title: Retrospective evaluation of the effect of carotid artery stenosis on cerebral oxygen saturation during off-pump coronary artery bypasses grafting in adult patients.

text: BACKGROUND It is unknown whether cerebral oxygenation in patients with carotid artery stenosis (CAS) undergoing off-pump coronary artery bypass grafting (CABG) differs from that in patients without CAS. Thus, the effect of the presence of CAS ≥ 50 % on cerebral oxygenation during off-pump CABG in adult patients was evaluated retrospectively. METHODS Eleven patients with CAS ≥ 50% and 14 patients without CAS ≥ 50% were enrolled. Regional cerebral tissue oxygen saturation (rSO2) was quantified using near-infrared spectroscopy. Mean arterial pressure, cardiac index, central venous pressure (CVP), and rSO2 at specific points were collected, and significant changes in each parameter were detected using repeated analysis of variance. Mean rSO2 and minimum rSO2 during anastomosis were analyzed by one-way analysis of variance. Multiple logistic regression analysis was used to estimate the odds ratio (OR) with 95% confidence interval (CI) for cerebral desaturation (a decrease in rSO2 ≥ 10% from preoperative value). RESULTS Two patients with CAS ≥ 50% who received complete carotid artery stenting preoperatively were excluded from the analyses. In both patients with and without CAS, a decrease in rSO2 and cardiac index and an increase in CVP were observed during anastomosis. Mean (SD) maximum decrease in rSO2 from preoperative value was 9.2 (12.7) % on the left side and 8.1 (11.7) % on the right side in patients with CAS ≥ 50%, and 13.5 (11.3) % on the left side and 16.1 (9.8) % on the right side in patients without CAS ≥ 50% (p = 0.316). Neurological complications were not identified in both patients with and without CAS ≥ 50%. In multiple logistic regression analysis, CAS ≥ 50% was not associated with an increased risk of cerebral desaturation (OR 0.160, 95% CI 0.036-0.707, p = 0.016), and rSO2 decreased with decreasing cardiac index < 2.0 l/min/m(2) (OR 3.287, 95 % CI 2.218-5.076, p < 0.001). CONCLUSIONS CAS ≥ 50% was not an independent risk factor of cerebral desaturation during off-pump CABG. Our results suggest that maintaining cardiac output can prevent a decrease in cerebral oxygenation in both patients with and without CAS ≥ 50%.


Telerheumatology in COVID-19 era: a study from a psoriatic arthritis cohort.


title: The role of alpha defensin in prosthetic joint infection (PJI) diagnosis: a literature review.

text: Prosthetic joint infection (PJI) management is not standardized worldwide and the outcome is frequently unsatisfactory.More and more arthroplasties are now being performed. An increasing number of highly virulent and antibiotic-resistant bacteria and an ageing population of patients presenting with many comorbidities make it necessary to focus on this important topic.Diagnosis of PJI remains challenging because the clinical signs and symptoms and elevation of systemic biomarkers (C-reactive protein, erythrocyte sedimentation rate) may be unclear.In the last few years, the clinical research has focused on synovial fluid biomarkers as a possible breakthrough in the complex scenario of PJI diagnosis.Synovial biomarkers have shown encouraging results and they should be used as diagnostic adjuncts to synovial white cell count and culture bacteriology. Synovial leukocyte esterase (LE) and synovial C-reactive protein (CRP) have been evaluated as good screening measures; however, the most promising synovial fluid biomarker in terms of sensitivity and specificity for PJI seems to be alpha defensin (AD).The laboratory-based alpha defensin enzyme-linked immunosorbent assay (ELISA) test demonstrated the highest ever reported accuracy for PJI diagnosis. However, an alpha defensin lateral flow test could have its place in ruling in a suspected PJI intraoperatively because of its high specificity and rapid results. Cite this article: EFORT Open Rev 2019;4:10-13. DOI: 10.1302/2058-5241.4.180029.


title: Equitable Pandemic Preparedness and Rapid Response: Lessons from COVID-19 for Pandemic Health Equity.

text: The novel coronavirus pandemic has set in high relief the entrenched health, social, racial, political, and economic inequities within American society as the incidence of severe morbidity and mortality from the disease caused by the virus appears to be much greater in Black and other racial/ethnic minority populations, within homeless and incarcerated populations, and in lower-income communities in general. The reality is that the U.S. is ill equipped to realize health equity in prevention and control efforts for any type of health outcome, including an infectious disease pandemic. In this article, we address an important question: When new waves of the current pandemic emerge or another novel pandemic emerges, how can the U.S. be better prepared and also ensure a rapid response that reduces rather than exacerbates social and health inequities? We argue for a health equity framework to pandemic preparedness, grounded in meaningful community engagement that, while recognizing the fundamental causes of social and health inequity, has a clear focus on upstream and midstream preparedness and downstream rapid response efforts that put social and health equity at the forefront.


title: Beating the Spread: Developing a Simulation Analog for Contagious Body Fluids.

text: INTRODUCTION Effective models simulating the spread of contagion from provider to other patients, visitors, and rooms in a physically simulated emergency department setting have not been reported, and the effect of personal protective equipment (PPE) on reducing such spread in a simulated emergency department environment has not been quantified. METHODS We developed a physical model for the spread of an Ebola-like virus. The scenario involved 3 computerized mannequins. One case was a febrile patient after Ebola exposure. Four residents (group A) had only masks and gloves and were initially unaware of exposure history, whereas 4 residents (group C) had known exposure history and had full PPE present in the room. Infected mannequins and surrounding surfaces were coated with Glo Germ, a UV tracer. Fluorescence to UV light was recorded after each scenario. Both tracer groups were compared with a control group (group B) in which no tracer was used to account for background fluorescence. RESULTS There was transfer of contagion to providers, other patients, nurse and family member confederates, and other treatment rooms. Half of group C used full PPE, and half used partial PPE. There were 3 contaminations in group C with full PPE use, 15 contaminations in group C with partial PPE, and 65 contaminations in group A. CONCLUSIONS The UV tracer seems to be a useful analog of contaminated bodily fluids because it spread easily and its spread decreased with the use of barrier methods. This model could be used in future studies to measure the effectiveness of different forms of PPE and to study the effectiveness of provider education on appropriately donning and doffing PPE.


title: Prognostic Impact of Preoperative Nutritional Risk in Patients Who Undergo Surgery for Pancreatic Adenocarcinoma.

text: BACKGROUND Nutritional derangements are common hallmarks of pancreatic cancer (PC). Their early detection and management are usually overlooked in routine practice. This study aimed to explore preoperative nutritional status and its prognostic value in patients undergoing surgery for PC. METHODS Data from 73 patients who underwent surgery for PC from November 2015 to January 2018 at the General and Pancreatic Surgery Unit, The Pancreas Institute, University Hospital of Verona Hospital, Verona, Italy, were retrospectively evaluated. The Nutritional Risk Screening (NRS)-2002 was used to evaluate the preoperative nutritional risk. Body composition was assessed using bioimpedance vectorial analysis (BIVA) on the day prior to surgery. The effect of clinical, pathological, and nutritional characteristics on overall survival (OS) was investigated using a Cox and logistic regression model. Kaplan-Meier curves were compared using the log-rank test. RESULTS Most patients (80.8%) were at preoperative risk of malnutrition (NRS-2002 ≥ 3) despite a mean BMI of 24.1 kg/m2(± 4.3). Twenty-four patients (32.9%) received neoadjuvant therapy prior to surgery. Preoperative NRS-2002 was significantly higher in this subset of patients (p = 0.026), with a significant difference by chemotherapy regimens (in favor of FOLFIRINOX, p = 0.035). In a multivariate analysis, the only independent prognostic factor for OS was the NRS-2002 score (HR 5.24, p = 0.013). Particularly, the likelihood of 2-year survival was higher in NRS < 3 (p = 0.009). CONCLUSIONS Our analysis confirms that preoperative malnutrition has a detrimental impact on OS in PC patients undergoing radical surgery for PC. Careful preoperative nutritional evaluation of PC patients should be mandatory, especially in those who are candidates for neoadjuvant therapy.


title: Single-incision laparoscopic splenectomy.

text: BACKGROUND AND OBJECTIVES The single-incision approach in laparoscopic surgery is a relatively new concept. This systematic review of the literature was performed to appraise the existing clinical evidence concerning the use of the single-incision technique for spleen resection. METHODS We performed a systematic search of the PubMed and Scopus databases, and the studies retrieved were included in our review. The references of the included studies were also hand searched. RESULTS Thirty-one relevant studies were found in the field including 81 patients with an age range from 0.6 to 90 years and a body mass index range from 18 to 36.7 kg/m2. Splenomegaly (44.6%), idiopathic thrombocytopenic purpura (31%), and immune thrombocytopenic purpura (6.8%) were the most common indications for the procedure. Concerning the applied port system, multiple single ports (5 to 12 mm) were used in 54.4% of patients, the SILS port (Covidien, Mansfield, Massachusetts) was used in 26.6%, the TriPort (Advanced Surgical Concepts, Wicklow, Ireland) was used in 7.6%, glove ports were used in 6.3%, and the GelPort (Applied Medical, Rancho Santa Margarita, California) was used in 5.1%. The median operative time was 125 minutes (range, 45-420 minutes), and the median quantity of blood loss was 50 mL (range, 10-450 mL). No conversion to open surgery and no transfusion were needed. The length of hospital stay was between 1 and 9 days. Low rates of complications and no patient deaths were found. The existing evidence on cosmesis is limited. CONCLUSION Single-site/single-port laparoscopic surgery is a minimally invasive procedure that seems to be a challenging alternative in the management of spleen resection.


title: Computer tomographic analysis of organ motion caused by respiration and intraoperative pneumoperitoneum in a porcine model for navigated minimally invasive esophagectomy.

text: BACKGROUND Navigation systems have the potential to facilitate intraoperative orientation and recognition of anatomical structures. Intraoperative accuracy of navigation in thoracoabdominal surgery depends on soft tissue deformation. We evaluated esophageal motion caused by respiration and pneumoperitoneum in a porcine model for minimally invasive esophagectomy. METHODS In ten pigs (20-34 kg) under general anesthesia, gastroscopic hemoclips were applied to the cervical (CE), high (T1), middle (T2), and lower thoracic (T3) level, and to the gastroesophageal junction (GEJ) of the esophagus. Furthermore, skin markers were applied. Three-dimensional (3D) and four-dimensional (4D) computed tomography (CT) scans were acquired before and after creation of pneumoperitoneum. Marker positions and lung volumes were analyzed with open source image segmentation software. RESULTS Respiratory motion of the esophagus was higher at T3 (7.0 ± 3.3 mm, mean ± SD) and GEJ (6.9 ± 2.8 mm) than on T2 (4.5 ± 1.8 mm), T1 (3.1 ± 1.8 mm), and CE (1.3 ± 1.1 mm). There was significant motion correlation in between the esophageal levels. T1 motion correlated with all other esophagus levels (r = 0.51, p = 0.003). Esophageal motion correlated with ventilation volume (419 ± 148 ml) on T1 (r = 0.29), T2 (r = 0.44), T3 (r = 0.54), and GEJ (r = 0.58) but not on CE (r = - 0.04). Motion correlation of the esophagus with skin markers was moderate to high for T1, T2, T3, GEJ, but not evident for CE. Pneumoperitoneum led to considerable displacement of the esophagus (8.2 ± 3.4 mm) and had a level-specific influence on respiratory motion. CONCLUSIONS The position and motion of the esophagus was considerably influenced by respiration and creation of pneumoperitoneum. Esophageal motion correlated with respiration and skin motion. Possible compensation mechanisms for soft tissue deformation were successfully identified. The porcine model is similar to humans for respiratory esophageal motion and can thus help to develop navigation systems with compensation for soft tissue deformation.


title: Misplacement of left-sided double-lumen tubes into the right mainstem bronchus: incidence, risk factors and blind repositioning techniques.

text: BACKGROUND Double-lumen endobronchial tubes (DLTs) are commonly advanced into the mainstem bronchus either blindly or by fiberoptic bronchoscopic guidance. However, blind advancement may result in misplacement of left-sided DLTs into the right bronchus. Therefore, incidence, risk factors, and blind repositioning techniques for right bronchial misplacement of left-sided DLTs were investigated. METHODS This was an observational cohort study performed on the data depository consecutively collected from patients who underwent intubation of left-sided DLTs for 2 years. Patients' clinical and anatomical characteristics were analyzed to investigate risk factors for DLT misplacements with logistic regression analysis. Moreover, when DLTs were misplaced into the right bronchus, the bronchial tube was withdrawn into the trachea and blindly readvanced without rotation, or with 90° or 180° counterclockwise rotation while the patient's head was turned right. RESULTS DLTs were inadvertently advanced into the right bronchus in 48 of 1135 (4.2 %) patients. DLT misplacements occurred more frequently in females, in patients of short stature or with narrow trachea and bronchi, and when small-sized DLTs were used. All of these factors were significantly inter-correlated each other (P < 0.001). In 40 of the 48 (83.3 %) patients, blind repositioning was successful. CONCLUSIONS Smaller left-sided DLTs were more frequently misplaced into the right mainstem bronchus than larger DLTs. Moreover, we were usually able to reposition the misplaced DLTs into the left bronchus by using the blind techniques. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01371773.


title: Concomitant medication use and clinical outcome of repetitive Transcranial Magnetic Stimulation (rTMS) treatment of Major Depressive Disorder.

text: BACKGROUND Repetitive Transcranial Magnetic Stimulation (rTMS) is commonly administered to Major Depressive Disorder (MDD) patients taking psychotropic medications, yet the effects on treatment outcomes remain unknown. We explored how concomitant medication use relates to clinical response to a standard course of rTMS. METHODS Medications were tabulated for 181 MDD patients who underwent a six-week rTMS treatment course. All patients received 10 Hz rTMS administered to left dorsolateral prefrontal cortex (DLPFC), with 1 Hz administered to right DLPFC in patients with inadequate response to and/or intolerance of left-sided stimulation. Primary outcomes were change in Inventory of Depressive Symptomatology Self Report (IDS-SR30) total score after 2, 4, and 6 weeks. RESULTS Use of benzodiazepines was associated with less improvement at week 2, whereas use of psychostimulants was associated with greater improvement at week 2 and across 6 weeks. These effects were significant controlling for baseline variables including age, overall symptom severity, and severity of anxiety symptoms. Response rates at week 6 were lower in benzodiazepine users versus non-users (16.4% vs. 35.5%, p = 0.008), and higher in psychostimulant users versus non-users (39.2% vs. 22.0%, p = 0.02). CONCLUSIONS Concomitant medication use may impact rTMS treatment outcome. While the differences reported here could be considered clinically significant, results were not corrected for multiple comparisons and findings should be replicated before clinicians incorporate the evidence into clinical practice. Prospective, hypothesis-based treatment studies will aid in determining causal relationships between medication treatments and outcome.


title: Antiviral Cystine Knot α-Amylase Inhibitors from Alstonia scholaris.

text: Cystine knot α-amylase inhibitors are cysteine-rich, proline-rich peptides found in the Amaranthaceae and Apocynaceae plant species. They are characterized by a pseudocyclic backbone with two to four prolines and three disulfides arranged in a knotted motif. Similar to other knottins, cystine knot α-amylase inhibitors are highly resistant to degradation by heat and protease treatments. Thus far, only the α-amylase inhibition activity has been described for members of this family. Here, we show that cystine knot α-amylase inhibitors named alstotides discovered from the Alstonia scholaris plant of the Apocynaceae family display antiviral activity. The alstotides (As1-As4) were characterized by both proteomic and genomic methods. All four alsotides are novel, heat-stable and enzyme-stable and contain 30 residues. NMR determination of As1 and As4 structures reveals their conserved structural fold and the presence of one or more cis-proline bonds, characteristics shared by other cystine knot α-amylase inhibitors. Genomic analysis showed that they contain a three-domain precursor, an arrangement common to other knottins. We also showed that alstotides are antiviral and cell-permeable to inhibit the early phase of infectious bronchitis virus and Dengue infection, in addition to their ability to inhibit α-amylase. Taken together, our results expand membership of cystine knot α-amylase inhibitors in the Apocynaceae family and their bioactivity, functional promiscuity that could be exploited as leads in developing therapeutics.


title: Association of cerebral oxygenation with estimated glomerular filtration rate and cognitive function in chronic kidney disease patients without dialysis therapy.

text: BACKGROUND A decline in estimated glomerular filtration rate (eGFR) is reportedly associated with increased prevalence rates of cognitive impairment. However, data concerning the association between the cerebral saturation of oxygen (rSO2) and cognitive function of patients with chronic kidney disease (CKD) is limited. This study aimed to (i) elucidate the clinical factors associating with cerebral rSO2 and (ii) investigate the association between cerebral rSO2 and cognitive assessment in CKD patients. METHODS A total of 40 CKD patients not requiring dialysis (26 men and 14 women; mean age, 61.0 ± 2.7 years) were recruited. The numbers of patients at each CKD stage were as follows: G1, 5; G2, 8; G3a, 6; G3b, 5; G4, 11; and G5, 5. Cerebral rSO2 was monitored at the forehead using the oxygen saturation monitor INVOS 5100C. The cognitive function of each patient was confirmed using the Mini-Mental State Examination (MMSE). RESULTS Cerebral rSO2 levels were significantly higher in CKD patients than in hemodialysis patients (63.8 ± 1.5% vs. 44.9 ± 2.2%, p < 0.001). Multiple regression analysis showed that cerebral rSO2 was independently associated with eGFR (standardized coefficient: 0.530), serum albumin concentration (standardized coefficient: 0.365), and serum sodium concentration (standardized coefficient: 0.224). Furthermore, MMSE showed a significantly positive correlation with cerebral rSO2 (r = 0.624, p < 0.001). CONCLUSIONS Cerebral rSO2 was affected by eGFR and serum albumin and sodium concentrations in CKD patients. Furthermore, cerebral rSO2 monitoring, which reflected MMSE scores, might be a useful method for assessing cognitive function in CKD patients.


title: Woven Endobridge (WEB) device for endovascular treatment of complex unruptured aneurysms-a single center experience.

text: INTRODUCTION The introduction of the Woven Endobridge (WEB) device increases the feasibility of endovascular treatment of wide-neck bifurcation aneurysms with limitations given by currently available sizes and shapes of the device. Parallel to other studies, we used the new device for selected patients who were no optimal candidates for established techniques like neurosurgical clipping or endovascular coiling. We aimed to report the angiographic and clinical results of WEB implantations or combinations between WEB and coiling or intracranial stents. METHODS We reviewed the records of n = 23 interventions in 22 patients with unruptured wide-neck aneurysms (UIA) who were assigned for aneurysm treatment with the use of the WEB or adjunctive techniques. Interventional procedures and clinical and angiographic outcomes are reported for the periprocedural phase and in mid-term FU. RESULTS Of the included 22 patients, six patients needed additional coiling, intracranial stenting, or implantation of a flow diverter. WEB implantation was technically feasible in 22 out of the 23 interventions. Follow-up angiographic imaging proved total or subtotal occlusion of the aneurysm in 19 of 22 cases. Two minor recurrences remained stable during a period of 15 months. One patient with a partially thrombosed giant MCA aneurysm had a major recurrence and was retreated with a second WEB in combination with coiling. CONCLUSION Despite of unfavorable anatomic conditions, broad-based and large UIA endovascular treatment with the WEB and adjunctive techniques was feasible with a low risk of complications and promising occlusion rates in mid-term follow-up.


title: Age-dependent changes of total and differential white blood cell counts in children.

text: BACKGROUND Total and differential white blood cell counts are important for the diagnostic evaluation of suspected diseases. To facilitate the interpretation of total and differential white blood cell counts in pediatric patients, the present study investigated age-dependent changes in total and differential white blood cell counts in healthy reference children. METHODS Data were obtained from the Pediatric Reference Intervals in China study (PRINCE), which aims to establish and verify pediatric reference intervals for Chinese children based on a nationwide multicenter cross-sectional study from January 2017 to December 2018. Quantile curves were calculated using the generalized additive models for location, shape, and scale method. The 2.5th, 50th, and 97.5th quantile curves were calculated for both total and differential white blood counts. Percent of stacked area charts were used to demonstrate the proportions of differential white blood cells. All statistical analyses were performed using R software. RESULTS Both 50th and 97.5th quantiles of total white blood cell count and monocyte count were highest at birth, then rapidly decreased in the first 6 months of life; relatively slow reduction continued until 2 years of age. The lymphocyte count was low during infancy and increased to its highest level at 6 months of age; it then exhibited moderate and continuous reduction until approximately 9 years of age. The pattern of neutrophil count changed with age in a manner opposite to that of lymphocyte count. Besides, there were two inter-sections of lymphocyte count and neutrophil count during infancy and at approximately 5 years of age, based on locally weighted regression (LOESS) analysis. There were no apparent age-related changes in eosinophil or basophil counts. CONCLUSION These data regarding age-related changes in total and differential white blood cell counts can be used to assess the health of pediatric patients and guide clinical decisions.


title: Simvastatin with or without ezetimibe in familial hypercholesterolemia.

text: BACKGROUND Ezetimibe, a cholesterol-absorption inhibitor, reduces levels of low-density lipoprotein (LDL) cholesterol when added to statin treatment. However, the effect of ezetimibe on the progression of atherosclerosis remains unknown. METHODS We conducted a double-blind, randomized, 24-month trial comparing the effects of daily therapy with 80 mg of simvastatin either with placebo or with 10 mg of ezetimibe in 720 patients with familial hypercholesterolemia. Patients underwent B-mode ultrasonography to assess the intima-media thickness of the walls of the carotid and femoral arteries. The primary outcome measure was the change in the mean carotid-artery intima-media thickness, which was defined as the average of the means of the far-wall intima-media thickness of the right and left common carotid arteries, carotid bulbs, and internal carotid arteries. RESULTS The primary outcome, the mean (+/-SE) change in the carotid-artery intima-media thickness, was 0.0058+/-0.0037 mm in the simvastatin-only group and 0.0111+/-0.0038 mm in the simvastatin-plus-ezetimibe (combined-therapy) group (P=0.29). Secondary outcomes (consisting of other variables regarding the intima-media thickness of the carotid and femoral arteries) did not differ significantly between the two groups. At the end of the study, the mean (+/-SD) LDL cholesterol level was 192.7+/-60.3 mg per deciliter (4.98+/-1.56 mmol per liter) in the simvastatin group and 141.3+/-52.6 mg per deciliter (3.65+/-1.36 mmol per liter) in the combined-therapy group (a between-group difference of 16.5%, P<0.01). The differences between the two groups in reductions in levels of triglycerides and C-reactive protein were 6.6% and 25.7%, respectively, with greater reductions in the combined-therapy group (P<0.01 for both comparisons). Side-effect and safety profiles were similar in the two groups. CONCLUSIONS In patients with familial hypercholesterolemia, combined therapy with ezetimibe and simvastatin did not result in a significant difference in changes in intima-media thickness, as compared with simvastatin alone, despite decreases in levels of LDL cholesterol and C-reactive protein. (ClinicalTrials.gov number, NCT00552097 [ClinicalTrials.gov].).


title: Uterus-sparing vaginolaparoscopic sacrocolpopexy for apical pelvic organ prolapse.

text: INTRODUCTION AND HYPOTHESIS Our aim was to evaluate the safety, feasibility, and effectiveness of a vaginolaparoscopic sacrocolpopexy (VLS) technique for treating apical pelvic organ prolapse (POP). MATERIALS AND METHODS This was a prospective interventional case series (design classification: Canadian Task Force II3) performed in the endoscopic unit of a tertiary care referral facility and university hospital. We assessed 15 symptomatic parous women with stage ≥2 apical POP according to the POP Quantification (POP-Q) classification. Interventions comprised posterior colpotomy with mesh fixation to the uterosacral ligaments and the back of the uterus that was further fixed to the anterior longitudinal ligament of the sacrum using a tacker via laparoscopy. RESULTS The main outcome was a significant postoperative improvement in prolapse and resultant improvement in quality of life (QoL) after VLS. Six patients required concomitant reconstructive procedures. Mean operative time for the vaginal phase was 8.54 ± 3.10 (7-12) min and 32.36 ± 8.2 (27-41) min. for the laparoscopic phase Mean duration of VLS ranged from 30 to 50 min. At the 6-months follow-up, the procedure was successful in 14 of 15 patients (93.34%); one woman (6.66%) presented with recurrence at a lower stage. Neither mesh complications nor sacral ostitis were encountered. There was significant improvement in vaginal symptoms, sexual well-being, QoL, and clinical staging after the procedure. CONCLUSION By eliminating all forms of intraperitoneal suturing, performing a posterior colpotomy, and the advent of tackers without evidence of sacral ostitis, VLS seems to be a simple, feasible, effective, and fast approach for treating POP.


title: Vedolizumab Induces Long-term Mucosal Healing in Patients With Crohn's Disease and Ulcerative Colitis.

text: Introduction Vedolizumab has proven efficacy in inflammatory bowel disease [IBD], but long-term mucosal healing in Crohn's disease [CD], as well as the incidence of colorectal neoplasia in IBD, among patients treated with vedolizumab have not been studied. We aimed to document mucosal healing and to explore the risk of colorectal neoplasia with vedolizumab maintenance therapy. Methods Surveillance colonoscopy was prospectively scheduled for patients with longstanding ulcerative coltis [UC] or CD at a tertiary referral centre, in the open-label extension phase (vedolizumab 300 mg intravenously [IV] every 4 weeks) of the Gemini studies [GEMINI LTS, study number NCT00790933]. Mayo score ≤ 1 or ulcer disappearance [in CD] was defined as mucosal healing. Targeted biopsies were graded for inflammation and dysplasia. Results Of 68 patients [29 CD/39 UC] treated for ≥ 1 year [median 3.2 years, range 1.1-6.1], 58 [24 CD/34 UC] were endoscopically monitored. Durable endoscopic healing corrected by non-responder imputation was found in 7/24, 29% [CD] and 17/34, 50% [UC]. Combined histological and mucosal healing was observed in 5/24 [CD] and 11/34 [UC] of those with endoscopic healing. Low-grade dysplasia was detected in 10% of patients and high-grade dysplasia in the resection specimen of one patient with biopsy-proven low-grade dysplasia. Conclusions Long-term endoscopic and histological healing was observed in a proportion of patients treated with vedolizumab long-term. The dysplasia risk with vedolizumab deserves further study.


title: Identification of respiratory viruses in asymptomatic subjects: asymptomatic respiratory viral infections.

text: The medical literature of the past 4 decades was searched regarding respiratory virus detection by polymerase chain reaction and conventional methods (culture, antigen detection, serology) in asymptomatic subjects in an attempt to determine the prevalence and clinical significance of such viruses in normal persons.


title: Clinical utility of PCR for common viruses in acute respiratory illness.

text: BACKGROUND Acute respiratory illness (ARI) accounts for a large proportion of all visits to pediatric health facilities. Quantitative real-time polymerase chain reaction (qPCR) analyses allow sensitive detection of viral nucleic acids, but it is not clear to what extent specific viruses contribute to disease because many viruses have been detected in asymptomatic children. Better understanding of how to interpret viral findings is important to reduce unnecessary use of antibiotics. OBJECTIVE To compare viral qPCR findings from children with ARI versus asymptomatic control subjects. METHODS Nasopharyngeal aspirates were collected from children aged ≤5 years with ARI and from individually matched, asymptomatic, population-based control subjects during a noninfluenza season. Samples were analyzed by using qPCR for 16 viruses. RESULTS Respiratory viruses were detected in 72.3% of the case patients (n = 151) and 35.4% of the control subjects (n = 74) (P = .001). Rhinovirus was the most common finding in both case patients and control subjects (47.9% and 21.5%, respectively), with a population-attributable proportion of 0.39 (95% confidence interval: 0.01 to 0.62). Metapneumovirus, parainfluenza viruses, and respiratory syncytial virus were highly overrepresented in case patients. Bocavirus was associated with ARI even after adjustment for coinfections with other viruses and was associated with severe disease. Enterovirus and coronavirus were equally common in case patients and control subjects. CONCLUSIONS qPCR detection of respiratory syncytial virus, metapneumovirus, or parainfluenza viruses in children with ARI is likely to be causative of disease; detection of several other respiratory viruses must be interpreted with caution due to high detection rates in asymptomatic children.


title: Pre-operative quantification of pulmonary function using hybrid-SPECT/low-dose-CT: A pilot study.

text: RATIONALE Pre-operative lobar function is estimated by scintigraphy in patients with pulmonary malignancies and compromised function. This study compared the lobar perfusion determined by scintigraphy (PS) with data from SPECT/low-dose-CT (SPECT/ldCT) analyzed manually and semi-automatic. METHODS Retrospective analysis on 39 patients (m/f = 25/14; age: 72.5 [22-89] years) with indication for pulmonary perfusion scintigraphy. Imaging was performed using SPECT/ldCT. Data was analyzed manually and by semi-automatic software. Readers' confidence in 3D-segmentation was scored by two independent readers. Interrater agreement was calculated. In addition, Spearman's rank correlation and Wilcoxon's test were used. RESULTS Results from PS differed significantly from SPECT/ldCT processed manually or semi-automatically in 4/5 lobes (total difference ≤21.6%; rho ≥0.44) and in 3/5 (total difference 21.6%; rho ≥0.37), respectively. Readers' confidence in 3D-segmentation showed a perfect interrater agreement (κ = 0.98). CONCLUSION Quantification of lobar perfusion by SPECT/ldCT differs significantly from planar scintigraphy (e.g., with potential influence on therapy). The semi-automatic software analysis provides an applicable methodology.


title: A Pilot Study of Pulmonary Segmentectomy With Indocyanine Green Near-Infrared Angiography.

text: OBJECTIVES Video-assisted thoracoscopic surgery (VATS) pulmonary segmentectomy is commonly used in treating small ground-glass opacity (GGO) nodules in lung. The identification of the intersegmental plane is one of the challenges. In this pilot study, we aimed to evaluate the feasibility of indocyanine green (ICG) angiography in VATS segmentectomy. METHODS Nineteen GGO patients were enrolled, and VATS segmentectomy with ICG near-infrared angiography were performed between July 2017 and December 2017. Conventional 3-port VATS was used. ICG was injected intravenously after dominant arties were ligated. Intersegmental plane was identified and divided by stapler and electrocautery. RESULTS All patients had perfect intersegmental plane visualization. The mean operation time was 140.8 minutes, and the mean blood loss was 23.7 mL. No complications due to ICG occurred. The mean chest tube duration was 4.6 days. No severe complications occurred in the perioperative period. The mean chest tube drainage duration was 4.6 days. Prolonged postoperative air leak (>5 days), which required no surgical intervention, occurred in 2 cases. There were no severe complications or in-hospital deaths. CONCLUSIONS VATS segmentectomy with ICG near-infrared angiography is a reasonable treatment option to treat small GGO in lung, especially due to its good surgical view maintenance.


title: Targeting CXCR4-dependent immunosuppressive Ly6Clow monocytes improves antiangiogenic therapy in colorectal cancer.

text: Antiangiogenic therapy with antibodies against VEGF (bevacizumab) or VEGFR2 (ramucirumab) has been proven efficacious in colorectal cancer (CRC) patients. However, the improvement in overall survival is modest and only in combination with chemotherapy. Thus, there is an urgent need to identify potential underlying mechanisms of resistance specific to antiangiogenic therapy and develop strategies to overcome them. Here we found that anti-VEGFR2 therapy up-regulates both C-X-C chemokine ligand 12 (CXCL12) and C-X-C chemokine receptor 4 (CXCR4) in orthotopic murine CRC models, including SL4 and CT26. Blockade of CXCR4 signaling significantly enhanced treatment efficacy of anti-VEGFR2 treatment in both CRC models. CXCR4 was predominantly expressed in immunosuppressive innate immune cells, which are recruited to CRCs upon anti-VEGFR2 treatment. Blockade of CXCR4 abrogated the recruitment of these innate immune cells. Importantly, these myeloid cells were mostly Ly6Clow monocytes and not Ly6Chigh monocytes. To selectively deplete individual innate immune cell populations, we targeted key pathways in Ly6Clow monocytes (Cx3cr1-/- mice), Ly6Chigh monocytes (CCR2-/- mice), and neutrophils (anti-Ly6G antibody) in combination with CXCR4 blockade in SL4 CRCs. Depletion of Ly6Clow monocytes or neutrophils improved anti-VEGFR2-induced SL4 tumor growth delay similar to the CXCR4 blockade. In CT26 CRCs, highly resistant to anti-VEGFR2 therapy, CXCR4 blockade enhanced anti-VEGFR2-induced tumor growth delay but specific depletion of Ly6G+ neutrophils did not. The discovery of CXCR4-dependent recruitment of Ly6Clow monocytes in tumors unveiled a heretofore unknown mechanism of resistance to anti-VEGF therapies. Our findings also provide a rapidly translatable strategy to enhance the outcome of anti-VEGF cancer therapies.


title: Contrast-Enhanced Nanofocus X-Ray Computed Tomography Allows Virtual Three-Dimensional Histopathology and Morphometric Analysis of Osteoarthritis in Small Animal Models.

text: OBJECTIVE One of the early hallmarks of osteoarthritis (OA) is a progressive degeneration of the articular cartilage. Early diagnosis of OA-associated cartilage alterations would be beneficial for disease prevention and control, and for the development of disease-modifying treatments. However, early diagnosis is still hampered by a lack of quantifiable readouts in preclinical models. DESIGN In this study, we have shown the potency of contrast-enhanced nanofocus x-ray computed tomography (CE-nanoCT) to be used for virtual 3-dimensional (3D) histopathology in established mouse models for OA, and we compared with standard histopathology. RESULTS We showed the equivalence of CE-nanoCT images to histopathology for the modified Mankin scoring of the cartilage structure and quality. Additionally, a limited set of 3D cartilage characteristics measured by CE-nanoCT image analysis in a user-independent and semiautomatic manner, that is, average and maximum of the noncalcified cartilage thickness distribution and loss in glycosaminoglycans, was shown to be predictive for the cartilage quality and structure as can be evaluated by histopathological scoring through the use of an empirical model. CONCLUSIONS We have shown that CE-nanoCT is a tool that allows virtual histopathology and 3D morphological quantification of multitissue systems, such as the chondro-osseous junction. It provides faster and more quantitative data on cartilage structure and quality compared with standard histopathology while eliminating user bias. CE-nanoCT thus should allow capturing subtle differences in cartilage characteristics, carefully mapping OA progression and, ultimately, asses the beneficial changes when testing a candidate disease-modifying treatment.


title: Early dinner or "dinner like a pauper": Evidence, the habitual time of the largest meal of the day - dinner - is predisposing to severe COVID-19 outcome - death.

text: COVID-19 and metabolic syndrome are devastating pandemics. Effective control of metabolic parameters and their dysfunction may help prevent or minimize the acute and devastating effects of SARS-CoV-2 by reducing the local inflammatory response and blocking the entry of the virus into cells. With such consideration in mind, we gathered data from dietary surveys conducted in nine European countries to explore the relationship between actual clock hour of the large dinner meal and also interval in minutes between it and sunset in the respective countries and death rate above the median rate of per one million people as an index of mortality due to COVID-19 infection. Clock time of the dinner meal varied between 16:00 and 21:00 h across the European counties sampled, and the correlation between dinner mealtime and death rate was strongly correlated, R = 0.7991 (two-tailed p = 0.0098), with R 2 explaining 63% of the variation within the data. This strong linear positive correlation indicates that the later the clock time of the dinner meal, the higher is the death rate (and vice versa). The relationship between meal timing in reference to sunset, utilized as a gross surrogate marker of the activity/rest synchronizer of circadian rhythms, and death rate was negative and even slightly stronger, R = -0.8025 (two-tailed p = 0.0092), with R 2 explaining 64% of the variation within the data. This strong linear negative correlation indicates that the shorter the interval between the dinner meal and sunset, i.e., the closer the time of the largest meal of the day to bedtime, the greater is the death rate (and vice versa). Our preliminary approach to nighttime eating, in terms of the day's largest caloric intake, as a risk factor for the predisposing conditions of obesity, metabolic syndrome, type 2 diabetes, and other commonly associated comorbidities of being overweight, and death from COVID-19 infection reveals strong correlation with the time of the dinner meal, both in terms of its actual clock and circadian time.


Managing chronic pain patients at the time of COVID-19 pandemic.


title: Integration of care for HIV and opioid use disorder: a systematic review of interventions in clinical and community-based settings.

text: OBJECTIVE We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings. DESIGN Systematic review. METHODS We searched Ovid MEDLINE, PubMed, Embase, and PsycINFO and pre-identified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country. RESULTS Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low to moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV- and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits. CONCLUSION Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions. REGISTRATION A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).


title: A proposed grading system for endovascular treatment of cerebral arteriovenous malformations: Buffalo score.

text: BACKGROUND The Spetzler-Martin arteriovenous malformation (AVM) grading system has proven to be useful in guiding treatment of cerebral AVMs with craniotomy. It is based on anatomical characteristics each of which makes surgical resection of an AVM more difficult, namely, deep venous drainage, eloquence of surrounding tissue, and large nidus size. A higher score correlates with more complications after treatment. Although this grading system has proven reliable over time, it does not reflect the major determinants of risk associated with endovascular treatment. The authors developed a grading system unique to endovascular treatment of cerebral AVMs. METHODS The proposed grading system accounts for the principal AVM anatomical and physiological features that make endovascular embolization more difficult and, thus, the likelihood of complications greater. These include number of arterial pedicles, diameter of arterial pedicles, and eloquent location of AVM nidus. The proposed grading system was retrospectively applied to 50 patients undergoing endovascular AVM embolization, and its ability to predict complications was compared to the Spetzler-Martin grading system. RESULTS Perioperative complications among the 50 patients included 4 major and 9 minor complications. The proposed grading system was predictive of complication risk, with an increasing rate of perioperative complications associated with an increasing AVM grade. An improved correlation of perioperative complication incidence was noted with the proposed system (P = 0.002), when compared with the Spetzler-Martin grading system (P = 0.33). CONCLUSION This grading system for the endovascular treatment of AVMs is simple, easily reproduced, and clinically valuable.


title: Influence of anatomic landmarks in the virtual environment on simulated angled laparoscope navigation.

text: BACKGROUND The aim of this study is to investigate the influence of the presence of anatomic landmarks on the performance of angled laparoscope navigation on the SimSurgery SEP simulator. METHODS Twenty-eight experienced laparoscopic surgeons (familiar with 30° angled laparoscope, >100 basic laparoscopic procedures, >5 advanced laparoscopic procedures) and 23 novices (no laparoscopy experience) performed the Camera Navigation task in an abstract virtual environment (CN-box) and in a virtual representation of the lower abdomen (CN-abdomen). They also rated the realism and added value of the virtual environments on seven-point scales. RESULTS Within both groups, the CN-box task was accomplished in less time and with shorter tip trajectory than the CN-abdomen task (Wilcoxon test, p < 0.05). No significant differences were found between the performances of the experienced participants and the novices on the CN tasks (Mann-Whitney U test, p > 0.05). In both groups, the CN tasks were perceived as hard work and more challenging than anticipated. CONCLUSIONS Performance of the angled laparoscope navigation task is influenced by the virtual environment surrounding the exercise. The task was performed better in an abstract environment than in a virtual environment with anatomic landmarks. More insight is required into the influence and function of different types of intrinsic and extrinsic feedback on the effectiveness of preclinical simulator training.


title: [Ebola virus disease].

text: The current Ebola outbreak in Western Africa differs from previous ones due to its extent. Serious shortcomings in the on-site management in Africa are obvious. In addition to the situation in the countries affected media and medical interests also focus on detection and management of imported cases in Germany. From the experience with such patients already treated in Germany the existing medical concepts have been updated and expanded. This overview addresses not only the latest clinical knowledge and epidemiological developments but also outlines the key measures as well as the practical procedure when there is a suspected case.


title: Suppression of host gene expression by nsp1 proteins of group 2 bat coronaviruses.

text: nsp1 protein of severe acute respiratory syndrome coronavirus (SARS-CoV), a group 2b CoV, suppresses host gene expression by promoting host mRNA degradation and translation inhibition. The present study analyzed the activities of nsp1 proteins from the group 2 bat CoV strains Rm1, 133, and HKU9-1, belonging to groups 2b, 2c, and 2d, respectively. The host mRNA degradation and translational suppression activities of nsp1 of SARS-CoV and Rm1 nsp1 were similar and stronger than the activities of the nsp1 proteins of 133 and HKU9-1. Rm1 nsp1 expression in trans strongly inhibited the induction of type I interferon (IFN-I) and IFN-stimulated genes in cells infected with an IFN-inducing SARS-CoV mutant, while 133 and HKU9-1 nsp1 proteins had relatively moderate IFN-inhibitory activities. The results of our studies suggested a conserved function among nsp1 proteins of SARS-CoV and group 2 bat CoVs.


title: Changes in H5N1 influenza virus hemagglutinin receptor binding domain affect systemic spread.

text: The HA of influenza virus is a receptor-binding and fusion protein that is required to initiate infection. The HA receptor-binding domain determines the species of sialyl receptors recognized by influenza viruses. Here, we demonstrate that changes in the HA receptor-binding domain alter the ability of the H5N1 virus to spread systemically in mice. The A/Vietnam/1203/04 (VN1203) and A/Hong Kong/213/03 (HK213) viruses are consistently lethal to domestic chickens but differ in their pathogenicity to mammals. Insertion of the VN1203 HA and neuraminidase (NA) genes into recombinant HK213 virus expanded its tissue tropism and increased its lethality in mice; conversely, insertion of HK213 HA and NA genes into recombinant VN1203 virus decreased its systemic spread and lethality. The VN1203 and HK213 HAs differ by 10 aa, and HK213 HA has shown greater binding affinity for synthetic alpha2,6-linked sialyl receptor. Introduction of an S227N change and removal of N-linked glycosylation at residue 158 increased the alpha2,6-binding affinity of VN1203 HA. Recombinant VN1203 virus carrying the S227N change alone or with the residue-158 glycosylation site removed showed reduced lethality and systemic spread in mice but not in domestic chickens. Wild-type VN1203 virus exhibited the greatest efficiency in systemic spread after intramuscular inoculation and in infection of mouse bone marrow-derived dendritic cells and conventional pulmonary dendritic cells. These results show that VN1203 HA glycoprotein confers pathogenicity by facilitating systemic spread in mice; they also suggest that a minor change in receptor binding domain may modulate the virulence of H5N1 viruses.


Covid-19 infection in kidney transplant recipients: endocrine and metabolic issues.


title: Finding Alternate Resources for Completing Senior Design Projects During the Current COVID-19 Pandemic.

text: At this time many (if not all) colleges and universities are on lockdown, students have returned home, and classes have transitioned to online instruction. Students in capstone design courses around the country have no access to their school's maker spaces and test equipment. Their prototype parts may be stored in a locked maker space, making it difficult to build, test, and deliver prototypes to sponsors or clients at the end of the semester.z.


title: Laparoscopic sacrocolpopexy: demonstration of a nerve-sparing technique.

text: Laparoscopic sacrocolpopexy is a well-established technique to treat apical vaginal prolapse. De novo micturition disorders, pelvic pain, and defecation disorders have been reported and may be due to intraoperative compromise of the superior hypogastric plexus. The video demonstrates our technique for nerve-sparing laparoscopic sacrocolpopexy. The patient is a 62-year-old woman with symptomatic stage III posthysterectomy vaginal vault prolapse. Key steps of the procedure are opening the peritoneum at the level of the promontory, identification of the fibers of the superior hypogastric plexus, deep anterior and posterior dissection with attachment of the mesh to the vagina, displacement of the nerve fibers to the left side during suturing of the mesh to the longitudinal ligament, and complete peritonealization. This technique of the identification and protection of relevant nerve structures appears to be reproducible and can be considered by surgeons who perform laparoscopic sacrocolpopexy.


title: Erratum to "A feasibility study of a complete low-cost consumer-grade brain-computer interface system" [Heliyon 6 (3) (March 2020) e03425].

text: [This corrects the article DOI: 10.1016/j.heliyon.2020.e03425.].


title: Acute dissection of the descending aorta: a case report and review of the literature.

text: Cardiovascular disease is the leading cause of death worldwide. Acute aortic syndromes, which include aortic dissection, intramural hematoma, and penetrating aortic ulcer, represent the most morbid presentations of aortic disease and can be difficult to diagnose. Recent advances in imaging have allowed for more rapid and accurate diagnosis of acute aortic syndromes and the options for management are expanding. This case report and review presents the case of a 43-year-old man with acute type B aortic dissection who underwent two endovascular procedures for malperfusion syndrome. The review focuses on the presentation, diagnosis, medical management, and procedural options for acute dissection of the descending aorta.


title: Functional Duration of Closure Systems Used in Partial Nephrectomy.

text: PURPOSE We determined the functional life of various configurations of partial nephrectomy closure systems. MATERIALS AND METHODS Sutures were prepared using standard techniques for sutured renorrhaphy during partial nephrectomy. Tested systems included knot/Hem-o-Lok®, Lapra-Ty®/Hem-o-Lok and Hem-o-Lok/Hem-o-Lok combinations. The saline filled tank was maintained at 37C. Vicryl®, Stratafix™ polyglycolic acid-polycaprolactone or V-Loc™ 180 sutures were suspended at 4 or 2 N. Suture material breakage or slippage was considered failure. RESULTS At 4 N 20% of sutures terminated with knot/Hem-o-Lok failed by 3 weeks compared to 56% and 100% terminated with Lapra-Ty/Hem-o-Lok and Hem-o-Lok/Hem-o-Lok, respectively (p <0.0001). The 55% and 100% of failures with Lapra-Ty/Hem-o-Lok and Hem-o-Lok/Hem-o-Lok, respectively, were generally due to slippage vs 11% with knot/Hem-o-Lok (p <0.0001). Overall failure rates with Lapra-Ty/Hem-o-Lok for zero to 4-zero sutures were 41% with Vicryl, 82% with polyglycolic acid-polycaprolactone and 24% with V-Loc 180 (p <0.0001). The only sutures without failure at 4 N with Lapra-Ty/Hem-o-Lok and knot/Hem-o-Lok closure systems were Vicryl zero, and V-Loc 2-zero and 3-zero. At 2 N Lapra-Ty/Hem-o-Lok failure (17.5% vs 0%, p = 0.039) and Hem-o-Lok/Hem-o-Lok failure (39% vs 16%, p = 0.074) were more common with polyglycolic acid-polycaprolactone than with V-Loc sutures. CONCLUSION Hem-o-Lok/Hem-o-Lok and Lapra-Ty/Hem-o-Lok combinations resulted in more frequent failures at 3 weeks or greater than knot/Hem-o-Lok. For all sutures tested knots were superior to Lapra-Tys to backstop Hem-o-Loks at 4 N. Preferably, Vicryl zero or V-Loc 2-zero/3-zero sutures should be used in combination with knots or Lapra-Tys at 4 N. Under these experimental conditions the Lapra-Ty/Hem-o-Lok combination did not reliably suspend the other sutures tested for 3 weeks. If Lapra-Ty/Hem-o-Lok or Hem-o-Lok/Hem-o-Lok combinations are used, we recommend closure at lesser tension and/or the use of appropriate sutures.


title: Sedation options for the morbidly obese intensive care unit patient: a concise survey and an agenda for development.

text: BACKGROUND We offer some perspectives and commentary on the sedation of obese patients in the intensive care unit (ICU). DISCUSSION Sedation in morbidly obese patients should conform to the same broad principles now current in ICU practice. These include a general presumption against benzodiazepines as first-line agents. Opioids should be avoided in any situation where spontaneous breathing is required. Remifentanil is the preferred agent where continuous stable opioid levels using an infusion are required, because of its lack of context-sensitive accumulation. Volatile anaesthetics may be an option for the same reason but there are no substantial, controlled demonstrations of effectiveness/safety in short-term use in the ICU setting. Propofol is a valuable resource in the morbidly obese patients but the duration of continuous sedation should not exceed 6 days, in order to avoid propofol infusion syndrome. Alpha-2 agonists offer a range of theoretically positive features for the sedation of morbidly obese patients, but at present there is a lack of pharmacokinetic data and a critical mass of high-grade clinical data. Dexmedetomidine has the attraction of not causing respiratory depression or obstructive breathing during sedation and its sympatholytic effects should help deliver stable blood pressure and heart rate. Ketamine has a poor tolerability profile in adults so its use in the ICU context is largely confined to paediatrics. CONCLUSION None of the agents currently available is ideal for every situation encountered in the management of morbidly obese patients. This article identifies additional research needed to place sedation practice of obese patients on a more systematic footing.


title: Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management.

text: BACKGROUND Laparoscopic Roux-en-Y gastric bypass (RYGB) is a well-established procedure to treat morbid obesity. Gastrojejunal anastomotic (GJA) ulcers can develop after surgery with subsequent perforation. Our aim was to evaluate the incidence, presentation and outcome of management of perforated GJA ulcer disease after laparoscopic RYGB. METHODS The database of all patients at the senior author's bariatric institutions was retrospectively reviewed. The results are presented as mean (range). RESULTS From April 2002 to April 2010, 1213 patients underwent laparoscopic RYGB, which included 1184 primary and 29 revision procedures. The operative mortality was .15%. Ten patients developed perforated GJA ulcers (.82%) at a mean of 13.5 (6-19) months. The patients who presented to bariatric surgeons (n = 5) were treated with laparoscopic closure and an omental patch, and those who presented to nonbariatric surgeons (n = 5) were treated with laparotomy. The morbidity and mortality rate was 30% and 10%, respectively, and the mean postoperative hospital stay for the survivors was 14 (5-44) days. CONCLUSION Perforated GJA ulcers can develop in 1 of 120 patients after laparoscopic RYGB and can be effectively managed by laparoscopic repair with an omental patch, if expertise is available.


Endotherapy for Barrett's Esophagus.


title: Perseverance in a pandemic: A unique pharmacy residency learning experience.

text: In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.


title: Single incision laparoscopic hepatectomy: Advances in laparoscopic liver surgery.

text: BACKGROUND Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in experienced hands. Single incision laparoscopic surgery (SILS) has been performed for cholecystectomies, nephrectomies, splenectomies and obesity surgery. However, the use of SILS in liver surgery has been rarely reported. We report our initial experience in seven patients on single incision laparoscopic hepatectomy (SILH). PATIENTS AND METHODS From October 2010 to September 2012, seven patients underwent single-incision laparoscopic liver surgery. The abdomen was approached through a 25 mm periumbilical incision. No supplemental ports were required. The liver was transected using a combination of LigaSure™ (Covidien-Valleylab. Boulder. USA), Harmonic Scalpel and Ligaclips (Ethicon Endo-Surgery, Inc.). RESULTS Liver resection was successfully completed for the seven patients. The procedures consisted of two partial resections of segment three, two partial resections of segment five and three partial resections of segment six. The mean operative time was 98.3 min (range: 60-150 min) and the mean estimated blood loss was 57 ml (range: 25-150 ml). The postoperative courses were uneventful and the mean hospital stay was 5.1 days (range: 1-13 days). Pathology identified three benign and four malignant liver tumours with clear margins. CONCLUSION SILH is a technically feasible and safe approach for wedge resections of the liver without oncological compromise and with favourable cosmetic results. This surgical technique requires relatively advanced laparoscopic skills. Further studies are needed to determine the potential advantages of this technique, apart from the better cosmetic result, compared to the conventional laparoscopic approach.


title: Endocrinology in the time of COVID-19: Management of neuroendocrine neoplasms (NENs).

text: In viral pandemics, most specifically Covid-19, many patients with neuroendocrine neoplasms (NENs), including phaeochromocytomas, paragangliomas and medullary thyroid carcinoma, may develop Covid-19 in a mild or severe form, or be concerned about the influence of viral infection relative to their anti-tumoral therapy. In general, newly-presenting patients should be assessed, and patients recently receiving chemotherapy, targeted therapy or radionuclide therapy, or showing tumour growth, should be closely followed. For previously diagnosed patients, who have indolent disease, some delay in routine follow-up or treatment may not be problematic. However, patients developing acute secretory syndromes due to functional neuroendocrine neoplasms (such as of the pancreas, intestine or lung), phaeochromocytomas and paragangliomas, will require prompt treatment. Patients with life-threatening Covid-19-related symptoms should be urgently treated and long-term anti-tumoral treatments may be temporarily delayed. In patients with especially aggressive NENs, a careful judgement should be made regarding the severity of any Covid-19 illness, tumour grade, and the immunosuppressant effects of any planned chemotherapy, immunotherapy, targeted therapy or related treatment. In other cases, especially patients with completely resected NENs, or who are under surveillance for a genetic disorder, a telephone or delayed consultation may be in order, balancing the risk of a delay against that of the possible development of Covid-19.


title: Epidemiology, Natural History, and Clinical Presentation of Large Vessel Ischemic Stroke.

text: Large vessel occlusions (LVOs), variably defined as blockages of the proximal intracranial anterior and posterior circulation, account for approximately 24% to 46% of acute ischemic strokes. Commonly refractory to intravenous tissue plasminogen activator (tPA), LVOs place large cerebral territories at ischemic risk and cause high rates of morbidity and mortality without further treatment. Over the past few years, an abundance of high-quality data has demonstrated the efficacy of endovascular thrombectomy for improving clinical outcomes in patients with LVOs, transforming the treatment algorithm for affected patients. In this review, we discuss the epidemiology, pathophysiology, natural history, and clinical presentation of LVOs as a framework for understanding the recent clinical strides of the endovascular era.


title: Training in Neurology: Adoption of resident teleneurology training in the wake of COVID-19: Telemedicine crash course.

text: The current COVID-19 pandemic has changed the way we engage patient care, with a move toward telemedicine-based healthcare encounters. Teleneurology is now being rapidly embraced by neurologists in clinics and hospitals nationwide but for many, this paradigm of care is unfamiliar. Exposure to telemedicine in neurology training programs is scarce despite previous calls to expand teleneurology education. Programs that do provide a teleneurology curriculum have demonstrated increased proficiency, accuracy, and post-training utilization among their trainees. With the current changes in healthcare, broad incorporation of teleneurology education in resident and fellow training after this pandemic dissipates will only serve to improve trainee preparedness for independent practice.The current COVID-19 pandemic is forcing a reckoning of current healthcare delivery and expediting a rapid transition to telemedicine-based care. Even in 2017, the Telemedicine Work Group of the American Academy of Neurology (AAN) recommended a teleneurology curriculum as an elective rotation for trainees1 How long ago 2017 seems now as we all hastily work to create operational teleneurology infrastructure in our clinics and hospitals. Although prior exposure in teleneurology is advantageous in tackling the complexities of moving to telehealth-based care, most of the neurology workforce is not formally trained in telemedicine. While we are far from fully understanding the long-term sequelae of this pandemic on our healthcare systems, broader exposure and increased comfort with teleneurology is imperative to prepare our trainees for the new world of medicine they will face after this current pandemic dissipates.


title: Respiratory protease/antiprotease balance determines susceptibility to viral infection and can be modified by nutritional antioxidants.

text: The respiratory epithelium functions as a central orchestrator to initiate and organize responses to inhaled stimuli. Proteases and antiproteases are secreted from the respiratory epithelium and are involved in respiratory homeostasis. Modifications to the protease/antiprotease balance can lead to the development of lung diseases such as emphysema or chronic obstructive pulmonary disease. Furthermore, altered protease/antiprotease balance, in favor for increased protease activity, is associated with increased susceptibility to respiratory viral infections such as influenza virus. However, nutritional antioxidants induce antiprotease expression/secretion and decrease protease expression/activity, to protect against viral infection. As such, this review will elucidate the impact of this balance in the context of respiratory viral infection and lung disease, to further highlight the role epithelial cell-derived proteases and antiproteases contribute to respiratory immune function. Furthermore, this review will offer the use of nutritional antioxidants as possible therapeutics to boost respiratory mucosal responses and/or protect against infection.


Human Vaccines and Immunotherapeutics: News.


title: [The virtualist].

text: The CoViD-19 pandemic has changed the concept of clinic and doctor-patient relationship. Due to the risk of mutual contagion, patients in many cases were managed without direct physical contact. This resulted in a forced acceleration towards e-health and remote consultation. The onset of a new professional figure is ever closer, the virtualist, the doctor who can treat patients without direct physical contact. For this reason, new skills and organizational methods are needed to create a care approach capable of integrating technology opportunities with the traditional clinical method.


Will pay for performance improve quality of care? The answer is in the details.


title: Rapid detection of neutralizing antibodies against bovine viral diarrhoea virus using quantitative high-content screening.

text: Bovine viral diarrhoea virus (BVDV) is an important cause of morbidity, mortality and economic losses in cattle worldwide. Humoral immunity to BVDV plays a major role in the protection against infection and disease. In vitro serum neutralization tests can quantify humoral responses, but standard protocols are time-consuming and labour-intensive. The objective of this study was to develop a highly sensitive assay based on high-content cell-by-cell screening that is faster and less subjective than the conventional protocols. It can detect a neutralizing antibody response within the first week after infection of an animal, takes less than 24h to complete and excludes operator bias by automated data acquisition and analysis.


title: Emergency surveillance of influenza during 2009 in the Chinese city of Qingdao.

text: BACKGROUND In April, 2009, a new influenza pandemic caused by a swine-origin H1N1 subtype influenza virus was imminent. We thereby carried out an emergency surveillance study in a Chinese city of Qingdao. METHODS Pharyngeal swab samples were collected from four targeted groups and tested by reverse-transcription polymerase chain reaction. Each laboratory-confirmed pandemic H1N1 case or cluster was investigated, and the hemagglutinin genes of some of the viruses were sequenced and analyzed. RESULTS A total of 140 pandemic H1N1 cases including 92 from 7 clusters were identified in the four targeted groups. None of them developed into severe infections. Meanwhile, 103 cases of seasonal influenza (98 H3N2 and 5 H1N1) and 10 clusters of seasonal H3N2 influenza were also identified. Among them, 38 pandemic H1N1 and two seasonal H3N2 influenza cases were air travellers, suggesting that air travel facilitates the spread of pandemic and seasonal influenza even in the northern hemisphere summer. In addition, it was found that pandemic H1N1 and seasonal H3N2 influenza viruses co-circulated in two clusters. No significant mutations were found in the hemagglutinin gene sequences of pandemic H1N1 viruses, but the seasonal H3N2 influenza viruses have become genetically distinguishable from those circulating in 2007-2008.


title: Single-incision versus hand-assisted laparoscopic colectomy: a case-matched series.

text: BACKGROUND Single-incision laparoscopic colorectal surgery is an emerging modality. We incorporated this technique as an alternative to hand-assisted laparoscopic surgery. We investigated intraoperative and short-term outcomes following single-incision laparoscopic colectomy compared with hand-assisted laparoscopic colectomy. METHODS Between July and November 2009, single-incision colorectal procedures were performed and matched to hand-assisted procedures based on five criteria: gender, age, body mass index, pathology, and type of procedure. Demographic, intraoperative, and postoperative data were assessed. RESULTS Twenty-four pairs of patients with a mean age of 55.1 years and mean body mass index of 28.5 kg/m(2) were matched. The majority of cases (79.2%) were right hemicolectomies. The ranges of incision length were 2-6 cm (single incision) and 5-11 cm (hand-assisted). Mean operating time was significantly longer for single-incision procedures (143.2 min) compared with hand-assisted procedures (112.8 min), p < 0.0004. There was no significant difference in the groups regarding conversions or intraoperative complications (p < 0.083 and p < 1.0, respectively). Mean length of stay for the single-incision approach (2.7 days) was significantly shorter compared with the hand-assisted approach (3.3 days), p < 0.02. CONCLUSION Single-incision laparoscopic colectomy is a safe and feasible alternative to hand-assisted laparoscopic surgery. Although the technique required longer operative time, it resulted in smaller incision size and significantly shorter length of hospitalization.


Conclusive proof needed for animal virus reservoirs.


title: Creation of short microwave ablation zones: in vivo characterization of single and paired modified triaxial antennas.

text: PURPOSE To characterize modified triaxial microwave antennas configured to produce short ablation zones. MATERIALS AND METHODS Fifty single-antenna and 27 paired-antenna hepatic ablations were performed in domestic swine (N = 11) with 17-gauge gas-cooled modified triaxial antennas powered at 65 W from a 2.45-GHz generator. Single-antenna ablations were performed at 2 (n = 16), 5 (n = 21), and 10 (n = 13) minutes. Paired-antenna ablations were performed at 1-cm and 2-cm spacing for 5 (n = 7 and n = 8, respectively) and 10 minutes (n = 7 and n = 5, respectively). Mean transverse width, length, and aspect ratio of sectioned ablation zones were measured and compared. RESULTS For single antennas, mean ablation zone lengths were 2.9 cm ± 0.45, 3.5 cm ± 0.55, and 4.2 cm ± 0.40 at 2, 5, and 10 minutes, respectively. Mean widths were 1.8 cm ± 0.3, 2.0 cm ± 0.32, and 2.5 cm ± 0.25 at 2, 5, and 10 minutes, respectively. For paired antennas, mean length at 5 minutes with 1-cm and 2-cm spacing and 10 minutes with 1-cm and 2-cm spacing was 4.2 cm ± 0.9, 4.9 cm ± 1.0, 4.8 cm ± 0.5, and 4.8 cm ± 1.3, respectively. Mean width was 3.1 cm ± 1.0, 4.4 cm ± 0.7, 3.8 cm ± 0.4, and 4.5 cm ± 0.7, respectively. Paired-antenna ablations were more spherical (aspect ratios, 0.72-0.79 for 5-10 min) than single-antenna ablations (aspect ratios, 0.57-0.59). For paired-antenna ablations, 1-cm spacing appeared optimal, with improved circularity and decreased clefting compared with 2-cm spacing (circularity, 0.85 at 1 cm, 0.78 at 2 cm). CONCLUSIONS Modified triaxial antennas can generate relatively short, spherical ablation zones. Paired-antenna ablations were rounder and larger in transverse dimension than single antenna ablations, with 1-cm spacing optimal for confluence of the ablation zone.


title: Acute kidney injury following cardiac surgery: role of perioperative blood pressure control.

text: BACKGROUND/AIMS Patients who develop acute kidney injury (AKI) after cardiac surgery continue to have a high mortality rate. Although factors that predispose to postoperative renal dysfunction have been identified, this knowledge has not been associated with a substantial reduction in the incidence of this serious adverse event. METHODS This review uses the existing literature to explore the relationship between AKI and perioperative blood pressure (BP) control in cardiac surgery patients. The results of recent novel analyses are introduced, and the implications of these studies for the management of cardiac surgery patients in the perioperative period are discussed. RESULTS Preexisting isolated systolic hypertension and wide pulse pressure increase the risk of postoperative renal dysfunction in the cardiac surgery population. New data suggest that BP lability (i.e., BP excursions outside an acceptable physiologic range) during cardiac surgery may also be an important predictor of subsequent renal dysfunction. CONCLUSION Recently published data suggest that perioperative BP lability influences both the risk of postoperative renal dysfunction and 30-day mortality. Future studies will determine whether the use of agents that allow improved BP control within a desirable range will reduce the incidence of postoperative AKI in cardiac surgery patients.


title: Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults.

text: BACKGROUND Community-acquired pneumonia is a leading infectious cause of hospitalization and death among U.S. adults. Incidence estimates of pneumonia confirmed radiographically and with the use of current laboratory diagnostic tests are needed. METHODS We conducted active population-based surveillance for community-acquired pneumonia requiring hospitalization among adults 18 years of age or older in five hospitals in Chicago and Nashville. Patients with recent hospitalization or severe immunosuppression were excluded. Blood, urine, and respiratory specimens were systematically collected for culture, serologic testing, antigen detection, and molecular diagnostic testing. Study radiologists independently reviewed chest radiographs. We calculated population-based incidence rates of community-acquired pneumonia requiring hospitalization according to age and pathogen. RESULTS From January 2010 through June 2012, we enrolled 2488 of 3634 eligible adults (68%). Among 2320 adults with radiographic evidence of pneumonia (93%), the median age of the patients was 57 years (interquartile range, 46 to 71); 498 patients (21%) required intensive care, and 52 (2%) died. Among 2259 patients who had radiographic evidence of pneumonia and specimens available for both bacterial and viral testing, a pathogen was detected in 853 (38%): one or more viruses in 530 (23%), bacteria in 247 (11%), bacterial and viral pathogens in 59 (3%), and a fungal or mycobacterial pathogen in 17 (1%). The most common pathogens were human rhinovirus (in 9% of patients), influenza virus (in 6%), and Streptococcus pneumoniae (in 5%). The annual incidence of pneumonia was 24.8 cases (95% confidence interval, 23.5 to 26.1) per 10,000 adults, with the highest rates among adults 65 to 79 years of age (63.0 cases per 10,000 adults) and those 80 years of age or older (164.3 cases per 10,000 adults). For each pathogen, the incidence increased with age. CONCLUSIONS The incidence of community-acquired pneumonia requiring hospitalization was highest among the oldest adults. Despite current diagnostic tests, no pathogen was detected in the majority of patients. Respiratory viruses were detected more frequently than bacteria. (Funded by the Influenza Division of the National Center for Immunizations and Respiratory Diseases.).


title: Laparoscopic treatment of obese patients with gastroesophageal reflux disease and Barrett's esophagus: a prospective study.

text: BACKGROUND Short-segment Barrett's esophagus (SSBE) or long-segment Barrett's esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett's esophagus reaches up to 9% of patients. METHODS In this prospective study, we evaluate the postoperative results after three different procedures--calibrated fundoplication + posterior gastropexy (CFPG), fundoplication + vagotomy + distal gastrectomy + Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)--among obese patients. RESULTS In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagitis was observed in 15% and 20.2% of them, respectively. Patients with LSBE were submitted to FVDGRYGJ or LRRYGBP which significantly improved their symptoms and erosive esophagitis. No modifications of LESP were observed in patients who submitted to LRRYGBP before or after the operation. Acid reflux diminished after the three types of surgery were employed. Patients who submitted to LRRYGBP presented a significant reduction of BMI from 41.5 ± 4.3 to 25.7 ± 1.3 kg/m(2) after 12 months. CONCLUSIONS Among patients with LSBE, FVDGRYGJ presents very good results in terms of improving GERD and Barrett's esophagus, but the reduction of weight is limited. LRRYGBP improves GERD disease and Barrett's esophagus with proven reduction in body weight and BMI, thus becoming the procedure of choice for obese patients.


Into the unknown.


COVID-19 and Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: What Is the Evidence?


title: Knowledge, Perceptions and Practices of Community Pharmacists Towards Antimicrobial Stewardship: A Systematic Scoping Review.

text: The scope of antimicrobial stewardship (AMS) surveys on community pharmacists (CPs) is uncertain. This study examines the breadth and quality of AMS survey tools measuring the stewardship knowledge, perceptions and practices (KPP) of CPs and analyse survey outcomes. Following PRISMA-ScR checklist and Arksey and O'Malley's methodological framework seven medical databases were searched. Two reviewers independently screened the literatures, assessed quality of surveys and KPP outcomes were analysed and described. Ten surveys were identified that assessed CPs' AMS perceptions (n = 7) and practices (n = 8) but none that assessed AMS knowledge. Three survey tools had been formally validated. Most CPs perceived that AMS improved patient care (median 86.0%, IQR, 83.3-93.5%, n = 6), and reduced inappropriate antibiotic use (84.0%, IQR, 83-85%, n = 2). CPs collaborated with prescribers for infection control (54.7%, IQR 34.8-63.2%, n = 4) and for uncertain antibiotic treatment (77.0%, IQR 55.2-77.8%, n = 5). CPs educated patients (53.0%, IQR, 43.2-67.4%, n = 5) and screened guideline-compliance of antimicrobial prescriptions (47.5%, IQR, 25.2-58.3%, n = 3). Guidelines, training, interactions with prescribers, and reimbursement models were major barriers to CP-led AMS implementation. A limited number of validated survey tools are available to assess AMS perceptions and practices of CPs. AMS survey tools require further development to assess stewardship knowledge, stewardship targets, and implementation by CPs.


Using therapeutic plasma exchange as a rescue therapy in CoVID-19 patients: a case series.


title: Noninvasive local correction of loop ileostomy prolapse using a stapling device for a patient in the terminal phase of malignancy.

text: A 64-year-old woman who underwent surgery for ovarian cancer, but were unable to be resected and were directly infiltrated at the terminal ileum, and the ileostomy in the oral side of the terminal ileum was performed as a palliative operation. Prolapse of the ileostomy appeared approximately 17 months after the operation, and after 19 months, the blood circulation disorder of the intestinal tract and the reduction of prolapse became difficult. Since the patient's systemic condition was poor, anesthesia was not enforced, and an ileostomy reconstruction was performed using a stapling device while performing mild sedation. During the operation, the patient was unconscious, and the operation time was 29 minutes, and the general condition was not abnormal. In this paper, we report noninvasive local correction of loop ileostomy prolapse using a stapling device for a patient in the terminal phase of malignancy.


Home sleep testing in the era of COVID-19: a community perspective.


title: Co-infection of SARS CoV-2 and influenza A in a Pediatric Patient in Germany.

text: In December 2019 a novel coronavirus was firstly encountered in Wuhan/China with a massive outbreak of fatal pneumonia leading to a pandemic declared by the World Health Organization in March 2020 (WHO Dashboard COVID-19. [WHO web site]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019), affecting mainly elderly adults with underlying co-morbidities. Clinical course in children below the age of 10 years is considered to be mild or even with subclinical signs (Sinha IP, Ha et al. The Lancet Respiratory medicine 2020;27;S2213-2600(20) 30152-1). We describe a 4 month old infant with co-infection of SARS CoV-2 and influenza A virus.


title: Magnetically anchored camera and percutaneous instruments maintain triangulation and improve cosmesis compared with single-site and conventional laparoscopic cholecystectomy.

text: BACKGROUND This study evaluated operative outcomes and ergonomics for a magnetic camera (MAGS) used in conjunction with percutaneous instruments [percutaneous surgical set (PSS)] compared with single-site laparoscopic (SSL) and conventional laparoscopic (LAP) cholecystectomy techniques. METHODS Four surgical trainees each performed three porcine cholecystectomies using three randomized techniques including MAGS/PSS, SSL, and LAP. The operative outcomes, procedure-specific ratings (1-5 scale; 1 = superior), workload (1-10 scale; 1 = superior), and global impressions (1-10 scale; 10 = superior) were recorded. Comparisons used analysis of variance (ANOVA) on ranks (Kruskal-Wallis), and p values lower than 0.05 were considered significant. RESULTS The operative outcomes were similar except for significantly higher blood loss with SSL (16.3 ± 10.3) versus LAP (2.8 ± 1.5; p < 0.05) but not with MAGS/PSS (4.8 ± 3.8). Several inadvertent tissue-damaging events occurred with SSL but not with MAGS/PSS or LAP. The incision was significantly shorter with MAGS/PSS (29.3 ± 2.8 mm) and SSL (29.3 ± 2.5 mm) than with LAP (48.0 ± 3.6 mm; p < 0.05). Compared with SSL (3.6 ± 0.5), the procedure-specific ratings significantly favored MAGS/PSS (2.8 ± 0.4) and LAP (1.7 ± 0.2; p < 0.05). Ergonomics and technical challenges both were rated significantly inferior with SSL (4.3 ± 1.0 and 3.8 ± 0.5, respectively) versus LAP (1.5 ± 0.6 and 2.0 ± 0.8, respectively; p < 0.05) but not with MAGS/PSS (2.5 ± 1.0 and 3.0 ± 0.8, respectively). Both MAGS/PSS (4.5 ± 0.5) and SSL (4.8 ± 1.0) were associated with a significantly greater workload than LAP (2.5 ± 0.6; p < 0.05). Global impression ratings were significantly higher for LAP (8.7 ± 1.3) versus SSL (5.8 ± 2.0; p < 0.05) but not for MAGS/PSS (7.1 ± 1.8). Cosmesis was significantly better with MAGS/PSS (9.5 ± 0.6) versus LAP (6.5 ± 2.4; p < 0.05) but not with SSL (8.8 ± 1.3). CONCLUSION The MAGS/PSS technique allows better triangulation and fewer technical difficulties than SSL and better cosmesis than LAP. Further development of these devices is warranted.


title: Communicable disease policy development in response to changing European political frontiers in Finland, Norway and Sweden.

text: AIMS The European Union (EU) enlargement of 2004 brings both opportunities and challenges for public health. It is believed that further integration will bring direct health benefits, mainly through improved socioeconomic conditions, but there are also risks associated with the EU expansion, in particular cross-border health risks, such as the impact of the internal EU market policy of free movement and migration on communicable disease patterns. Against this background, this article examines communicable disease policy development in Finland, Norway and Sweden in response to changing European political frontiers, in particular the EU accession of the Baltic States. The emphasis is on HIV/AIDS and tuberculosis. METHODS The study is based on a qualitative and quantitative approach, using two complementary methods: documentary analysis and stakeholder analysis. RESULTS The article identifies a distinct pattern in communicable disease policy development between 1990 and 2005. The turn of the new millennium saw a sharp increase in national attention and the priority assigned to communicable diseases in Finland, Norway and Sweden. The article argues that this development is likely to be related to the rising national, regional and European awareness of the public health challenges associated with communicable diseases in today's borderless Europe. It also shows that the Baltic health situation is a particular concern for Finland. CONCLUSIONS Although there is increasing national and regional activity within the communicable disease area, there is a need for a more effective European approach to tackle the future communicable disease challenges that may follow in an increasingly interdependent and integrated Europe.


title: Comparison of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy on Weight Loss, Weight Regain, and Remission of Comorbidities: A 5 Years of Follow-up Study.

text: BACKGROUND This study was conducted to evaluate the amount of weight loss and weight regain and also remission rate of obesity-related comorbidities including diabetes mellitus (DM), hypertension (HTN), and dyslipidemia in patients who underwent LRYGB or LSG during 5 years of follow-up. METHODS A total of 120 patients who underwent LRYGB or LSG from 2011 to 2013 were enrolled and followed-up for 5 years. Changes in weight, body mass index (BMI), percent weight loss (%WL), and percentage of excess weight loss (%EWL) were recorded. RESULT %WL and %EWL were similar between two procedures at 1 year following operation. In patients who underwent LSG, %WL and %EWL were 24.6 ± 1.3% and 61.9 ± 3.5%, respectively, and in LRYGB were 30.4 ± 1.3% and 79.4 ± 3.6%, respectively, 5 years after surgery. Weight regain was 32.0% in LSG and 9.3% in LRYGB after 5 years. The remission rate of diabetes mellitus, hypertension, and dyslipidemia was 70%, 54%, and 100%, respectively, after 5 years of surgery. CONCLUSION Comparing the 5-year success rate of these two techniques, LRYGB seems to be superior to LSG, with lower weight regain and higher weight loss. The short- and long-term effects of two procedures on remission of comorbidities were comparable.


JAVMA News.


title: Effects of hyperbaric oxygen therapy on uncomplicated incisional and open wound healing in dogs.

text: OBJECTIVE To determine the safety of a hyperbaric oxygen therapy (HBOT) protocol and its influence on the healing of uncomplicated open and incisional wounds in dogs. STUDY DESIGN Prospective, controlled experimental study. ANIMALS Adult dogs (n = 10). METHODS Two 2 × 2-cm open wounds and two 3-cm-long full-thickness dermal incisions were created on the dorsum of each dog. Dogs in the hyperbaric oxygen treatment group (HBO) received HBOT once daily (1.7 atmospheres absolute [ATA], 30 minutes on day 1; 2.0 ATA, 40 minutes on days 2-7) for 7 consecutive days, and dogs in the control group (CON) received standardized wound care. Dogs were monitored during HBOT for adverse side effects. Total wound area, percentage epithelialization, and percentage contraction were compared for the open wounds. Subjective wound scores were compared for the open and incisional wounds. Biopsies of both wound types were taken and used to determine histopathology scores. Bacterial cultures were completed on open wounds. RESULTS No difference was detected between HBO and CON uncomplicated open and incisional wounds at any time for contraction, epithelialization, subjective wound scores, histopathology scores, or bacterial loads. All HBO dogs tolerated hyperbaric oxygen treatments with no adverse effects. CONCLUSION The HBOT protocol tested here was safe but did not enhance the healing of uncomplicated acute wounds and incisions of dogs. CLINICAL SIGNIFICANCE These results do not provide evidence to support the use of HBOT to manage uncomplicated wounds in dogs.


title: Media Exposure and Anxiety during COVID-19: The Mediation Effect of Media Vicarious Traumatization.

text: The rapid spread and high death rates of the COVID-19 pandemic resulted in massive panic and anxiety all over the world. People rely heavily on media for information-seeking during the period of social isolation. This study aimed to explore the relationship between media exposure and anxiety, and highlighted the underlying mechanisms mediated by the media vicarious traumatization effect. A total of 1118 Chinese citizens participated in the online survey, who were from 30 provinces in mainland China. Results showed that all four types of media (official media, commercial media, social media, and overseas media) cause vicarious traumatization to their audiences to different degrees. It was also found that the impact of media exposure on anxiety was mediated by media vicarious traumatization: there were full mediation effects for commercial media exposure and overseas media exposure, while there were indirect-only mediation effects for official media exposure and social media exposure. Audiences staying in cities with a relatively severe pandemic were more susceptible to the vicarious traumatization caused by commercial media compared to those staying in Hubei. This study expanded the concept and application of vicarious traumatization to the mediated context, and the findings provided insightful advice to media practitioners in the face of major crisis.


title: Clinical review: Does it matter which hemodynamic monitoring system is used?

text: Hemodynamic monitoring and management has greatly improved during the past decade. Technologies have evolved from very invasive to non-invasive, and the philosophy has shifted from a static approach to a functional approach. However, despite these major changes, the critical care community still has potential to improve its ability to adopt the most modern standards of research methodology in order to more effectively evaluate new monitoring systems and their impact on patient outcome. Today, despite the huge enthusiasm raised by new hemodynamic monitoring systems, there is still a big gap between clinical research studies evaluating these monitors and clinical practice. A few studies, especially in the perioperative period, have shown that hemodynamic monitoring systems coupled with treatment protocols can improve patient outcome. These trials are small and, overall, the corpus of science related to this topic does not yet fit the standard of clinical research methodology encountered in other specialties such as cardiology and oncology. Larger randomized trials or quality improvement processes will probably answer questions related to the real impact of these systems.


title: Diagnosis and Management of Infantile Hemangioma.

text: Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.


title: A novel mutation in murine hepatitis virus nsp5, the viral 3C-like proteinase, causes temperature-sensitive defects in viral growth and protein processing.

text: Sequencing and reversion analysis of murine hepatitis virus (MHV) temperature-sensitive (ts) viruses has identified putative ts mutations in the replicase nonstructural proteins (nsp's) of these coronaviruses. In this study, reverse transcriptase PCR sequencing of the RNA genome of an isolate of the MHV ts virus Alb ts6, referred to as Alb/ts/nsp5/V148A, identified a putative ts mutation in nsp5 (T10651C, Val148Ala), the viral 3C-like proteinase (3CLpro). The introduction of the T10651C mutation into the infectious MHV clone resulted in the recovery of a mutant virus, the nsp5/V148A virus, that demonstrated reduced growth and nsp5 proteinase activity identical to that of Alb/ts/nsp5/V148A at the nonpermissive temperature. Sequence analysis of 40 degrees C revertants of Alb/ts/nsp5/V148A identified primary reversion to Ala148Val in nsp5, as well as two independent second-site mutations resulting in Ser133Asn and His134Tyr substitutions in nsp5. The introduction of the Ser133Asn or His134Tyr substitution into the cloned nsp5/V148A mutant virus background resulted in the recovery of viruses with increased growth fitness and the partial restoration of nsp5 activity at the nonpermissive temperature. Modeling of the nsp5 structure of Alb/ts/nsp5/V148A predicted that the Val148Ala mutation alters residue 148 interactions with residues of the substrate binding S1 subsite of the nsp5 active-site cavity. This study identifies novel residues in nsp5 that may be important for regulating substrate specificity and nsp5 proteinase activity.


title: Surgical technique of laparoscopic hybrid approach for recurrent inguinal hernia: Report a case.

text: INTRODUCTION Currently, laparoscopic surgery (LS) is a widely accepted surgical treatment for inguinal hernias, and it has major advantages, especially for recurrent cases. PRESENTATION OF CASE We diagnosed the recurrent inguinal hernia after wound infection and performed the laparosocopic approach. We would like to introduce our method. We distinguished between the presence and absence of bilateral inguinal hernia with an intra-abdominal scope using the transabdominal preperitoneal inguinal hernia repair (TAPP) technique, which we call laparoscopic examination. Thus, we can distinguish between the types of inguinal hernias and whether they are bilateral or not. We dissected the Retzius space on the inside of an epigastric arteriovenous fistula as part of TEP part A, and dissection was performed without a balloon. We separated and dissected the Retzius space. We also performed lateral dissection of the preperitoneal space. We made an incision in the peritoneum at the inner groin ring (hernia sac). We isolated the cord structures (parietalization) using TAPP. We finally checked this operation from the abdominal space (TAPP filed) and determined whether the repair was satisfactorily completed or not. DISCUSSION Our hybrid method is not special but the conventional laparoscopic approach adapted each merits both TAPP and TEP. CONCLUSION Our method is effective for difficult recurrent inguinal hernias.


title: [Importance of imaging diagnostics in the care of COVID-19 infected patients].

text: The recent coronavirus epidemic poses a serious challenge to practicing intensive care physicians due to the high incidence of hypoxic respiratory failure. Because pneumonia plays a prominent role in the critical pathomechanism of COVID-19, imaging studies are at the forefront of both the diagnosis and follow-up of the disease and the detection of potential complications. Reviewing the literature data so far, we present the characteristic differences between chest CT, chest X-ray and chest wall ultrasound, and make recommendations for the use of different examination modalities. The initial, atypical appearance of the viral infection is the CT-detected right lower lobe, peripheral, multifocal milk glass haze, which soon degenerates into a bilateral lesion affecting the middle and lower lung fields. As the disease progresses, the proportion of consolidated areas increases, followed by a fibrotic pattern enhancement. Due to special infection control rules for SARS-CoV-2 virus, bedside ultrasound plays an important role in keeping infected patients in contact with as few healthcare professionals as possible. Orv Hetil. 2020; 161 (17): 672-677.