title: Aneurysm coil embolization using a 1.5-fr distal outer diameter microcatheter.

text: The current assortment of microcatheters widely used for aneurysm coil embolization may not be well suited for several anatomic variants, including excessive vascular tortuosity and small aneurysms less than 3 mm. Longer microcatheters designed with a smaller caliber that can accommodate and deliver coils may be of use in these situations. This case series and literature review illustrates the advantages and limitations of the Marathon microcatheter (Covidien, Irvine, CA, USA) when used for coil embolization of cerebral aneurysms. Despite some technical compromises including the distal marker, length, and the risk of buckling, the Marathon microcatheter was able to adequately deliver coils to achieve satisfactory occlusion of cerebral aneurysms. We found unique advantages with regards to length and smaller distal outer diameter (OD). These results may serve as a guide for the further development of a microcatheter used for coil embolization that has the features of a smaller distal OD and longer length.


title: Laparoscopic microwave thermosphere ablation of malignant liver tumors: an initial clinical evaluation.

text: BACKGROUND Microwave ablation (MWA) has been recently recognized as a technology to overcome the limitations of radiofrequency ablation. The aim of the current study was to evaluate the safety and efficacy of a new 2.45-GHz thermosphere MWA system in the treatment of malignant liver tumors. METHODS This was a prospective IRB-approved study of 18 patients with malignant liver tumors treated with MWA within a 3-month time period. Tumor sizes and response to MWA were obtained from triphasic liver CT scans done before and after MWA. The ablation zones were assessed for complete tumor response and spherical geometry. RESULTS There were a total of 18 patients with an average of three tumors measuring 1.4 cm (range 0.2-4). Ablations were performed laparoscopically in all, but three patients who underwent combined liver resection. A single ablation was created in 72% and overlapping ablations in 28% of lesions. Total ablation time per patient was 15.6 ± 1.9 min. There was no morbidity or mortality. At 2-week CT scans, there was 100% tumor destruction, with no residual lesions. Roundness indices A, B and transverse were 1.1, 0.9 and 0.9, respectively, confirming the spherical nature of ablation zones. CONCLUSIONS To the best of our knowledge, this is the first report of a new thermosphere MWA technology in the laparoscopic treatment of malignant liver tumors. The results demonstrate the safety of the technology, with satisfactory spherical ablation zones seen on post-procedural CT scans.


The SARS-CoV-2 pandemic: An urgent need to relook at the training of the African health workforce.


title: Pre-registration undergraduate nurses and the COVID-19 pandemic: students or workers?

text: The COVID-19 pandemic has changed our perspective on a myriad of things as it sweeps across the globe. One issue we are forced to pay more attention to is the risk that COVID related care entails and the fact that nurses have tragically lost their lives in this pandemic (Cook et al 2020). This loss of life has included student nurses (Ford 2020).


title: Proteomic analysis of multiple myeloma: current status and future perspectives.

text: Multiple myeloma (MM) is a malignant plasma cell neoplasm that accounts for slightly more than 10% of all hematologic cancers and remains incurable. The major challenge remains the identification of better diagnosis and prognostic biomarkers. The advent of proteomic technologies creates new opportunities and challenges for those seeking to gain greater understanding of MM. Although there is a limited number of proteomic studies to date in MM, those performed highlight the potential impact of these technologies in our understanding of MM pathogenesis and the identification of novel therapeutic targets. In this review, we introduce the proteomic technologies available for the study of MM, summarize results of the published proteomic studies on MM, and discuss the novel developments and applications for the analysis of protein PTM in MM. The application of proteomic technologies will be valuable to better understand the pathogenesis of MM and may in the future open novel avenues in the treatment of MM.


title: The use of barbed sutures for vaginal cuff closure during laparoscopic hysterectomy.

text: PURPOSE To compare surgical outcomes and complications of 334 women who underwent total laparoscopic hysterectomy with or without the use of barbed sutures for vaginal cuff closure. METHODS A retrospective study was conducted on a cohort of women who underwent total laparoscopic hysterectomy for benign gynecologic diseases at Dae-Jeon St. Mary's Hospital, between May 2009 and May 2016. Surgical outcomes and complications were compared between the two groups. RESULTS A total of 334 women were included: 212 cases of vaginal cuff suture performed with traditional suture material and 122 cases of vaginal cuff suture performed with the barbed suture. No difference in major complications including vaginal bleeding and vaginal cuff dehiscence was found between the two groups, with a significant reduction in operative times for the barbed suture group (P = 0.002). Underlying clinical variables including diabetes, pelvic adhesion, and obesity showed no significant differences in complication rate. CONCLUSION Vaginal cuff suture performed with barbed suture material is a safe and well-tolerated procedure and reduces operative times. We did not find any meaningful decrease in postoperative vaginal complications including vaginal cuff dehiscence based on the suture material.


From the Editors.


title: Comparison of permanent and nonpermanent staple line buttressing materials for linear gastric staple lines during laparoscopic Roux-en-Y gastric bypass.

text: BACKGROUND Several publications have suggested that staple line buttressing might decrease staple line bleeding, increase burst pressure, and decrease the likelihood of acute failure resulting in leak. Currently, permanent and nonpermanent options are available. However, concern has been raised about the permanent buttress material and its potential for delayed strip expulsion. This study analyzed our experience with 3 different buttressing materials for creating the gastric division during laparoscopic Roux-en-Y gastric bypass. METHODS From July 5, 2001 to May 30, 2007, 1451 consecutive patients underwent laparoscopic gastric bypass with buttressing material used for the stapled creation of the gastric pouch. Peristrips Dry (PSDs), permanent bovine pericardial strips, were used in 926 cases from July 5, 2001 to October 11, 2005. Seamguards, a synthetic bioabsorbable product, were used in 145 cases from November 2, 2004 to July 18, 2006, and PSD Veritas, remodelable, nonpermanent bovine pericardial strips, were placed in 380 patients from October 11, 2005 to May 30, 2007. All products were applied to the 60-mm-long, 3.5-mm cartridges of the EndoGIA II stapler. The ease of use, operative complications, visual bleeding, and postoperative leaks were recorded. RESULTS The patient characteristics were comparable for all groups. All products were easy to load on the stapler, and no operative complications related to the use of the buttress materials occurred. The incidence and severity of staple line bleeding was not specifically calculated but was visually noted to be minimal in all cases. Of the 3 groups, 4 contained leaks occurred in the Seamguards group, and all were successfully managed nonoperatively. No acute leaks were discovered in the PSD or PSD Veritas groups. This difference was statistically significant (p <.001). CONCLUSION Neither the PSDs or PSD Veritas group exhibited staple line complications. However, 4 leaks occurred in the patients who had Seamguards incorporated into their gastric pouch linear staple lines.


Response to Letter Regarding Article, "Proton Pump Inhibitors, Platelet Reactivity, and Cardiovascular Outcomes After Drug-Eluting Stents in Clopidogrel-Treated Patients: The ADAPT-DES Study".


title: Improving Detection and Response to Respiratory Events - Kenya, April 2016-April 2020.

text: Respiratory pathogens, such as novel influenza A viruses, Middle East respiratory syndrome coronavirus (MERS-CoV), and now, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), are of particular concern because of their high transmissibility and history of global spread (1). Clusters of severe respiratory disease are challenging to investigate, especially in resource-limited settings, and disease etiology often is not well understood. In 2014, endorsed by the Group of Seven (G7),* the Global Health Security Agenda (GHSA) was established to help build country capacity to prevent, detect, and respond to infectious disease threats.† GHSA is a multinational, multisectoral collaboration to support countries towards full implementation of the World Health Organization's International Health Regulations (IHR).§ Initially, 11 technical areas for collaborator participation were identified to meet GHSA goals. CDC developed the Detection and Response to Respiratory Events (DaRRE) strategy in 2014 to enhance country capacity to identify and control respiratory disease outbreaks. DaRRE initiatives support the four of 11 GHSA technical areas that CDC focuses on: surveillance, laboratory capacity, emergency operations, and workforce development.¶ In 2016, Kenya was selected to pilot DaRRE because of its existing respiratory disease surveillance and laboratory platforms and well-developed Field Epidemiology and Laboratory Training Program (FELTP) (2). During 2016-2020, Kenya's DaRRE partners (CDC, the Kenya Ministry of Health [MoH], and Kenya's county public health officials) conceptualized, planned, and implemented key components of DaRRE. Activities were selected based on existing capacity and determined by the Kenya MoH and included 1) expansion of severe acute respiratory illness (SARI) surveillance sites; 2) piloting of community event-based surveillance; 3) expansion of laboratory diagnostic capacity; 4) training of public health practitioners in detection, investigation, and response to respiratory threats; and 5) improvement of response capacity by the national emergency operations center (EOC). Progress on DaRRE activity implementation was assessed throughout the process. This pilot in Kenya demonstrated that DaRRE can support IHR requirements and can capitalize on a country's existing resources by tailoring tools to improve public health preparedness based on countries' needs.


Psychosocial Impact of COVID-19 on Older Adults: A Cultural Geriatric Mental Health-Care Perspectived.


title: Mice with megabase humanization of their immunoglobulin genes generate antibodies as efficiently as normal mice.

text: Mice genetically engineered to be humanized for their Ig genes allow for human antibody responses within a mouse background (HumAb mice), providing a valuable platform for the generation of fully human therapeutic antibodies. Unfortunately, existing HumAb mice do not have fully functional immune systems, perhaps because of the manner in which their genetic humanization was carried out. Heretofore, HumAb mice have been generated by disrupting the endogenous mouse Ig genes and simultaneously introducing human Ig transgenes at a different and random location; KO-plus-transgenic humanization. As we describe in the companion paper, we attempted to make mice that more efficiently use human variable region segments in their humoral responses by precisely replacing 6 Mb of mouse Ig heavy and kappa light variable region germ-line gene segments with their human counterparts while leaving the mouse constant regions intact, using a unique in situ humanization approach. We reasoned the introduced human variable region gene segments would function indistinguishably in their new genetic location, whereas the retained mouse constant regions would allow for optimal interactions and selection of the resulting antibodies within the mouse environment. We show that these mice, termed VelocImmune mice because they were generated using VelociGene technology, efficiently produce human:mouse hybrid antibodies (that are rapidly convertible to fully human antibodies) and have fully functional humoral immune systems indistinguishable from those of WT mice. The efficiency of the VelocImmune approach is confirmed by the rapid progression of 10 different fully human antibodies into human clinical trials.


title: Midterm functional results of taTME with neuromapping for low rectal cancer.

text: BACKGROUND Information on functional outcomes after laparoscopic-assisted transanal total mesorectal excision (taTME) is limited. This study analyzed the functional results in patients with low rectal cancer. METHODS Ten consecutive patients (nine males) undergoing electrophysiologically controlled nerve-sparing taTME were investigated prospectively and asked to complete functional questionnaires [the International Prostate Symptom Score (IPSS), International Index of Erectile Function, Female Sexual Function Index, Wexner score, and low anterior resection syndrome (LARS) score]. Bladder function was also assessed according to residual urine volume. Preoperative function was compared to the functional outcome 3 and 6 months, and 9 months if eligible, after stoma closure or surgery in the absence of a diverting stoma. RESULTS Prior to therapy, urinary and sexual function was impaired in 40 and 60% of patients, respectively. None of the patients developed pathological residual urine volumes after at least unilateral functional pelvic nerve-sparing. Median IPSS was lower than preoperative scores (p > 0.05). Two males with incomplete nerve preservation were considered impotent during a median follow-up of 15 months (range 6-20 months). The female was judged to be sexually inactive. The median Wexner score was 1 (range 0-7) prior to any therapy and increased to 7 (range 0-15) at 6 months (p = 0.029), with 40% of patients categorized as having no LARS and 50% minor LARS. The median LARS score was 28 (range 9-38) at 3 months and 26 (range 9-32) at 6 months (p = 0.165). CONCLUSIONS Despite a small sample size and confounding factors, data indicate that taTME has the potential to preserve continence, sufficient bowel function, and urogenital function.


Transanal Total Mesorectal Excision: The Work is Progressing Well.


Finding Ways to Reduce Coronavirus Exposure During Dialysis.


title: A combined thoracoscopic and laparoscopic approach for high epiphrenic diverticula and the importance of complete myotomy.

text: BACKGROUND The traditional approach to epiphrenic diverticula is thoracotomy and diverticulectomy, together with myotomy ± partial fundoplication to address underlying dysmotility. A laparoscopic approach has been advocated but access to more proximal diverticula is problematic. We propose the selective addition of a thoracoscopic approach to overcome these challenges and reviewed our results. METHODS A retrospective review from 2004 to 2015 identified 17 patients with an epiphrenic diverticulum who underwent surgery. Patients were grouped according to height of the diverticular neck (HDN) above the GEJ: group A < 5 cm, group B > 5 cm. Preoperative evaluation and type of surgery performed were recorded. Postoperative complications, mortality, and clinical outcomes using quality of life metrics and objective testing were assessed. RESULTS The mean size of the diverticulum was 3.3 cm (2-6 cm) with a mean height above the GEJ of 5.5 cm (0-12 cm). A motility disorder was identified in 15/17. Group A, 9 patients, underwent laparoscopic diverticulectomy, myotomy, and partial fundoplication. For group B, 8 patients, the intended procedure was thoracoscopic diverticulectomy followed by laparoscopic myotomy and partial fundoplication, but this was only completed in 5. In 3 the myotomy was aborted or incomplete with subsequent staple line leaks resulting in 1 death. At a mean follow-up of 21 months, improvement of median QOLRAD scores from 3.42 to 6.2 (p = 0.18); GERD-HRQL from 23 to 1 (p = 0.05), swallowing score from 17.5 to 30 (p = 0.22), and Eckardt scores from 5 to 0 (p < 0.05) were observed. CONCLUSIONS A minimally invasive strategy for epiphrenic diverticula based HDN above the GEJ and selective thoracoscopy for higher diverticula is feasible and appropriate, and resulted in improved quality of life. Incomplete myotomy was associated with a substantially higher complication rate. Laparoscopic myotomy should precede diverticulectomy for all cases, especially for high diverticula.


title: Digital innovations and emerging technologies for enhanced recovery programmes.

text: Enhanced recovery programmes (ERPs) are increasingly used to improve post-surgical recovery. However, compliance to various components of ERPs-a key determinant of success-remains sub-optimal. Emerging technologies have the potential to help patients and caregivers to improve compliance with ERPs.Preoperative physical condition, a major determinant of postoperative outcome, could be optimized with the use of text messages (SMS) or digital applications (Apps) designed to facilitate smoking cessation, modify physical activity, and better manage hypertension and diabetes. Several non-invasive haemodynamic monitoring techniques and decision support tools are now available to individualize perioperative fluid management, a key component of ERPs. Objective nociceptive assessment may help to rationalize the use of pain medications, including opioids. Wearable sensors designed to monitor cardio-respiratory function may help in the early detection of clinical deterioration during the postoperative recovery and to address 'failure to rescue'. Activity trackers may be useful to monitor early mobilization, another major element of ERPs. Finally, electronic checklists have been developed to ensure that none of the above-mentioned ERP elements is omitted during the surgical journey.By optimizing compliance to the multiple components of ERPs, digital innovations, non-invasive techniques and wearable sensors have the potential to magnify the clinical and economic benefits of ERPs. Among the growing number of technical innovations, studies are needed to clarify which tools and solutions have real clinical value and are cost-effective.


title: Acute abdomen as an early symptom of COVID-19.

text: A woman with acute abdominal pain was admitted to hospital with suspected cholecystitis. In addition to abdominal pain, she had vomiting, loss of appetite, diarrhoea and symptoms of pyrexia. She had no symptoms from the respiratory tract, but was later found to have COVID-19. A number of patients have presented with similar symptoms at our hospital. This has led to temporary changes in our procedures for handling and investigating patients with acute abdominal pain.


title: Managing pulmonary complications in allogeneic hematopoietic stem cell transplantation.

text: INTRODUCTION Progress in allogeneic hematopoietic stem cell transplantation (HSCT) procedures have been associated with improved survival in HSCT recipients. However, they have also brought to light organ-specific complications, especially pulmonary complications. In this setting, pulmonary complications are consistently associated with poor outcomes, and improved management of these complications is required. Areas covered: We review the multiple infectious and noninfectious lung complications that occur both early and late after allogeneic HSCT. This includes the description of these complications, risk factors, diagnostic approach and outcome. A literature search was performed using PubMed-indexed journals. Expert commentary: Multiple lung complications after allogeneic HSCT can be diagnosed concomitantly and require a multidisciplinary approach. A specific clinical evaluation including a precise analysis of a lung CT scan is necessary. Management of these lung complications, especially the noninfectious ones, is impaired by the lack of prospective, randomized control trials, suggesting preventive strategies should be developed.


title: Objective analysis of surgeons' ergonomy during laparoendoscopic single-site surgery through the use of surface electromyography and a motion capture data glove.

text: BACKGROUND Adding to the ergonomic inconveniences already presented by traditional laparoscopy (LAP), laparoendoscopic single-site (LESS) surgery has been found to entail other more specific problems, including greater reduction in movement freedom, in-line vision with loss of triangulation, and greater proximity of instruments. The objective of this study was to evaluate surgeons' ergonomy during LESS surgery, through the study of muscular activity, wrist angle, and hand movements, and compare it with conventional laparoscopy. METHODS The study group was composed by 14 experienced laparoscopic surgeons, all right-handed. Each one performed dissection tasks on a physical simulator through LAP and LESS approaches. For LAP, straight laparoscopic scissors and dissector were used, whilst for LESS articulating tip scissors and dissector were chosen. During both tasks, muscular activity of biceps brachii, triceps brachii, forearm flexors and extensors, and trapezius muscles was registered through surface electromyography. Simultaneously right-hand movements and wrist angles were obtained through a motion capture data glove (CyberGlove(®)), which allowed for the use of a modified RULA test applied to the recorded angles with subsequent establishment of risk levels for the wrist joint. RESULTS Muscular activity for trapezius (LAP 6.94 ± 4.12 vs. LESS 11.32 ± 4.68; p ≤ 0.05) and forearm extensor muscles (LAP 9.2 ± 2.45 vs. LESS 37.07 ≤ 16.05; p ≤ 0.001) was significantly lower in conventional laparoscopy compared with LESS approach. No statistical significance was obtained between the different sensors, except in 3 of the 11 analyzed CyberGlove(®) sensors. The modified RULA test showed a score of 3 for laparoscopy (unacceptable), whereas for LESS a score of 2 was obtained (acceptable), with statistically significant differences between them (p ≤ 0.05). CONCLUSIONS The LESS approach entails greater level of muscular activity in the trapezius and forearm extensor muscles, but we have found evidences of a better wrist position during LESS compared with traditional laparoscopy.


title: Order of amino acids in C-terminal cysteine-containing peptide-based chelators influences cellular processing and biodistribution of 99mTc-labeled recombinant Affibody molecules.

text: Affibody molecules constitute a novel class of molecular display selected affinity proteins based on non-immunoglobulin scaffold. Preclinical investigations and pilot clinical data have demonstrated that Affibody molecules provide high contrast imaging of tumor-associated molecular targets shortly after injection. The use of cysteine-containing peptide-based chelators at the C-terminus of recombinant Affibody molecules enabled site-specific labeling with the radionuclide 99mTc. Earlier studies have demonstrated that position, composition and the order of amino acids in peptide-based chelators influence labeling stability, cellular processing and biodistribution of Affibody molecules. To investigate the influence of the amino acid order, a series of anti-HER2 Affibody molecules, containing GSGC, GEGC and GKGC chelators have been prepared and characterized. The affinity to HER2, cellular processing of 99mTc-labeled Affibody molecules and their biodistribution were investigated. These properties were compared with that of the previously studied 99mTc-labeled Affibody molecules containing GGSC, GGEC and GGKC chelators. All variants displayed picomolar affinities to HER2. The substitution of a single amino acid in the chelator had an appreciable influence on the cellular processing of 99mTc. The biodistribution of all 99mTc-labeled Affibody molecules was in general comparable, with the main difference in uptake and retention of radioactivity in excretory organs. The hepatic accumulation of radioactivity was higher for the lysine-containing chelators and the renal retention of 99mTc was significantly affected by the amino acid composition of chelators. The order of amino acids influenced renal uptake of some conjugates at 1 h after injection, but the difference decreased at later time points. Such information can be helpful for the development of other scaffold protein-based imaging and therapeutic radiolabeled conjugates.


title: Surgical referral systems in low- and middle-income countries: A review of the evidence.

text: BACKGROUND Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions. METHODS MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach. RESULTS Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities. DISCUSSION The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.


title: Identification of a virus-specific and conserved B-cell epitope on NS1 protein of Japanese encephalitis virus.

text: NS1 protein of Japanese encephalitis virus (JEV) is an important non-structural protein, which is able to induce protective immune response in target animals and can be used as specific serological diagnosis tool, but the epitopes on NS1 of JEV have not been identified. For epitope mapping, in this study, a series of 51 partially overlapping fragments covering entire NS1 protein were expressed with a GST-tag and then screened by a monoclonal antibody (mAb). Through enzyme-linked immunosorbent assay (ELISA), linear epitope-containing fragment, the overlapping region of NS1-18 and NS1-19 (residues 145-152), was located. Then a set of peptides derived from that overlapping region with deletions were expressed and subjected to ELISA and Western blot for further mapping purpose. Results indicated that the motif of (146)EHARW(150) is the minimal unit of the linear epitope recognized by that monoclonal antibody (mAb). Western blot showed that this epitope could be recognized by JEV-positive serum from pigs. Furthermore, it was found that the epitope is highly conserved among JEV strains through sequence alignments analysis. Notably, none of the homologous regions on NS1 proteins of other flavivirus could react with the mAb when they were tested for cross-reactivity, suggesting the potential clinical application of this epitope in differential diagnosis.


Seattle's covid-19 lessons are yielding hope.


title: Incidence of incisional hernias following single-incision versus traditional laparoscopic surgery: a meta-analysis.

text: PURPOSE To compare, using a meta-analysis of randomized controlled trials, the risk of incisional hernia in patients undergoing single-incision laparoscopic surgery to those undergoing traditional laparoscopic surgery. METHODS MEDLINE and EMBASE databases were searched. Randomized controlled trials comparing single-incision laparoscopic surgery to traditional laparoscopic surgery and which reported incisional hernias over a minimum 6-month follow-up period were eligible. Risk of bias was assessed as outlined in the Cochrane Handbook. Pooled odds ratios were calculated using RevMan. RESULTS Of 309 identified studies, 22 were included in this meta-analysis. Pooled results showed higher odds of incisional hernia following single-incision laparoscopic surgery relative to traditional laparoscopic surgery (odds ratio 2.83, 95% CI 1.34-5.98, p = 0.006, I2 = 0%). There was no difference in the odds of incisional hernias requiring surgical repair (p = 0.10). Subgroup analysis found no difference in the odds of incisional hernias based on procedure type (p = 0.69) or method of follow-up (p = 0.85). The quality of evidence was determined to be moderate. CONCLUSION Single-incision laparoscopic surgery is associated with a threefold increase in the odds of incisional hernia compared with traditional laparoscopic surgery.


Renin-Angiotensin-Aldosterone Inhibitors and Susceptibility to and Severity of COVID-19.


Failure of free flaps in head and neck oncology surgery in COVID-19 patients.


Challenges in the Production of Convalescent Hyperimmune Plasma in the Age of COVID-19.


title: Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?

text: BACKGROUND Minimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision. METHODS From March 2004 to July 2007, 512 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. Patients were divided into three groups depending on the type of incision (open, midline, and Pfannenstiel). Demographic variables, rate of incisional hernia, and risk factors for hernia were compared among the groups. RESULTS There were 142, 231, and 139 patients in the open, midline, and Pfannenstiel groups, respectively. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with malignancy, and duration of follow-up. The Pfannenstiel group had a higher mean BMI (p = 0.015) and the open group had a higher rate of wound infection (28.2%) compared to the other groups. Incidence of incisional hernia was similar for the open and midline groups (19.7 and 16%, p = 0.36). At a mean follow-up of 17.5 months, not a single patient with a Pfannenstiel incision developed an incisional hernia (p < 0.001). BMI (p = 0.019), follow-up (p < 0.001), and Pfannenstiel incision (p < 0.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis. CONCLUSION A Pfannenstiel incision is associated with the lowest rate of incisional hernia and should be the incision of choice for hand assistance and specimen extraction in minimally invasive colorectal resections wherever applicable.


title: Does reduced-port laparoscopic surgery for medically uncontrolled ulcerative colitis do more harm than good?

text: INTRODUCTION Reduced-port laparoscopic surgery is a novel minimally invasive surgery. However, reduced-port surgery for ulcerative colitis (UC) remains controversial. Here, we describe the clinical outcomes of single-incision plus one port laparoscopic surgery (SILS + 1) for medically uncontrolled UC. METHODS Between May 2011 and September 2014, 10 UC patients underwent SILS + 1 port surgery. All procedures were performed with the use of a SILS port and either a 5-mm or a 12-mm port placed at the planned ileostomy site. RESULTS The median age of patients was 32 years (range, 22-53 years). Six patients underwent two-stage SILS + 1 port restorative proctocolectomy with ileal pouch-anal anastomosis, two patients underwent SILS + 1 total proctocolectomy, and the remaining two patients underwent SILS + 1 subtotal colectomy with subsequent three-stage SILS + 1 ileal pouch-anal anastomosis. The median operative time was 363.1 min (range, 253-465 min) and the median estimated blood loss was 29 mL (range, 0-100 mL). There were no conversions or additional ports required. Two patients previously underwent SILS + 1 subtotal colectomy, and in one of those patients, SILS + 1 ileal pouch-anal anastomosis was performed successfully 6 months after the previous surgery. There were no intra-abdominal adhesions, and no extra wounds were necessary because the previous stoma site had been used to access the SILS port. The median postoperative period was 24 months, during which five patients had their ileostomies closed. No patients reported occasional minor daily soiling or the need to wear a pad. CONCLUSION Reduced-port laparoscopic surgery for medically uncontrolled UC is a feasible and safe procedure when performed by skilled surgeons.


title: Effects of oral meloxicam administration to beef cattle receiving lipopolysaccharide administration or vaccination against respiratory pathogens.

text: This study evaluated the effects of oral meloxicam administration on metabolic, inflammatory, and acute-phase responses of beef cattle receiving a lipopolysaccharide (LPS) challenge (Exp. 1; d -1 to 6) or vaccinated against respiratory pathogens (Exp. 2; d 7 to 21). Twenty-one Angus steers ( = 11) and heifers ( = 10) were housed in individual pens on d -15 and were offered free-choice water, mineral-vitamin mix, and hay until d 21. In Exp. 1, cattle were ranked on d -1 by sex and BW and assigned to 1) oral meloxicam administration (1 mg/kg BW daily) from day -1 to 6 (MEL8), 2) oral meloxicam administration (1 mg/kg BW) on d 0 and oral lactose monohydrate administration (1 mg/kg BW) on d -1 and from d 1 to 6 (MEL1), or 3) oral lactose monohydrate administration (1 mg/kg BW daily) from d -1 to 6 (CON). On d 0, cattle received an intravenous LPS bolus (0.5 μg/kg BW) concurrently with treatment administration. Rectal temperature (RTEMP) was assessed, and blood samples were collected at -2, 0, 2, 4, 6, 8, 12, 16, 24, 36, 48, 60, 72, 96, 120, and 144 h relative to LPS administration. No treatment effects were detected ( ≥ 0.36) for RTEMP, concentrations of serum tumor necrosis factor α (TNFα), plasma haptoglobin, cortisol, insulin, and leptin, as well as blood mRNA expression of α and cyclooxygenase-2, although all variables increased ( < 0.01) across treatments after LPS administration. In Exp. 2, cattle received the same treatments that they were assigned to in Exp. 1 from d 7 to d 13 and were vaccinated against respiratory pathogens concurrently with treatment administration on d 8. Blood samples were collected, and RTEMP was assessed as in Exp. 1 in addition to 168, 240, and 336 h relative to vaccination. No treatment effects were detected ( ≥ 0.26) for RTEMP, the same plasma and serum variables evaluated in Exp. 1, and serum concentrations of antibodies against or serum titers against bovine respiratory syncytial virus, bovine herpesvirus-1, bovine viral diarrhea virus-1, and parainfluenza-3 virus. All variables increased ( < 0.01) across treatments after vaccination, except for serum TNFα and titers against bovine viral diarrhea virus-1 ( ≥ 0.40). Collectively, this study found no evidence that oral meloxicam administration, at the doses and intervals utilized herein, mitigated the metabolic, inflammatory, and acute-phase reactions elicited by LPS administration or vaccination against respiratory pathogens.


title: Meta-analysis of the Clinical Efficacy and Safety of High- and Low-dose Methylprednisolone in the Treatment of Children With Severe Mycoplasma Pneumoniae Pneumonia.

text: BACKGROUND Mycoplasma pneumoniae pneumonia is generally a self-limiting disease, but it can develop into severe Mycoplasma pneumoniae pneumonia (SMPP). Immunologic mechanisms are thought to play an important role in the pathogenesis of SMPP. Therefore, the use of systemic glucocorticoids may have beneficial effects. However, to date, the use of glucocorticoid therapy in SMPP is limited to small case series, and the glucocorticoid dosage for children with SMPP has not been established. METHODS Here, we used a meta-analysis method to collect data from randomized control trials of different doses of methylprednisolone in SMPP to assess the safety and efficacy of treatment with low- versus high-dose methylprednisolone in children with SMPP. RESULTS We included 13 Chinese randomized control trials that included 1049 children. The high- and low-dose groups were comprised of 524 and 525 children, respectively. The high-dose group was significantly more effective than the low-dose group in clinical efficacy [risk ratio = 1.30, 95% confidence interval (CI) (1.23, 1.38), P < 0.05]. In addition, compared with low-dose methylprednisolone, high-dose methylprednisolone significantly shortened hospital stays and antipyretic therapy, pulmonary rales disappearance, cough disappearance and pulmonary shadow absorption times. There was no significant difference in adverse events between the high- and low-dose groups: risk ratio= 0.85, 95% CI (0.53, 1.36), P > 0.05. CONCLUSIONS We conclude that high-dose methylprednisolone is effective in the treatment of SMPP without increasing the incidence of adverse reactions.


title: Objective performance goals of safety and blood pressure efficacy for clinical trials of renal artery bare metal stents in hypertensive patients with atherosclerotic renal artery stenosis.

text: OBJECTIVE To provide safety and performance goals for prospective single-arm trials of bare metal renal artery stenting in patients with resistant hypertension associated with high grade atherosclerotic renal artery stenosis. BACKGROUND To date, there have been no US Pre-Market Approval (PMA) bare metal renal stent device trials which have focused on improvement of blood pressure control as a primary effectiveness endpoint. METHODS Analysis of subject-level data from three large industry sponsored pre-market approval (PMA) trials was performed. Hypertensive patients (≥ 155 mmHg) with a ≥ 50% atherosclerotic renal artery stenosis were included. Thirty day and 9-month systolic and diastolic blood pressure measurements, renal function and 9-month duplex ultrasound assessment of renal artery patency were analyzed. RESULTS Initial data analysis of 600 patients from the 3 PMA trials identified 286 patients who met inclusion criteria. The mean baseline systolic blood pressure was 177.8 ± 19.3 mmHg with a mean 68.1% diameter renal artery stenosis. Nine months after successful stenting, the mean SBP was 156.7 ± 24.1 mmHg; the 9 month restenosis rate was 14.4%. CONCLUSION Based on the statistical modeling of these data and a priori established performance criteria, the co-primary endpoints of 9 month reduction in blood pressure and in-stent restenosis are proposed. The reduction in blood pressure will be analyzed as a continuous variable and will be compared to this performance goal.


title: Assessing and minimizing the risk of percutaneous coronary intervention in patients with chronic kidney disease.

text: INTRODUCTION Chronic kidney disease (CKD) is commonly present in patients undergoing percutaneous coronary intervention (PCI). These patients frequently present with more complex coronary artery disease (CAD) and higher risk of peri-procedural and post-procedural adverse events, including bleeding, thrombotic events, and contrast-induced acute kidney injury (CI-AKI). This article contains updated knowledge and management of patients with CKD undergoing PCI. Areas covered: In this article, the pathophysiological mechanisms behind the association of CKD, complex CAD lesions, and complications of PCI are reviewed and the different risk scores available to assess the occurrence of CI-AKI are detailed. Furthermore, various strategies developed to prevent or reduce the impact of complications of PCI are described. Expert commentary: Patients with CKD have remained a challenge in the field of PCI. Several strategies have been evaluated in the last 20 years, with uneven results. Intravascular expansion therapy remains the cornerstone of CI-AKI prevention although recent studies have emphasized the benefit of guided hydration rather than a one-size-fits-all model. N-acetylcysteine and sodium bicarbonate have recently been challenged while pretreatment with high-dose statins may be of interest. Finally, recent studies based on intravascular ultrasound and minimal-to-no-use of contrast media have yielded promising results.


title: Primary stentriever versus combined stentriever plus aspiration thrombectomy approaches: in vitro stroke model comparison.

text: BACKGROUND Artificial stroke models can be used for testing various thrombectomy devices. OBJECTIVE To determine the value of combined stentriever-aspiration thrombectomy compared with the stentriever-alone approach. METHODS We designed an in vitro model of the intracranial circulation with a focus on the middle cerebral artery (MCA) that closely resembles the human intracranial circulation. After introducing fresh clot in the MCA, we used conventional biplane angiography and microangiographic fluoroscopy to compare recanalization rates and occurrence of emboli in new, unaffected territory for thrombectomy approaches in which a stentriever (Solitaire flow restoration stentriever, Covidien) was used alone or in combination with continuous manual aspiration through a Navien catheter (Covidien). RESULTS In a total of 22 experiments (11 for each approach), successful clot delivery to the MCA was achieved in all cases. Successful angiographic recanalization (thrombolysis in cerebral infarction score of 2b-3) was achieved more frequently with the combined stentriever-aspiration approach than with the stentriever-alone approach (in 10 vs 4 experiments, p=0.023). Emboli in new territory occurred in three experiments with the stentriever-alone approach, and none were seen with the combined approach (p=0.21). CONCLUSIONS The combined stentriever-aspiration approach to thrombectomy leads to better angiographic recanalization rates than use of the stentriever alone. Further experiments are needed to test the value of balloon-guide catheters and aspiration performed using other types of catheters and modes of aspiration.


Leveraging e-learning for medical education in low- and middle-income countries.


title: Urethrotomy in combination with or after temporary tube cystostomy for treatment of obstructive urolithiasis in male goats.

text: OBJECTIVE To report the clinical findings, outcome, and complications associated with urethrotomy performed in combination with or after temporary tube cystostomy for treatment of obstructive urolithiasis in male goats. STUDY DESIGN Retrospective case series. SAMPLE POPULATION Castrated male goats (n = 15). METHODS The medical records of male goats admitted for obstructive urolithiasis were reviewed. Goats that underwent aurethrotomy performed in combination with or after a temporary tube cystostomy were included in the study population. Follow-up information was obtained through hospital records and telephone communication. RESULTS Thirteen of 15 goats were discharged from the hospital a median of 13 days (range, 7-25) after urethrotomy. Complications related to the urinary system occurred in 5 goats and included recurrent obstruction, urination from open urethrotomy, uroabdomen and intra-abdominal adhesions after removal of the Foley catheter, and incisional infection. Five of 7 goats with long-term follow-up (2-24 months after surgery) were healthy, with normal urinary function. The remaining 2 goats returned to the hospital with signs of reobstruction that were attributed to uroliths at necropsy in 1 goat. CONCLUSION Goats treated with urethrotomy for persistent urethral obstruction after temporary tube cystostomy generally survived the procedure. Normal long-term urinary function was obtained in some goats, although recurrence was the most common complication. CLINICAL SIGNIFICANCE Urethrotomy is a surgical option for male goats with persistent urethral obstruction due to urethral calculi after temporary tube cystostomy.


title: Recent advances in soft tissue minimally invasive surgery.

text: Advancements in soft tissue minimally invasive surgery have been rapid and comprehensive since its inception in human medicine approximately 25 years ago. From its origins in traditional laparoscopy, followed rapidly by video-assisted thoracoscopic surgery, minimally invasive surgery in human medicine has evolved through a number of different platforms that now include single-port approach devices, robotic surgery as well as natural orifice transluminal endosurgery. Whilst some of these remain beyond the reach of veterinary medicine for now, largely because of technical challenges and the prohibitive costs of some single-use disposable components, veterinary minimally invasive surgery is advancing rapidly allowing our small animal patients to benefit from some of the many documented advantages that a minimally invasive approach affords the patient.


title: Epigenetics of Sepsis.

text: OBJECTIVES Recent evidence from the fields of microbiology and immunology, as well as a small number of human sepsis studies, suggest that epigenetic regulation may play a central role in the pathogenesis of sepsis. The term "epigenetics" refers to regulatory mechanisms that control gene expression but are not related to changes in DNA sequence. These include DNA methylation, histone modifications, and regulation of transcription via non-coding RNAs. Epigenetic modifications, occurring in response to external stressors, lead to changes in gene expression, and thus lie at the intersection between genetics and the environment. In this review, we examine data from in vitro studies, animal studies, and the existing human sepsis studies in epigenetics to demonstrate that epigenetic mechanisms are likely central to the pathogenesis of sepsis and that epigenetic therapies may have potential in the treatment of sepsis and its associated organ failures. DATA SOURCES Online search of published scientific literature via Pubmed using the term "epigenetics" in combination with the terms "sepsis", "infection", "bacterial infection", "viral infection", "critical illness", "acute respiratory distress syndrome", and "acute lung injury". STUDY SELECTION Articles were chosen for inclusion based on their relevance to sepsis, acute inflammation, sepsis-related immune suppression, and sepsis-related organ failure. Reference lists were reviewed to identify additional relevant articles. DATA EXTRACTION Relevant data was extracted and synthesized for narrative review. DATA SYNTHESIS Epigenetic regulation is a key determinant of gene expression in sepsis. At the onset of infection, host-pathogen interactions often result in epigenetic alterations to host cells that favor pathogen survival. In parallel, the host inflammatory response is characterized by epigenetic modifications in key regulatory genes, including tumor necrosis factor and interleukin-1β. In human sepsis patients, multiple epigenetic modifying enzymes show differential expression in early sepsis, suggesting a role for epigenetics in coordinating the response to infection. In the later stages of sepsis, epigenetic modifications accompany endotoxin tolerance and the immune-suppressed state. In animal models, treatment with epigenetic modifiers can mitigate the effects of sepsis and improve survival as well as reverse sepsis-associated organ injury. CONCLUSIONS Epigenetic modifications are associated with key phases of sepsis, from the host-pathogen interaction, to acute inflammation, to immune suppression. Epigenetic markers show promise in the diagnosis and prognosis of sepsis and epigenetic modifying agents show promise as therapeutic tools in animal models of sepsis. Human studies in the area of epigenetics are sorely lacking and should be a priority for sepsis researchers.


title: Stochastic model based on preharvest peripheral CD34-positive cell count and collection efficiency predicting processed blood volume in peripheral hematopoietic stem cell apheresis.

text: BACKGROUND Processed blood volume (PBV) required to obtain a predefined number of stem cells can be estimated from peripheral blood CD34+ cell concentration, body weight, and collection efficiency (CE). Because CE is indefinite, this study was designed to formulate and validate a new model of PBV based on stochastic CE distribution. STUDY DESIGN AND METHODS Data were retrospectively collected on 146 peripheral blood stem cell harvests from 114 patients and donors in a single institution from April 2014 to February 2018. The training set consisted of all procedures performed from April 2014 to June 2016 and the validation set of all procedures performed from July 2016 to February 2018. A new algorithm, based on CE2 distribution of the training set, was affirmed using the validation set. The positive predictive value of the model was estimated from the expected percentage of procedures that reached the target CD34-positive dose, with predicted PBV processed as the gold standard. RESULTS The 10th and 50th percentiles of CE2 were 33.4% and 52.5%, respectively. When PBV was assorted into three categories, defined as greater than 90%, 50% to 90%, and less than 50% of procedures reaching the targeted CD34-positive dose, the positive predictive values of the new model were 100%, 70%, and 100%, respectively. CONCLUSION The new model was validated with a high positive predictive value and can reliably estimate the required PBV and the success rate corresponding to the PBV. The model can be utilized easily with a Web-based tool.


title: The Advances of Laparoscopic Gastrectomy for Gastric Cancer.

text: Laparoscopic gastrectomy is evolving. With the increasing expertise and experience of oncologic surgeons in the minimally invasive surgery for gastric cancer, the indication for laparoscopic gastrectomy is expanding to advanced cases. Many studies have demonstrated the benefits of minimally invasive surgery, including reduced risk of surgery-related injury, reduced blood loss, less pain, and earlier recovery. In order to establish concrete evidence for the suitability of minimal invasive surgery for gastric cancer, many multicenter RCTs, comparing the short- and long-term outcomes of laparoscopic versus open surgery, are in progress. Advances in laparoscopic gastrectomy are moving toward increasingly minimally invasive approaches that enable the improvement of the quality of life of patients, without compromising on oncologic safety.


title: Definition and functions of health unified command and emergency operations centers for large-scale bioevent disasters within the existing ICS.

text: The incident command system provides an organizational structure at the agency, discipline, or jurisdiction level for effectively coordinating response and recovery efforts during most conventional disasters. This structure does not have the capacity or capability to manage the complexities of a large-scale health-related disaster, especially a pandemic, in which unprecedented decisions at every level (eg, surveillance, triage protocols, surge capacity, isolation, quarantine, health care staffing, deployment) are necessary to investigate, control, and prevent transmission of disease. Emerging concepts supporting a unified decision-making, coordination, and resource management system through a health-specific emergency operations center are addressed and the potential structure, function, roles, and responsibilities are described, including comparisons across countries with similar incident command systems.


title: Sequence analysis of the G gene of hRSVA ON1 genotype from Egyptian children with acute respiratory tract infections.

text: Human respiratory syncytial virus causes severe lower respiratory tract infection in neonates and children. Genotype ON1, with duplication of 72-nt in the G gene, was first detected in Canada and then recorded in other countries. In the current study, we describe the first detection of the ON1 genotype among children in Egypt in 2014/2015. Sequence analysis of the full-attachment G gene revealed that the majority of the strains examined were related to the ON1 genotype and only one sample related to N1 genotype. The Egyptian ON1 strains showed unique non-silent mutations in addition to variable mutations near the antigenic sites in comparison to the original ON1 ancestor strain. Continuous surveillance of hRSV regionally and globally is needed to understand the evolutionary mechanisms and strategies adopted by hRSV and their inducers for better adaption to the host.


title: Performance of the RealStar Chikungunya virus real-time reverse transcription-PCR kit.

text: A novel commercial Chikungunya virus real-time reverse transcription-PCR (RT-PCR) kit was evaluated on a comprehensive panel of original patient samples. The assay was 100% sensitive and specific in comparison to a published real-time RT-PCR. Viral loads from both assays were highly correlated. The kit proved to be suitable for routine use in patient care.


title: Prospective evaluation of unidirectional barbed suture for various indications in surgeon-controlled robotic reconstructive urologic surgery: Wake Forest University experience.

text: PURPOSE To evaluate the usage of unidirectional barbed suture and its related implications in various surgeon-controlled robotic reconstructive urologic surgeries. METHODS From March 2010 to March 2011, all patients undergoing various surgeon-controlled robotic reconstructive urologic surgeries utilizing barbed sutures were prospectively enrolled in this study. Type and number of procedure performed were noted. Intraoperative and peri-operative outcomes potentially related to suture technique and material were recorded. RESULTS This study reports on 210 patients, in whom barbed suture was used during this period. These included partial nephrectomy (20), pyeloplasty (9), ureteric tailoring and reimplantation (1), closure of bladder after Nephroureterectomy with excision of bladder cuff (8), closure of vaginal cuff in female radical cystectomy (12), partial cystectomy (1), radical prostatectomy (152), simple prostatectomy (2), vesicovaginal fistula repair (3), sacrocolpopexy (1), and hernia repair (1). We encountered 5 instances (2.38%) of tissue cut through possibly attributable to the use of barbed suture and 4 instances of misplacement of suture occurred, of these two required a new suture, whereas retrograde pull back of suture and needle was performed in 2 cases. No instance of slip back/loosening of suture was noted once it was tightened. At mean follow-up of 6.8 (1-14 months) months, we did not encounter any complications of urinary leakage, stone formation or fistula or any clinical evidence of urinary tract obstruction due to the use of barbed suture. CONCLUSION Use of unidirectional barbed suture is safe, feasible, and efficient at short-term follow-up for reconstructive part of urological procedures.


title: AirSeal system insufflator to maintain a stable pneumorectum during TAMIS.

text: Transanal minimally invasive surgery (TAMIS) is typically used for treating intraluminal rectal tumors. Other applications have recently been described. We here present the use of TAMIS as a tool to treat a chronic anastomotic fistula after restorative rectal resection. A new insufflation device expected to solve the problem of maintaining a stable pneumorectum is described.


title: Successful Treatment of Acute Ocular-Involving Toxic Epidermal Necrolysis Using Amniotic Membrane Suture Fixated to Custom Designed Symblepharon Rings.

text: PURPOSE The purpose of this study is to describe a novel technique using amniotic membrane suture-fixated onto custom-designed symblepharon rings in a patient with acute toxic epidermal necrolysis (TEN). METHODS A 61-year-old man developed bilateral symblephara and severe ocular surface inflammation from Stevens-Johnson syndrome/TEN secondary to allopurinol. Eight days after admission, he was treated with placement of custom-designed symblepharon rings, designed by one of the authors (A.A.), covered with amniotic membrane. This method was used to allow for efficient placement of the membrane and to minimize operative time and perioperative risks due to his worsening systemic condition. RESULTS On postoperative day 49, his visual acuity was 20/20 in the right eye and 20/25 in the left eye. Both eyes were quiet with only small symblephara noted temporally. CONCLUSIONS The use of amniotic membrane suture-fixated to custom-designed symblepharon rings provides sufficient coverage of the ocular surface, leading to excellent visual and clinical outcomes by reducing inflammation and protecting the ocular surface from the cicatrizing sequelae associated with ocular-involving TEN. This novel technique is less invasive, more time efficient, and likely safe for even the most critically ill patients with significant risk for mortality, thus allowing any treating ophthalmologist to comfortably perform this important sight-saving procedure.


title: Variable computed tomography appearances of COVID-19.

text: The coronavirus disease 2019 (COVID-19) is typically diagnosed by specific assays that detect viral nucleic acid from the upper respiratory tract; however, this may miss infections involving only the lower airways. Computed tomography (CT) has been described as a diagnostic modality in the COVID-19 diagnosis and treatment plan. We present a case series with virologically confirmed COVID-19 pneumonia. Variable CT features were observed: consolidation with ground-glass opacities, ground-glass opacities with subpleural reticular bands, and an anterior-posterior gradient of lung abnormalities resembling that of acute respiratory distress syndrome. In one patient, we noted evolution of CT findings, where there was interval resolution of bilateral lung consolidation with development of bronchiolectasis and subpleural fibrotic bands. While sensitive for detecting lung parenchymal abnormalities in COVID-19 pneumonia, CT for initial diagnosis is discouraged and should be reserved for specific clinical indications. Interpretation of chest CT findings should be correlated with duration of symptoms to better determine the disease stage and aid in patient management.


COVID-19 and pulmonary embolism: an unwanted alliance.


title: Expression and effect of resistin on bovine and rat granulosa cell steroidogenesis and proliferation.

text: Resistin, initially identified in adipose tissue and macrophages, was implicated in insulin resistance. Recently, its mRNA was found in hypothalamo-pituitary axis and rat testis, leading us to hypothesize that resistin may be expressed in ovary. In this study, we determined in rats and cows 1) the characterization of resistin in ovary by RT-PCR, immunoblotting, and immunohistochemistry and 2) the effects of recombinant resistin (10, 100, 333, and 667 ng/ml) ± IGF1 (76 ng/ml) on steroidogenesis, proliferation, and signaling pathways of granulosa cells (GC) measured by enzyme immunoassay, [(3)H]thymidine incorporation, and immunoblotting respectively. We observed that resistin mRNA and protein were present in several bovine and rat ovarian cells. Nevertheless, only bovine GC abundantly expressed resistin mRNA and protein. Resistin treatment decreased basal but not IGF1-induced progesterone (P<0.05; whatever the dose) and estradiol (P<0.005; for 10 and 333 ng/ml) production by bovine GC. In rats, resistin (10 ng/ml) increased basal and IGF1-induced progesterone secretion (P<0.0001), without effect on estradiol release. We found no effect of resistin on rat GC proliferation. Conversely, in cows, resistin increased basal proliferation (P<0.0001; for 100-667 ng/ml) and decreased IGF1-induced proliferation of GC (P<0.0001; for 10-333 ng/ml) associated with a decrease in cyclin D2 protein level (P<0.0001). Finally, resistin stimulated AKT and p38-MAPK phosphorylation in both species, ERK1/2-MAPK phosphorylation in rats and had the opposite effect on the AMPK pathway (P<0.05). In conclusion, our results show that resistin is expressed in rat and bovine ovaries. Furthermore, it can modulate GC functions in basal state or in response to IGF1 in vitro.


title: Concurrent SPECT/PET-CT imaging as a method for tracking adoptively transferred T-cells in vivo.

text: BACKGROUND The ability of T-cells to traffic to and penetrate tumors impacts the clinical efficacy of T-cell therapy therefore methods to track transferred T-cells in vivo are needed. In this preliminary report, we evaluated the use of concurrent SPECT/PET-CT imaging to monitor the egress of HER-2/neu specific T-cells in a breast cancer patient with extensive bone-only metastatic disease. FINDINGS Indium (In-111) labeled T-cells demonstrated similar or greater viability than unlabeled T-cells at either a low or high dose of In-111 over a 24-h incubation period in vitro. The function of labeled or unlabeled T-cells was not significantly different (p > 0.05) at either dose. T-cells trafficked to all sites of metastatic disease and infiltrated the tumor as assessed by SPECT imaging. In-111 uptake at 24 h after infusion varied from 3.8 (right proximal humerus) to 6.3 (right sacrum) background corrected counts per pixel and remained elevated at 48 h. Concurrent PET-CT imaging demonstrated a fluorodeoxyglucose flare, measured by increase in tumor site uptake as high as 32 % and at most sites of disease at 48 h. This flare was associated with focal pain after T-cell infusion at metastatic sites. The patient had stable disease for 18 months after completion of T-cell therapy. CONCLUSION Concurrent SPECT/PET-CT imaging, over a 48-h period after T-cell infusion, provided evidence of T-cell homing to all disease sites as well as a tumor metabolism flare response. This technique may be useful for monitoring T-cell trafficking after autologous as well as chimeric antigen receptor T-cell infusion. TRIAL REGISTRAION Trial registered at ClinicalTrials.gov registration number NCT00791037, registered 13 November 2008.


title: Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia: the randomised multicentre EMMA trial study protocol.

text: INTRODUCTION The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients. METHODS AND ANALYSIS The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications. ETHICS AND DISSEMINATION The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT 02611986; pre-results.


title: Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial.

text: PURPOSE The purpose of this study was to evaluate the effect of intraoperative neuromonitoring (IONM) on the injury rate of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy. METHODS A total of 133 consenting patients (98 female, 35 male; mean age, 45.6 ± 11.7 years) undergoing thyroidectomy were randomly assigned to 2 groups. In group 1 (n = 65 patients, 105 nerves), superior thyroid pole dissection was performed with no attempt to identify the EBSLN; in group 2 (n = 68 patients, 106 nerves), IONM was used to identify the EBSLN during surgery. EBSLN function was evaluated by intraoperative electromyography of the cricothyroid muscle. The EBSLN Voice Impairment Index-5 (VII-5) was conducted preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was the prevalence of EBSLN injury. The secondary outcomes were the identification rate of the EBSLN using IONM and changes in postoperative voice performance. RESULTS EBSLN injury was detected in eight (12.3%) patients and nine (8.6%) nerves in group 1 and in one (1.5%) patient and one (0.9%) nerve in group 2 (patients, p = 0.015; nerves, p = 0.010). IONM contributed significantly to visual (p < 0.001) and functional (p < 0.001) nerve identification in group 2. The VII-5 indicated more voice changes in group 1 than 2 at 1, 3, and 6 months postoperatively (p = 0.012, p = 0.015, and p = 0.02, respectively). CONCLUSION IONM contributes to visual and functional identification of the EBSLN and decreases the rate of EBSLN injury during superior pole dissection. Routine use of IONM to identify the EBSLN will minimize the risk of injury during thyroidectomy.


title: Global oral health inequalities: the view from a research funder.

text: Despite impressive worldwide improvements in oral health, inequalities in oral health status among and within countries remain a daunting public health challenge. Oral health inequalities arise from a complex web of health determinants, including social, behavioral, economic, genetic, environmental, and health system factors. Eliminating these inequalities cannot be accomplished in isolation of oral health from overall health, or without recognizing that oral health is influenced at multiple individual, family, community, and health systems levels. For several reasons, this is an opportune time for global efforts targeted at reducing oral health inequalities. Global health is increasingly viewed not just as a humanitarian obligation, but also as a vehicle for health diplomacy and part of the broader mission to reduce poverty, build stronger economies, and strengthen global security. Despite the global economic recession, there are trends that portend well for support of global health efforts: increased globalization of research and development, growing investment from private philanthropy, an absolute growth of spending in research and innovation, and an enhanced interest in global health among young people. More systematic and far-reaching efforts will be required to address oral health inequalities through the engagement of oral health funders and sponsors of research, with partners from multiple public and private sectors. The oral health community must be "at the table" with other health disciplines and create opportunities for eliminating inequalities through collaborations that can harness both the intellectual and financial resources of multiple sectors and institutions.


title: Pretargeted immuno-PET and radioimmunotherapy of prostate cancer with an anti-TROP-2 x anti-HSG bispecific antibody.

text: PURPOSE TF12 is a trivalent bispecific antibody that consists of two anti-TROP-2 Fab fragments and one anti-histamine-succinyl-glycine (HSG) Fab fragment. The TROP-2 antigen is found in many epithelial cancers, including prostate cancer (PC), and therefore this bispecific antibody could be suitable for pretargeting in this cancer. In this study, the characteristics and the potential for pretargeted radioimmunoimaging and radioimmunotherapy with TF12 and the radiolabeled di-HSG peptide IMP288 in mice with human PC were investigated. METHODS The optimal TF12 protein dose, IMP288 peptide dose, and dose interval for PC targeting were assessed in nude mice with s.c. PC3 xenografts. Immuno-positron emission tomography (PET)/CT was performed using TF12/⁶⁸Ga-IMP288 at optimized conditions. The potential of pretargeted radioimmunotherapy (PRIT) using the TF12 pretargeted ¹⁷⁷Lu-IMP288 was determined. RESULTS TF12 and ¹¹¹In-IMP288 showed high and fast accumulation in the tumor [20.4 ± 0.6%ID/g at 1 h post-injection (p.i.)] at optimized conditions, despite the internalizing properties of TF12. The potential for PRIT was shown by retention of 50% of the ¹¹¹In-IMP288 in the tumor at 48 h p.i. One cycle of treatment with TF12 and ¹⁷⁷Lu-IMP288 showed significant improvement of survival compared to treatment with ¹⁷⁷Lu-IMP288 alone (90 vs. 67 days, p<0.0001) with no renal or hematological toxicity. CONCLUSION TROP-2-expressing PC can be pretargeted efficiently with TF12, with very rapid uptake of the radiolabeled hapten-peptide, IMP288, sensitive immuno-PET, and effective therapy.


title: Particular imaging features and customized thermal ablation treatment for intramedullary osteoid osteoma in pediatric patients.

text: OBJECTIVE To report on the particular imaging features and high success rate of cold mode radio-frequency thermal ablation (RFTA) as the treatment of choice for intramedullary osteoid osteoma. MATERIALS AND METHODS The study population consisted of 51 patients (39 males, 12 females; mean age 7.2 years; 11 patients under 6 years of age, including 7 males and 4 females) who underwent RFTA for osteoid osteoma and were retrospectively observed. The affected sites were the tibia (n = 22, 43%), femur (n = 13, 25%), pelvis (n = 5, 10%), anklebone (n = 3, 6%), humerus (n = 2, 4%), sacrum (n = 2, 4%), heel, radium, patella ,and rib (n = 1, 2%), respectively. Three patients had tibial intramedullary osteoid osteoma (14% of the tibial lesions, 6% of all cases). Cold mode RFTA was performed for these three patients to obtain a large ablation area without positioning two probes. The noncooled mode was used to treat cortical and subperiosteal lesions. RESULTS Following RFTA, all patients were pain-free and in good clinical condition. In the intramedullary osteoid osteoma group, no recurrences were observed during the 24-month follow-up period, but one patient, who was affected by cortical osteoid osteoma, required two RFTA treatments to heal completely. CONCLUSION Children less than 6 years of age with recurrent nocturnal pain and limb swelling should be investigated for intramedullary osteoid osteoma. Once confirmed, CT-guided RFTA should be the first treatment for intramedullary osteoid osteomas because of the high success rate and reduced invasivity, especially with cold mode RFTA. The outcome is related to the disappearance of pain, and the efficacy may be checked shortly after treatment with MR imaging to evaluate the absence of lesion in the ablation area.


Impact of the COVID-19 pandemic on ongoing cardiovascular research projects: considerations and adaptations.


title: A Comprehensive Analysis of Clinical Trials in the COVID-19 Pandemic Era.

text: Background and objective: Despite medical advances, we are facing the unprecedented disaster of the coronavirus disease 2019 (COVID-19) pandemic without available treatments and effective vaccines. As the COVID-19 pandemic has approached its culmination, desperate efforts have been made to seek proper treatments and response strategies, and the number of clinical trials has been rapidly increasing. In this time of the pandemic, it is believed that learning lessons from it would be meaningful in preparing for future pandemics. Thus, this study aims at providing a comprehensive landscape of COVID-19 related clinical trials based on the ClinicalTrials.gov database. Materials and methods: Up to 30 March 2020, we identified a total of 147 eligible clinical trials and reviewed the overview of the studies. Results: Until then, the most clinical trials were set up in China. Treatment approaches are the most frequent purpose of the registered studies. Chloroquine, interferon, and antiviral agents such as remdesivir, lopinavir, and ritonavir are agents under investigation in these trials. Conclusions: In this study, we introduced the promising therapeutic options that many researchers and clinicians are interested in, and to address the hidden issues behind clinical trials in this COVID-19 pandemic.


title: Bile reflux after Roux-en-Y gastric bypass: an unrecognized cause of postoperative pain.

text: BACKGROUND To determine, in a private practice, whether symptomatic bile reflux can occur after Roux-en-Y gastric bypass (RYGB) for morbid obesity and the outcome after laparoscopic alimentary (Roux) limb lengthening. Bile reflux as a cause of pain after laparoscopic RYGB has not been previously described. We report on a series of patients with chronic pain after RYGB as a result of bile reflux owing an abnormally short alimentary limb. METHODS A prospective database of patients who underwent revisional surgery to treat symptomatic bile reflux at our center was retrospectively reviewed and analyzed for the onset of symptoms, interval to revision, length of alimentary limb, and outcome after revision. RESULTS A total of 16 patients were diagnosed with bile reflux and underwent revisional surgery. The onset of symptoms occurred at 58.3 +/- 22.2 months after RYGB. All patients complained of pain, 13 (81.3%) had vomiting, and 7 (43.8%) had dysphagia. Endoscopy was performed in all patients and confirmed the presence of bile in all patients and detected marginal ulceration in 5 (31.3%) and gastritis in 8 (50.0%). At revisional surgery, the mean alimentary limb length was 37.7 +/- 12.4 cm (range 20-62 cm). At a mean follow-up of 14.9 months after revision, all patients had reported resolution of their symptoms. CONCLUSION Although previously unreported after RYGB, bile reflux can be an important possible cause of chronic pain. Bile reflux, however, responds favorably to alimentary limb lengthening to 100 cm and was not been seen in patients with an alimentary limb length >62 cm.


title: Effects of different anaesthetics on cytokine levels in children with community-acquired pneumonia undergoing flexible fibreoptic bronchoscopy.

text: OBJECTIVE To determine the effects of propofol and sevoflurane on cytokine levels in children with community-acquired pneumonia undergoing flexible fibreoptic bronchoscopy (FFB). METHOD Children with community-acquired pneumonia were randomly assigned to receive 3-5 mg/kg propofol i.v. or 8% inhaled sevoflurane. Haemodynamic variables, stress hormone responses and serum cytokines were compared between the two groups. RESULTS Out of 50 children aged 2-12 years (propofol, n = 25; sevoflurane, n = 25), there were no significant between-group differences in haemodynamic variables and stress hormones. Interleukin (IL)-6 and IL-10 decreased significantly following FFB in both groups. IL-6 levels were significantly lower in the sevoflurane group than propofol group at 4 h and 1 d following FFB (61.3 ± 11.9 versus 82.6 ± 19.7 pg/ml; 52.8 ± 9.7 versus 75.4 ± 13.6 pg/ml, respectively). IL-10 levels in the sevoflurane group were significantly lower than in the propofol group at 1 d following FFB. CONCLUSIONS In children with community-acquired pneumonia, use of sevoflurane was associated with lower circulating IL-6 and IL-10 levels compared with propofol, following FFB. Pneumonia severity is reflected by higher blood cytokine levels, thus, sevoflurane may be more beneficial to recovery from community-acquired pneumonia than propofol, however further studies are required to test this hypothesis.


title: Case report: uniportal video-assisted thoracoscopic resection of a solitary fibrous tumor preoperatively predicted visceral pleura origin using dynamic chest radiography.

text: BACKGROUND Dynamic chest radiography (DCR) is a flat-panel detector (FPD)-based functional X-ray imaging, which is performed as an additional examination in chest radiography. DCR provides objective and quantifiable information, such as diaphragm movement, pulmonary ventilation and circulation, and is reasonable for detecting tumor invasion or adhesion. CASE PRESENTATION We present a case of Solitary Fibrous Tumor of Pleura (SFTP), preoperatively predicted visceral pleura origin using Dynamic chest radiography (DCR) and surgically resected through single-access (uniportal) video-assisted thoracoscopic surgery (UVATS). CONCLUSIONS UVATS may be a suitable surgical option for pedunculated SFTPs. Dynamic chest radiography provides information, such as tumor invasion or adhesion and helpful for predicting origin of the tumor.


title: [Healing the schism between public health and medicine, promoting the integration of prevention and treatment].

text: The 'Healing the Schism: Epidemiology, Medicine, and the Public's Health' by professor Kerr L. White's be published has a history of nearly 30 years. Since then, although scholars have appealed to incorporating public health and clinical medicine education, and breaking down separations between public health and clinical workforce in China, the effect is yet not so obvious. The outbreak of coronavirus disease 2019 (COVID-19) has opened a public class on the treatment, prevention and control of infectious diseases for the Chinese citizens. Consequently, the Chinese people have higher expectations on the modernization of public health governance, and the social atmosphere of incorporating preventive medicine and clinical medical education is establishing. In future, when combating with novel infectious diseases and public health emergencies, the response capacity of public health system and treatment capacity of clinical system will be significantly improved, while the situation on insufficient integration of prevention and treatment is bound to be reversed.


title: Efficacy and safety of interferon β-1a in treatment of severe COVID-19: A randomized clinical trial.

text: OBJECTIVES To the best of our knowledge, there is no published study regarding use of IFN β-1a in the treatment of severe COVID-19. In this randomized clinical trial efficacy and safety of IFN β-1a has been evaluated in patients with severe COVID-19. METHODS Forty-two patients in the interferon group received IFN β-1a in addition to the national protocol medications (hydroxychloroquine plus lopinavir/ritonavir or atazanavir/ritonavir). Each 44 micrograms/ml (12 million IU/ml) of interferon β-1a was subcutaneously injected three times weekly for two consecutive weeks. The control group consisted 39 patients that received only the national protocol medications. Primary outcome of study was time to reach clinical response. Secondary outcomes were duration of hospital stay, length of ICU stay, 28-day mortality, effect of early or late administration of IFN on mortality, adverse effects and complications during the hospitalization. RESULTS Between 29th February to 3rd April 2020, 92 patients were recruited that finally 42 patients in the IFN group and 39 patients in the control group completed the study. As primary outcome, time to the clinical response was not significantly different between the IFN and the control groups (9.7 ± 5.8 vs. 8.3 ± 4.9 days respectively, P=0.95). On day 14, 66.7% vs. 43.6% of patients in the IFN group and the control group were discharged, respectively (OR= 2.5; 95% CI: 1.05- 6.37). The 28-day overall mortality was significantly lower in the IFN than the control group (19% vs. 43.6% respectively, p= 0.015). Early administration significantly reduced mortality (OR=13.5; 95% CI: 1.5-118). CONCLUSION Although IFN did not change time to reach the clinical response, adding it to the national protocol significantly increased discharge rate on day 14 and decreased 28-day mortality.


title: Gastric bypass improves β-cell function and increases β-cell mass in a porcine model.

text: The most frequently used and effective treatment for morbid obesity is Roux-en-Y gastric bypass surgery (RYGB), which results in rapid remission of type 2 diabetes in most cases. To what extent this is accounted for by weight loss or other factors remains elusive. To gain insight into these mechanisms, we investigated the effects of RYGB on β-cell function and β-cell mass in the pig, a species highly reminiscent of the human. RYGB was performed using linear staplers during open surgery. Sham-operated pigs were used as controls. Both groups were fed a low-calorie diet for 3 weeks after surgery. Intravenous glucose tolerance tests were performed 2 weeks after surgery. Body weight in RYGB pigs and sham-operated, pair-fed control pigs developed similarly. RYGB pigs displayed improved glycemic control, which was attributed to increases in β-cell mass, islet number, and number of extraislet β-cells. Pancreatic expression of insulin and glucagon was elevated, and cells expressing the glucagon-like peptide 1 receptor were more abundant in RYGB pigs. Our data from a pig model of RYGB emphasize the key role of improved β-cell function and β-cell mass to explain the improved glucose tolerance after RYGB as food intake and body weight remained identical.


Covid-19: Women's health campaigners sue FDA over access to medical abortion pills.


title: The bronchiolitis season is upon us--recommendations for the management and prevention of acute viral bronchiolitis.

text: Despite being so common, bronchiolitis remains poorly diagnosed and managed. This article is intended as an update on issues pertaining to this condition.


title: Use of pancreatic duct stents after pancreaticoduodenectomy.

text: After pancreaticoduodenectomy, the pancreatic anastomosis carries the highest risk of leak and cause of morbidity and mortality. In this review article, three randomized controlled clinical trials and a fourth prospective trial focused on pancreaticoduodenectomy that contribute to level-one evidence are examined. The Johns Hopkins group demonstrated that internal pancreatic duct stenting did not decrease the frequency or severity of postoperative pancreatic fistulas. The Queen Mary Hospital group demonstrated that external drainage of the pancreatic duct with a stent reduced the leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy. The University of Athens group demonstrated that internal stenting of the pancreaticojejunostomy anastomosis did not reduce the incidence of pancreatic fistula and related complications. Finally, the French Surgery Research Group demonstrated that the use of an external stent through the pancreatic anastomosis reduced the pancreatic fistula rate. In summary, two studies do not demonstrate an advantage to the use of internal pancreatic duct stents and two studies demonstrate a possible advantage to the use of external pancreatic duct stents, especially in highest risk patients with soft glands and small pancreatic ducts.


title: Hydrodynamic comparison of the Penumbra system and commonly available syringes in forced-suction thrombectomy.

text: BACKGROUND The Penumbra system uses a coaxial separator and continuous extracorporeal suction to remove a clot from a cerebral artery. Forced-suction thrombectomy (FST) involves aspirating clots through the same reperfusion catheter using only a syringe, decreasing the procedure time and supplies needed. OBJECTIVE To evaluate multiple combinations of catheters and syringes to determine the optimal pairing for use in FST. METHODS Tests were performed using both the Penumbra system and syringes to aspirate water through Penumbra 0.041 inch (041), 4Max, 0.054 inch (054) and 5Max reperfusion catheters and a shuttle sheath. Dynamic pressure and flow at the catheter tip were calculated from the fill times for each system. Static pressure and force for each aspiration source were determined with a vacuum gauge. RESULTS All syringes provided significantly higher dynamic pressure at the catheter tip than the Penumbra system (p<0.001). Increasing syringe volume significantly increased static pressure (p<0.001). Both flow and aspiration force significantly increased with catheter size (p<0.001). Cases are presented to demonstrate the clinical value of the laboratory principles. CONCLUSIONS Maximizing static and dynamic pressure when performing FST is achieved by aspirating with a syringe possessing both the largest volume and the largest inlet diameter available. Maximizing aspiration force and flow rate is achieved by using the largest catheter possible.


Festina lente: hydroxychloroquine, covid-19 and the role of the rheumatologist.


title: Decreased hernia recurrence using autologous platelet-rich plasma (PRP) with Strattice™ mesh in a rodent ventral hernia model.

text: BACKGROUND Recurrence after ventral hernia repair (VHR) remains a multifactorial problem still plaguing surgeons today. Some of the many contributing factors include mechanical strain, poor tissue-mesh integration, and degradation of matrices. The high recurrence rate witnessed with the use of acellular dermal matrices (ADM) for definitive hernia repair has reduced their use largely to bridging repair and breast reconstruction. Modalities that improve classic cellular metrics of successful VHR could theoretically result in improved rates of hernia recurrence; autologous platelet-rich plasma (PRP) may represent one such tool, but has been underinvestigated for this purpose. METHODS Lewis rats (32) had chronic ventral hernias created surgically and then repaired with Strattice™ mesh alone (control) or mesh + autologous PRP. Samples were harvested at 3 and 6 months postoperatively and compared for gross, histologic, and molecular outcomes of: neovascularization, tissue incorporation, peritoneal adhesions, hernia recurrence, and residual mesh thickness. RESULTS Compared to control at 3 months postoperatively, PRP-treated rats displayed significantly more neovascularization of implanted mesh and considerable upregulation of both angiogenic genes (vEGF 2.73-fold, vWF 2.21-fold) and myofibroblastic genes (αSMA 9.68-fold, FSP-1 3.61-fold, Col1a1 3.32-fold, Col31a1 3.29-fold). Histologically, they also showed enhanced tissue deposition/ingrowth and diminished chronic immune cell infiltration. Peritoneal adhesions were less severe at both 3 (1.88 vs. 2.94) and 6 months (1.63 vs. 2.75) by Modified Hopkins Adhesion Scoring. PRP-treated rats experienced decreased hernia recurrence at 6 months (0/10 vs. 7/10) and had significantly improved ADM preservation as evidenced by quantification of residual mesh thickness. CONCLUSIONS PRP is an autologous source of pro-regenerative growth factors and chemokines uniquely suited to soft tissue wound healing. When applied to a model of chronic VHR, it incites enhanced angiogenesis, myofibroblast recruitment and tissue ingrowth, ADM preservation, less severe peritoneal adhesions, and diminished hernia recurrence. We advocate further investigation regarding PRP augmentation of human VHR.


title: Microglia exacerbate white matter injury via complement C3/C3aR pathway after hypoperfusion.

text: Microglial activation participates in white matter injury after cerebral hypoperfusion. However, the underlying mechanism is unclear. Here, we explore whether activated microglia aggravate white matter injury via complement C3-C3aR pathway after chronic cerebral hypoperfusion. Methods: Adult male Sprague-Dawley rats (n = 80) underwent bilateral common carotid artery occlusion for 7, 14, and 28 days. Cerebral vessel density and blood flow were examined by synchrotron radiation angiography and three-dimensional arterial spin labeling. Neurobehavioral assessments, CLARITY imaging, and immunohistochemistry were performed to evaluate activation of microglia and C3-C3aR pathway. Furthermore, C3aR knockout mice were used to establish the causal relationship of C3-C3aR signaling on microglia activation and white matter injury after hypoperfusion. Results: Cerebral vessel density and blood flow were reduced after hypoperfusion (p<0.05). Spatial learning and memory deficits and white matter injury were shown (p<0.05). These impairments were correlated with aberrant microglia activation and an increase in the number of reactive microglia adhering to and phagocytosed myelin in the hypoperfusion group (p<0.05), which were accompanied by the up-regulation of complement C3 and its receptors C3aR (p<0.05). Genetic deletion of C3ar1 significantly inhibited aberrant microglial activation and reversed white matter injury after hypoperfusion (p<0.05). Furthermore, the C3aR antagonist SB290157 decreased the number of microglia adhering to myelin (p<0.05), attenuated white matter injury and cognitive deficits in chronic hypoperfusion rats (p<0.05). Conclusions: Our results demonstrated that aberrant activated microglia aggravate white matter injury via C3-C3aR pathway during chronic hypoperfusion. These findings indicate C3aR plays a critical role in mediating neuroinflammation and white matter injury through aberrant microglia activation, which provides a novel therapeutic target for the small vessel disease and vascular dementia.


title: Resource analysis of tonsillectomy in children.

text: OBJECTIVES/HYPOTHESIS To analyze variables that affect time and cost parameters of pediatric adenotonsillectomy. STUDY DESIGN Longitudinal 7-month retrospective review of sequential tonsil and adenoid surgery at a university pediatric tertiary care hospital. METHODS All children aged 2 to 12 years who underwent adenotonsillectomy from May 2008 to October 2008 had charts and billing records analyzed for variations in charges and times of adenotonsillectomy according to patient age, body mass index for age (BMIFA), American Society of Anesthesiologists (ASA) status, surgical indication, technology used, and teaching status of case. A total of 214 children had records reviewed. RESULTS Statistically significant variations were observed for all measured parameters except for indications for surgery. Children 3 years and younger had shorter procedures (P = .005) and total operating room times (P = .037). Charges for supplies were lower for ASA 1 patients than for ASA 2 patients (P = .010). Obese children with elevated BMIFA required longer procedures (P = .039) and more expensive surgery (P = .003). Procedure times were shorter for Coblation (ArthroCare, Austin, TX) compared with electrocautery (P = .27) and for microdebrider compared with electrocautery (P < .001). Charges for Coblation were substantially higher (P < .001). Teaching cases took longer (P < .001). CONCLUSIONS Charges and times for adenotonsillectomy surgery varied by patient age, BMIFA, ASA status, tonsillectomy technique, and teaching case status. Clinically salient differences were noted for ASA status, BMIFA, and surgical technique. This method of cost analysis provides useful information for resource management in tonsillectomy.


title: High-avidity IgA protects the intestine by enchaining growing bacteria.

text: Vaccine-induced high-avidity IgA can protect against bacterial enteropathogens by directly neutralizing virulence factors or by poorly defined mechanisms that physically impede bacterial interactions with the gut tissues ('immune exclusion'). IgA-mediated cross-linking clumps bacteria in the gut lumen and is critical for protection against infection by non-typhoidal Salmonella enterica subspecies enterica serovar Typhimurium (S. Typhimurium). However, classical agglutination, which was thought to drive this process, is efficient only at high pathogen densities (≥108 non-motile bacteria per gram). In typical infections, much lower densities (100-107 colony-forming units per gram) of rapidly dividing bacteria are present in the gut lumen. Here we show that a different physical process drives formation of clumps in vivo: IgA-mediated cross-linking enchains daughter cells, preventing their separation after division, and clumping is therefore dependent on growth. Enchained growth is effective at all realistic pathogen densities, and accelerates pathogen clearance from the gut lumen. Furthermore, IgA enchains plasmid-donor and -recipient clones into separate clumps, impeding conjugative plasmid transfer in vivo. Enchained growth is therefore a mechanism by which IgA can disarm and clear potentially invasive species from the intestinal lumen without requiring high pathogen densities, inflammation or bacterial killing. Furthermore, our results reveal an untapped potential for oral vaccines in combating the spread of antimicrobial resistance.


title: The chronicle of COVID-19: possible strategies to curb the pandemic.

text: COVID-19, an epidemic that emerged in Wuhan, has become a pandemic affecting worldwide and is in a rapidly evolving condition. Day by day, the confirmed cases and deaths are increasing many folds. SARS-CoV-2 is a novel virus; therefore, limited data are available to curb the disease. Epidemiological approaches, isolation, quarantine, social distancing, lockdown, and curfew are being employed to halt the spread of the disease. Individual and joint efforts all over the world are producing a wealth of data and information which are expected to produce therapeutic strategies against COVID-19. Current research focuses on the utilization of antiviral drugs, repurposing strategies, vaccine development as well as basic to advanced research about the organism and the infection. The review focuses on the life cycle, targets, and possible therapeutic strategies, which can lead to further research and development of COVID-19 therapy.


title: Concomitant ovarian drilling and oocyte retrieval by laparoendoscopic single-site surgery led to live birth using in vitro maturation of oocyte and transfer of frozen-thawed blastocyst in woman with polycystic ovary syndrome.

text: This case report describes a case of concomitant ovarian drilling and retrieval of oocytes using laparoendoscopic single-site surgery and the resultant birth of a healthy infant after transfer of frozen-thawed blastocyst from in vitro matured oocyte in a woman with polycystic ovary syndrome. A 33-year-old woman presented with anovulatory, clomiphene-resistant polycystic ovary syndrome, and 1-year history of infertility. Thirty-seven immature oocytes were retrieved and multiperforation of ovaries was performed at the same time by laparoendoscopic single-site surgery. Twenty-three oocytes reached metaphase II after 24-h culture in in vitro maturation medium, which was followed by intracytoplasmic sperm injection. Eventually, seven embryos were vitrified and spontaneous ovulation was restored after the operation. Although the first single frozen-thawed blastocyst transferred in a natural cycle ended up a biochemical pregnancy, the second frozen-thawed blastocyst transfer resulted in successful pregnancy, followed by live birth of a healthy male infant.


title: Extracellular matrix biomaterials for soft tissue repair.

text: The biological and physical augmentation provided by extracellular matrix (ECM) derived implants continues to challenge and refine the conventional wisdom of biomaterials. It is now appreciated that different tissue-processing methodologies can produce ECM devices with characteristic post-implantation responses ranging from the classic foreign body encapsulation of a permanent implant, to one where the implant is degraded and resorbed, to one where the processed ECM implant is populated by local fibroblasts and supporting vasculature to generate a new, metabolically active tissue (gTissue). This article reviews the multiple ECM devices available clinically and highlights the impact of tissue source and processing on physicomechanical properties and host-implant interactions, with regard to surgical applications and clinical considerations.