title: Tackle the problem when it gets here: pandemic preparedness among small and medium businesses.

text: Globally, governments and health authorities are preparing for pandemic influenza and producing resources to promote preparedness planning; however, there is little information available to inform the design of strategies to promote preparedness. Three focus groups were conducted to identify and to describe beliefs and perceptions about pandemic influenza and response planning among small and medium business owners and managers. Most participants were not concerned about the risk of pandemic influenza, and none had engaged in any planning for a pandemic. Findings show that participants were uncertain of the modes of transmission of pandemic influenza and what precautions could be taken prior to, or in the event of, a pandemic. Among the most important findings was participants' perceived inability to effectively prevent or control the spread of influenza within their workplace. These findings have important implications for the design of communication strategies to promote preparedness.


I Can't Breathe - Race, Violence and COVID-19.


title: Comparison of Abbott ID Now and Abbott m2000 methods for the detection of SARS-CoV-2 from nasopharyngeal and nasal swabs from symptomatic patients.

text: The ID NOW COVID-19 (IDNCOV) assay performed on the ID Now Instrument (Abbott Diagnostics, Scarborough, Inc. Scarborough, ME) is a rapid diagnostic test that can be performed in a point of care setting equivalent to CLIA waived testing.….


title: Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial.

text: PURPOSE This study was designed to evaluate potential preventive effects of meditation or exercise on incidence, duration, and severity of acute respiratory infection (ARI) illness. METHODS Community-recruited adults aged 50 years and older were randomized to 1 of 3 study groups: 8-week training in mindfulness meditation, matched 8-week training in moderate-intensity sustained exercise, or observational control. The primary outcome was area-under-the-curve global illness severity during a single cold and influenza season, using the Wisconsin Upper Respiratory Symptom Survey (WURSS-24) to assess severity. Health care visits and days of missed work were counted. Nasal wash collected during ARI illness was assayed for neutrophils, interleukin-8, and viral nucleic acid. RESULTS Of 154 adults randomized into the study, 149 completed the trial (82% female, 94% white, mean age 59.3 ± 6.6 years). There were 27 ARI episodes and 257 days of ARI illness in the meditation group (n = 51), 26 episodes and 241 illness days in the exercise group (n = 47), and 40 episodes and 453 days in the control group (n = 51). Mean global severity was 144 for meditation, 248 for exercise, and 358 for control. Compared with control, global severity was significantly lower for meditation (P = .004). Both global severity and total days of illness (duration) trended toward being lower for the exercise group (P=.16 and P=.032, respectively), as did illness duration for the meditation group (P=.034). Adjusting for covariates using zero-inflated multivariate regression models gave similar results. There were 67 ARI-related days of-work missed in the control group, 32 in the exercise group (P = .041), and 16 in the meditation group (P <.001). Health care visits did not differ significantly. Viruses were identified in 54% of samples from meditation, 42% from exercise, and 54% from control groups. Neutrophil count and interleukin-8 levels were similar among intervention groups. CONCLUSIONS Training in meditation or exercise may be effective in reducing ARI illness burden.


title: Cardiac recovery via extended cell-free delivery of extracellular vesicles secreted by cardiomyocytes derived from induced pluripotent stem cells.

text: The ability of extracellular vesicles (EVs) to regulate a broad range of cellular processes has recently been exploited for the treatment of diseases. For example, EVs secreted by stem cells injected into infarcted hearts can induce recovery through the delivery of stem-cell-specific miRNAs. However, the retention of the EVs and the therapeutic effects are short-lived. Here, we show that an engineered hydrogel patch capable of slowly releasing EVs secreted from cardiomyocytes derived from induced pluripotent stem (iPS) cells reduced arrhythmic burden, promoted ejection-fraction recovery, decreased cardiomyocyte apoptosis 24 hours after infarction, and reduced infarct size and cell hypertrophy 4 weeks post-infarction when implanted onto infarcted rat hearts. We also show that the EVs are enriched with cardiac-specific miRNAs known to modulate cardiomyocyte-specific processes. The extended delivery of EVs secreted from iPS-cell-derived cardiomyocytes into the heart may help understand heart recovery and treat heart injury.


title: COVID-19 and the renin, angiotensin, aldosterone system. A complex relationship.

text: The COVID-19 pandemic has had major negative health, psychological, social and economic repercussions for individuals, families, communities, countries and for humanity in general. The interrelation with age and the presence of chronic non-communicable diseases (hypertension, diabetes, obesity, smoking) seems to go further than what would be explained by the prevalence and distribution of both. The drugs that act on the renin-angiotensin-aldosterone system are in many cases the backbone for the management of these diseases, it has been known for a long time that these drugs significantly increase the expression of receptors for angiotensin conversion enzyme type 2 in the lung tissue. This fact, together with the knowledge that the route of entry of the virus into the cell is precisely the ACE-2 receptor, initiated a hypothesis, based on very low-quality evidence, which quickly became generalized in the media, that the use of these drugs could be negative and that they should be interrupted immediately. The response of practically all Scientific Societies was almost immediate, with the precise indication that treatment with these drugs should not be discontinued, since the evidence of their usefulness is based on very solid and high-quality evidence. Simultaneously, a different hypothesis also appeared, also based on very preliminary evidence, that these drugs are not only harmful but also beneficial, however these medicaments are not yet accepted as agents for the prevention or treatment of this disease or its complications. This review reports current knowledge on the relationship between COVID-19 and SRAA.


Middle East Respiratory Syndrome in Korea.


title: TICI and Age: What's the Score?

text: BACKGROUND AND PURPOSE Previous studies have suggested that advanced age predicts worse outcome following mechanical thrombectomy. We assessed outcomes from 2 recent large prospective studies to determine the association among TICI, age, and outcome. MATERIALS AND METHODS Data from the Solitaire FR Thrombectomy for Acute Revascularization (STAR) trial, an international multicenter prospective single-arm thrombectomy study and the Solitaire arm of the Solitaire FR With the Intention For Thrombectomy (SWIFT) trial were pooled. TICI was determined by core laboratory review. Good outcome was defined as an mRS score of 0-2 at 90 days. We analyzed the association among clinical outcome, successful-versus-unsuccessful reperfusion (TICI 2b-3 versus TICI 0-2a), and age (dichotomized across the median). RESULTS Two hundred sixty-nine of 291 patients treated with Solitaire in the STAR and SWIFT data bases for whom TICI and 90-day outcome data were available were included. The median age was 70 years (interquartile range, 60-76 years) with an age range of 25-88 years. The mean age of patients 70 years of age or younger was 59 years, and it was 77 years for patients older than 70 years. There was no significant difference between baseline NIHSS scores or procedure time metrics. Hemorrhage and device-related complications were more common in the younger age group but did not reach statistical significance. In absolute terms, the rate of good outcome was higher in the younger population (64% versus 44%, P < .001). However, the magnitude of benefit from successful reperfusion was higher in the 70 years of age and older group (OR, 4.82; 95% CI, 1.32-17.63 versus OR 7.32; 95% CI, 1.73-30.99). CONCLUSIONS Successful reperfusion is the strongest predictor of good outcome following mechanical thrombectomy, and the magnitude of benefit is highest in the patient population older than 70 years of age.


title: Large eddy simulation for predicting turbulent heat transfer in gas turbines.

text: Blade cooling technology will play a critical role in the next generation of propulsion and power generation gas turbines. Accurate prediction of blade metal temperature can avoid the use of excessive compressed bypass air and allow higher turbine inlet temperature, increasing fuel efficiency and decreasing emissions. Large eddy simulation (LES) has been established to predict heat transfer coefficients with good accuracy under various non-canonical flows, but is still limited to relatively simple geometries and low Reynolds numbers. It is envisioned that the projected increase in computational power combined with a drop in price-to-performance ratio will make system-level simulations using LES in complex blade geometries at engine conditions accessible to the design process in the coming one to two decades. In making this possible, two key challenges are addressed in this paper: working with complex intricate blade geometries and simulating high-Reynolds-number (Re) flows. It is proposed to use the immersed boundary method (IBM) combined with LES wall functions. A ribbed duct at Re=20 000 is simulated using the IBM, and a two-pass ribbed duct is simulated at Re=100 000 with and without rotation (rotation number Ro=0.2) using LES with wall functions. The results validate that the IBM is a viable alternative to body-conforming grids and that LES with wall functions reproduces experimental results at a much lower computational cost.


title: Extra-pulmonary complications of COVID-19: a multi-system disease?

text: The outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been recently declared a pandemic by the World Health Organization. In addition to its acute respiratory manifestations, SARS-CoV-2 may also adversely affect other organ systems. To date, however, there is very limited understanding of the extent and management of COVID-19-related conditions outside of the pulmonary system. This narrative review provides an overview of the current literature about the extra-pulmonary manifestations of COVID-19 that may affect the urinary, cardiovascular, gastrointestinal, hematological, hematopoietic, neurological, or reproductive systems. This review also describes current understanding of the extra-pulmonary complications caused by COVID-19 in order to improve the management and prognosis of patients with COVID-19. This article is protected by copyright. All rights reserved.


Providing Safe and Effective Surgical Care During the COVID-19 Outbreak in the UK - Changing Strategies.


title: Acute alcohol intoxication in adolescents: frequency of respiratory depression.

text: BACKGROUND Adolescents and young adults are frequent users of alcohol. Younger patients may be more sensitive to the effects of alcohol than their adult counterparts, and toxicity has been known to occur at lower doses. Respiratory depression is a serious adverse effect of alcohol intoxication; however, current monitoring practices may not adequately detect respiratory depression. OBJECTIVE Our objective was to determine the frequency of hypoventilation as measured by capnography among adolescents with acute alcohol intoxication. Our secondary objective was to determine if an association exists between alcohol levels and incidence of hypoventilation. METHODS This was a prospective observational pilot study of patients 14-20 years of age with acute alcohol intoxication. Blood or breath alcohol measurements were obtained on arrival. Hourly measurements of vital signs including capnography were recorded. RESULTS Sixty-five subjects were analyzed. Mean alcohol level was 185 mg/dL. Twenty-eight percent of subjects had episodes of hypoventilation. Episodes occurred in similar proportions on arrival and during the first 5 h of measurements. There was no difference in alcohol levels between subjects who did and did not hypoventilate (185 mg/dL vs. 186 mg/dL; 95% confidence interval -29 to 25). Oxygen desaturations occurred in 14 subjects and were associated with hypoventilation (p = 0.015). CONCLUSIONS Hypoventilation is common among adolescents who are acutely intoxicated with alcohol. It is independent of alcohol level and occurs at a steady rate during the first several hours of intoxication. Capnography should be considered as an additional monitoring device to detect these episodes and enhance patient safety.


title: Feasibility and Safety of Repeat Instant Endovascular Interventions in Patients with Refractory Cerebral Vasospasms.

text: BACKGROUND AND PURPOSE For patients with cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular therapies often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the feasibility and safety of multiple repeat instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions. MATERIALS AND METHODS This was a single-center retrospective study of prospectively collected data on patients with cerebral vasospasm refractory to therapies requiring ≥3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary end point was functional outcome at last follow-up (mRS ≤2). The secondary end point was angiographic response to endovascular therapies and the appearance of cerebral infarctions. RESULTS During a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, ≤2 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with ≥3 interventions compared with 31 (61%) of those with ≤2 interventions (P = .82). The initial Hunt and Hess score of ≤2 was a significant independent predictor of good outcome (OR, 4.7; 95% CI, 1.2-18.5; P = .03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3-6; OR, 13.5; 95% CI, 2.3-81.2; P = .004). CONCLUSIONS Repeat instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated.


Stop the Wuhan virus.


title: Community-acquired pneumonia requiring hospitalization among U.S. children.

text: BACKGROUND Incidence estimates of hospitalizations for community-acquired pneumonia among children in the United States that are based on prospective data collection are limited. Updated estimates of pneumonia that has been 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 children younger than 18 years of age in three hospitals in Memphis, Nashville, and Salt Lake City. We excluded children with recent hospitalization or severe immunosuppression. Blood and respiratory specimens were systematically collected for pathogen detection with the use of multiple methods. Chest radiographs were reviewed independently by study radiologists. RESULTS From January 2010 through June 2012, we enrolled 2638 of 3803 eligible children (69%), 2358 of whom (89%) had radiographic evidence of pneumonia. The median age of the children was 2 years (interquartile range, 1 to 6); 497 of 2358 children (21%) required intensive care, and 3 (<1%) died. Among 2222 children with radiographic evidence of pneumonia and with specimens available for bacterial and viral testing, a viral or bacterial pathogen was detected in 1802 (81%), one or more viruses in 1472 (66%), bacteria in 175 (8%), and both bacterial and viral pathogens in 155 (7%). The annual incidence of pneumonia was 15.7 cases per 10,000 children (95% confidence interval [CI], 14.9 to 16.5), with the highest rate among children younger than 2 years of age (62.2 cases per 10,000 children; 95% CI, 57.6 to 67.1). Respiratory syncytial virus was more common among children younger than 5 years of age than among older children (37% vs. 8%), as were adenovirus (15% vs. 3%) and human metapneumovirus (15% vs. 8%). Mycoplasma pneumoniae was more common among children 5 years of age or older than among younger children (19% vs. 3%). CONCLUSIONS The burden of hospitalization for children with community-acquired pneumonia was highest among the very young, with respiratory viruses the most commonly detected causes of pneumonia. (Funded by the Influenza Division of the National Center for Immunization and Respiratory Diseases.).


title: Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol.

text: BACKGROUND Enhanced recovery after surgery (ERAS) is a multimodal approach to perioperative care that combines a range of interventions to enable early mobilization and feeding after surgery. We investigated the feasibility, clinical effectiveness, and cost savings of an ERAS program at a major U. S. teaching hospital. METHODS Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, before and after implementation of an ERAS protocol. Data collected included patient demographics, operative, and perioperative surgical and anesthesia data, need for analgesics, complications, inpatient medical costs, and 30-day readmission rates. RESULTS There were 99 patients in the traditional care group, and 142 in the ERAS group. The median length of stay (LOS) was 5 days in the ERAS group compared with 7 days in the traditional group (P < 0.001). The reduction in LOS was significant for both open procedures (median 6 vs 7 days, P = 0.01), and laparoscopic procedures (4 vs 6 days, P < 0.0001). ERAS patients had fewer urinary tract infections (13% vs 24%, P = 0.03). Readmission rates were lower in ERAS patients (9.8% vs 20.2%, P = 0.02). DISCUSSION Implementation of an enhanced recovery protocol for colorectal surgery at a tertiary medical center was associated with a significantly reduced LOS and incidence of urinary tract infection. This is consistent with that of other studies in the literature and suggests that enhanced recovery programs could be implemented successfully and should be considered in U.S. hospitals.


title: The pain quality response profile of pregabalin in the treatment of neuropathic pain.

text: OBJECTIVE To identify and describe the response profile of pregabalin on the qualities of pain associated with peripheral neuropathy. METHODS A post hoc analysis to examine the effects of pregabalin on pain quality in patients with moderate-to-severe peripheral neuropathic pain was performed using data from an enriched enrollment randomized withdrawal proof-of-concept study. Patients rated the quality of their pain experience using the Pain Quality Assessment Scale (PQAS) at baseline, after a 12-day titration period, after a 9-day maintenance period, and after a 19-day randomized withdrawal period. Pretitration to posttitration and prewithdrawal to postwithdrawal changes in PQAS paroxysmal, surface, and deep pain scale scores were examined. RESULTS PQAS data were available for 99 of the 104 participants who entered all phases of the study. There were significant (P<0.006, Bonferroni adjusted for multiple tests) improvements pretitration to posttitration in all 3 PQAS subscales, with a greater effect on paroxysmal and deep pain than on surface pain. During the withdrawal phase, pregabalin was significantly (P<0.006) more effective than placebo for improvements in paroxysmal and surface pain only, although the pregabalin group continued to show numerical improvement in deep pain relative to placebo. DISCUSSION Pregabalin had a greater effect on PQAS-assessed paroxysmal pain than on surface or deep pain in patients with peripheral neuropathy. The findings corroborate previous research demonstrating differential effects of analgesic drugs across pain qualities, further emphasizing the need to assess individual pain qualities in addition to overall pain intensity.


title: [Analysis of the first cluster of cases in a family of COVID-19 in Gansu Province].

text: The epidemiological history and clinical characteristics of 7 cases of COVID-19 and 1 case of close contact in the first family aggregation epidemic of COVID-19 in Gansu Province were analyzed. The first patient A developed on January 22, 2020, with a history of residence in Wuhan, and confirmed severe cases of NCP on January 24, 2020; patient B, on January 23, 2020, diagnosed on January 31, severe cases; patient C, asymptomatic, diagnosed on January 27; patient D, asymptomatic, diagnosed on January 27; patient E, on January 24, diagnosed on January 28; patient F, asymptomatic, diagnosed on January 31; Patient G was asymptomatic and was diagnosed on January 31. In close contact, H was asymptomatic, PCR test was negative and asymptomatic, and he was discharged early. Among the 7 patients, 1 case died of (B) aggravation, and the other patients' condition was effectively controlled after active treatment. Except for the discharged cases, 5 cases were positive for COVID-19 specific IgM antibody and 1 case was negative. In this clustering outbreak, 4 patients remained asymptomatic, but PCR and IgM antibodies were positive, indicating that asymptomatic patients may be the key point to control the epidemic. Specific IgM antibody screening for patients whose pharyngeal swab nucleic acid test is negative but with ground glass-like lung lesions is very important for early detection and early isolation.


title: Efficient Methods To Isolate Human Monoclonal Antibodies from Memory B Cells and Plasma Cells.

text: In this article, we highlight the advantages of isolating human monoclonal antibodies from the human memory B cells and plasma cell repertoires by using high-throughput cellular screens. Memory B cells are immortalized with high efficiency using Epstein-Barr virus (EBV) in the presence of a toll-like receptor (TLR) agonist, while plasma cells are maintained in single-cell cultures by using interleukin 6 (IL-6) or stromal cells. In both cases, multiple parallel assays, including functional assays, can be used to identify rare cells that produce antibodies with unique properties. Using these methods, we have isolated potent and broadly neutralizing antibodies against a variety of viruses, in particular, a pan-influenza-A-neutralizing antibody and an antibody that neutralizes four different paramyxoviruses. Given the high throughput and the possibility of directly screening for function (rather than just binding), these methods are instrumental to implement a target-agnostic approach to identify the most effective antibodies and, consequently, the most promising targets for vaccine design. This approach is exemplified by the identification of unusually potent cytomegalovirus-neutralizing antibodies that led to the identification of the target, a pentameric complex that we are developing as a candidate vaccine.


title: Fucoidans inhibit the formation of post-operative abdominal adhesions in a rat model.

text: PURPOSE Fibrin clot is essential for post-operative abdominal adhesion formation. Fucoidans, sulfated polysaccharides, inhibit fibrin clot formation. In addition, they inhibit inflammation and fibrosis, which also play important roles in adhesion formation. The purpose of this study was to evaluate fucoidans' potential for inhibiting post-operative abdominal adhesions and measure their effects on systemic coagulation parameters when administered intraperitoneally (IP). METHODS AND MATERIALS Female Sprague Dawley rats were studied. A 2.5x2.5cm full thickness segment of abdominal wall was excised. The skin edges were approximated. This model induces extensive adhesions and allows objective quantitation. Three fucoidans were evaluated- Sigma Fucoidan Crude (SFC), Fucus vesiculosis 95% (Sigma) and, Peridan. One protocol involved continuous infusion into the abdomen from a subcutaneous osmotic pump. Alternatively, boluses of the solutions were injected IP at the end of the operation. Rats were sacrificed a week later. Adhesion extent was scored. Systemic coagulation effects of fucoidans were also evaluated. INR and aPTT were measured following IP injection of the fucoidan solutions and after 7 days of continuous infusion. RESULTS Animals given a continuous infusion of either SFC or Peridan yielded adhesion reduction of 80 to 90% from control. Bolus Peridan had no discernable influence on adhesion formation, but a single bolus of SFC caused significant adhesion reductions. Peridan resulted in prompt aPTT elevations which fell to nearly normal by 5 hours. The maximum peak value after SFC injection was seen in 15 hours. The maximal INR elevations were around 2. Measurement of INR and aPTT after a week of continuous infusion of either Peridan or SFC, were always in the normal control range. The third agent, Sigma, frequently yielded intraperitoneal infection found at autopsy. CONCLUSIONS These findings indicate that selected fucoidans infused intraperitoneally for a week after abdominal operations reduce adhesion extent by up to 90%.


title: Polyclonal and monoclonal antibodies for the treatment of influenza.

text: PURPOSE OF REVIEW This review summarizes past and ongoing efforts for using polyclonal and monoclonal antibodies for the treatment of influenza, and is focused on products that have entered clinical trials. RECENT FINDINGS At least three polyclonal and eight monoclonal antibody products have been tested in clinical trials for the treatment of influenza. Considered across the two classes of therapeutics, these products appear to be safe and well tolerated. However, the efficacy results have been mixed and inconclusive. To date, no products have consistently shown superiority to currently available antivirals. SUMMARY No products within these two classes have been licensed, and several products appear to have stopped further clinical development. There are several ongoing studies that are anticipated to be completed or reported in the next 1-2 years which will be critical for understanding the value of polyclonal and monoclonal antibodies in the treatment of influenza.


Getting to the heart of the matter of COVID-19.


COVID-19 Research in Brief: 30 May to 5 June, 2020.


title: Constrained pupil balance compensation for specific lithographic illuminator settings.

text: Pupil energy balances have always been considered significant elements for emersion lithography generally due to the large angle of incidence and offset imaging field. Those imbalances impact on exposure uniformity and decay pattern resolution. To overcome such shortcomings, a study on pupil compensation is discussed in this manuscript. A computational method based on a constrained optimization solution is proposed. By using a self-designed optical model of a zoomed system incorporating axicon lenses, a series of computations are developed and discussed. Also, the validity of our compensation method has been fully verified by simulations under multiple illumination settings.


New analyses of standard physiological signals: the old pipes give the sweetest smoke.


title: Acute Pain in the African Prehospital Setting: A Scoping Review.

text: Background Acute pain is a common reason for seeking prehospital emergency care. Regrettably, acute pain is often underestimated and poorly managed in this setting. The scoping review was conducted to gain insight into existing research on the topic and to make recommendations for future work. Objectives To identify all available evidence related to acute pain assessment and management in the African prehospital setting, describe the extent of the evidence, encapsulate findings, and identify research gaps. Methods The scoping review considered primary and secondary research related to acute pain assessment and management of both medical and traumatic origins in all age groups in the African prehospital setting. The search strategy aimed to identify published, unpublished, and ongoing research which met the inclusion criteria. Potentially eligible studies were identified by a comprehensive search of electronic databases, trial registers, dissertation/thesis databases, grey literature databases, and conference proceedings. Screening and data extraction were conducted independently and in duplicate. Results The comprehensive search identified 3823 potential studies, duplicate titles were removed, and 3358 titles/abstracts were screened. Full text of 66 potentially eligible titles was screened, 60 were excluded, and six publications met the inclusion criteria. Despite recommendations for pain assessment during general patient care, most studies reported no/limited pain assessment. In general, pain management was concluded to be insufficient and not conforming to best practice. Conclusions Only six publications addressing prehospital acute pain care in Africa could be identified, possibly indicative of a knowledge gap. Future research is indicated to enable a better understanding of the epidemiology of acute pain and barriers and enablers of acute pain care and to develop evidence-based clinical practice guidelines (CPGs) catering for all EMS systems in Africa. Additionally, educational initiatives should be implemented to improve the quality of acute pain care and to monitor quality through continuous quality improvement (CQI) programs.


title: A practical system for recording instrument interactions during live robotic surgery.

text: We have developed a system for measuring and recording the high-frequency vibrations that characterize instrument interactions during minimally invasive robotic surgery. Consisting of simple circuitry and a DVD recorder, this system is low-cost and easily implementable, requires no sterilization, and enables measurement of a validated, objective technical skill metric in both the simulated setting and the operating room. The vibration recordings of fourteen sleeve gastrectomies were processed by segmenting the operation into seven phases and calculating the root mean square (RMS) vibration within each phase. Statistical analysis showed that the observed differences match expectations drawn from knowledge of the operation, substantiating the premise that RMS vibration provides a good measure of the intensity of instrument interactions during live robotic surgery.


Could the NHS ever be truly independent?


title: THE MENTAL HEALTH OF THOSE WHOSE RIGHTS HAVE BEEN TAKEN AWAY: AN ESSAY ON THE MENTAL HEALTH OF INDIGENOUS PEOPLES IN THE FACE OF THE 2019 CORONAVIRUS (2019-NCOV) OUTBREAK

text: BACKGROUND: : In Latin America there are about 45 million indigenous people in 826 communities that represent 8.3% of the population. An estimated 798,365 Aboriginal and Torres Strait Islander were in Australia, 5,2 million indigenous people living in America and 2,13 million in Canada. Racial/ethnic disparities in mental health service use have increased especially in the context of the new coronavirus pandemic. Thus, we aimed to describe the mental health situation of the indigenous population in the context of the COVID-19 pandemic METHOD: : The studies were identified in well-known international journals found in three electronic databases: PubMed, Scopus, and MEDLINE. The data were cross-checked with information from the main international newspapers. RESULTS: : According to the literature, due to the COVID-19 pandemic there is a lack of specialized mental health services and professionals, a restricted access to quality information and a lack of access to inputs, causing negative feelings and it can exacerbate pre-existing mental problems (eg: depression, suicidal ideation, smoking and binge drink). The cultural differences are a risk factor to worsen the mental health of this already vulnerable population. CONCLUSION: : providing psychological first aid is an essential care component for indigenous populations that have been victims COVID-19 pandemic.


title: Outcomes of cancer surgery after inhalational and intravenous anesthesia: A systematic review.

text: Perioperative factors are probably essential for different oncological outcomes. This systematic review investigates the literature concerning overall mortality and postoperative complications after cancer surgery with inhalational (INHA) and intravenous anesthesia (TIVA). A search was conducted according to the PRISMA guidelines, including studies with patients undergoing surgery for cancer and where TIVA was compared with INHA. Two investigators identified relevant papers in the databases: PubMed, Scopus, EMBASE and the Cochrane Library. Risks of bias assessment tools from the Cochrane Collaboration were used for evaluating quality of evidence. Eight studies with a total of 10,696 patients were included. Four studies reported data regarding overall mortality and four studies reported data regarding postoperative complications. Evidence was evaluated to be of moderate to serious risk of bias. Three retrospective studies presented a hazard ratio (HR) adjusting for several confounders. One study reported an increased overall mortality after INHA with a HR of 1.47 (95% CI 1.31-1.64, p≤0.001), while another study reported a tendency of decreased overall mortality after TIVA (HR 0.85, 95% CI 0.72-1.00, p=0.051). A third study showed no difference in the overall mortality, but prolonged recurrence-free survival after TIVA with a HR of 0.48 (95% CI 0.27-0.86, p=0.014). In one study, the rate of pulmonary complications was significantly higher after INHA compared with TIVA, while other postoperative complications were comparable. There are currently four propensity-adjusted retrospective studies indicating that TIVA might be the preferred anesthetic choice in cancer surgery. However, evidence is currently of low quality and randomized clinical trials are required for further investigation.


Coronavirus pushes education online.


title: The transmembrane domain of the severe acute respiratory syndrome coronavirus ORF7b protein is necessary and sufficient for its retention in the Golgi complex.

text: The severe acute respiratory syndrome coronavirus (SARS-CoV) ORF7b (also called 7b) protein is an integral membrane protein that is translated from a bicistronic open reading frame encoded within subgenomic RNA 7. When expressed independently or during virus infection, ORF7b accumulates in the Golgi compartment, colocalizing with both cis- and trans-Golgi markers. To identify the domains of this protein that are responsible for Golgi localization, we have generated a set of mutant proteins and analyzed their subcellular localizations by indirect immunofluorescence confocal microscopy. The N- and C-terminal sequences are dispensable, but the ORF7b transmembrane domain (TMD) is essential for Golgi compartment localization. When the TMD of human CD4 was replaced with the ORF7b TMD, the resulting chimeric protein localized to the Golgi complex. Scanning alanine mutagenesis identified two regions in the carboxy-terminal portion of the TMD that eliminated the Golgi complex localization of the chimeric CD4 proteins or ORF7b protein. Collectively, these data demonstrate that the Golgi complex retention signal of the ORF7b protein resides solely within the TMD.


COVID-19, Substance Use, Anorexia Nervosa, 22q11.2 Deletion Syndrome, and Stress.


title: Bioinformatics in Africa: The Rise of Ghana?

text: Until recently, bioinformatics, an important discipline in the biological sciences, was largely limited to countries with advanced scientific resources. Nonetheless, several developing countries have lately been making progress in bioinformatics training and applications. In Africa, leading countries in the discipline include South Africa, Nigeria, and Kenya. However, one country that is less known when it comes to bioinformatics is Ghana. Here, I provide a first description of the development of bioinformatics activities in Ghana and how these activities contribute to the overall development of the discipline in Africa. Over the past decade, scientists in Ghana have been involved in publications incorporating bioinformatics analyses, aimed at addressing research questions in biomedical science and agriculture. Scarce research funding and inadequate training opportunities are some of the challenges that need to be addressed for Ghanaian scientists to continue developing their expertise in bioinformatics.


title: State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018.

text: Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were 'never the same' prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects.


title: Aggressive Intrasegmental Recurrence of Hepatocellular Carcinoma after Radiofrequency Ablation: Risk Factors and Clinical Significance.

text: PURPOSE To evaluate the frequency, risk factors, and clinical significance of aggressive intrasegmental recurrence (AIR) found after radiofrequency (RF) ablation for hepatocellular carcinoma (HCC). MATERIALS AND METHODS Institutional review board approval was obtained for this retrospective study. Between March 2005 and December 2010, 539 patients (414 men, 125 women; mean age, 57.91 years; age range, 30-82 years) underwent ultrasonography-guided percutaneous RF ablation as a first-line treatment for a single HCC classified as Barcelona Clinic Liver Cancer (BCLC) stage 0 or A. AIR of HCC was defined as (a) initial tumor recurrence with disease-free status at least 6 months after initial RF ablation and (b) the simultaneous development of multiple nodular (at least three) or infiltrative tumor recurrence in the treated segment. Patients were stratified into two groups: those with AIR (n = 20) and those without AIR (n = 519) during follow-up. Risk factors for AIR were assessed with logistic regression analysis, and risk factors for long-term overall survival were assessed with time-dependent Cox proportional hazard models. RESULTS In a median follow-up period of 49 months (range, 6-95 months), AIR was observed in 3.7% of the patients (20 of 539 patients), with the frequency increasing to 15% in the subgroup with periportal HCC (11 of 72 patients). AIRs manifested as either multiple nodular type (n = 14, BCLC stage A or B) or diffusely infiltrative type with tumor thrombus formation (n = 6, BCLC stage C). At multivariate analysis, periportal tumor location and younger patient age were significant risk factors for AIR. The presence of AIR during the follow-up period has a significant effect on the overall survival rate (hazard ratio = 5.72, P = .002). CONCLUSION The overall frequency of AIR after RF ablation for HCC was low, with periportal location and patient age showing a significant relationship to the development of AIR. The occurrence of AIR had an adverse effect on overall survival rate.


title: Laparoendoscopic single-site partial nephrectomy without hilar clamping using a microwave tissue coagulator.

text: PURPOSE To report our initial experience and evaluate the possibility of nonhilar clamp laparoendoscopic single-site (LESS) partial nephrectomy by using a microwave tissue coagulator. PATIENTS AND METHODS From December 2010 to May 2012, all patients with an exophytic, solitary, enhancing small (≤4.0 cm) renal mass were chosen to receive the study treatment. A multichannel port provided both a retroperitoneal and transperitoneal approach. A rigid, articulating apparatus was used to perform dissection, exposure of tumor, tissue coagulation, and resection without hilar clamping. Pathologic and hematologic data, subjective evaluation of pain, and scar appearance were analyzed. RESULTS Nonhilar clamp LESS partial nephrectomy by using a microwave tissue coagulator was performed in seven patients (mean operative time, 208 min; mean blood loss, 39 mL; mean renal mass size, 1.7 cm); one procedure with uncontrolled bleeding needed to be converted to conventional laparoscopic partial nephrectomy. No transfusion was necessary. Pathologic investigation demonstrated six renal-cell carcinomas and one oncocytoma. The hemoglobin level decreased by a mean of 1.1 g/dL. Patients did not complain about pain, and they had great satisfaction with the results. The mean duration of hospital stay was 13.8 days. CONCLUSIONS LESS partial nephrectomy without hilar clamping by using a microwave tissue coagulator is possible for renal masses, confers postoperative outcomes comparable to the standard counterpart, and assures patient satisfaction. By use of a microwave tissue coagulator, additional trocars were not necessary, and LESS partial nephrectomy could be accomplished through a single port, which reduced invasion and increased the cosmetic satisfaction of the patients.


Proximal humeral fracture surgery in the COVID-19 pandemic: advocacy for regional anesthesia.


title: Guidance for the prevention and treatment of the post-thrombotic syndrome.

text: The post-thrombotic syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations include symptoms and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening and in severe cases, leg ulcers. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20-30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of post-thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children.


The breakthrough balloon for critical limb ischemia?


title: Evaluation of a novel liquid embolic agent (precipitating hydrophobic injectable liquid (PHIL)) in an animal endovascular embolization model.

text: BACKGROUND The choice of the embolic agent and the embolization technique can have a significant impact on the success of endovascular embolization. OBJECTIVE To evaluate a novel iodinated copolymer-based liquid embolic agent (precipitating hydrophobic injectable liquid (PHIL)) in the porcine rete mirabile (RM), serving as an endovascular embolization model. Onyx, as an established liquid embolic agent, served as comparator. MATERIALS AND METHODS Sixteen embolization procedures were performed using PHIL (n=8) or Onyx (n=8) as liquid embolic agent. Waiting time between injections was set to 30 or 60 s (n=4 per study group). Survival time after intervention was 2 hours or 7 days. Embolization characteristics (eg, procedure times, number of injections and volume of embolic agent) and embolization extent (percentage of embolized RM in post-interventional x-ray) were assessed. Post-interventional CT and histopathological analyses were performed. RESULTS Embolization characteristics and embolization extent were not significantly different for PHIL and Onyx, including subgroups (eg, embolization extent 44% vs 69% (medians); p=0.101). For PHIL, extension of the waiting time from 30 to 60 s led to a significantly higher embolization extent (24% vs 72% (medians); p=0.035). Moderate disintegration and mild inflammation of the embolized blood vessels were present for both embolic agents. CONCLUSION PHIL is feasible for transarterial embolization in an acute and subacute endovascular embolization model. In this preliminary experimental in vivo study, embolization characteristics, embolization extent, and biocompatibility seem to be similar to those of Onyx.


David Oliver: Preventing more deaths in care homes in a second pandemic surge.


title: Minimally invasive renal auto-transplantation: the first report.

text: BACKGROUND Regarding transplant surgery, the minimally invasive revolution was started in 1995 by laparoscopic living donor nephrectomy (L-LDN). In 2006, we made the first report on a minimally invasive technique for kidney transplantation; restricted to a 7-9 cm transverse incision targeted on the anastomotic area of the iliac vessels, and with the meticulously prepared kidney placed in a fitting, retroperitoneal pouch lateral to the skin incision. MATERIALS AND METHODS By combining "hand-assisted laparoscopic nephrectomy" and "minimally invasive kidney transplantation" - using the same incision (7-8 cm) for hand-assistance, kidney harvesting, and transplantation - we have during 2009 conducted "minimally invasive renal auto-transplantation" in two patients. RESULTS In both cases, the postoperative course was uneventful. When examined 3 mo postoperatively, both auto-transplants were shown to have excellent function by renal scintigraphy. CONCLUSIONS Renal auto-transplantation, a traditionally major surgical procedure, can be made minimally invasive by a similar incision as that used for L-LDN. Taking into regard the highly traumatic conventional incisions, we expect the generally proven minimally invasive benefits to be considerable.


title: Inadvertent Detachment of a Retrievable Intracranial Stent: Review of Manufacturer and User Facility Device Experience.

text: Few systematic surveys have dealt with the potential procedural risks associated with the use of retrievable intracranial stents [Solitaire Flow Restoration (Solitaire FR)], which have become effective tools for recanalizing acutely occluded cerebral arteries. The aim of this study was to present the real-world experiences of Solitaire-FR-related adverse events by reviewing the MAUDE (Manufacturer and User Facility Device Experience) as published on the United States Food and Drug Administration website. In total, 85 adverse events related to the use of the Solitaire FR stent were reported between March 2012 and October 2014. In 80 patients these adverse events were attributable to inadvertent detachment of the device. Thirteen of these 80 patients (16%) died after the procedure. Morbidity data were available in 62 patients, among whom 11 (18%) had suffered a procedure-related injury. Detachment occurred at the first, second, and third pass in nine (21%), 21 (49%), and 13 (30%) of the 43 patients for whom this information was available, respectively. Resistance was perceived by the physician during retrieval of the device in 12 patients, and lesion characteristics were noted in 13. A rescue maneuver was reported in 20 (25%) of the 80 patients in whom the adverse event was attributable to detachment of the device, resulting in flow reestablishment in 13 (65%). The risk of inadvertent detachment during stent retrieval cannot be overemphasized in real-world scenarios, and careful consideration of the "dos and don'ts" is essential for the achievement of a safe procedure.


title: Assessment of cross-species transmission of hepatitis C virus-related non-primate hepacivirus in a population of humans at high risk of exposure.

text: The recent discovery of hepatitis C virus (HCV)-related viruses in different animal species has raised new speculations regarding the origin of HCV and the possibility of a zoonotic source responsible for the endemic HCV transmission. As a consequence, these new findings prompt questions regarding the potential for cross-species transmissions of hepaciviruses. The closest relatives to HCV discovered to date are the non-primate hepaciviruses (NPHVs), which have been described to infect horses. To evaluate the risk of a potential zoonotic transmission, we analysed NPHV RNA and antibodies in humans with occupational exposure to horses in comparison with a low-risk group. Both groups were negative for NPHV RNA, even though low seroreactivities against various NPHV antigens could be detected irrespective of the group. In conclusion, we did not observe evidence of NPHV transmission between horses and humans.


title: A randomized clinical study on postoperative pain comparing between the supraglottic airway device and endotracheal tubing in transabdominal preperitoneal repair (TAPP).

text: BACKGROUND Transabdominal preperitoneal (TAPP) repair is the most widely used laparoscopic technique for the treatment of inguinal hernia in Japan. Many studies have shown that in comparison with open hernia repair, laparoscopic repair results in less pain and a shorter convalescence. However, postoperative pain remains a concern. One possible cause of postoperative pain in the early postoperative phase is strain or cough on removal of the endotracheal tube. Use of a supraglottic airway (SGA) device helps to avoid such complaints. We evaluated postoperative pain after TAPP repair using the SGA for general anesthesia. METHODS We evaluated the postoperative pain in 146 patients with inguinal hernia repaired by TAPP in our hospital between May 2013 and May 2016. A total of 144 adult patients of American Society of Anesthesiologists physical status I and II who underwent needlescopic TAPP surgery were randomly allocated to one of two groups of 72 patients: group A (SGA), in which the patient's airway was secured with an appropriately sized I-gel, and group B (endotracheal tube), in which the airway was secured under laryngoscopy. RESULTS There was no significant difference between the groups regarding patient background, postoperative hospital stay, and operation time, and TAPP was performed safely in all cases. In the analysis of postoperative pain, the mean Numerical Rating Scale score of peak pain in group A was significantly less than that of group B (2.10 ± 2.05 vs 2.90 ± 2.65; p = 0.043). In group A, the percentage of patients who had an NRS score of 0 was 51.4% 30 min after surgery, 62.5% after 6 h and 68.1% at POD1, and compared to group B, the NRS scores were significantly higher at POD1 (p = 0.003), and the level of postoperative pain in group A tended to decrease earlier than that in group B. CONCLUSIONS The results of this study are the first to show that an SGA device can reduce postoperative pain after laparoscopic surgery.


title: Liposomal delivery of nucleic acid-based anticancer therapeutics: BP-100-1.01.

text: INTRODUCTION Antisense oligonucleotides, siRNA, anti-microRNA are designed to selectively bind to target mRNAs, and silence disease-causing or -associated proteins. The clinical development of nucleic acid drugs has been limited by their poor bioavailability. AREAS COVERED This review article examines the strategies that have been utilized to improve the bioavailability of nucleic acids. The chemical modifications made to nucleic acids that have improved their resistance against nuclease degradation are briefly discussed. The design of cationic and neutral lipid nanoparticles that enable the systemic delivery of nucleic acids in vivo is reviewed, and the proof-of-concept evidence that intravenous administration of nucleic acids incorporated into lipid nanoparticles leads to decreased expression of target genes in humans. Preclinical results of the neutral BP-100-1.01 nanoparticle are highlighted. EXPERT OPINION To further improve the clinical potential of nucleic acid cancer drugs, we predict research on the next generation of lipid nanoparticles will focus on: i) enhancing nucleic acid delivery to poorly vascularized tumors, as well as tumors behind the blood-brain barrier; and ii) improving the accessibility of nucleic acids to the cytoplasm by enhancing endosomal escape of nucleic acids and/or reducing exocytosis of nucleic acids to the external milieu.


title: Severity of hypoxic ischemic encephalopathy and heart rate variability in neonates: a systematic review.

text: BACKGROUND Several studies have investigated heart rate variability (HRV) as a biomarker for acute brain injury in hypoxic ischemic encephalopathy (HIE). However, the current evidence is heterogeneous and needs further reviewing to direct future studies. We aimed to systematically review whether HIE severity is associated with HRV. METHODS This systematic review was conducted according to the preferred reporting items for systematic review and meta analyses (PRISMA). We included studies comparing neonates with severe or moderate HIE with neonates with mild or no HIE with respect to different HRV measures within 7 days of birth. Article selection and quality assessment was independently performed by two reviewers. Risk of bias and strength of evidence was evaluated by the Newcastle-Ottawa scale (NOS) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS We screened 1187 studies. From these, four observational studies with 248 neonates were included. For all HRV measures, the strength of evidence was very low. Neonates with severe or moderate HIE showed a reduction in most HRV measures compared to neonates with mild or no HIE with a greater reduction in those with severe HIE. CONCLUSIONS Moderate and severe HIE was associated with a reduction in most HRV measures. Accordingly, HRV is a potential biomarker for HIE severity during the first week of life. However, the uncertainty calls for more studies.


title: Therapeutic Pneumoperitoneum: Relevant or Obsolete in 2015?

text: Background Therapeutic pneumoperitoneum (TP) is one alternative to manage pleural space problems. We describe our technique and experience. Materials and Methods Medical records of all patients who underwent TP from January 1, 2007, to January 1, 2015, were reviewed after Institutional Review Board approval. We report indication, preprocedure pulmonary function tests, volume of insufflated air, time to chest tube removal, and complications. We place a red rubber catheter into the peritoneal space through the diaphragm or a small abdominal incision, insufflate with room air, record volume (liters), intraperitoneal pressure (goal 9-10 mm Hg), and monitor vital signs, airway pressures, and urine output. Results We performed TP in 32 patients. Follow-up was available for 31 patients. Indications were prevention of pleural space problems in bilobectomy patients (n = 11), following decortication for empyema (n = 11), prevention of prolonged air leak (n = 3), prevention of postresection space (n = 4), and spontaneous chylothorax (n = 2). TP was done postoperatively in three patients. Median air volume used was 3.5 L (3-6 L). Time to chest tube removal overall was 7.8 days (3-20 days) and to discharge 10.2 days (4-32 days). No patient developed respiratory failure, renal failure, or required evacuation of TP. Conclusion TP is a simple, safe, and effective technique to manage pleural space problems. Proper patient selection and meticulous technique are imperative for the successful clinical application of TP. We believe that TP is an underutilized tool for the management of pleural space problems and merits wider application in thoracic surgical practice.


Remote monitoring of physical and mental state of 2019-nCoV victims using social internet of things, fog and soft computing techniques.


title: Thermal ablation of intrahepatic cholangiocarcinoma: Safety, efficacy, and factors affecting local tumor progression.

text: PURPOSE To evaluate the safety and oncologic efficacy of percutaneous thermal ablation of intrahepatic cholangiocarcinoma (ICC) and identify risk factors for local tumor progression (LTP). MATERIALS AND METHODS Retrospective review of an institutional tumor ablation registry demonstrated that 20 patients (9 males, 11 females; mean age 62.5 ± 15.8 years) with 50 ICCs (mean size 1.8 ± 1.3 cm) were treated with percutaneous radiofrequency ablation (RFA) or microwave ablation (MWA) between 2006 and 2015. Thirty-eight of the treated ICCs (76%) were metastases that developed after surgical resection of the primary tumor. Patient demographics, procedure technical parameters, and clinical outcomes were reviewed. A Cox proportional hazards model was used to examine the risk of LTP by ablation modality. Survival analyses were performed using the Kaplan-Meier method. RESULTS Mean imaging follow-up time was 41.5 ± 42.7 months. Forty-four (88%) ICCs were treated with RFA, and 6 (12%) with MWA. Eleven (22%) cases of LTP developed in 5 (25%) patients. The median time to LTP among these 11 tumors was 7.1 months (range, 2.3-22.9 months). Risk of LTP was not significantly different for ICCs treated with MWA compared to RFA (HR 2.72; 95% CI 0.58-12.84; p = 03.21). Median disease-free survival was 8.2 months (1.1-70.4 months), and median overall survival was 23.6 months (7.4-122.5 months). No major complication occurred. CONCLUSIONS Percutaneous thermal ablation is a safe and effective treatment for patients with ICCs and may be particularly valuable in unresectable patients, or those who have already undergone hepatic surgery. Tumor size and ablation modality were not associated with LTP, whereas primary tumors and superficially located tumors were more likely to subsequently recur.


title: Quality measurement in physician-staffed emergency medical services: a systematic literature review.

text: PURPOSE Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS. DATA SOURCES The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus. STUDY SELECTION The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool. DATA EXTRACTION The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well. RESULTS OF DATA SYNTHESIS In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were 'Adherence to medical protocols', 'Provision of advanced interventions', 'Response time' and 'Adverse events'. CONCLUSION The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.


title: Separating the wheat from the chaff: region of interest combined with metal artifact reduction for completion angiography following cerebral aneurysm treatment.

text: INTRODUCTION Following complicated endovascular or microsurgical treatments, assessment of radiographic outcome can be challenging due to device resolution and metallic artifact. Two-dimensional and three-dimensional angiography can reveal information about flow and aneurysm obliteration, but may be limited by beam hardening, overlapping vessels, and image degradation in the region of metallic implants. In this study, we investigated the combination of a collimated volumetric imaging (volume of interest, VOI) protocol followed by metal artifact reduction (MAR) post-processing to evaluate the correct positioning of stents, flow diverters, coils, and clips while limiting the radiation dose to the patient. METHODS 9 patients undergoing 10 procedures were included in our study. All patients underwent endovascular or surgical treatment of a cerebral aneurysm involving stents, flow diverting stents, coils, and/or clips followed by either immediate or early postoperative evaluation of our protocol. RESULTS Image datasets corrected for metallic artifacts (VOI-MAR) were judged to be better-a statistically significant finding-than image datasets only corrected for field of view truncation (VOI alone). Qualitatively, images were more interpretable and informative with regards to device position and apposition to the vessel wall for those cases involving a pipeline, and with regards to encroachment on the parent artery and possible residual aneurysm, in all cases. CONCLUSIONS VOI acquisition combined with MAR post-processing provides for accurate and informative evaluation of cerebral aneurysm treatment while limiting the radiation dose to patients.


title: Molecular detection of SARS-CoV-2 in formalin fixed paraffin embedded specimens.

text: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of human coronavirus disease 2019 (COVID-19), emerged in Wuhan, China in December 2019. The virus rapidly spread globally, resulting in a public-health crisis including more than 3.1 million cases and 224,000 deaths as of May 1, 2020. Here, we describe the identification and evaluation of commercially available reagents and assays for the molecular detection of SARS-CoV-2 in infected formalin fixed paraffin embedded (FFPE) cell pellets. We identified a suitable rabbit polyclonal anti-SARS-CoV spike protein antibody and a mouse monoclonal anti-SARS-CoV nucleocapsid protein (NP) antibody for cross detection of the respective SARS-CoV-2 proteins by immunohistochemistry (IHC) and immunofluorescence assay (IFA). Next, we established RNAscope in situ hybridization (ISH) to detect SARS-CoV-2 RNA. Furthermore, we established a multiplex fluorescence ISH (mFISH) to detect positive-sense SARS-CoV-2 RNA and negative-sense SARS-CoV-2 RNA (a replicative intermediate indicating viral replication). Finally, we developed a dual staining assay using IHC and ISH to detect SARS-CoV-2 antigen and RNA in the same FFPE section. These reagents and assays will accelerate COVID-19 pathogenesis studies in humans and in COVID-19 animal models.


title: [Results of deconstructive endovascular surgery in treatment of large and giant intracranial aneurysms].

text: AIM To clarify the indications for deconstructive endovascular surgery in patients with large and giant intracranial aneurysms and to evaluate short-term and long-term postoperative outcomes. MATERIAL AND METHODS The study was based on a retrospective analysis of the treatment results in 50 patients with large (15-25 mm) and giant (more than 25 mm) intracranial aneurysms, aged from 18 to 75 years, who were treated at the Burdenko Neurosurgical Institute in 2002-2014. The patients underwent a balloon occlusion test (BOT) in various modifications before stationary occlusion of the carrier artery. For vascular occlusion, we used detachable latex balloon catheters (33 cases) and microcoils (17 cases). The condition of patients in the pre- and postoperative period was assessed by using the modified Rankin Scale. RESULTS There were no deaths due to occlusion of the internal carotid artery (37 patients). Postoperative complications occurred in 5 patients. On the basis of BOT, revascularization surgery involving placement of an extra-intracranial microanastomosis (EICMA) was performed in 6 cases. In more 4 cases, EICMA was placed in the early postoperative period due to developing signs of ischemia. Two of 7 patients underwent occlusion of both vertebral arteries (VAs) in the vertebrobasilar basin, which led to fatal outcomes. One more patient died of aggravation of brainstem compression after VA occlusion. There was no worsening of neurological symptoms among survivors. There were no deaths and persistent neurological disorders upon occlusion of branches of the main cerebral arteries, starting with the first order arteries (6 patients). Thirty one patients (66%) were followed-up in the period from 1 to 104 months. There were no deaths associated with artery occlusion. Two patients experienced delayed ischemic disorders. CONCLUSION Occlusion of the carrier artery should be performed in a carefully selected group of BOT-negative patients. This surgery can be indicated for aneurysms with a complicated configuration, the topographic and anatomical features of which exclude reconstructive surgery.


title: The differential expression of micro-RNAs 21, 200c, 204, 205, and 211 in benign, dysplastic and malignant melanocytic lesions and critical evaluation of their role as diagnostic biomarkers.

text: Overlapping histological features between benign and malignant lesions and a lack of firm diagnostic criteria for malignancy result in high rates of inter-observer variation in the diagnosis of melanocytic lesions. We aimed to investigate the differential expression of five miRNAs (21, 200c, 204, 205, and 211) in benign naevi (n = 42), dysplastic naevi (n = 41), melanoma in situ (n = 42), and melanoma (n = 42) and evaluate their potential as diagnostic biomarkers of melanocytic lesions. Real-time PCR showed differential miRNA expression profiles between benign naevi; dysplastic naevi and melanoma in situ; and invasive melanoma. We applied a random forest machine learning algorithm to classify cases based on their miRNA expression profiles, which resulted in a ROC curve analysis of 0.99 for malignant melanoma and greater than 0.9 for all other groups. This indicates an overall very high accuracy of our panel of miRNAs as a diagnostic biomarker of benign, dysplastic, and malignant melanocytic lesions. However, the impact of variable lesion percentage and spatial expression patterns of miRNAs on these real-time PCR results was also considered. In situ hybridisation confirmed the expression of miRNA 21 and 211 in melanocytes, while demonstrating expression of miRNA 205 only in keratinocytes, thus calling into question its value as a biomarker of melanocytic lesions. In conclusion, we have validated some miRNAs, including miRNA 21 and 211, as potential diagnostic biomarkers of benign, dysplastic, and malignant melanocytic lesions. However, we also highlight the crucial importance of considering tissue morphology and spatial expression patterns when using molecular techniques for the discovery and validation of new biomarkers.


title: Ablation of perivascular hepatic malignant tumors with irreversible electroporation.

text: BACKGROUND Ablation is increasingly used to treat primary and secondary liver cancer. Ablation near portal pedicles and hepatic veins is challenging. Irreversible electroporation (IRE) is a new ablation technique that does not rely on heat and, in animals, appears to be safe and effective when applied near hepatic veins and portal pedicles. This study evaluated the safety and short-term outcomes of IRE to ablate perivascular malignant liver tumors. STUDY DESIGN A retrospective review of patients treated with IRE between January 1, 2011 and November 2, 2011 was performed. Patients were selected for IRE when resection or thermal ablation was not indicated due to tumor location. Treatment outcomes were classified by local, regional, and systemic recurrence and complications. Local failure was defined as abnormal enhancement at the periphery of an ablation defect on post-procedure contrast imaging. RESULTS Twenty-eight patients had 65 tumors treated. Twenty-two patients (79%) were treated via an open approach and 6 (21%) were treated percutaneously. Median tumor size was 1 cm (range 0.5 to 5 cm). Twenty-five tumors were <1 cm from a major hepatic vein; 16 were <1 cm from a major portal pedicle. Complications included 1 intraoperative arrhythmia and 1 postoperative portal vein thrombosis. Overall morbidity was 3%. There were no treatment-associated mortalities. At median follow-up of 6 months, there was 1 tumor with persistent disease (1.9%) and 3 tumors recurred locally (5.7%). CONCLUSIONS This early analysis of IRE treatment of perivascular malignant hepatic tumors demonstrates safety for treating liver malignancies. Larger studies and longer follow-up are necessary to determine long-term efficacy.


title: Variations in Laparoscopic Colectomy Utilization in the United States.

text: BACKGROUND Recent published articles reported a wide geographic variation in the utilization of laparoscopic colectomy in the United States. OBJECTIVES This study aimed to report the current rates of laparoscopic colon resection in different types of hospitals in the United States. DESIGN The Nationwide Inpatients Sample database was used to examine the clinical data of patients undergoing elective colon resection for the diagnosis of colon cancer or diverticular disease from 2009 to 2012. SETTING Multivariate regression analysis was performed to compare different hospital types and regions regarding the utilization of laparoscopy. PATIENTS Patients undergoing elective colon resection for the diagnosis of colon cancer or diverticular disease from 2009 to 2012 were selected. MAIN OUTCOME MEASURES The primary outcome measured was the rates of laparoscopic colon resection in different types of hospitals. RESULTS We sampled a total of 309,816 patients who underwent elective colon resection. Of these, 171,666 (55.4%) had a laparoscopic operation. The utilization of a laparoscopic approach increased from 51.3% in 2009 to 59.3% in 2012. The increased utilization of a laparoscopic approach was seen in both urban (53.6% vs 61.6%) and rural hospitals (33.4% vs 42.3%), for colon cancer (45% vs 53.5%), and diverticular disease (61.9% vs 68.2%). The conversion rate to open surgery for diverticular disease was significantly higher than for colon cancer (adjusted odds ratio (AOR), 1.23; p < 0.01). After adjustment, urban hospitals (AOR, 2.13; p < 0.01), teaching hospitals (AOR, 1.13; p < 0.01), and large hospitals (AOR, 1.33; p < 0.01) had a greater utilization of laparoscopic surgery. LIMITATIONS This study was limited by its retrospective nature. CONCLUSIONS Although we have finally reached the point where a majority of patients undergoing an elective colectomy for diverticular disease and colon cancer receive a laparoscopic operation, there is wide variation in the implementation of laparoscopic surgery in colon resection in the United States. The utilization of a laparoscopic approach has associations with hospital factors such as size, teaching status of the hospital, and geographic location (urban vs rural).


title: Inflammatory joint disease in cats: diagnostic approach and treatment.

text: PRACTICAL RELEVANCE Osteoarthritis, a degenerative non-inflammatory joint disease, is common in cats, usually causing gradual changes in behavior and lifestyle rather than severe lameness. Inflammatory arthritis occurs much less frequently and is nearly always associated with debilitating lameness. It may have an infectious or immune-mediated cause - but, unlike the canine disease, is much more likely to be infectious in origin. CLINICAL CHALLENGES Cats with inflammatory joint disease are presented for evaluation of lethargy, anorexia, reluctance to walk or fever. Synovial fluid collection and analysis is required to confirm joint inflammation, but this is a procedure many veterinarians are not comfortable performing in cats. Once inflammatory arthritis is confirmed, extensive testing is required to diagnose infectious causes and determine appropriate treatment. Immune-mediated polyarthritis can be treated with immunosuppressive drugs only after all infectious possibilities are eliminated. Radiographs are used to characterize the arthritis as erosive or nonerosive, but radiographic changes in cats are often subtle compared with those described in canine rheumatoid-like arthritis. AUDIENCE This review, aimed at all veterinarians who treat cats, describes the general clinical approach to feline joint disease, the collection and analysis of synovial fluid, and the diagnosis and management of inflammatory joint diseases affecting cats. The diagnostic approach to an unusual case of erosive polyarthritis is discussed in the Case Notes. EVIDENCE BASE To date, the veterinary literature on inflammatory joint disease in cats has been limited to older reviews of immune-mediated disorders and multiple single case reports or small case series describing infectious disorders. This article offers a current comprehensive review of these disorders.


title: Fetal myelomeningocele repair: the post-MOMS experience at the Children's Hospital of Philadelphia.

text: BACKGROUND Fetal myelomeningocele (fMMC) repair has become accepted as a standard of care option in selected circumstances. We reviewed our outcomes for fMMC repair from referral and evaluation through surgery, delivery and neonatal discharge. MATERIAL AND METHODS All patients referred for potential fMMC repair were reviewed from January 1, 2011 through March 7, 2014. Maternal and neonatal data were collected on the 100 patients who underwent surgery. RESULTS 29% of those evaluated met the criteria and underwent fMMC repair (100 cases). The average gestational age was 21.9 weeks at evaluation and 23.4 weeks at fMMC repair. Complications included membrane separation (22.9%), preterm premature rupture of membranes (32.3%) and preterm labor (37.5%). Average gestational age at delivery was 34.3 weeks and 54.2% delivered at ≥35 weeks. The perinatal loss rate was 6.1% (2 intrauterine fetal demises and 4 neonatal demises); 90.8% of women delivered at the Children's Hospital of Philadelphia and 3.4% received transfusions. With regard to the neonates, 2 received ventriculoperitoneal shunts prior to discharge; 71.1% of neonates had no evidence of hindbrain herniation on MRI. Of the 80 neonates evaluated, 55% were assigned a functional level of one or more better than the prenatal anatomic level. CONCLUSION In an experienced program, maternal and neonatal outcomes for patients undergoing fMMC repair are comparable to results of the MOMS trial.


title: Inorganic hemostats: The state-of-the-art and recent advances.

text: Hemorrhage is the most common cause of death both in hospitals and on the battlefield. The need for an effective hemostatic agent remains, since all injuries are not amenable to tourniquet use. There are many topical hemostatic agents and dressings available to control severe bleeding. This article reviews the most commonly used inorganic hemostats, subcategorized as zeolite and clay-based hemostats. Their hemostatic functions as well as their structural properties that are believed to induce hemostasis are discussed. The most important findings from in vitro and in vivo experiments are also covered.


title: The Nationwide Burden of Neurological Conditions Requiring Emergency Neurosurgery.

text: BACKGROUND Neurosurgical emergencies are an important cause of disability and mortality. OBJECTIVE To examine the nationwide burden of neurological conditions requiring emergency neurosurgery. METHODS The Nationwide Inpatient Sample database (2002-2011) was queried to identify adult patients with a primary discharge diagnosis of a neurosurgical condition who were admitted urgently/emergently or through a trauma center and underwent surgical intervention within 2 days of admission. Diagnostic groups were ranked based on their inpatient complication and mortality burden, and their contribution to total complications, deaths, hospital charges, and length of stay (LOS) was assessed. All analyses were weighted to produce national estimates. RESULTS After application of discharge weights, 810 404 patients who underwent emergency neurosurgery were identified. The average complication rate for the entire sample was 8.8%, the mortality rate was 11.2%, average charges were $106 802, and average LOS was 9.0 days. The top 4 diagnostic groups ranked by complication/mortality burden accounted for 76% of all complications, 96% of all deaths, 81% of all charges, and 82% of all days in the hospital for the entire study sample. This was equal to 62 648 complications, 86 683 deaths, $69 billion in charges, and 5962 932 days. These 4 diagnostic groups included (1) acute cerebrovascular disease, (2) intracranial injury, (3) spinal cord injury, and (4) occlusion or stenosis of precerebral arteries. CONCLUSION Acute cerebrovascular disease, intracranial injury, spinal cord injury, and occlusion/stenosis of precerebral arteries requiring emergency neurosurgery carry an important nationwide burden in terms of complications, deaths, charges, and LOS. Efforts in prevention and/or treatment of these conditions should continue.


[Consideration on the strategies during epidemic stage changing from emergency response to continuous prevention and control].


title: A retrospective comparison of robotic versus laparoscopic distal resection and enucleation for potentially benign pancreatic neoplasms.

text: PURPOSE The present study aimed to compare robotic-assisted versus laparoscopic distal pancreatic resection and enucleation for potentially benign pancreatic neoplasms. METHODS Patients were retrieved from a prospectively maintained database. Demographic data, tumor types, and the perioperative outcomes were retrospectively analyzed. RESULTS In a 10-year period, 75 patients (female, n = 44; male, n = 31; median age, 53 years [range, 9-84 years]) were identified. The majority of patients had pancreatic neuroendocrine neoplasms (n = 39, 52%) and cystic neoplasms (n = 23, 31%) with a median tumor size of 17 (3-60) mm. Nineteen (25.3%) patients underwent enucleation (robotic, n = 11; laparoscopic, n = 8) and 56 (74.7%) patients underwent distal pancreatic resection (robotic, n = 24; laparoscopic, n = 32), of those 48 (85%) underwent spleen-preserving procedures. Eight (10.7%) procedures had to be converted to open surgery. The rate of vessel preservation in distal pancreatectomy was significantly higher in robotic-assisted procedures (62.5% vs. 12.5%, p = 0.01). Twenty-six (34.6%) patients experienced postoperative complications (Clavien-Dindo grade > 3). Twenty (26.7%) patients developed a pancreatic fistula type B. There was no mortality. After a median follow-up period of 58 months (range 2-120 months), one patient (1.3%) developed local recurrence (glucagonoma) after enucleation, which was treated with a Whipple procedure. CONCLUSION The robotic approach is comparably safe, but increases the rate of splenic vessel preservation and reduces the risk of conversion to open surgery.


title: The Mechanics of Seated and Nonseated Cycling at Very-High-Power Output: A Joint-level Analysis.

text: Cyclists frequently use a non-seated posture when accelerating, climbing steep hills, and sprinting; yet, the biomechanical difference between seated and non-seated cycling remains unclear. PURPOSE To test the effects of posture (seated and non-seated) and cadence (70 rpm and 120 rpm) on joint power contributions, effective mechanical advantage, and muscle activations within the leg during very-high-power output cycling. METHODS Fifteen male participants rode on an instrumented ergometer at 50% of their individualised instantaneous maximal power (10.74 ± 1.99 W⋅kg; above the reported threshold for seated to non-seated transition) in different postures (seated and non-seated) and at different cadences (70 rpm and 120 rpm); whilst leg muscle activity, full body motion capture, and crank radial and tangential forces were recorded. A scaled, full-body model was used to solve inverse kinematics and inverse dynamics to determine joint displacements and net joint moments. Statistical comparisons were made using repeated measure, two-way analyses of variance (posture x cadence). RESULTS There were significant main effects of posture and cadence on joint power contributions. A key finding was that the non-seated posture increased negative power at the knee, with an associated significant decrease of net power at the knee. The contribution of knee power decreased by 15% at both 70 and 120 rpm (~=0.8 W·kg) when non-seated compared to seated. Subsequently, hip power and ankle power contributions were significantly higher when non-seated compared to seated at both cadences. In both postures, knee power was 9% lower at 120 rpm compared to 70 rpm (~=0.4 W·kg). CONCLUSION These results evidenced that the contribution of knee joint power to leg power was reduced by switching from a seated to non-seated posture during very-high-power output cycling, however the size of the reduction is cadence dependent.


title: Improvement of the Targeting of Radiolabeled and Functionalized Liposomes with a Two-Step System Using a Bispecific Monoclonal Antibody (Anti-CEA × Anti-DTPA-In).

text: UNLABELLED This study proposes liposomes as a new tool for pretargeted radioimmunotherapy (RIT) in solid tumors. Tumor pretargeting is obtained by using a bispecific monoclonal antibody [BsmAb, anti-CEA × anti-DTPA-indium complex (DTPA-In)] and pegylated radioactive liposomes containing a lipid-hapten conjugate (DSPE-PEG-DTPA-In). In this work, the immunospecificity of tumor targeting is demonstrated both in vitro by fluorescence microscopy and in vivo by biodistribution studies. METHODS Carcinoembryonic antigen (CEA)-expressing cells (LS174T) were used either in cell culture or as xenografts in nude mice. Doubly fluorescent liposomes or doubly radiolabeled liposomes were, respectively, used for in vitro and in vivo studies. In each case, a tracer of the lipid bilayer [rhodamine or indium-111 ((111)In)] and a tracer of the aqueous phase [fluorescein or iodine-125 ((125)I)] were present. The targeting of liposomes was assessed with BsmAb for active targeting or without for passive targeting. RESULTS Data obtained with the lipid bilayer tracer showed a fluorescent signal on cell membranes two to three times higher for active than for passive targeting. This immunospecificity was confirmed in vivo with tumor uptake of 7.5 ± 2.4% ID/g (percentage of injected dose per gram of tissue) for active targeting versus 4.5 ± 0.45% ID/g for passive targeting (p = 0.03). Regarding the aqueous phase tracer, results are slightly more contrasted. In vitro, the fluorescent tracer seems to be released in the extracellular matrix, which can be correlated with the in vivo data. Indeed, the tumor uptake of (125)I is lower than that of (111)In: 5.1 ± 2.5% ID/g for active targeting and 2.7 ± 0.6% ID/g for passive targeting, but resulted in more favorable tumor/organs ratios. CONCLUSION This work demonstrated the tumor targeting immunospecificity of DSPE-PEG-DTPA-In liposomes by two different methods. This original and new approach suggests the potential of immunospecific targeting liposomes for the RIT of solid tumors.


title: Perceptual Surprise Improves Action Stopping by Nonselectively Suppressing Motor Activity via a Neural Mechanism for Motor Inhibition.

text: Motor inhibition is a cognitive control ability that allows humans to stop actions rapidly even after initiation. Understanding and improving motor inhibition could benefit adaptive behavior in both health and disease. We recently found that presenting surprising, task-unrelated sounds when stopping is necessary improves the likelihood of successful stopping. In the current study, we investigated the neural underpinnings of this effect. Specifically, we tested whether surprise-related stopping improvements are due to a genuine increase in motor inhibition. In Experiment 1, we measured motor inhibition in primary motor cortex of male and female humans by quantifying corticospinal excitability (CSE) via transcranial magnetic stimulation and electromyography during a hybrid surprise-Go/NoGo task. Consistent with prior studies of motor inhibition, successful stopping was accompanied by nonselective suppression of CSE; that is, CSE was suppressed even in task-unrelated motor effectors. Importantly, unexpected sounds significantly increased this motor-system inhibition to a degree that was directly related to behavioral improvements in stopping. In Experiment 2, we then used scalp encephalography to investigate whether unexpected sounds increase motor-inhibition-related activity in the CNS. We used an independent stop-signal localizer task to identify a well characterized frontocentral low-frequency EEG component that indexes motor inhibition. We then investigated the activity of this component in the surprise-Go/NoGo task. Consistent with Experiment 1, this signature of motor inhibition was indeed increased when NoGo signals were followed by unexpected sounds. Together, these experiments provide converging evidence suggesting that unexpected events improve motor inhibition by automatically triggering inhibitory control.SIGNIFICANCE STATEMENT The ability to stop ongoing actions rapidly allows humans to adapt their behavior flexibly and rapidly. Action stopping is important in daily life (e.g., stopping to cross the street when a car approaches) and is severely impaired in many neuropsychiatric disorders. Therefore, finding ways to improve action stopping could aid adaptive behaviors in health and disease. Our current study shows that presenting unexpected sounds in stopping situations facilitates successful stopping. This improvement is specifically due to a surprise-related increase in a neural mechanism for motor inhibition, which rapidly suppresses the excitability of the motor system after unexpected events. These findings suggest a tight interaction between the neural systems for surprise processing and motor inhibition and yield a promising avenue for future research.


title: Packing and postoperative rhinoplasty management: a survey report.

text: BACKGROUND Postoperative management following rhinoplasty varies greatly among aesthetic surgeons. Few studies have addressed practice trends in postoperative rhinoplasty care or questioned the frequency of packing and splinting. Many conventional postoperative techniques remain controversial (eg, packing). OBJECTIVE To investigate current postoperative practices in the United States, correlating the results with surgical education, practice type, and complication rates. METHODS An online survey was distributed to members of the American Society for Aesthetic Plastic Surgery. Respondents were polled about their background, route of education, type of practice, frequency and preference of postoperative nasal care, and most frequent rhinoplasty complications. Statistical analysis was performed with the χ(2) test. RESULTS Of the 1550 total surveys sent, 126 responses were received (8.1%). The majority of respondents were in private practice (86%) and trained in plastic surgery (83%). Approximately 33% continue to regularly employ packing following rhinoplasty, but data show that surgeons performing 21 or more rhinoplasties per year were less likely to utilize packing (P = .06). Those surgeons with higher rhinoplasty case volumes were significantly more likely to utilize a secondary therapy (eg, steroids, arnica) in combination with ice packs (P = .03) to prevent postoperative ecchymosis. Finally, surgeons with lower rhinoplasty case volumes reported more frequent postoperative nasal tip deformities (P = .01). CONCLUSIONS Postoperative rhinoplasty care varies greatly among practicing aesthetic surgeons. Importantly, a high percentage of private practice aesthetic surgeons continue to utilize nasal packing following rhinoplasty. However, these numbers trend downward in surgeons who perform rhinoplasties more frequently.


title: Effects of Fampridine in People with Multiple Sclerosis: A Systematic Review and Meta-analysis.

text: BACKGROUND Prolonged-release (PR) fampridine is a potassium channel blocker used as a symptomatic treatment for walking disability in patients with multiple sclerosis (MS). Its clinical effects in such patients have not been systematically reviewed, and may be more wide-ranging than expected. OBJECTIVES To summarize the evidence on the effects of PR fampridine in patients with MS. METHODS A systematic search of Pubmed, Scopus (including EMBASE), and PsycINFO (completed in 01/2019) was carried out to identify randomized controlled trials (RCT) that compared PR fampridine to placebo. When appropriate, data were pooled using a random-effects model, and standardized mean differences (SMD) were computed. Study quality was assessed using the Downs and Black checklist. PRISMA guidelines were followed. All retrieved functional outcomes were categorized according to the International Classification of Functioning, Disability and Health (ICF). RESULTS A total of 706 articles were screened for inclusion. Twenty RCTs involving 2616 patients met the eligibility criteria. Most studies were of good-to-excellent quality. PR fampridine administration resulted in significant benefits in relation to walking short distances (SMD: 1.23 (95% IC 0.65-1.81)) and perceived walking capacity (0.64 (0.27-1.02)). Its effects on muscle strength and middle-distance walking were not significant (0.53 (- 0.04 to 1.10) and 0.31 (- 0.18 to 0.80), respectively). No effect on higher-level cognitive functions (- 0.07 (- 0.58 to 0.45)) or hand and arm use (0.16 (- 0.33 to 0.64)) was observed. Individual studies reported effects on other outcomes across the ICF domains. CONCLUSIONS There is strong evidence that PR fampridine exerts strong effects on the ability to walk short distances and on perceived walking capacity. Other effects of PR fampridine according to the ICF are possible but still unclear.


title: Animal model of respiratory syncytial virus: CD8+ T cells cause a cytokine storm that is chemically tractable by sphingosine-1-phosphate 1 receptor agonist therapy.

text: UNLABELLED The cytokine storm is an intensified, dysregulated, tissue-injurious inflammatory response driven by cytokine and immune cell components. The cytokine storm during influenza virus infection, whereby the amplified innate immune response is primarily responsible for pulmonary damage, has been well characterized. Now we describe a novel event where virus-specific T cells induce a cytokine storm. The paramyxovirus pneumonia virus of mice (PVM) is a model of human respiratory syncytial virus (hRSV). Unexpectedly, when C57BL/6 mice were infected with PVM, the innate inflammatory response was undetectable until day 5 postinfection, at which time CD8(+) T cells infiltrated into the lung, initiating a cytokine storm by their production of gamma interferon (IFN-γ) and tumor necrosis factor alpha (TNF-α). Administration of an immunomodulatory sphingosine-1-phosphate (S1P) receptor 1 (S1P1R) agonist significantly inhibited PVM-elicited cytokine storm by blunting the PVM-specific CD8(+) T cell response, resulting in diminished pulmonary disease and enhanced survival. IMPORTANCE A dysregulated overly exuberant immune response, termed a "cytokine storm," accompanies virus-induced acute respiratory diseases (VARV), is primarily responsible for the accompanying high morbidity and mortality, and can be controlled therapeutically in influenza virus infection of mice and ferrets by administration of sphingosine-1-phosphate 1 receptor (S1P1R) agonists. Here, two novel findings are recorded. First, in contrast to influenza infection, where the cytokine storm is initiated early by the innate immune system, for pneumonia virus of mice (PVM), a model of RSV, the cytokine storm is initiated late in infection by the adaptive immune response: specifically, by virus-specific CD8 T cells via their release of IFN-γ and TNF-α. Blockading these cytokines with neutralizing antibodies blunts the cytokine storm and protects the host. Second, PVM infection is controlled by administration of an S1P1R agonist.


title: Duodenal-jejunal bypass improves glycemia and decreases SGLT1-mediated glucose absorption in rats with streptozotocin-induced type 2 diabetes.

text: OBJECTIVE To elucidate whether duodenal-jejunal-bypass (DJB), which improves blood glucose control, changes activity of Na-D-glucose cotransporter SGLT1 in small intestine. BACKGROUND DJB has been shown to improve oral glucose tolerance in normal rats and a genetic diabetic rat model. Because intestinal D-glucose absorption is mediated by SGLT1 localized in the brush border membrane of small intestinal enterocytes, it is unclear whether function of SGLT1 is altered by DJB and whether this contributes to the improvement of glycemic control. METHODS A high-fat diet and low-dose streptozotocin administration were used to induce a type 2 diabetes in male Lewis rats. The diabetic animals underwent DJB or sham surgery. An oral glucose tolerance test (OGTT) was used to evaluate glucose control 3 weeks after surgery. SGLT1-mediated glucose transport was assessed using everted rings of different small intestinal segments. SGLT1 mRNA expression was determined by quantitative reverse transcription polymerase chain reaction (RT-PCR). RESULTS DJB improved the OGTT significantly (P < 0.001) compared with sham-operated rats while body weight was not different among the surgical groups. DJB induced a 50% reduction of SGLT1-mediated glucose uptake into enterocytes of duodenum and jejunum (P < 0.001). The concentration of D-glucose in the blood following glucose gavage increased more slowly after DJB versus sham. CONCLUSIONS The data indicate that DJB surgery decreases glucose absorption in the small intestine by downregulation of SGLT1-mediated glucose uptake. We suggest that the downregulation of SGLT1 contributes to the body-weight independent improvement of diabetes type 2.


title: Prestroke CHA2DS2-VASc Score and Severity of Acute Stroke in Patients with Atrial Fibrillation: Findings from RAF Study.

text: BACKGROUND AND PURPOSE The aim of this study was to investigate for a possible association between both prestroke CHA2DS2-VASc score and the severity of stroke at presentation, as well as disability and mortality at 90 days, in patients with acute stroke and atrial fibrillation (AF). METHODS This prospective study enrolled consecutive patients with acute ischemic stroke, AF, and assessment of prestroke CHA2DS2-VASc score. Severity of stroke was assessed on admission using the National Institutes of Health Stroke Scale (NIHSS) score (severe stroke: NIHSS ≥10). Disability and mortality at 90 days were assessed by the modified Rankin Scale (mRS <3 or ≥3). Multiple logistic regression was used to correlate prestroke CHA2DS2-VASc and severity of stroke, as well as disability and mortality at 90 days. RESULTS Of the 1020 patients included in the analysis, 606 patients had an admission NIHSS score lower and 414 patients higher than 10. At 90 days, 510 patients had mRS ≥3. A linear correlation was found between the prestroke CHA2DS2-VASc score and severity of stroke (P = .001). On multivariate analysis, CHA2DS2-VASc score correlated with severity of stroke (P = .041) and adverse functional outcome (mRS ≥3) (P = .001). A logistic regression with the receiver operating characteristic graph procedure (C-statistics) evidenced an area under the curve of .60 (P = .0001) for severe stroke. Furthermore, a correlation was found between prestroke CHA2DS2-VASc score and lesion size. CONCLUSIONS In patients with AF, in addition to the risk of stroke, a high CHA2DS2-VASc score was independently associated with both stroke severity at onset and disability and mortality at 90 days.


Prophylactic radiotherapy to prevent procedure-tract metastases.


title: Combining simple patient-oriented tests with state-of-the-art molecular diagnostics for early diagnosis of cancer.

text: Early diagnosis is an important strategy to improve outcomes from cancer. Oesophageal adenocarcinoma is an example of a cancer that presents late, with very poor outcomes, and for which the presence of the precursor lesion Barrett's oesophagus provides the opportunity to intervene at an early stage. In this review, I describe the challenges in the field and the work that we have done to devise a conceptually novel approach to early diagnosis, using a cell collection device (Cytosponge), coupled with molecular assays. This is a personal perspective in which I also describe the career pathway that led me into academic gastroenterology, and the rewards and challenges of translational research in molecular diagnostics. There are fantastic opportunities for clinicians wishing to pursue academic medicine, because it is a time when massive strides are being made in a whole number of areas; for example: imaging, sequencing technology and targeted therapies. Clinicians who can straddle the laboratory and the clinic are essential, to maximise the progress that can be made for the benefit of patients.


Intracranial dural arteriovenous fistulas: a treatment paradigm in flux.