortality in patients treated with either thrombectomy or intravenous thrombolysis followed by thrombectomy. CONCLUSIONS Patients with CMBs are not at increased risk for HT and mortality following mechanical thrombectomy for acute stroke. Excluding such patients from mechanical thrombectomy is unwarranted. The risk of HT in patients with ≥5 CMBs requires further study.


title: [Viral respiratory co-infections in pediatric patients admitted for acute respiratory infection and their impact on clinical severity].

text: INTRODUCTION Respiratory viruses are the leading cause of acute respiratory tract infection (ARI) in children. It has been reported that viral respiratory co-infection could be associated with severe clinical course. OBJECTIVES To describe the frequency of viral co-infection in children admitted for AlRI and evaluate whether this co-infection was associated with more severe clinical course. PATIENTS AND METHODS Prospective, descriptive study in pediatric patients who were hospitalized for ARI, with molecular detection of at least 1 respiratory virus in nasopharyngeal sample studied by PCR-Microarray for 17 respiratory viruses. RESULTS 110 out of 147 patients with detection of > 1 respiratory virus were included. Viral co-infection was detected in 41/110 (37%). 22/110 children (20%) were classified as moderate to severe clinical course and 88/110 (80%) were classified as mild clinical course. In the group of moderate to severe clinical course, viral respiratory co-infection was detected in 6/22 (27.3%), compared to 35/88 (39.8 %) in the mild clinical course group. No statistically significant difference was found regarding the presence of co-infection between groups (p = 0.33). CONCLUSIONS We detected high rates of viral co-infection in children with ARI. It was not possible to demonstrate that viral co-infections were related with severe clinical course in hospitalized children.


title: Minimally invasive resection of adrenal masses in infants and children: results of a European multi-center survey.

text: BACKGROUND Minimal access adrenal surgery (MAAS) for adrenal pathologies is the standard for many pediatric surgical centers. However, the literature offers few reports and minimal evidence from small case series. The aim of this study was to evaluate the outcomes of pediatric MAAS through a multi-center data analysis. METHOD Pediatric patients who underwent MAAS between January 2002 and December 2013 were retrospectively included. Data analysis was conducted using Spss software (Welch's t-test, X-square, Fisher tests, multiple regression model). RESULTS Six European centers participated, 68 patients were included with mean age of 5.2 years (2 months-16 years). Lesion volume was of 18.1 cc (0.78-145.6), with a mean diameter of 2.8 cm (1.1-6.5). Localization was 50% left-sided masses, 45.6% right-side masses, and 4.4% bilateral. Histological examination revealed 36 neuroblastomas, 15 adenomas, nine pheochromocytomas, three ganglioneuromas, two ganglioneuroblastomas, one bilateral hyperplasia, one adrenocortical carcinoma, an alveolar sarcoma, and a calcification. Surgical access was transperitoneal in 63 (92.6%) and retroperitoneal in 5 (7.4%). Mean operative time was 170 ± 87 min (285 ± 30 min for bilateral lesions). Mean hospital stay was 4.2 ± 2.5 days. Complications included blood loss requiring transfusion in five patients (7.4%) and a diaphragmatic tear. Infiltration of surrounding structures correlated with intraoperative complication rate (p = 0.027) and operative time (p < 0.01). No mass rupture, conversion, or post-operative complications were observed. Median follow-up was 52 months (1-161). Two recurrences occurred in patients with pheochromocytoma. Age, weight, symptoms, characteristics at imaging, chemistry, volume, or histology, did not influence operative time, hospital stays, or complication rate. CONCLUSIONS Pediatric MAAS was safe adopted for masses up to 145.6 cc, with a very low rate of complication. Conversion to open is not necessary even in the presence of infiltrations. MAAS should represent the first-line treatment for selected cases in centers experienced in laparoscopy.


title: Porcine Deltacoronavirus Engages the Transmissible Gastroenteritis Virus Functional Receptor Porcine Aminopeptidase N for Infectious Cellular Entry.

text: Identification of cellular receptors used by coronavirus (CoV) entry into the host cells is critical to an understanding of pathogenesis and to development of intervention strategies. The fourth CoV genus, Deltacoronavirus, evolutionarily related to the Gammacoronavirus, has just been defined recently. In the current study, we demonstrate that porcine aminopeptidase N (pAPN) acts as a cross-genus CoV functional receptor for both enteropathogenic porcine deltacoronovirus (PDCoV) and alphacoronovirus (AlphaCoV) (transmissible gastroenteritis virus [TGEV]) based upon three lines of evidence. First, the soluble S1 protein of PDCoV bound to the surface of target porcine cell lines known to express pAPN as efficiently as TGEV-S1, which could be blocked by soluble pAPN pretreatment. Second, both PDCoV-S1 and TGEV-S1 physically recognized and interacted with pAPN by coimmunoprecipitation in pAPN cDNA-transfected cells and by dot blot hybridization assay. Finally, exogenous expression of pAPN in refractory cells conferred susceptibility to PDCoV-S1 binding and to PDCoV entry and productive infection. PDCoV-S1 appeared to have a lower pAPN-binding affinity and likely consequent lower infection efficiency in pAPN-expressing refractory cells than TGEV-S1, suggesting that there may be differences between these two viruses in the virus-binding regions in pAPN. This study paves the way for dissecting the molecular mechanisms of PDCoV-host interactions and pathogenesis as well as facilitates future vaccine development and intervention strategies against PDCoV infection.IMPORTANCE The emergence of new human and animal coronaviruses is believed to have occurred through interspecies transmission that is mainly mediated by a species-specific receptor of the host. Among the four genera of the Coronavirinae, a couple of functional receptors for the representative members in the genera Alphacoronavirus and Betacoronavirus have been identified, whereas receptors for Gammacoronavirus and Deltacoronavirus, which are believed to originate from birds, are still unknown. Porcine coronaviruses, including the newly discovered porcine deltacoronavirus (PDCoV) associated with diarrhea in newborn piglets, have posed a serious threat to the pork industry in Asia and North America. Here, we report that PDCoV employs the alphacoronavirus TGEV functional receptor porcine aminopeptidase N (pAPN) for cellular entry, demonstrating the usage of pAPN as a cross-genus CoV functional receptor. The identification of the PDCoV receptor provides another example of the expanded host range of CoV and paves the way for further investigation of PDCoV-host interaction and pathogenesis.


title: Effort-adapted modes of assisted breathing.

text: PURPOSE OF REVIEW New developments in mechanical ventilation have focused on increasing the patient's control of the ventilator by implementing information on lung mechanics and respiratory drive. Effort-adapted modes of assisted breathing are presented and their potential advantages are discussed. RECENT FINDINGS Adaptive support ventilation, proportional assist ventilation with load adjustable gain factors and neurally adjusted ventilatory assist are ventilatory modes that follow the concept of adapting the assist to a defined target, instantaneous changes in respiratory drive or lung mechanics. Improved patient ventilator interaction, sufficient unloading of the respiratory muscles and increased comfort have been recently associated with these ventilator modalities. There are, however, scarce data with regard to outcome improvement, such as length of mechanical ventilation, ICU stay or mortality (commonly accepted targets to demonstrate clinical superiority). SUMMARY Within recent years, a major step forward in the evolution of assisted (effort-adapted) modes of mechanical ventilation was accomplished. There is growing evidence that supports the physiological concept of closed-loop effort-adapted assisted modes of mechanical ventilation. However, at present, the translation into a clear outcome benefit remains to be proven. In order to fill the knowledge gap that impedes the broader application, larger randomized controlled trials are urgently needed. However, with clearly proven drawbacks of conventional assisted modes such as pressure support ventilation, it is probably about time to leave these modes introduced decades ago behind.


title: Social support and psychological adjustment to SARS: the mediating role of self-care self-efficacy.

text: The study tested the model of perceived support from medical staff and family/friends on severe acute respiratory syndrome (SARS) survivors' mental health as mediated by self-care self-efficacy. One hundred and forty-three SARS survivors recruited from the Hong Kong Hospital Authority following 18 months recovery were surveyed by trained interviewers using structured questionnaires. Based on structural equation modeling, findings showed that self-care self-efficacy completely mediated the effects of perceived medical staff support and perceived family/friends support on mental health status. The model achieved a satisfactory fit, CFI = 0.98, NNFI = 0.98, RMSEA = 0.06, and explained 75.2% of the variance in mental health status. The study is the first attempt in understanding long-term psychological adjustment of SARS survivors. Findings may be applicable to other infectious disease outbreaks in informing psychosocial factors that are important to long-term recovery.


Preprint servers: a 'rush to publish' or 'just in time delivery' for science?


title: Fatal Complications after Pediatric Surgical Interventions: Lessons Learned.

text: Placement of catheters, drains, shunts, and tubes in children can lead to serious or even fatal complications at the moment of placement, such as hemorrhage at insertion, or in the longterm, such as infections and migration into adjacent organs. The clinician should always be aware of these potential complications, especially if the child is unwell. For postmortem diagnostic evaluation, either with a computed tomography scan or an invasive autopsy, all tubes, drains, shunts, and/or catheters should be left in situ. We present three cases with fatal complications after the placement of a chest drain, ventriculoperitoneal shunt, and gastrostomy tube.


title: The Effect of Caffeine on Diaphragmatic Activity and Tidal Volume in Preterm Infants.

text: OBJECTIVE To determine the effect of caffeine on diaphragmatic activity, tidal volume (Vt), and end-expiratory lung volume (EELV) in preterm infants. STUDY DESIGN Using transcutaneous electromyography of the diaphragm (dEMG), we measured diaphragmatic activity from 30 minutes before (baseline) to 3 hours after administration of an intravenous caffeine-base loading dose in 30 spontaneously breathing preterm infants (mean gestational age, 29.1 ± 1.3 weeks), most of whom were on noninvasive respiratory support. Diaphragmatic activity was expressed as the percentage change in dEMG amplitude, area under the curve, respiratory rate, and inspiratory and expiratory times. Using respiratory inductive plethysmography, we measured changes in Vt and EELV from baseline. These outcome variables were calculated at 8 fixed time points after caffeine administration (5, 15, 30, 60, 90, 120, 150, and 180 minutes) and compared with baseline. RESULTS Caffeine administration resulted in rapid (within 5 minutes) increases in dEMG amplitude (median, 43%; IQR, 24%-63%; P < .001) and area under the curve (median, 28%; IQR, 14%-48%; P < .001). Vt also increased by a median of 30% (IQR, 7%-48%), and this change was significantly correlated with the change in dEMG amplitude (r = 0.67; P < .001). These effects were relatively stable until 120 minutes after caffeine administration. Caffeine did not consistently impact EELV, respiratory rate, or inspiratory and expiratory times. CONCLUSION Caffeine treatment results in a rapid and sustained increase in diaphragmatic activity and Vt in preterm infants.


title: Comparison of the Luminex NxTAG respiratory pathogen panel and a multiplex in-house real-time PCR panel for the detection of respiratory viruses in symptomatic patients.

text: PURPOSE To evaluate the Luminex NxTAG respiratory pathogen panel (NxTAG RPP) for the detection of respiratory viruses in clinical samples from patients with the symptoms of respiratory infection. METHODOLOGY The NxTAG RPP was compared to an in-house multiplex real-time PCR panel (LDT) for the detection of respiratory viruses in 314 clinical samples from patients with the symptoms of respiratory infection. RESULTS Thirty-one samples were negative in both tests and 193 samples contained a single virus that was detected in both tests. Polymicrobial infections were detected in 74 samples, with 268 samples overall having concordant results in both assays, and there were a total of 51 discordant results in 44 samples. Two samples were invalid in the NxTAG RPP assay and were excluded from the final analysis. The overall agreement between the NxTAG RPP and LDT was very high, as indicated by the Kappa coefficients, which ranged from 0.85 for metapneumovirus up to 0.96 for RSV A, and the overall percentage agreement values of 96.2 % for enterovirus/rhinovirus and 100 % for influenza A, influenza B, PIV 4 and RSV B. CONCLUSION The NxTAG RPP is a sensitive and specific test for the detection of respiratory viruses and the high sample throughput and low hands-on time make the NxTAG RPP assay suitable for screening clinical samples for respiratory pathogens.


title: Serum levels of the Th1 chemoattractant interferon-gamma-inducible protein (IP) 10 are elevated in patients with essential hypertension.

text: Growing evidence shows that inflammation has a pivotal role in the pathophysiology of essential hypertension (EH). Although it has been acknowledged that target organ damage involves an inflammatory response, most work has focused on the role of macrophages, but T lymphocytes have recently become the center of interest. The goal of our study was to evaluate the role of T-cell-specific cytokines in the pathogenesis of EH. The study examined 39 patients with EH (57.7±6.8 years, systolic blood pressure (SBP) 157.5±11.8 mm Hg, diastolic blood pressure 92.2±12.9 mm Hg, mean arterial pressure 113.9±12.6 mm Hg) and 30 healthy, normotensive controls (55.2±4.9 years). Blood was drawn from a peripheral vein, and serum levels of interferon-inducible protein (IP)-10 and interleukins (IL)-4, -7 and -13 were measured by a multiplexing assay. Hypertensive patients had significantly higher levels of IP-10, IL-4, IL-7 and IL-13 than control subjects. When the patients were classified into tertiles according to their serum IP-10 levels (T1: 41.2-94.1 pg ml(-1); T2: 103.4-162.5 pg ml(-1); T3: 171.7-443.5 pgml(-1)), the patients classified into the highest tertile also had the highest blood pressure. In a correlation analysis, plasma IP-10 concentration was significantly associated with SBP (r=0.59, P<0.001). Furthermore, hypertensives with microalbuminuria, an early sign of hypertensive target organ damage, had the highest IP-10 levels. A stepwise multivariate regression analysis revealed IP-10 as the strongest independent predictor of SBP (P=0.01). In conclusion, our study provides new insights into the pathophysiological mechanisms in EH linking inflammation and IP-10. However, these preliminary results need to be confirmed in larger trials.


title: Comparison of i-Gel as a Conduit for Intubation between under Fiberoptic Guidance and Blind Endotracheal Intubation during Cardiopulmonary Resuscitation: A Randomized Simulation Study.

text: Purpose This study aimed to compare intubation performances among i-gel blind intubation (IGI), i-gel bronchoscopic intubation (IBRI), and intubation using Macintosh laryngoscope (MCL) applying two kinds of endotracheal tube during chest compressions. We hypothesized that IGI using wire-reinforced silicone (WRS) tube could achieve endotracheal intubation most rapidly and successfully. Methods In 23 emergency physicians, a prospective randomized crossover manikin study was conducted to examine the three intubation techniques using two kinds of endotracheal tubes. The primary outcome was the intubation time. The secondary outcome was the cumulative success rate for each intubation technique. A significant difference was considered when identifying p < 0.05 between two devices or p < 0.017 in post hoc analysis of the comparison among three devices. Results The mean intubation time using IGI was shorter (p < 0.017) than that of using IBRI and MCL in both endotracheal tubes (17.6 vs. 29.3 vs. 20.2 in conventional polyvinyl chloride (PVC) tube; 14.6 vs. 27.4 vs. 19.9 in WRS tube; sec). There were no significant (p < 0.05) differences between PVC and WRS tubes for each intubation technique. The intubation time to reach 100% cumulative success rate was also shorter in IGI (p < 0.017) than that in IBRI and MCL in both PVC and WRS tubes. Conclusions IGI was an equally successful and faster technique compared with IBRI or MCL regardless of the use of PVC or WRS tube. IGI might be an appropriate technique for emergent intubation by experienced intubators during chest compressions.


title: Effect of Applying Force to Self-Adhesive Electrodes on Transthoracic Impedance: Implications for Electrical Cardioversion.

text: BACKGROUND Current guidelines disagree on the role for applying force to electrodes during electrical cardioversion (ECV) for atrial fibrillation, particularly when using self-adhesive pads. We evaluated the impact of this practice on transthoracic impedance (TTI) with varying force and in individuals with differing body mass indices (BMI). We additionally assessed whether specific prompts could improve physicians' ECV technique. METHODS The study comprised three parts: (1) TTI was measured in 11 participants throughout the respiratory cycle and with variable force applied to self-adhesive electrodes in anteroposterior (AP) and anterolateral (AL) configurations. (2) Three participants in different BMI classes then had TTI measured with prespecified incremental force applied. (3) Ten blinded cardiology trainees simulated ECV on one participant with and without prompting (guideline reminders and force analogies) while force applied and TTI were measured. RESULTS The AP approach was associated with 13% lower TTI than AL (P < 0.001). Strongly negative correlations were observed between force applied and TTI in the AL position, irrespective of BMI (P ≤ 0.003). In all cases, 80% of the total reduction in TTI observed was achieved with 8 kg-force (∼80 N). All prompts resulted in significantly greater force applied and modest reductions in TTI. CONCLUSIONS Applying force to self-adhesive electrodes reduces TTI and should be considered as a means of improving ECV success. Numerically greater mean force applied with a "push-up" force analogy suggests that "concrete" cues may be useful in improving ECV technique.


Elective surgeries during COVID-19 storm: The best surgeon knows when not to operate.


title: Use of a human acellular dermal wound matrix in patients with complex wounds and comorbidities.

text: OBJECTIVE Rising prevalence of obesity and uncontrolled diabetes mellitus has resulted in an increasing number of patients with multiple comorbidities who require treatment for chronic complex wounds. Because patients with diabetes and foot ulcers may have a higher risk for amputations, techniques that facilitate complex wound healing and prevent limb amputation are desirable. Here, we investigate a limb preservation strategy that includes application of a human acellular dermal wound matrix (HADWM). METHOD Medical history, physical examination and full wound assessment were completed for all patients. Systemic antibiotics and appropriate offloading were prescribed as needed. Wounds were debrided to create a bleeding bone and/or wound base for HADWM (Graftjacket regenerative tissue matrix, Wright Medical Technology, Inc., licensed by KCI, an Acelity company, San Antonio, TX). Healing progress was monitored over four weeks with weekly postoperative visits. 'Healed' was defined as full epithelialisation without drainage. RESULTS Lower extremity ulcers, 16 in 13 patients, were treated with HADWM between May 2004 and July 2013. The median patient age was 76 years (range: 38-90). The average number of comorbidities was three per patient, while 6 (46%) patients had ≥4 comorbidities. Diabetes mellitus (92%) and peripheral vascular disease (77%) were the two most common. All 16 (100%) wounds healed without complications. There were no recurrences in the 11 wounds of the nine patients available for follow-up. Of these patients two had previously advised to receive major leg amputations retained functional limbs. CONCLUSION The results in this small study reflect our practice's 10-year experience using HADWM as part of a limb preservation strategy.


Hundreds of people volunteer to be infected with coronavirus.


title: A death-promoting role for ISG54/IFIT2.

text: The cellular responses to infection are many, and include programmed cell death to inhibit microbial dissemination and the production and secretion of interferons (IFNs), which confer resistance to uninfected cells. In addition to the antimicrobial effects of IFNs, these cytokines have been used clinically for the treatment of various neoplasias to inhibit proliferation and stimulate apoptosis. However, the precise mechanisms of action of IFNs remain to be completely understood. One of the primary response genes induced after an infection or treatment with type I or III IFN is known as IFN-stimulated gene 54 (ISG54) or IFN-induced gene with tetratricopeptide repeats 2 (IFIT2). ISG54/IFIT2 is a member of a family of IFN-induced genes related in the sequence and structure. Expression of this protein has been found to promote cellular apoptosis by a mitochondrial pathway dependent on the action of Bcl2 proteins. ISG54/IFIT2 does not function as a monomer, and it forms complexes with itself and with the related ISG56/IFIT1 and ISG60/IFIT3 proteins to elicit complex cellular responses. The apoptotic response to ISG54/IFIT2 may contribute to other functions that have been reported, including translational regulation, inhibition of tumor colonization, and protection against a lethal viral infection.


title: Aerosol Therapy in Pulmonary Critical Care.

text: Aerosolized medications are routinely used for the treatment of critically ill patients. This paper reviews aerosol delivery devices with a focus on issues related to their performance in pulmonary critical care. Factors affecting aerosol drug delivery to mechanically ventilated adults and spontaneously breathing patients with artificial airways are reviewed. Device selection, optimum device technique, and unmet medical needs of aerosol medicine in pulmonary critical care are also discussed.


title: Continuous absorbable intradermal sutures yield better cosmetic results than nonabsorbable interrupted sutures in open appendectomy wounds: a prospective, randomized trial.

text: BACKGROUND Acute appendicitis is the most common reason for abdominal surgery in young adults and children. Open appendectomy is still the treatment often chosen because it is simple, safe, and effective. Our aim was to study whether cosmetic results of appendectomy wounds are better after using continuous absorbable intradermal (A) sutures compared with wound closure with interrupted nonabsorbable (NA) sutures. METHODS A total of 206 adult patients with clinically suspected appendicitis were allocated to the study and prospectively randomized into two wound-closure groups: the interrupted NA suture group and the A suture group. Of these, 193 patients with sufficient data were invited to the outpatient clinic for cosmetic analysis. Cosmetic results were evaluated after a median of 14 months. For subjective scar assessment, the Vancouver scar scale, the patient and observer scar assessment scale (POSAS), and a visual analog scale (VAS) were used. Objective evaluation was carried out by measuring surface area, average width, and estimated concentration change (ECC) of hemoglobin and melanin in the scar using spectrocutometry. For statistical analyses we used the Mann-Whitney test and Student's t test. RESULTS Both objective and subjective analyses showed better cosmetic results for absorbable intradermal suturing. The difference between the two groups was statistically significant as regards POSAS in both patient (p = 0.032) and observer scales (p = 0.001), and VAS (p = 0.002). Scar surface area was significantly smaller in group A than in group NA (p = 0.002). ECC measurements showed higher values for melanin in group NA than in group A (p = 0.034). CONCLUSION Continuous intradermal absorbable suturing yields a better cosmetic result than interrupted nonabsorbable suturing in lower abdominal transverse appendectomy.


title: Venous thromboembolism in patients with COVID-19 (SARS-CoV-2 infection) - a position paper of the German Society of Angiology (DGA).

text: As observed in other infections with a systemic inflammatory response, severe COVID-19 is associated with hypercoagulability and a prothrombotic state. Currently, there is growing evidence that pulmonary embolism and thrombosis contribute to adverse outcomes and increased mortality in critically ill patients with COVID-19. The optimal thromboprophylactic regimen for patients with COVID-19 is not known. Whereas pharmacologic thromboprophylaxis is generally recommended for all hospitalized COVID-19 patients, adequate dosing of anticoagulants remains a controversial issue. Therefore, we summarize current evidence from the available literature and, on behalf of the German Society of Angiology (DGA), we aim to provide advice to establish an improved and more uniform strategy for thromboprophylaxis in patients with COVID-19.


title: Use of chicken immunoglobulin Y in general virology.

text: Immunoglobulin Y (IgY), an antibody present in birds, reptiles, and amphibians, is actively transported from the serum to egg yolks, where it is stored in large quantities. The use of chicken polyclonal IgY instead of mammalian IgG antibodies for biomedical applications has ethical and economic advantages, such as the lack of a need for animal bleeding because the antibodies are extracted from eggs after hen immunization and the low cost of the production and purification methods. This article reviews the latest IgY applications in diagnostic virology and the therapeutic use of IgY in viral gastroenteritis.


title: Towards integration of health economics into medical education and clinical practice in Saudi Arabia.

text: In an era of expanding health sectors and rising costs, doctors are expected to have a working knowledge of health economics to better use resources and improve outcomes and quality of health care. This article recognizes the dearth of knowledge and application of economic analyses in medical education and clinical practice in Saudi Arabia. In particular, it highlights the desirability of knowledge of health economics in ensuring certain competencies in medical education and the rationale for inviting doctors to apply knowledge of economics in Saudi Arabia. In addition, the article discusses challenges that hinder integrating health economics into clinical practice. Furthermore, the article typifies some of the important economic phenomena that physicians need to discern. Besides, the article provides implications for incorporating economic analysis into medical education and clinical practice in Saudi Arabia. Finally, the article concludes by demonstrating how health economics can enhance doctors' knowledge and recommends the country to move towards integrating health economics into medical education and clinical practice for best practice.


title: Laparoscopic technique and safety experience with barbed suture closure for pelvic cavity after abdominoperineal resection.

text: BACKGROUND Between April 2005 and December 2012, we performed laparoscopic colorectal resection with regional lymph node dissection on 273 cases of colorectal cancer patients. However, Laparoscopic rectal cancer surgery requires a high degree of skill. Any surgeon who is going to embark on these difficult resections should have at a minimum laparoscopic suturing skills in order to be able to close the peritoneal defect. METHODS In laparoscopic surgery for rectal cancer, the intracorporeal suture technique required to close the pelvic cavity is very difficult. Barbed sutures have recently been proposed to facilitate laparoscopic suturing. Two patients with rectal cancer who underwent laparoscopic abdominoperineal resection (APR) with intracorporeal closure of the pelvic cavity from September to October 2012 were enrolled in this study. RESULTS We present our initial experience of two consecutive cases of intracorporeal closure of the pelvic cavity by totally laparoscopic APR. After clinical follow-up, the two patients have no complaints and have shown no signs of recurrence. CONCLUSIONS We hypothesized that barbed sutures could potentially improve the efficiency of intracorporeal closure of the pelvic cavity after laparoscopic APR. Further, we expect that use of the V-Loc™ will reduce intra-operative stress on the endoscopic surgeon.


title: Flow-diversion for ophthalmic segment aneurysms.

text: BACKGROUND The use of flow-diversion to treat ophthalmic segment aneurysms (OSA) has not been well evaluated. OBJECTIVE To assess the visual outcomes, the obliteration rate, and the need for retreatment of OSA treated by the pipeline embolization device (PED). METHODS Patients who underwent treatment with PED for OSA from 2009 to 2014 were selected and retrospectively reviewed. Patient's age, sex, mode of presentation, and aneurysm size were recorded. The complication rates, the need for retreatment (due to recurrence of the aneurysm or worsening symptoms), the aneurysm occlusion rates, the evolution of visual symptoms, and the evolution of headache/retro-orbital pain were registered. RESULTS Forty-one patients harboring 44 OSA treated by flow-diversion were identified. Females constituted 87.80% (37/41) of the cohort. The mean age was 59.16 ± 12.54 years. At final angiographic follow-up, 77.27% (34/44) had complete occlusion, 6.81% (3/44) had near-complete occlusion, and 15.90% (7/44) had incomplete occlusion. Of the 22 symptomatic OSA, complete resolution or significant improvement was noted in 72.72% (16/22), while worsening of symptoms occurred in 4.54% (1/22). Five patients out of 22 (22.72%; 5/22) had no significant changes in their symptoms. The complication rate was 2.27% (1/44). The mortality rate was 0%. CONCLUSION The low complication rate, the high obliteration rate, and the high rate of improvement in the visual symptoms make flow-diversion an appealing option for the treatment of OSA.


title: ACE2 gene polymorphisms and invasively measured central pulse pressure in cardiac patients indicated for coronarography.

text: BACKGROUND AND AIM The objective of this research was to determine whether invasively measured central pulse pressure (PP) in patients indicated for coronarography is associated with two common polymorphisms in the ACE2 region (rs4646156 and rs4646174). METHODS A total of 307 patients were enrolled in the study. The genotyping of both SNPs from peripheral blood samples was carried out using 5'exonuclease (Taqman®) chemistry on the ABI Prism® 7000 system (Applied Biosystems, Foster City, CA, USA). RESULTS In both polymorphisms, the associations with central PP were found to be highly significant when all five possible genotypes in the population had been compared (p = 0.0001). In men, there was a higher incidence of previous myocardial infarction in G0 genotype carriers of rs54646174 (OR ratio = 7; p = 0.005). The AA genotype of rs4646156 had a 7.81× higher risk of severe angina pectoris in women (OR = 7.81, p = 0.05). A significant difference in allelic frequency of ACE2rs4646174 was found between women with and without significant stenoses of the circumflex branch of the left coronary artery. CONCLUSION More research into the role of ACE2 genetic variability in PP regulations is necessary for more detailed physiological and pathophysiological comprehension of PP regulation.


title: Interventions to Increase Depression Treatment Initiation in Primary Care Patients: a Systematic Review.

text: INTRODUCTION Nearly 50% of depressed primary care patients referred to mental health services do not initiate mental health treatment. The most promising interventions for increasing depression treatment initiation in primary care settings remain unclear. METHODS We performed a systematic search of publicly available databases from inception through August 2017 to identify interventions designed to increase depression treatment initiation. Two authors independently selected, extracted data, and rated risk of bias from included studies. Eligible studies used a randomized or pre-post design and assessed depression treatment initiation (i.e., ≥ 1 mental health visit or antidepressant fill) among adults, the majority of whom met criteria for depression. Interventions were classified as simple or complex and sub-classified into intervention strategies that were graded for strength of evidence. RESULTS Of 9516 articles identified, we included 14 unique studies representing 16 (4 simple and 12 complex) interventions and 8 treatment initiation strategies. We found low to moderate strength of evidence for collaborative/integrated care (3 studies), treatment preference matching (2 studies), and case management (2 studies) strategies. However, there was insufficient evidence to determine the benefit of cultural tailoring (2 studies), motivation (alone, with reminders or with cultural tailoring (5 studies)), education (1 study), and shared decision-making strategies (1 study). Overall, we found moderate strength of evidence for complex interventions (8 of 12 complex interventions demonstrated statistically significant effects on treatment initiation). DISCUSSION Collaborative/integrated care, preference treatment matching, and case management strategies had the best evidence for improving depression treatment initiation, but none of the strategies had high strength of evidence. While primary care settings can consider using some of these strategies when referring depressed patients to treatment, our review highlights the need for further rigorous research in this area.


title: A method of identifying the blood contributor in mixture stains through detecting blood specific mRNA polymorphism.

text: In the past decades, messenger RNA (mRNA) biomarkers have been employed to identify the origin of body fluids in forensic medicine. We hypothesized that the polymorphism of mRNA could be applied to identifying individuals in mixture samples composed of two body fluids. In this study, we selected 5 blood-specific mRNA biomarkers of venous blood (SPTB, CD3G, AMICA1, ANK1, GYPA) that encompass 16 SNPs to identify the mixture contributor(s). Five specific gene markers for menstrual blood, semen, skin, saliva and vaginal secretions were amplified and typed as body-fluid positive controls. We established the system of multiplex PCR and single base extension reaction (SBE) followed by capillary electrophoresis. The amplicon size was between 90bp-294bp. The peripheral blood specificity was examined against other human body fluids, including saliva, semen, skin, menstrual blood, and vaginal secretion. The 16 SNPs were peripheral blood specific and could be successfully typed in home-made mixtures which are composed of different body fluids with 1ng peripheral blood mRNA added. This system showed a super sensitivity (1:100) in detecting the trace amount of peripheral blood mixed in other body fluids and a combined discrimination power (CDP) of 0.99929 in Chinese population. It was the first time to establish a method of identifying the blood donors and deconvoluting mixtures through detecting mRNA polymorphism with SNaPshot assay. This peripheral blood-specific SNP typing system showed high sensitivity to the typing of blood-source specific markers regardless of other body fluids in the mixture. This article is protected by copyright. All rights reserved.


Infectious mononucleosis.


title: Efficacy and Safety of Digital Single-Operator Cholangioscopy for Difficult Biliary Stones.

text: BACKGROUND & AIMS It is not clear whether digital single-operator cholangioscopy (D-SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D-SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones. METHODS We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D-SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D-SOC electrohydraulic or laser lithotripsy session to clear the bile duct. RESULTS The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26-21.2; P = .02). Procedure time increased odds of more than 1 session of D-SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P < .001). CONCLUSIONS In a multicenter, international, retrospective analysis, we found D-SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.


title: Instrumentation and equipment for single-site umbilical laparoscopic surgery.

text: The minimally invasive approach has become the preferred technique for many pediatric operations. Advances in instrumentation and equipment have allowed for the introduction of a new type of minimally invasive surgery: single-site umbilical laparoscopic surgery (SSULS). The ultimate goal of SSULS is to leave the patient with no visible scar. In this article, we describe an array of instruments and equipment that are used for SSULS and discuss some of the related controversies of SSULS in children.


title: Strengthening the Immune System and Reducing Inflammation and Oxidative Stress through Diet and Nutrition: Considerations during the COVID-19 Crisis.

text: The coronavirus-disease 2019 (COVID-19) was announced as a global pandemic by the World Health Organization. Challenges arise concerning how to optimally support the immune system in the general population, especially under self-confinement. An optimal immune response depends on an adequate diet and nutrition in order to keep infection at bay. For example, sufficient protein intake is crucial for optimal antibody production. Low micronutrient status, such as of vitamin A or zinc, has been associated with increased infection risk. Frequently, poor nutrient status is associated with inflammation and oxidative stress, which in turn can impact the immune system. Dietary constituents with especially high anti-inflammatory and antioxidant capacity include vitamin C, vitamin E, and phytochemicals such as carotenoids and polyphenols. Several of these can interact with transcription factors such as NF-kB and Nrf-2, related to anti-inflammatory and antioxidant effects, respectively. Vitamin D in particular may perturb viral cellular infection via interacting with cell entry receptors (angiotensin converting enzyme 2), ACE2. Dietary fiber, fermented by the gut microbiota into short-chain fatty acids, has also been shown to produce anti-inflammatory effects. In this review, we highlight the importance of an optimal status of relevant nutrients to effectively reduce inflammation and oxidative stress, thereby strengthening the immune system during the COVID-19 crisis.


title: Balloon expulsion testing for the diagnosis of dyssynergic defecation in women with chronic constipation.

text: INTRODUCTION AND HYPOTHESIS Dyssynergic defecation can be difficult to diagnose. Anorectal manometry and defecography are often used to make this diagnosis. However, these tests are expensive and require expertise. Balloon expulsion testing may be a simple alternative. We compared balloon expulsion to anorectal manometry and defecography for diagnosing dyssynergia in women with chronic constipation. METHODS We conducted a retrospective review. All women presenting for evaluation of chronic constipation who underwent concurrent balloon testing, manometry, and defecography were included. A diagnosis of dyssynergic defecation was established by either defecography revealing prolonged/incomplete rectal evacuation and/or by manometry revealing paradoxical contraction/inadequate relaxation of the pelvic floor. Inability to expel a 50-ml balloon defined dyssynergic defecation by balloon testing. Sensitivity, specificity, and predictive values were calculated. RESULTS A total of 61 women met inclusion criteria. Mean age was 50 years. There were 36 women (59 %) who met Rome III criteria for dyssynergic defecation on defecography and/or manometry. Only 12 of these 36 (33 %) were similarly diagnosed by balloon testing. The sensitivity and positive predictive value of balloon testing for dyssynergia were 33 and 71 %, respectively. Of the 25 (41 %) women who did not meet Rome III criteria for dyssynergia on defecography and/or manometry, 20 (80 %) also had negative balloon testing. Thus, the specificity and negative predictive value of balloon testing for diagnosing dyssynergia were 80 and 50 %, respectively. CONCLUSIONS In our population, balloon expulsion was not an ideal screening test for dyssynergic defecation in women with constipation. Multimodal testing is necessary for more accurate diagnosis.


title: Global changes and factors of increase in caloric/salty food, screen, and substance use, during the early COVID-19 containment phase in France: a general population online survey.

text: BACKGROUND The international outbreak of the COVID-19 pandemic has led many countries to enforce drastic containment measures. It has been suggested that this abrupt lockdown of populations would foster addiction-related habits, such as caloric/salty (C/S) food intake, screen use, and substance use. However, no data has supported this assumption until now. OBJECTIVE To assess the global changes and factors of increase in addiction-related habits during the early COVID-19 containment phase in France. METHODS Online survey among 11,391 participants, opened from day-8 to day-13 of the containment (started 03/17/2020). Questions explored sociodemographic features, psychiatric/addiction history, material conditions of lockdown, general stress ([1-10] Visual Analog Scale), Warwick-Edinburgh Mental Well-being Scale (WEMWBS), and reported changes in several addiction-related behaviors. Global changes were described, and factors of increase were explored using population-weighted and adjusted logistic regression models, providing adjusted odds ratios (aORs) and their 95% confidence intervals (95%CI). RESULTS Overall, increases in addiction-related habits were more frequent than decreases, as they were reported by 28.4% (C/S food), 64.6% (screens), 35.6% (tobacco), 24.8% (alcohol), and 31.2% (cannabis) of the concerned subjects, respectively. Reduced well-being score and increase stress score were general factors of increase in addiction-related habits (p-values<0.001 for all types of habits). The main specific factors of increase in C/S food intake (n=10,771) were female gender (aOR=1.62; 95%CI=1.48-1.77), being aged less than 29 years (p-values<0.001), having a partner (aOR=1.19; 95%CI=1.06-1.35), being locked down in a more confined space (per one m2/person decrease: aOR=1.02; 95%CI=1.01-1.03), being locked down alone (aOR=1.29; 95%CI=1.11-1.49), and reporting a current (aOR=1.94; 95%CI=1.62-2.31) or past (aOR=1.27; 95%CI=1.09-1.47) psychiatric treatment. The main specific factors of increase in screen use (n=11,267) were female gender (aOR=1.31; 95%CI=1.21-1.43), being aged less than 29 years (p<0.001), having no partner (aOR=1.18; 95%CI=1.06-1.32), being professionally active (p-values <0.001), an intermediate/high education level (p-values <0.001), being locked down with no access to an outdoor space (aOR=1.16; 95%CI=1.05-1.29), being locked down alone (aOR=1.15; 95%CI=1.01-1.32), in an urban environment (p-values <0.01), and not working (p-values <0.001). The main specific factors of increase in tobacco use (n=2,787) were female gender (aOR=1.31; 95%CI=1.11-1.55), having no partner (aOR=1.30; 95%CI=1.06-1.59), having and intermediate/low education level (p-values <0.01), and still working at workplace (aOR=1.47; 95%CI=1.17-1.86). The main specific factors of increase in alcohol use (n= 7,108) were being aged 30-49 years (p-values <0.05), a high level of education (p-values <0.001), or a current psychiatric treatment (aOR=1.44; 95%CI=1.10-1.88). The main specific factor of increase in cannabis use (n=620) was an intermediate/low level of education (p-values <0.001). CONCLUSIONS The early phase of the COVID-19 containment in France led to widespread increases in addiction-related habits in the general population. Reduced well-being and increased stress were universal factors of increase. More specific factors were associated with increases in each of the explored habits. CLINICALTRIAL


Preventing Dengue Epidemics during the COVID-19 Pandemic.


title: Effects of sleeve gastrectomy in high fat diet-induced obese mice: respective role of reduced caloric intake, white adipose tissue inflammation and changes in adipose tissue and ectopic fat depots.

text: BACKGROUND Sleeve gastrectomy (SG) has become a popular bariatric procedure. The mechanisms responsible for weight loss and improvement of metabolic disturbances have still not been completely elucidated. We investigated the effect of SG on body weight, adipose tissue depots, glucose tolerance, and liver steatosis independent of reduced caloric intake in high-fat-diet-induced obese mice. METHODS C57BI/6 J mice fed a high fat diet (45 %) for 33 weeks were divided into three groups: sleeve gastrectomy (SG, 13 mice), sham-operated ad libitum fed (SALF, 13 mice) and sham-operated pair fed (PFS, 13 mice). The animals were humanely killed 23 days after surgery. RESULTS In SG mice, food intake was reduced transiently, but weight loss was significant and persistent compared to controls (SG vs. PFS, P < 0.05; PFS vs. SALF, P < 0.05). SG mice showed improved glucose tolerance and lower levels of liver steatosis compared with controls (area under the curve, SG vs. PFS, P < 0.01; PFS vs. SALF, P < 0.05) (liver steatosis, SG vs. PFS, P < 0.05; PFS vs. SALF, P < 0.01). This was associated with a decrease in the ratios of the weight of pancreas, epididymal and inguinal adipose tissues to body weight, and an increase in the ratio of brown adipose tissue weight to body weight. Epididymal adipose tissue was also infiltrated by fewer activated T cells and by more anti-inflammatory regulatory T cells. Serum levels of fasting acyl ghrelin were still significantly decreased 3 weeks after surgery in SG mice compared to PFS mice (P < 0.05). CONCLUSIONS Reduced white adipose tissue inflammation, modification of adipose tissue development (brown vs. white adipose tissue), and ectopic fat are potential mechanisms that may account for the reduced caloric intake independent effects of SG.


Emerging diseases. Soaring MERS cases in Saudi Arabia raise alarms.


title: Discovery of diverse polyomaviruses in bats and the evolutionary history of the Polyomaviridae.

text: Polyomaviruses (PyVs) have been identified in a wide range of avian and mammalian species. However, little is known about their occurrence, genetic diversity and evolutionary history in bats, even though bats are important reservoirs for many emerging viral pathogens. This study screened 380 specimens from 35 bat species from Kenya and Guatemala for the presence of PyVs by semi-nested pan-PyV PCR assays. PyV DNA was detected in 24 of the 380 bat specimens. Phylogenetic analysis revealed that the bat PyV sequences formed 12 distinct lineages. Full-genome sequences were obtained for seven representative lineages and possessed similar genomic features to known PyVs. Strikingly, this evolutionary analysis revealed that the bat PyVs were paraphyletic, suggestive of multiple species jumps between bats and other mammalian species, such that the theory of virus-host co-divergence for mammalian PyVs as a whole could be rejected. In addition, evidence was found for strong heterogeneity in evolutionary rate and potential recombination in a number of PyV complete genomes, which complicates both phylogenetic analysis and virus classification. In summary, this study revealed that bats are important reservoirs of PyVs and that these viruses have a complex evolutionary history.