title: Artificial Intelligence and Primary Care Research: A Scoping Review.

text: PURPOSE Rapid increases in technology and data motivate the application of artificial intelligence (AI) to primary care, but no comprehensive review exists to guide these efforts. Our objective was to assess the nature and extent of the body of research on AI for primary care. METHODS We performed a scoping review, searching 11 published or gray literature databases with terms pertaining to AI (eg, machine learning, bayes* network) and primary care (eg, general pract*, nurse). We performed title and abstract and then full-text screening using Covidence. Studies had to involve research, include both AI and primary care, and be published in Eng-lish. We extracted data and summarized studies by 7 attributes: purpose(s); author appointment(s); primary care function(s); intended end user(s); health condition(s); geographic location of data source; and AI subfield(s). RESULTS Of 5,515 unique documents, 405 met eligibility criteria. The body of research focused on developing or modifying AI methods (66.7%) to support physician diagnostic or treatment recommendations (36.5% and 13.8%), for chronic conditions, using data from higher-income countries. Few studies (14.1%) had even a single author with a primary care appointment. The predominant AI subfields were supervised machine learning (40.0%) and expert systems (22.2%). CONCLUSIONS Research on AI for primary care is at an early stage of maturity. For the field to progress, more interdisciplinary research teams with end-user engagement and evaluation studies are needed.


title: Early dialogue with health technology assessment bodies: a European perspective.

text: INTRODUCTION Evidence requirements may differ across HTA bodies, and so pharmaceutical companies must plan to synergize their evidence generation strategy, across global regulatory and HTA bodies. Until recently, companies had no official platform to discuss the clinical development of a drug with HTA bodies; however, this is changing. OBJECTIVES To achieve broad usage in the EU, products must achieve both regulatory and reimbursement approval, the latter of which is based on HTA appraisal in many markets. The objective of this study is to present and evaluate the different options available for early HTA consultation (during drug development/Phase III) in the major European markets from the industry perspective. METHODS An exploratory (nonsystematic) literature review was performed to identify the European markets offering early HTA consultations, and each process was analyzed using a set of predefined metrics that are relevant to industry (the ability to consult with the regulatory body in parallel, consultation fees, length of consultation meeting, language of consultation meeting, maximum number of pharmaceutical company employees attending, procedural timelines, nature of data for which consultative advice can be sought, the output of the process, and the ability to involve external experts). RESULTS Four different types of early HTA consultation processes were identified across the major European HTA markets. The nature of these processes varied in terms of the types and number of questions that can be addressed, the length of the meeting, the reporting output, and the ability to involve external experts. CONCLUSIONS The availability of various options for early HTA consultation may help to avoid a mismatch between the evidence generated by means of a product's clinical development program, and the evidence expected by HTA bodies and payers, which can facilitate the pricing and reimbursement process upon a product's market authorization.


title: Utility and feasibility of integrating pulse oximetry into the routine assessment of young infants at primary care clinics in Karachi, Pakistan: a cross-sectional study.

text: BACKGROUND Hypoxemia may occur in young infants with severe acute illnesses or congenital cardiac anomalies, but is not reliably detected on physical exam. Pulse oximetry (PO) can be used to detect hypoxemia, but its application in low-income countries has been limited, and its feasibility in the routine assessment of young infants (aged 0-59 days) has not been previously studied. The aim of this study was to characterize the operational feasibility and parent/guardian acceptability of incorporating PO into the routine clinical assessment of young infants in a primary care setting in a low-income country. METHODS This was a cross-sectional study of 862 visits by 529 infants at two primary care clinics in Karachi, Pakistan (March to June, 2013). After clinical assessment, oxygen saturation (Sp02) was measured by a handheld PO device (Rad-5v, Masimo Corporation) according to a standardized protocol. Performance time (PT) was the time between sensor placement and attainment of an acceptable PO reading (i.e., stable SpO2 + 1% for at least 10 s, heart rate displayed, and adequate signal indicators). PT included the time for one repeat attempt at a different anatomical site if the first attempt did not yield an acceptable reading within 1 min. Parent/guardian acceptability of PO was based on a questionnaire and unprompted comments about the procedure. All infants underwent physician assessment. RESULTS Acceptable PO readings were obtained in ≤ 1 and ≤ 5 min at 94.4% and 99.8% of visits, respectively (n = 862). Median PT was 42 s (interquartile range 37; 50). Parents/guardians overwhelmingly accepted PO (99.6% overall satisfaction, n = 528 first visits). Of 10 infants with at least one visit with Sp02 <92% on a first PO attempt, 3 did not have a significant acute illness on physician assessment. There were no PO-related adverse events. DISCUSSION Using a commercially available handheld pulse oximeter, acceptable Sp02 measurements were obtained in nearly all infants in under 1 minute. The procedure was readily integrated into existing assessment pathways and parents/guardians had positive views of the technology. CONCLUSIONS When incorporated into routine clinical assessment of young infants at primary care clinics in a low-income country, PO was feasible and acceptable to parents/guardians. Future research is needed to determine if the introduction of routine PO screening of young infants will improve outcomes in low-resource settings.


title: Incidence of Complications During Initial Experience with Revision of the Agility and Agility LP Total Ankle Replacement Systems: A Single Surgeon's Learning Curve Experience.

text: As the frequency in which foot and ankle surgeons are performing primary total ankle replacement (TAR) continues to build, revision TAR will likely become more commonplace, creating a need for an established benchmark by which to evaluate the safety of revision TAR as determined by the incidence of complications. Currently, no published data exist on the incidence of intraoperative and early postoperative complications during revision of the Agility or Agility LP Total Ankle Replacement Systems during the surgeon learning curve period; therefore, the authors sought to determine this incidence during the senior author's learning curve period.


Deeply reconsidering elective surgery: worldwide concerns regarding colorectal surgery in a COVID-19 pandemic and a Singapore perspective.


title: Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature.

text: Pyogenic spondylodiscitis includes a spectrum of spinal infections such as discitis, osteomyelitis, epidural abscess, meningitis, subdural empyema, and spinal cord abscess. This is a rare complication of sacral colpopexy, but can lead to devastating consequences for the patient. We present two cases of pyogenic spondylodiscitis following sacral colpopexy. In addition, we discuss 26 cases of pyogenic spondylodiscitis reported in the literature from 1957 to 2012. Techniques to decrease rates of infection include proper identification of the S1 vertebra, awareness of the suture placement depth at the level of the sacrum and at the vagina, and early treatment of post-operative urinary tract and vaginal infections. Awareness of symptoms, timely diagnosis and multidisciplinary approach to management is essential in preventing long-term complications.


title: Thoracoscopic esophageal mobilization during minimally invasive esophagectomy: a head-to-head comparison of prone versus decubitus positions.

text: BACKGROUND Minimally invasive esophagectomy (MIE) is being performed at an increasing number of institutions. The thoracoscopic portion is generally performed in the left lateral decubitus position. Recently there has been increasing interest in esophageal mobilization in the prone position and the potential benefits of this technique with regard to operative time, surgeon ergonomics, and operative exposure. We sought to objectively compare thoracoscopic mobilization of the esophagus in the left lateral decubitus position versus the prone position and identify potential differences between the two techniques. METHODS A retrospective review of a prospectively maintained esophagectomy database identified 44 patients undergoing MIE during a 20-month period (June 2005-February 2007). Of these, 32 patients underwent thoracoscopic esophageal mobilization with cervical esophagogastric anastomosis. Eleven cases were performed in the left lateral decubitus position and 21 performed in the prone position. RESULTS The patients were comparable in age, tumor stage, and fraction undergoing neoadjuvant therapy. There was no statistically significant difference between decubitus position and prone position with regard to number of lymph nodes procured (14.6 versus 15.5, p = 0.69), complications (6/11 versus 10/21, p = 1.0), length of stay (9 versus 10 days, p = 1.0), or intraoperative blood loss (85 versus 65 cc, p = 0.14). Thoracoscopic operative times were significantly shorter in the prone group than the decubitus group (86 versus 123 min, p = 0.0001). CONCLUSIONS Prone thoracoscopic esophageal mobilization appears to be equivalent to decubitus thoracoscopic esophageal mobilization with respect to blood loss, number of lymph nodes dissected, and complications, but with a significant reduction in thoracoscopic surgical time.


Coronavirus vaccines: five key questions as trials begin.


title: Transorbital Cavernous Sinus Direct Puncture : Alternative to treat dural arteriovenous fistula.

text: INTRODUCTION The authors present a retrospective series of their clinical experience in the treatment of cavernous dural arteriovenous fistulas (DAVF) by direct transorbital puncture of the cavernous sinus as an alternative to the endovascular approach. METHODS Between October 2012 and September 2014, eight patients harboring cavernous DAVF underwent percutaneous treatment by direct transorbital puncture of the cavernous sinus at three institutions. All patients presented with ocular symptoms. Standard endovascular approaches, including transvenous and transarterial routes, were primarily attempted without success in all cases. Direct puncture was performed through two different approaches, namely inferolateral and superomedial. The entry point was the inferior and superior eyelid, respectively. Embolization was performed with coils or Onyx (Covidien, Irvine, CA). Immediate and late angiographies were used to evaluate the occlusion of the fistula. RESULTS Of the patients seven had complete occlusion of the cavernous DAVFs noted on the immediate and follow-up angiograms and one patient had residual filling but reduction of the shunt resulted in clinical improvement. None of the patients had worsening of neurological function. One case was complicated by inadvertent internal carotid puncture but without clinical manifestations. One patient experienced postoperative superior ophthalmic vein thrombosis. CONCLUSION In very specific cases, when endovascular access is not possible or fails to occlude cavernous DAVF, direct transorbital puncture of the cavernous sinus was shown to be feasible, safe and very effective.


title: Effects of transcranial photobiomodulation with near-infrared light on sexual dysfunction.

text: OBJECTIVES Transcranial photobiomodulation (t-PBM) consists of the delivery of near-infrared (NIR) or red light to the scalp designed to penetrate to subjacent cortical areas of the brain. NIR t-PBM has recently emerged as a potential therapy for brain disorders. This study assessed the efficacy of repeated sessions of NIR t-PBM on sexual dysfunction. METHODS We performed a secondary analysis of a double-blind clinical trial on t-PBM for major depressive disorder (MDD). Twenty individuals received NIR t-PBM (n = 9) or sham therapy (n = 11) twice a week for 8 weeks. Sexual desire, arousal, and orgasm were assessed using the Systematic Assessment for Treatment-Emergent Effects-Specific Inquiry (SAFTEE-SI). RESULTS The mean improvement in sexual function (decrease in SAFTEE sex total score) in subjects receiving t-PBM in NIR-mode was significantly greater than in subjects receiving sham-mode in the whole sample (NIR [n = 9] -2.55 ± 1.88 vs. sham [n = 11] -0.45 ± 1.21; z = 2.548, P = 0.011]) and in the completers (NIR [n = 5] -3.4 ± 1.95 vs. sham [n = 7] -0.14 ± 1.21; z = 2.576, P = 0.010]). CONCLUSION This exploratory study with a small sample size indicates that repeated sessions of NIR t-PBM may be associated with therapeutic effects on sexual dysfunction. The latter appeared unrelated to the antidepressant effect of t-PBM in our cohort. Lasers Surg. Med. 51:127-135, 2019. © 2018 Wiley Periodicals, Inc.


title: Structure-Activity Relationship Studies of Substituted 2-(Isoxazol-3-yl)-2-oxo-N'-phenyl-acetohydrazonoyl Cyanide Analogues: Identification of Potent Exchange Proteins Directly Activated by cAMP (EPAC) Antagonists.

text: Exchange proteins directly activated by cAMP (EPAC) as guanine nucleotide exchange factors mediate the effects of the pivotal second messenger cAMP, thereby regulating a wide variety of intracellular physiological and pathophysiological processes. A series of novel 2-(isoxazol-3-yl)-2-oxo-N'-phenyl-acetohydrazonoyl cyanide EPAC antagonists was synthesized and evaluated in an effort to optimize properties of the previously identified high-throughput (HTS) hit 1 (ESI-09). Structure-activity relationship (SAR) analysis led to the discovery of several more active EPAC antagonists (e.g., 22 (HJC0726), 35 (NY0123), and 47 (NY0173)) with low micromolar inhibitory activity. These inhibitors may serve as valuable pharmacological probes to facilitate our efforts in elucidating the biological functions of EPAC and developing potential novel therapeutics against human diseases. Our SAR results have also revealed that further modification at the 3-, 4-, and 5-positions of the phenyl ring as well as the 5-position of the isoxazole moiety may allow for the development of more potent EPAC antagonists.


title: Endovascular treatment of debilitating tinnitus secondary to cerebral venous sinus abnormalities: a literature review and technical illustration.

text: BACKGROUND AND OBJECTIVE Pulsatile tinnitus (PT) can be debilitating and lead to significant morbidity. Cerebral venous sinus lesions, such as venous sinus stenosis, diverticula, and high-riding jugular bulb, are uncommon causes of PT, for which there is no standard treatment. Endovascular interventions have shown promising results for PT secondary to idiopathic intracranial hypertension, and may be a valid therapeutic option for isolated venous PT. METHODS We conducted a systematic literature review on the outcome and safety of endovascular treatment for patients with isolated, debilitating venous PT. The venous lesion characteristics, endovascular techniques, complications, and clinical outcomes were assessed. In addition, an illustrative case of endovascular stenting for PT caused by venous sinus stenosis was included. RESULTS A total of 41 patients (90.2% female) from 26 papers were included. The median age was 46 years (IQR 23; range 25-72 years). Focal venous sinus stenosis (20 patients) and sinus diverticula (14 patients) were the most common culprit lesions. Endovascular treatment included venous sinus stenting in 35 patients, 11 of whom had adjuvant coil embolization, and coil embolization alone in six patients. Complete resolution of the tinnitus was achieved in 95.1% of patients. There was one complication of cerebellar infarct, and no procedure-related mortality. CONCLUSIONS In patients with debilitating PT secondary to venous sinus lesions, endovascular treatment by stenting and/or coil embolization appears to be safe and effective. Prospective randomized studies with objective outcome assessments are needed to confirm the treatment benefits.


title: Pediatric ophthalmology, strabismus and neuro-ophthalmology practice in the COVID-19 era: All India Ophthalmological Society guidelines.

text: The COVID-19 Pandemic has prompted substantial changes in the way ophthalmology is practiced globally. General guidelines on safe ophthalmic practice have been issued by various bodies across the globe including the All India Ophthalmological Society. While these are suitable to ophthalmology overall, they are not entirely suitable to a subspecialty practice, particularly pediatric ophthalmology, strabismus and neuro-ophthalmology, which entails dealing with children, surgery under general anesthesia and managing possible life threatening situations. A group of sub-specialists and anesthetists met virtually and arrived at a consensus with regard to practice and general anesthesia protocols pertaining to these subspecialties of ophthalmology. The recommendations made by the expert group are specific yet can be universally followed to ensure the best and safest outcome for the practitioner and patient alike. The recommendations pertain to listing conditions which need emergency or urgent care in the fields of pediatric ophthalmology and neuro-ophthalmology, precautions and technique of pediatric and neuro-ophthalmic eye examination and a protocol for delivering a safe general anesthesia for a pediatriceye surgery.


title: Cross-linking in biomaterials: a primer for clinicians.

text: The purpose of this primer is to provide the clinical surgeon with a survey overview of the basic biochemistry of collagen and the methods and rationale of collagen cross-linking in the processing and preparation of bioprosthetics for surgical implantation. The author highlights the critical biologic factors, such as strength over time, integration, and rate, and type of remodeling, that are to an extent controllable by the cross-linking of collagen tissues so that clinicians may be better capable of understanding differences among the devices, which may be more applicable to their clinical indications.


title: Fear, anger, and media-induced trauma during the outbreak of COVID-19 in the Czech Republic.

text: Fear, anger and hopelessness were the most frequent traumatic emotional responses in the general public during the first stage of outbreak of the COVID-19 epidemic in the Czech Republic (N = 1,000). The four most frequent categories of fear were determined: (a) fear of the negative impact on household finances, (b) fear of the negative impact on the household finances of significant others, (c) fear of the unavailability of health care, and (d) fear of an insufficient food supply. The pessimistic communications used by the Czech mass media contributed to intensifying traumatic feelings, fears and psychological distress in the general public during the outbreak of the COVID-19 epidemic. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Laparoscopic treatment of a large cystic adenomyosis of the uterus: A case report.

text: INTRODUCTION We describe a patient with a large cystic adenomyosis of the uterus who was treated by a laparoscopic approach. CASE PRESENTATION A 38-year-old woman presented with dysmenorrhoea for 4 months. A 104 mm × 55 mm × 60 mm cystic mass was detected on the right side of the posterior wall of the uterus by ultrasound. Laparoscopy was performed, during which a bumpy mass was discovered protruding from the surface of the uterine myometrium. Both ovaries were normal. When the wall of the cystic mass was opened, chocolate-colored fluid was visible. The cyst was completely removed, and postoperative histopathology confirmed a cystic adenomyosis. One month later, the uterus was found to be normal on ultrasound. DISCUSSION Endometriosis is a common disease in women and is divided into ovarian endometrioid cysts, superficial endometriosis, deep infiltrating endometriosis and other special types according to pathological characteristics. As a special type of endometriosis, the incidence of cystic adenomyosis is low, and its specific incidence is unknown. Cystic adenomyosis is clinically characterized by the appearance of one or more cystic cavities between the walls of the uterine muscles. CONCLUSION Laparoscopic surgery is an effective method for the diagnosis and treatment of large cystic masses in the uterine myometrium.


title: Factorial validity of the Urdu version of the obsession with COVID-19 scale: Preliminary investigation using a University Sample in Pakistan.

text: The psychological toll of the COVID-19 pandemic is being felt by people around the world. Persistent and disturbed thinking about the disease appears to be contributing to this mental health concern. Although the Obsession with COVID-19 Scale (OCS) has been shown to be a reliable and valid instrument in the U.S., it has not been examined with in Pakistan. The current study addressed this problem by examining the validity of an Urdu translated version of the OCS using online survey data from 240 university students and teachers in Pakistan. The results showed that the OCS exhibited factorial validity, as well as measurement invariance for gender. However, the OCS also showed limited evidence of construct validity in terms of showing weak positive correlations with the total scale and social dysfunction and self-confidence subscales of the General Heath Questionnaire and no correlation with the depression and anxiety subscale (GHQ-12). These findings suggest that further research is necessary before the Urdu version of the OCS is widely adopted in Pakistan.


title: Conical polyurethane implants: an uplifting augmentation.

text: BACKGROUND Polyurethane-coated conical implants were introduced by Silimed (US distributor: Sientra, Santa Barbara, California) in 2008 and offer an alternative to round or anatomically shaped implants. By their design and volume distribution, they naturally create central volume and give a reasonable fullness to the upper pole while lifting some ptotic breasts, thus avoiding the need for classical mastopexy. OBJECTIVES The authors discuss the advantages of conical implants as an alternative to conventional silicone implants for women with breast ptosis. METHODS In the 2-year period between December 2010 and December 2012, a consecutive series of 302 women underwent implant-based breast surgery procedures (236 primary augmentations, 59 revisions, and 7 mastopexy-augmentations) with conical polyurethane devices. Implant volumes ranged from 225 to 560 cc, with low- to medium-profile devices predominating. No extra-high-profile implants were used. Only 1 patient had a drain inserted on completion of a revision augmentation. RESULTS There were no infections (0%) and no wound dehiscence (0%). Four cases required reoperation (1.3%). Patient satisfaction scores were universally high (average, 9.94/10). There have been no capsular contractures to date, but follow-up is short. CONCLUSION The modern conical, polyurethane implant has many advantages over the conventional round or anatomically shaped implants and offers patients an ideal compromise between volume, natural upper pole fullness, and a lift without mastopexy scars.


title: Transtracheal ventilation with a novel ejector-based device (Ventrain) in open, partly obstructed, or totally closed upper airways in pigs.

text: BACKGROUND Transtracheal access and subsequent jet ventilation are among the last options in a 'cannot intubate-cannot oxygenate' scenario. These interventions may lead to hypercapnia, barotrauma, and haemodynamic failure in the event of an obstructed upper airway. The aim of the present study was to evaluate the efficacy and the haemodynamic effects of the Ventrain, a manually operated ventilation device that provides expiratory ventilation assistance. Transtracheal ventilation was carried out with the Ventrain in different airway scenarios in live pigs, and its performance was compared with a conventional jet ventilator. METHODS Pigs with open, partly obstructed, or completely closed upper airways were transtracheally ventilated either with the Ventrain or by conventional jet ventilation. Airway pressures, haemodynamic parameters, and blood gases obtained in the different settings were compared. RESULTS Mean (SD) alveolar minute ventilation as reflected by arterial partial pressure of CO2 was superior with the Ventrain in partly obstructed airways after 6 min in comparison with traditional manual jet ventilation [4.7 (0.19) compared with 7.1 (0.37) kPa], and this was also the case in all simulated airway conditions. At the same time, peak airway pressures were significantly lower and haemodynamic parameters were altered to a lesser extent with the Ventrain. CONCLUSIONS The results of this study suggest that the Ventrain device can ensure sufficient oxygenation and ventilation through a small-bore transtracheal catheter when the airway is open, partly obstructed, or completely closed. Minute ventilation and avoidance of high airway pressures were superior in comparison with traditional hand-triggered jet ventilation, particularly in the event of complete upper airway obstruction.


title: Use of human immunoglobulins as an anti-infective treatment: the experience so far and their possible re-emerging role.

text: INTRODUCTION Pooled human immunoglobulins (IGs) are prepared from plasma obtained from healthy donors as a concentrated antibody-containing solution. In addition, high-titer IGs (hyperimmune) against a specific pathogen can be obtained from vaccinated or convalescing donors. Currently, IGs can be used for the treatment of a variety of infections for which no specific therapy exists or that remain difficult to treat. Moreover, the recent pathogen outbreaks for which there is no approved treatment have renewed attention to the role of convalescent plasma and IGs. Areas covered: In this review, a historical perspective of the use of sera and IGs in humans as anti-infective agents (any viral, bacterial, parasitic infection), excluding immunodeficient patients, is presented from early development to the latest clinical studies. A Medline search was conducted to examine the peer-reviewed literature, with no date limits. Expert commentary: Human pooled plasma-derived IG products benefit from the polyclonal response of every individual donor and from the interindividual variability in such response. The trend to increased availability of vaccines for infectious diseases also opens new potential applications of hyperimmune IGs for emerging or re-emerging infectious diseases (e.g.: Ebola, Zika, Dengue), for the prevention and treatment in the general population, healthcare personnel and caregivers.


title: Immunogenicity and protective efficacy in mice and hamsters of a β-propiolactone inactivated whole virus SARS-CoV vaccine.

text: The immunogenicity and efficacy of β-propiolactone (BPL) inactivated whole virion SARS-CoV (WI-SARS) vaccine was evaluated in BALB/c mice and golden Syrian hamsters. The vaccine preparation was tested with or without adjuvants. Adjuvant Systems AS01(B) and AS03(A) were selected and tested for their capacity to elicit high humoral and cellular immune responses to WI-SARS vaccine. We evaluated the effect of vaccine dose and each adjuvant on immunogenicity and efficacy in mice, and the effect of vaccine dose with or without the AS01(B) adjuvant on the immunogenicity and efficacy in hamsters. Efficacy was evaluated by challenge with wild-type virus at early and late time points (4 and 18 wk post-vaccination). A single dose of vaccine with or without adjuvant was poorly immunogenic in mice; a second dose resulted in a significant boost in antibody levels, even in the absence of adjuvant. The use of adjuvants resulted in higher antibody titers, with the AS01(B)-adjuvanted vaccine being slightly more immunogenic than the AS03(A)-adjuvanted vaccine. Two doses of WI-SARS with and without Adjuvant Systems were highly efficacious in mice. In hamsters, two doses of WI-SARS with and without AS01(B) were immunogenic, and two doses of 2 μg of WI-SARS with and without the adjuvant provided complete protection from early challenge. Although antibody titers had declined in all groups of vaccinated hamsters 18 wk after the second dose, the vaccinated hamsters were still partially protected from wild-type virus challenge. Vaccine with adjuvant provided better protection than non-adjuvanted WI-SARS vaccine at this later time point. Enhanced disease was not observed in the lungs or liver of hamsters following SARS-CoV challenge, regardless of the level of serum neutralizing antibodies.


title: Mobility and interactions of coronavirus nonstructural protein 4.

text: Green fluorescent protein (GFP)-tagged mouse hepatitis coronavirus nonstructural protein 4 (nsp4) was shown to localize to the endoplasmic reticulum (ER) and to be recruited to the coronavirus replicative structures. Fluorescence loss in photobleaching and fluorescence recovery after photobleaching experiments demonstrated that while the membranes of the ER are continuous with those harboring the replicative structures, the mobility of nsp4 at the latter structures is relatively restricted. In agreement with that observation, nsp4 was shown to be engaged in homotypic and heterotypic interactions, the latter with nsp3 and nsp6. In addition, the coexpression of nsp4 with nsp3 affected the subcellular localization of the two proteins.


title: Differential inhibitory effects of cyanovirin-N, griffithsin, and scytovirin on entry mediated by envelopes of gammaretroviruses and deltaretroviruses.

text: The antiviral lectins griffithsin (GRFT), cyanovirin-N (CV-N), and scytovirin (SVN), which inhibit several enveloped viruses, including lentiviruses, were examined for their ability to inhibit entry mediated by Env proteins of delta- and gammaretroviruses. The glycoproteins from human T-cell leukemia virus type 1 (HTLV-1) were resistant to the antiviral effects of all three lectins. For gammaretroviruses, CV-N inhibited entry mediated by some but not all of the envelopes examined, whereas GRFT and SVN displayed only little or no effect.


Endoscopic vacuum therapy in Boerhaave's syndrome with open-pore polyurethane foam and a new open-pore film drainage.


title: Ultrasonographic Measurement of Subglottic Diameter for Paediatric Cuffed Endotracheal Tube Size Selection: Feasibility Report.

text: OBJECTIVE The aim of this feasibility study was to investigate the first attempt success of ultrasonography (USG) in paediatric patients in predicting an appropriate cuffed endotracheal tube (ETT) size. METHODS Fifty children who were 1-10 years of age and who received general anaesthesia with endotracheal intubation for adenoidectomy or adenotonsillectomy were enrolled in the study. In all participants, the transverse diameter of the subglottic airway was measured with USG at the cricoid level without ventilation. The outer diameter (OD) of the maximum allowable ETT was chosen according to the measured subglottic airway diameter. In the presence of resistance to passage of the tube into the trachea or in the absence of an audible leak at airway pressure of >25 cm H2O, the ETT was replaced with a tube whose internal diameter (ID) was 0.5 mm smaller. If a leak was audible at airway pressures of <10 cm H2O, if a seal could not be achieved with a cuff pressure of >25 cm H2O or if a peak airway pressure of >25 cm H2O was observed during ventilation, the tube was changed to a tube one size larger. The OD of the best-fit ETT was converted to the ID. The best-fit ID, the requirement for ETT replacement, the duration of airway diameter measurement by USG and the peak airway pressure were recorded. RESULTS The success rate of the first attempt with USG was 86%; the ETT was replaced in five patients with a tube one size larger and in two patients with a tube one size smaller. CONCLUSION Our findings show the subglottic diameter measured by USG to be a reliable predictor in estimating the appropriate paediatric ETT size.


Books for our time: seven classics that speak to us now.


title: Rhabdomyolysis: a review of clinical presentation, etiology, diagnosis, and management.

text: Rhabdomyolysis is a condition that results from many underlying etiologies and can present in a myriad of ways to the emergency physician. However, some clinical and laboratory features are almost always present and, if noted, can help in making the diagnosis. This review article will focus on the presenting symptoms, the various etiologies, the underlying mechanisms, and the current management of pediatric rhabdomyolysis.


title: Pilot-testing an applied competency-based approach to health human resources planning.

text: A competency-based approach to health human resources (HHR) planning is one that explicitly considers the spectrum of knowledge, skills and judgement (competencies) required for the health workforce based on the health needs of the relevant population in some specific circumstances. Such an approach is of particular benefit to planners challenged to make optimal use of limited HHR as it allows them to move beyond simply estimating numbers of certain professionals required and plan instead according to the unique mix of competencies available from the existing health workforce. This kind of flexibility is particularly valuable in contexts where healthcare providers are in short supply generally (e.g. in many developing countries) or temporarily due to a surge in need (e.g. a pandemic or other disease outbreak). A pilot application of this approach using the context of an influenza pandemic in one health district of Nova Scotia, Canada, is described, and key competency gaps identified. The approach is also being applied using other conditions in other Canadian jurisdictions and in Zambia.


Secondary acquired cholesteatoma after adenoidectomy and myringotomy.


title: A simplified measurement of pulse wave velocity is not inferior to standard measurement in young adults and children.

text: The standard measurement of pulse wave velocity (PWV) is restricted by the need for simultaneous tonometry measurements requiring two technicians and expensive equipment, limiting this technique to well-resourced settings. In this preliminary study, we compared a simplified method of pulse wave detection from the finger and toe to pulse wave detection from the carotid and radial arteries using applanation tonometry in children and young adults. We hypothesized that the simplified method of PWV measurement would strongly correlate with the standard measurement in different age groups and oxygen conditions. Participants included (a) boys and girls aged 8-12 years and (b) men and women aged 18-40 years. Participants rested supine while carotid and radial artery pulse waves were measured using applanation tonometry and finger and toe pulse waves were simultaneously collected using a Finometer Midi and a piezo-electric pulse transducer, respectively. These measurements were repeated under hypoxic conditions. Finger-toe PWV measurements were strongly correlated to carotid-radial PWV in adults (R=0.58; P=0.011), but not in children (R=0.056; P=0.610). Finger-toe PWV was sensitive enough to show increases in PWV with age (P<0.0001) and hypoxia in children (P<0.0001) and adults (P=0.003). These results indicate that the simplified measurement of finger-toe PWV strongly correlates with the standard measurement of carotid-radial PWV in adults, but not in children. However, finger-toe PWV can be used in either population to determine changes with hypoxia.


title: COVID-19, Australia: Epidemiology Report 11 (Reporting week to 23:59 AEST 12 April 2020).

text: Confirmed cases in Australia notified up to 12 April 2020: notifications = 6,394; deaths = 46. The reduction in international travel and domestic movement, social distancing measures and public health action have likely slowed the spread of the disease. Notifications in Australia remain predominantly among people with recent overseas travel, with some locally-acquired cases being detected. Most locally-acquired cases are able to be linked back to a confirmed case, with a small portion unable to be epidemiologically linked. The distribution of overseas-acquired cases to locally acquired cases varies by jurisdiction. Internationally, cases continue to increase. The rates of increase have started to slow in several regions, although it is too soon to tell whether this trend will be sustained. The epidemiology differs from country to country depending not only on the disease, but also on differences in case detection, testing and implemented public health measures.


title: Is immunosuppression status a risk factor for noninvasive ventilation failure in patients with acute hypoxemic respiratory failure? A post hoc matched analysis.

text: BACKGROUND Recent European/American guidelines recommend noninvasive ventilation (NIV) as a first-line therapy to manage acute hypoxemic respiratory failure in immunocompromised patients. By contrast, NIV may have deleterious effects in nonimmunocompromised patients and experts have been unable to offer a recommendation. Immunocompromised patients have particularly high mortality rates when they require intubation. However, it is not clear whether immunosuppression status is a risk factor for NIV failure. We assessed the impact of immunosuppression status on NIV failure in a post hoc analysis pooling two studies including patients with de novo acute hypoxemic respiratory failure treated with NIV. Patients with hypercapnia, acute exacerbation of chronic lung disease, cardiogenic pulmonary edema, or with do-not-intubate order were excluded. RESULTS Among the 208 patients included in the analysis, 71 (34%) were immunocompromised. They had higher severity scores upon ICU admission, higher pressure-support levels, and minute ventilation under NIV, and were more likely to have bilateral lung infiltrates than nonimmunocompromised patients. Intubation and in-ICU mortality rates were higher in immunocompromised than in nonimmunocompromised patients: 61% vs. 43% (p = 0.02) and 38% vs. 15% (p < 0.001), respectively. After adjustment or using a propensity score-matched analysis, immunosuppression was not associated with intubation, whereas it remained independently associated with ICU mortality with an adjusted odds ratio of 2.64 (95% CI 1.24-5.67, p = 0.01). CONCLUSIONS Immunosuppression status may directly influence mortality but does not seem to be associated with an increased risk of intubation in patients with de novo acute hypoxemic respiratory failure treated with NIV. Studies in this specific population are needed.


title: Advanced imaging in acute ischemic stroke.

text: The evaluation and management of acute ischemic stroke has primarily relied on the use of conventional CT and MRI techniques as well as lumen imaging sequences such as CT angiography (CTA) and MR angiography (MRA). Several newer or less-established imaging modalities, including vessel wall MRI, transcranial Doppler ultrasonography, and 4D CTA and MRA, are being developed to complement conventional CT and MRI techniques. Vessel wall MRI provides high-resolution analysis of both extracranial and intracranial vasculature to help identify previously occult lesions or characteristics of lesions that may portend a worse natural history. Transcranial Doppler ultrasonography can be used in the acute setting as a minimally invasive way of identifying large vessel occlusions or monitoring the response to stroke treatment. It can also be used to assist in the workup for cryptogenic stroke or to diagnose a patent foramen ovale. Four-dimensional CTA and MRA provide a less invasive alternative to digital subtraction angiography to determine the extent of the clot burden and the degree of collateral blood flow in large vessel occlusions. Along with technological advances, these new imaging modalities are improving the diagnosis, workup, and management of acute ischemic stroke- roles that will continue to expand in the future.


Medical and dental consultants' association of nigeria (MDCAN) standard operating procedure (SOP) on COVID-19 outbreaks for use by consultants and other health workers at service points within hospitals in Nigeria.


title: The deformation monitoring of foundation pit by back propagation neural network and genetic algorithm and its application in geotechnical engineering.

text: The objective is to improve the prediction accuracy of foundation pit deformation in geotechnical engineering, thereby provide early warning for engineering practice. The digital close-range photogrammetry is used to obtain monitoring data. The error compensation method is used to optimize the center of the monitoring point. Aiming at the limitations of back propagation neural network (BPNN), a genetic algorithm (GA)-optimized BPNN algorithm is proposed. Then, the optimized algorithm is applied to predict the deformation and displacement of foundation pits from three aspects, i.e., simple horizontal displacement, simple longitudinal displacement, and the combination of horizontal and longitudinal displacements. Meanwhile, the time domain, space domain, and time-space domain are used as input features to compare the prediction results of the BPNN model and the GA-optimized BPNN model. Finally, the GA-improved BPNN is compared with the Support Vector Regression (SVR) model and Random Forest (RF) model. The results show that the prediction result, obtained by simultaneously using horizontal displacement and longitudinal displacement as input features, has smaller errors; also, the actual output is closer to the expected output. Compared with the prediction result with time domain and space domain as input features, the prediction result with time-space domain as input features is closer to the expected output. Taking the combination of time and space domains as input features, compared with the BPNN model, the GA-optimized BPNN model has a lower Root Mean Squared Error (RMSE) value (0.0163), a larger Index of Agreement (IA) value (0.9800), and a shorter training time (7.08 s). Compared with the SVR model and RF model, the GA-improved BPNN model has a lower Root Mean Squared Error (RMSE) value (0.0211), a larger Index of Agreement (IA) value (0.9706), and shorter training time (7.61 s). Therefore, the foundation pit deformation prediction model based on BPNN and GA has strong prediction ability, which can be popularized and applied in similar geotechnical engineering.


title: Truncation of the enzootic nasal tumor virus envelope protein cytoplasmic tail increases Env-mediated fusion and infectivity.

text: Enzootic nasal tumor virus (ENTV) and Jaagsiekte sheep retrovirus (JSRV) are highly related ovine betaretroviruses that induce nasal and lung tumours in small ruminants, respectively. While the ENTV and JSRV envelope (Env) glycoproteins mediate virus entry using the same cellular receptor, the glycosylphosphatidylinositol-linked protein hyaluronoglucosaminidase, ENTV Env pseudovirions mediate entry into cells from a much more restricted range of species than do JSRV Env pseudovirions. Unlike JSRV Env, ENTV Env does not induce cell fusion at pH 5.0 or above, but rather requires a much lower pH (4.0-4.5) for fusion to occur. The cytoplasmic tail of retroviral envelope proteins is a key modulator of envelope-mediated fusion and pseudotype efficiency, especially in the context of virions composed of heterologous Gag proteins. Here we report that progressive truncation of the ENTV Env cytoplasmic tail improves transduction efficiency of pseudotyped retroviral vectors and that complete truncation of the ENTV Env cytoplasmic tail increases transduction efficiency to wild-type JSRV Env levels by increasing fusogenicity without affecting sensitivity to inhibition by lysosomotropic agents, subcellular localization or efficiency of inclusion into virions. Truncation of the cytoplasmic domain of ENTV Env resulted in a significant advantage in viral entry into all cell types tested, including foetal ovine lung and nasal cells. Taken together, we demonstrate that the cytoplasmic tail modulates the fusion activity of the ENTV Env protein and that truncation of this region enhances Eenv-mediated entry into target cells.


title: Cone-beam computed tomography fusion and navigation for real-time positron emission tomography-guided biopsies and ablations: a feasibility study.

text: PURPOSE To describe a novel technique for multimodality positron emission tomography (PET) fusion-guided interventions that combines cone-beam computed tomography (CT) with PET/CT before the procedure. MATERIALS AND METHODS Subjects were selected among patients scheduled for a biopsy or ablation procedure. The lesions were not visible with conventional imaging methods or did not have uniform uptake on PET. Clinical success was defined by adequate histopathologic specimens for molecular profiling or diagnosis and by lack of enhancement on follow-up imaging for ablation procedures. Time to target (time elapsed between the completion of the initial cone-beam CT scan and first tissue sample or treatment), total procedure time (time from the moment the patient was on the table until the patient was off the table), and number of times the needle was repositioned were recorded. RESULTS Seven patients underwent eight procedures (two ablations and six biopsies). Registration and procedures were completed successfully in all cases. Clinical success was achieved in all biopsy procedures and in one of the two ablation procedures. The needle was repositioned once in one biopsy procedure only. On average, the time to target was 38 minutes (range 13-54 min). Total procedure time was 95 minutes (range 51-240 min, which includes composite ablation). On average, fluoroscopy time was 2.5 minutes (range 1.3-6.2 min). CONCLUSIONS An integrated cone-beam CT software platform can enable PET-guided biopsies and ablation procedures without the need for additional specialized hardware.


title: Coronavirus replicase-reporter fusions provide quantitative analysis of replication and replication complex formation.

text: UNLABELLED The replication of coronaviruses occurs in association with multiple virus-induced membrane structures that evolve during the course of infection; however, the dynamics of this process remain poorly understood. Previous studies of coronavirus replication complex organization and protein interactions have utilized protein overexpression studies and immunofluorescence of fixed cells. Additionally, live-imaging studies of coronavirus replicase proteins have used fluorescent reporter molecules fused to replicase proteins, but expressed from nonnative locations, mostly late-transcribed subgenomic mRNAs, in the presence or absence of the native protein. Thus, the timing and targeting of native replicase proteins expressed in real time from native locations in the genome remain unknown. In this study, we tested whether reporter molecules could be expressed from the replicase polyprotein of murine hepatitis virus as fusions with nonstructural protein 2 or 3 and whether such reporters could define the targeting and activity of replicase proteins during infection. We demonstrate that the fusion of green fluorescent protein and firefly luciferase with either nonstructural protein 2 or 3 is tolerated and that these reporter-replicase fusions can be used to quantitate replication complex formation and virus replication. The results show that the replicase gene has flexibility to accommodate a foreign gene addition and can be used directly to study replicase complex formation and evolution during infection as well as to provide highly sensitive and specific markers for protein translation and genome replication. IMPORTANCE Coronaviruses are a family of enveloped, positive-sense RNA viruses that are important agents of disease, including severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus. Replication is associated with multiple virus-induced membrane structures that evolve during infection; however, the dynamics of this process remain poorly understood. In this study, we tested whether reporter molecules expressed from native locations within the replicase polyprotein of murine hepatitis virus as fusions with nonstructural proteins could define the expression and targeting of replicase proteins during infection in live cells. We demonstrate that the replicase gene tolerates the introduction of green fluorescent protein or firefly luciferase as fusions with replicase proteins. These viruses allow early quantitation of virus replication as well as real-time measurement of replication complexes.


title: Nasopharyngeal Lactobacillus is associated with a reduced risk of childhood wheezing illnesses following acute respiratory syncytial virus infection in infancy.

text: BACKGROUND Early life acute respiratory infection (ARI) with respiratory syncytial virus (RSV) has been strongly associated with the development of childhood wheezing illnesses, but the pathways underlying this association are poorly understood. OBJECTIVE To examine the role of the nasopharyngeal microbiome in the development of childhood wheezing illnesses following RSV ARI in infancy. METHODS We conducted a nested cohort study of 118 previously healthy, term infants with confirmed RSV ARI by RT-PCR. We used next-generation sequencing of the V4 region of the 16S ribosomal RNA gene to characterize the nasopharyngeal microbiome during RSV ARI. Our main outcome of interest was 2-year subsequent wheeze. RESULTS Of the 118 infants, 113 (95.8%) had 2-year outcome data. Of these, 46 (40.7%) had parental report of subsequent wheeze. There was no association between the overall taxonomic composition, diversity, and richness of the nasopharyngeal microbiome during RSV ARI with the development of subsequent wheeze. However, the nasopharyngeal detection and abundance of Lactobacillus was consistently higher in infants who did not develop this outcome. Lactobacillus also ranked first among the different genera in a model distinguishing infants with and without subsequent wheeze. CONCLUSIONS The nasopharyngeal detection and increased abundance of Lactobacillus during RSV ARI in infancy are associated with a reduced risk of childhood wheezing illnesses at age 2 years.


title: A new arenavirus in a cluster of fatal transplant-associated diseases.

text: BACKGROUND Three patients who received visceral-organ transplants from a single donor on the same day died of a febrile illness 4 to 6 weeks after transplantation. Culture, polymerase-chain-reaction (PCR) and serologic assays, and oligonucleotide microarray analysis for a wide range of infectious agents were not informative. METHODS We evaluated RNA obtained from the liver and kidney transplant recipients. Unbiased high-throughput sequencing was used to identify microbial sequences not found by means of other methods. The specificity of sequences for a new candidate pathogen was confirmed by means of culture and by means of PCR, immunohistochemical, and serologic analyses. RESULTS High-throughput sequencing yielded 103,632 sequences, of which 14 represented an Old World arenavirus. Additional sequence analysis showed that this new arenavirus was related to lymphocytic choriomeningitis viruses. Specific PCR assays based on a unique sequence confirmed the presence of the virus in the kidneys, liver, blood, and cerebrospinal fluid of the recipients. Immunohistochemical analysis revealed arenavirus antigen in the liver and kidney transplants in the recipients. IgM and IgG antiviral antibodies were detected in the serum of the donor. Seroconversion was evident in serum specimens obtained from one recipient at two time points. CONCLUSIONS Unbiased high-throughput sequencing is a powerful tool for the discovery of pathogens. The use of this method during an outbreak of disease facilitated the identification of a new arenavirus transmitted through solid-organ transplantation.


title: Economics of Palliative Care for Hospitalized Adults With Serious Illness: A Meta-analysis.

text: Importance Economics of care for adults with serious illness is a policy priority worldwide. Palliative care may lower costs for hospitalized adults, but the evidence has important limitations. Objective To estimate the association of palliative care consultation (PCC) with direct hospital costs for adults with serious illness. Data Sources Systematic searches of the Embase, PsycINFO, CENTRAL, PubMed, CINAHL, and EconLit databases were performed for English-language journal articles using keywords in the domains of palliative care (eg, palliative, terminal) and economics (eg, cost, utilization), with limiters for hospital and consultation. For Embase, PsycINFO, and CENTRAL, we searched without a time limitation. For PubMed, CINAHL, and EconLit, we searched for articles published after August 1, 2013. Data analysis was performed from April 8, 2017, to September 16, 2017. Study Selection Economic evaluations of interdisciplinary PCC for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders. Data Extraction and Synthesis Eight eligible studies were identified, all cohort studies, of which 6 provided sufficient information for inclusion. The study estimated the association of PCC within 3 days of admission with direct hospital costs for each sample and for subsamples defined by primary diagnoses and number of comorbidities at admission, controlling for confounding with an instrumental variable when available and otherwise propensity score weighting. Treatment effect estimates were pooled in the meta-analysis. Main Outcomes and Measures Total direct hospital costs. Results This study included 6 samples with a total 133 118 patients (range, 1020-82 273), of whom 93.2% were discharged alive (range, 89.0%-98.4%), 40.8% had a primary diagnosis of cancer (range, 15.7%-100.0%), and 3.6% received a PCC (range, 2.2%-22.3%). Mean Elixhauser index scores ranged from 2.2 to 3.5 among the studies. When patients were pooled irrespective of diagnosis, there was a statistically significant reduction in costs (-$3237; 95% CI, -$3581 to -$2893; P < .001). In the stratified analyses, there was a reduction in costs for the cancer (-$4251; 95% CI, -$4664 to -$3837; P < .001) and noncancer (-$2105; 95% CI, -$2698 to -$1511; P < .001) subsamples. The reduction in cost was greater in those with 4 or more comorbidities than for those with 2 or fewer. Conclusions and Relevance The estimated association of early hospital PCC with hospital costs may vary according to baseline clinical factors. Estimates may be larger for primary diagnosis of cancer and more comorbidities compared with primary diagnosis of noncancer and fewer comorbidities. Increasing palliative care capacity to meet national guidelines may reduce costs for hospitalized adults with serious and complex illnesses.


Searching for the ideal endobronchial blocker.


title: Laparoscopic percutaneous jejunostomy with intracorporeal V-Loc jejunopexy in esophageal cancer.

text: BACKGROUND Barbed sutures are widely used in various laparoscopic digestive surgeries. The purpose of this paper is to present our initial experience of laparoscopic percutaneous jejunostomy with unidirectional barbed sutures in esophageal cancer patients and compare it with our early cases using traditional transabdominal sutures. METHODS A total of 118 esophageal cancer patients who underwent laparoscopic percutaneous jejunostomy were identified in a single institution in Taiwan from June 2014 to May 2016. The authors' traditional technique consisted of using transabdominal sutures with bolsters to fix a jejunum loop onto the anterior abdominal wall. A novel technique was introduced using intracorporeal suturing with knotless unidirectional barbed monofilament absorbable sutures (V-Loc) to attain a seal around the feeding catheter. A comparison between these two techniques was performed. RESULTS Twenty cases with barbed V-Loc sutures and 98 cases with transabdominal sutures were identified. The V-Loc sutures appeared to reduce peristomal skin ulcers (19.4 vs. 0 %, p = 0.040), postoperative pain scores during the first 24 h (1.8 ± 1.4 vs. 0.9 ± 1.1, p = 0.007) and on postoperative day 2 (1.7 ± 1.4 vs. 1.0 ± 0.8, p = 0.026) when compared to patients receiving transabdominal sutures. The mean suturing time using V-Loc sutures was 22 min (14-60 min). The mean onset to resumption of enteral feeding was 1.8 ± 0.8 days and the mean duration of postoperative hospital stay was 8 ± 5.1 days, both of which were comparable in the two groups. There was no surgical mortality in our series. CONCLUSIONS In the study cohort, the use of knotless unidirectional barbed sutures instead of traditional transabdominal sutures had similar outcomes and appears to be a feasible option for intracorporeal jejunopexy when performing laparoscopic jejunostomy in patients with esophageal cancer.


Commentary: The molecular pandemonium of coronavirus disease 2019.


Assessment of immune response to SARS-CoV-2 with fully automated MAGLUMI 2019-nCoV IgG and IgM chemiluminescence immunoassays.


title: Risk adjustment for case mix and the effect of surgeon volume on morbidity.

text: IMPORTANCE Retrospective studies of large administrative databases have shown higher mortality for procedures performed by low-volume surgeons, but the adequacy of risk adjustment in those studies is in doubt. OBJECTIVE To determine whether the relationship between surgeon volume and outcomes is an artifact of case mix using a prospective sample of carotid endarterectomy cases. DESIGN Observational cohort study from January 1, 2008, through December 31, 2010, with preoperative, immediate postoperative, and 30-day postoperative assessments acquired by independent monitors. SETTING Urban, tertiary academic medical center. PATIENTS All 841 patients who underwent carotid endarterectomy performed by a vascular surgeon or cerebrovascular neurosurgeon at the institution. INTERVENTION Carotid endarterectomy without another concurrent surgery. MAIN OUTCOME MEASURES Stroke, death, and other surgical complications occurring within 30 days of surgery along with other case data. A low-volume surgeon performed 40 or fewer cases per year. Variables used in a comparison administrative database study, as well as variables identified by our univariate analysis, were used for adjusted analyses to assess for an association between low-volume surgeons and the rate of stroke and death as well as other complications. RESULTS The rate of stroke and death was 6.9% for low-volume surgeons and 2.0% for high-volume surgeons (P = .001). Complications were similarly higher (13.4% vs 7.2%, P = .008). Low-volume surgeons performed more nonelective cases. Low-volume surgeons were significantly associated with stroke and death in the unadjusted analysis as well as after adjustment with variables used in the administrative database study (odds ratio, 3.61; 95% CI, 1.70-7.67, and odds ratio, 3.68; 95% CI, 1.72-7.89, respectively). However, adjusting for the significant disparity of American Society of Anesthesiologists Physical Status classification in case mix eliminated the effect of surgeon volume on the rate of stroke and death (odds ratio, 1.65; 95% CI, 0.59-4.64) and other complications. CONCLUSIONS AND RELEVANCE Variables selected for risk adjustment in studies using administrative databases appear to be inadequate to control for case mix bias between low-volume and high-volume surgeons. Risk adjustment should empirically analyze for case mix imbalances between surgeons to identify meaningful risk modifiers in clinical practice such as the American Society of Anesthesiologists Physical Status classification. A true relationship between surgeon volume and outcomes remains uncertain, and caution is advised in developing policies based on these findings.


docid: krjzcrru

title: Advanced digital subtraction angiography and MR fusion imaging protocol applied to accurate placement of flow diverter device.

text: In recent years there has been a progressive increase in interventional neuroradiology procedures, partially due to improvements in devices, but also to the simultaneous development of technologies and radiological images. Cone beam CT (Dyna-CT; Siemens) is a method recently used to obtain pseudo CT images from digital subtraction angiography (DSA) with a flat panel detector. Using dedicated software, it is then possible to merge Dyna-CT images with images from a different source. We report here the usefulness of advanced DSA techniques (Syngo-Dyna CT, three-dimensional DSA iPilot) for the treatment of an intracranial aneurysm with a flow diverter device. Merging MR and Dyna-CT images at the end of the procedure proved to be a simple and rapid additional method of verifying the success of the intervention.


title: [Analysis of transmission characteristics of COVID-19 in Shaanxi Province].

text: A total of 245 cases of COVID-19 in Shaanxi Province reported in the China information system for disease control and prevention as of February 24, 2020 were selected as the research objects, the cases are divided into imported cases (116 cases, 47.3%) and local cases (129 cases, 52.7%), their basic characteristics, time distribution, transmission mode, intergenerational interval and latent period transmission are analyzed. The age of local cases [(51.74±15.67) years old], female patients (69 cases, 53.5%), housework and retired staff (40 cases, 31.0%), and patients isolated at the time of onset (50 cases, 38.8%) were higher than imported cases, respectively[(40.66±15.41) years old, (45 cases, 38.8%), (21 cases, 18.1%), (17 cases, 14.6%)] (P values were < 0.05); The infection rate was 0.8% (31/3 666) in close contacts with local cases, which was lower than imported cases 2.0% (69/3 435) (P<0.001); The main source of infection in local cases was relatives (70 cases, 54.3%), and the main way of infection was living together and party (90 cases, 69.8%); the proportion of latent period transmission in our province was 15.5% (20 cases), and the interval between the second-generation case and the source of infection was about 4 days, and the interval between generations was about 6 days. In summary, the main way of infection of local cases in Shaanxi Province was living together and party, there were a certain proportion of latent period transmission cases at present, it's suggested that the investigation of close contacts should be started 4 days or earlier before the onset of the case.


Surgeon who said covid-19 was a hoax has been suspended pending GMC investigation.


title: Nonthrombotic Pulmonary Artery Embolism: Imaging Findings and Review of the Literature.

text: OBJECTIVE The purpose of this article is to emphasize the imaging findings encountered in the setting of nonthrombotic pulmonary embolism. CONCLUSION Nonthrombotic pulmonary embolism refers to a spectrum of clinical and radiologic disorders caused by embolization of the pulmonary artery vasculature by various cell types, microorganism, and foreign bodies. Awareness of the imaging and clinical features of the nonthrombotic pulmonary embolism may facilitate prompt diagnosis.


title: Lower limb muscle activity during table tennis strokes.

text: This study aimed to compare the muscle activity of lower limbs across typical table tennis strokes. Fourteen high-level players participated in this study in which five typical strokes (backhand top, forehand top, forehand spin, forehand smash, flick) were analysed. Surface electromyography activity (EMG) of eight muscles was recorded (gluteus maximus, biceps femoris, vastus medialis, vastus lateralis, rectus femoris, gastrocnemius medialis, gastrocnemius lateralis, soleus) and normalised to the maximal activity measured during squat jump or isometric maximal voluntary contractions. The forehand spin, the forehand top and the forehand smash exhibited significant higher EMG amplitude when compared with other strokes. Both biceps femoris and gluteus maximus were strongly activated during the smash, forehand spin and forehand top (from 62.8 to 91.7% of maximal EMG activity). Both vastii and rectus femoris were moderately to strongly activated during the forehand spin (from 50.4 to 62.2% of maximal EMG activity) whereas gastrocnemii and soleus exhibited the highest level of activity during the smash (from 67.1 to 92.1% of maximal EMG activity). Our study demonstrates that offensive strokes, such as smash or forehand top, exhibit higher levels of activity than other strokes.


title: A Naturally Transmitted Epitheliotropic Polyomavirus Pathogenic in Immunodeficient Rats: Characterization, Transmission, and Preliminary Epidemiologic Studies.

text: We report the identification, pathogenesis, and transmission of a novel polyomavirus in severe combined immunodeficient F344 rats with null Prkdc and interleukin 2 receptor gamma genes. Infected rats experienced weight loss, decreased fecundity, and mortality. Large basophilic intranuclear inclusions were observed in epithelium of the respiratory tract, salivary and lacrimal glands, uterus, and prostate gland. Unbiased viral metagenomic sequencing of lesioned tissues identified a novel polyomavirus, provisionally named Rattus norvegicus polyomavirus 2 (RatPyV2), which clustered with Washington University (WU) polyomavirus in the Wuki clade of the Betapolyomavirus genus. In situ hybridization analyses and quantitative polymerase chain reaction (PCR) results demonstrated viral nucleic acids in epithelium of respiratory, glandular, and reproductive tissues. Polyomaviral disease was reproduced in Foxn1rnu nude rats cohoused with infected rats or experimentally inoculated with virus. After development of RatPyV2-specific diagnostic assays, a survey of immune-competent rats from North American research institutions revealed detection of RatPyV2 in 7 of 1,000 fecal samples by PCR and anti-RatPyV2 antibodies in 480 of 1,500 serum samples. These findings suggest widespread infection in laboratory rat populations, which may have profound implications for established models of respiratory injury. Additionally, RatPyV2 infection studies may provide an important system to investigate the pathogenesis of WU polyomavirus diseases of man.


title: Leveraging the COVID-19 response to improve emergency care systems in the Eastern Mediterranean Region.

text: The COVID-19 pandemic began as a cluster of reported cases of acute respiratory illness in China on 31 December 2019 and went on to spread with exponential growth across the globe. By the time it was characterized as a global pandemic on 11 March 2020, 17 of 22 countries in the Eastern Mediterranean Region (EMR) had reports of infected persons. EMR countries are particularly susceptible to such outbreaks due to the presence of globally interconnected markets; complex emergencies in more than half of the countries; religious mass gatherings that draw tens of millions of pilgrims annually; and variation in emergency care systems capacity and health systems performance within and between countries.


Five principles for pandemic preparedness: lessons from the Australian COVID-19 primary care response.


title: Binding insight of clinically oriented drug famotidine with the identified potential target of SARS-CoV-2.

text: Communicated by Ramaswamy H. Sarma.


The ABCs of skin care for wound care clinicians: dermatitis and eczema.


title: Laparoendoscopic single-site surgery in gynecologic oncology: An update.

text: The preferred surgical approach for many gynecologic oncology procedures is now laparoscopy. Reduced morbidity, shorter hospitalization and a more rapid recovery have been associated with minimally invasive surgical approaches when compared to laparotomy. Incisional morbidity, including vascular and viscous injury, postoperative hernia, infection, and pain remain significant concerns. Use of fewer and smaller incisions during laparoscopy may be expected to further minimize these risks. Laparoendoscopic single-site surgery (LESS), or single incision laparoscopy, describes the use of one small skin incision to complete laparoscopic surgical procedures. Recent advances in instrumentation have allowed increasingly complex procedures in gynecologic cancer patients to be completed. This review will serve as an update in regards to implementation of LESS in gynecologic oncology. Technical challenges encountered during performance of LESS as well as strategies to overcome these challenges will be discussed.


title: Effectiveness and safety of morphine sulfate extended-release capsules in patients with chronic, moderate-to-severe pain in a primary care setting.

text: BACKGROUND The purpose of this study was to determine the effectiveness and safety of morphine sulfate extended-release capsules among primary care patients with chronic, moderate-to-severe pain using a universal precautions approach that assessed and monitored risk for opioid misuse and abuse. METHODS This open-label, uncontrolled, multicenter, prospective study was conducted in primary care centers (n = 281) and included opioid-naïve and opioid-experienced patients with either a pain score ≥4 (0 = no pain, 10 = pain as bad as you can imagine), or with unacceptable side effects while taking opioids. The patients were treated with morphine sulfate extendedrelease capsules for up to four months. Patient-rated pain intensity (worst, least, average) over the past 24 hours (0-10 scale), pain interference with seven activities of daily living (0 = no interference, 10 = completely interferes), and adverse events were recorded. RESULTS Of 1487 patients who filled at least one prescription, 561 (38%) completed the study. Patients were primarily white (87%) and female (57%); 92% had pain for more than one year; and 79% were opioid-experienced. Median age was 52 years. Decreases in mean (± standard deviation) average pain scores (baseline 6.2 ± 2.3) were -0.8 ± 2.2 at visit 2 (5-14 days later), and -1.6 ± 2.3 and -1.7 ± 2.2 at visits 3 and 4 (spaced 3-4 weeks apart), respectively, and -1.1 ± 2.4 at visit 5 (included patients withdrawn from the study who were no longer taking the study drug). A similar trend was observed for worst pain and least pain scores and for pain interference with activities. Fifty-one percent of the safety population patients and 81% in the completer population reported being satisfied or very satisfied with the study treatment. Most common adverse events were typical of opioids, ie, constipation (14%), nausea (11%), vomiting (5%), and somnolence (5%). CONCLUSION The results suggest that pain outcomes improved in patients with chronic, moderate-to-severe pain receiving morphine sulfate extended-release capsules within the context of a structured universal precautions approach in the primary care setting.


title: Impact of humidification and nebulization during expiratory limb protection: an experimental bench study.

text: BACKGROUND Different filtering devices are used during mechanical ventilation to avoid dysfunction of flow and pressure transducers or for airborne microorganisms containment. Water condensates, resulting from the use of humidifiers, but also residual nebulization particles may have a major influence on expiratory limb resistance. OBJECTIVES To evaluate the influence of nebulization and active humidification on the resistance of expiratory filters. METHODS A respiratory system analog was constructed using a test lung, an ICU ventilator, heated humidifiers, and a piezoelectric nebulizer. Humidifiers were connected to different types of circuits (unheated, mono-heated, new-generation and old-generation bi-heated). Five filter types were evaluated: electrostatic, heat-and-moisture exchanger, standard, specific, and internal heated high-efficiency particulate air [HEPA] filter. Baseline characteristics were obtained from each dry filter. Differential pressure measurements were carried out after 24 hours of continuous in vitro use for each condition, and after 24 hours of use with an old-generation bi-heated circuit without nebulization. RESULTS While using unheated circuits, measurements had to be interrupted before 24 hours for all the filtering devices except the internal heated HEPA filter. The heat-and-moisture exchangers occluded before 24 hours with the unheated and mono-heated circuits. The circuit type, nebulization practice, and duration of use did not influence the internal heated HEPA filter resistance. CONCLUSION Expiratory limb filtration is likely to induce several major adverse events. Expiratory filter resistance increase is due mainly to the humidification circuit type, rather than to nebulization. If filtration is mandatory while using an unheated circuit, a dedicated filter should be used for ≤ 24 hours, or a heated HEPA for a longer duration.


title: Comparison between a novel knotless technique and the conventional single knot technique of laparoscopic radical prostatectomy by novice laparoscopists.

text: OBJECTIVES This study aimed to investigate a novel knotless technique for novice laparoscopists in traditional laparoscopic radical prostatectomy. METHODS We studied 68 patients who had a novel technique performed in laparoscopic radical prostatectomy (knotless group) and 89 who had the conventional single knot technique (single knot group). The operations were all performed by novice laparoscopists with experience of fewer than 100 cases of laparoscopic radical prostatectomy. Knotless suture of the dorsal vein complex was conducted using a barbed self-retaining suture with three bites at the same location. The knotless urethrovesical anastomosis technique was conducted using a unidirectional single running fashion with a barbed self-retaining suture. RESULTS There were no significant differences in the estimated blood loss, complication rate, postoperative hospital stay, anastomotic leakage rate, continence at 6 months after surgery, and positive margin rate between the two groups. The mean anastomotic time (24.9 vs. 44.2 min), operative time (168.1 vs. 201.8 min), and duration of catheter placement (12.8 vs. 19.8 days) were shorter in the knotless group than in the single-knot group. CONCLUSIONS The knotless technique of laparoscopic radical prostatectomy is a safe and effective procedure.


title: Emergency revascularization of acute internal carotid artery occlusion: Follow the spike, it guides you.

text: The present study sought to examine the incidence of the angiographic "spike sign" and to assess its predictive significance for achieving carotid revascularization in 54 patients with acute internal carotid artery (ICA) occlusions that required urgent endovascular revascularization. Clinical and imaging files of consecutive patients with ICA occlusion who were treated in a tertiary care academic medical center from 2011-2015 were retrospectively examined under Institutional Review Board approval with a waiver of the requirement for informed consent. All proximal ICA occlusions were treated by stent-assisted carotid angioplasty, and all distal embolic occlusions were managed with stent-assisted mechanical thrombectomy. The study included 24 patients with acute ICA occlusion (group 1) and 30 patients with tandem ICA-intracranial occlusions (group 2). The spike sign was seen in 16/24 patients in group 1 (67%), and successful ICA revascularization was achieved in 14/16 (88%). The sign was seen in 26/30 patients in group 2 (87%), and ICA revascularization was successful in all 26 (100%). The remaining 12 patients had no spike sign, and ICA revascularization was successful in only 7/12 (58%). The spike sign is a transient finding that represents the proximal patent remnant of the stenotic corridor in fresh clot. Acute ICA occlusion frequently leaves the spike sign as a marker of the recent thrombotic event. The spike vertex points to the "path of least resistance" for the guidewire to cross the occlusion and engage the true arterial lumen, a critical step during ICA endovascular revascularization.


title: Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn's disease: the LIR!C Trial.

text: OBJECTIVE Evaluate the cost-effectiveness of laparoscopic ileocaecal resection compared with infliximab in patients with ileocaecal Crohn's disease failing conventional therapy. DESIGN A multicentre randomised controlled trial was performed in 29 centres in The Netherlands and the UK. Adult patients with Crohn's disease of the terminal ileum who failed >3 months of conventional immunomodulators or steroids without signs of critical strictures were randomised to laparoscopic ileocaecal resection or infliximab. Outcome measures included quality-adjusted life-years (QALYs) based on the EuroQol (EQ) 5D-3L Questionnaire and the Inflammatory Bowel Disease Questionnaire (IBDQ). Costs were measured from a societal perspective. Analyses were performed according to the intention-to-treat principle. Missing cost and effect data were imputed using multiple imputation. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated to show uncertainty. RESULTS In total, 143 patients were randomised. Mean Crohn's disease total direct healthcare costs per patient at 1 year were lower in the resection group compared with the infliximab group (mean difference €-8931; 95% CI €-12 087 to €-5097). Total societal costs in the resection group were lower than in the infliximab group, however not statistically significant (mean difference €-5729, 95% CI €-10 606 to €172). The probability of resection being cost-effective compared with infliximab was 0.96 at a willingness to pay (WTP) of €0 per QALY gained and per point improvement in IBDQ Score. This probability increased to 0.98 at a WTP of €20 000/QALY gained and 0.99 at a WTP of €500/point of improvement in IBDQ Score. CONCLUSION Laparoscopic ileocaecal resection is a cost-effective treatment option compared with infliximab. CLINICAL TRIAL REGISTRATION NUMBER Dutch Trial Registry NTR1150; EudraCT number 2007-005042-20 (closed on 14 October 2015).


title: School-based health centers during academic disruption: Challenges and opportunity in urban mental health.

text: School based health centers (SBHC) provide healthcare services to youth and their families. In response to the global health crisis from COVID-19, schools' closures have impacted the access to vital services during times of increased need for physical and mental healthcare. Youth of minority racial and ethnic backgrounds living in urban settings face compounding factors including adverse childhood events, economic disadvantages, and barriers to healthcare. The mental health response of SBHCs in New York City as it relates to population specific factors such as family supports, economic considerations, and healthcare correlates is explored. The role of school based health centers and recommendations for interventions addressing mental health concerns in youth during COVID-19 are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Large foreign body reaction to tension-free vaginal tape masquerading as inguinal hernia.

text: We report a case of a 73-year-old woman who presented to general surgery with a tender lump in the groin 5 years after insertion of a tension-free vaginal tape. The lesion was thought to be an incarcerated inguinal hernia. Emergency surgical exploration revealed a 7 × 5 × 4 cm soft tissue mass which was adherent to the external inguinal ring, emanating from the end of the tension-free vaginal tape at the level of the symphysis pubis. Resection and histological examination revealed a central track of granulation tissue with a surrounding foreign body inflammatory response. The surgery was complicated by an infected seroma requiring surgical drainage and antibiotic therapy, following which the patient made a full recovery. Large foreign body reaction is a rare but an important complication of tension-free vaginal tapes and may be mistaken for a groin hernia or lymphadenopathy.


title: Impact of Lipo-Body Lift Compared to Classical Lower Body Lift on Postoperative Outcome and Patient's Satisfaction: A Retrospective Study.

text: INTRODUCTION Lately, the growing number of bariatric procedures performed each year led to an increasing demand for lower trunk reconstruction. Our team previously described the lipo-body lift (LBL) technique into lower duration of drainage and therefore seromas and other complications. In this study, we compared the classical body lift (CBL) technique to the LBL procedure. MATERIALS AND METHODS All patients who underwent a LBL or CBL after massive weight loss between November 2012 and October 2017 were included. Surgery outcome parameters were collected as well as patient satisfaction through a satisfaction score realized at least after 1 year postoperative. Comparisons between CBL and LBL were conducted to assess the surgery's safety and the patient's satisfaction. RESULTS A total of 130 patients were included, 61 patients who had a LBL were compared to 69 patients who had a CBL. The mean patient age was 39.64 ± 9.97 (21-66) years old, the mean body mass index before plastic surgery was 26.83 ± 3.08 kg/m2 (19.83-32.69), and the average weight loss was 53.40 ± 17.37 kg. The two groups had comparable preoperative data. Duration of drainage and hospital stay was significantly lower in the LBL group than in the CBL (p < 0.0001 and p < 0.0001, respectively). Surgical outcomes were comparable between groups as well as patient satisfaction scores. CONCLUSION Lipo-body lift allows early discharge of the patient by reducing the duration of drainage without increasing the risk for complications. In our opinion, this technique should be used for type 1 and 2 patients with no contraindication for abdominal liposuction. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .


title: Evidence for causal links between education and maternal and child health: systematic review.

text: OBJECTIVE Numerous studies have documented an inverse association between years of schooling attained, particularly by women, and reduced maternal, infant and child mortality. However, if factors affecting educational attainment - many of which are unobservable, e.g. motivation and genetic endowment - also affect the likelihood of engaging in behaviours that enhance health, then assumed effects of schooling will be inflated in analyses that do not address this endogeneity. This systematic review assesses evidence for a causal link between education and maternal and child health in low and middle-income countries. METHODS Eligible studies controlled for observable and unobservable factors affecting both education and health. Reported effects were converted into partial correlations. When possible, we also conducted meta-analyses to estimate mean effects by outcome. RESULTS Of 4952 papers identified, 16 met the inclusion criteria. The 15 child health papers examined neonatal, infant and child mortality, stunting and wasting. Significant effects of education on infant and child health were observed for 30 of 33 models that did not account for endogeneity. In contrast, only 18 of 46 effects were significant in models that addressed endogeneity. Notably, for only one outcome -child mortality measured dichotomously -was the effect of maternal educational attainment significant in a meta-analysis. The one maternal morbidity paper found significant effects for the two preventable outcomes considered. CONCLUSION While we find evidence for a causal link between education and health, effects are weaker in models that address endogeneity compared to naïve models that do not account for unobservable factors affecting both education and health. Advances in women's educational outcomes have undoubtedly played a role in improving health in many settings; however, the effect is not as strong as some researchers and advocates have claimed.


title: Perturbation in the conserved methyltransferase-polymerase interface of flavivirus NS5 differentially affects polymerase initiation and elongation.

text: UNLABELLED The flavivirus NS5 is a natural fusion of a methyltransferase (MTase) and an RNA-dependent RNA polymerase (RdRP). Analogous to DNA-dependent RNA polymerases, the NS5 polymerase initiates RNA synthesis through a de novo mechanism and then makes a transition to a processive elongation phase. However, whether and how the MTase affects polymerase activities through intramolecular interactions remain elusive. By solving the crystal structure of the Japanese encephalitis virus (JEV) NS5, we recently identified an MTase-RdRP interface containing a set of six hydrophobic residues highly conserved among flaviviruses. To dissect the functional relevance of this interface, we made a series of JEV NS5 constructs with mutations of these hydrophobic residues and/or with the N-terminal first 261 residues and other residues up to the first 303 residues deleted. Compared to the wild-type (WT) NS5, full-length NS5 variants exhibited consistent up- or downregulation of the initiation activities in two types of polymerase assays. Five representative full-length NS5 constructs were then tested in an elongation assay, from which the apparent single-nucleotide incorporation rate constant was estimated. Interestingly, two constructs exhibited different elongation kinetics from the WT NS5, with an effect rather opposite to what was observed at initiation. Moreover, constructs with MTase and/or the linker region (residues 266 to 275) removed still retained polymerase activities, albeit at overall lower levels. However, further removal of the N-terminal extension (residues 276 to 303) abolished regular template-directed synthesis. Together, our data showed that the MTase-RdRP interface is relevant in both polymerase initiation and elongation, likely with different regulation mechanisms in these two major phases of RNA synthesis. IMPORTANCE The flavivirus NS5 is very unique in having a methyltransferase (MTase) placed on the immediate N terminus of its RNA-dependent RNA polymerase (RdRP). We recently solved the crystal structure of the full-length NS5, which revealed a conserved interface between MTase and RdRP. Building on this discovery, here we carried out in vitro polymerase assays to address the functional relevance of the interface interactions. By explicitly probing polymerase initiation and elongation activities, we found that perturbation in the MTase-RdRP interface had different impacts on different phases of synthesis, suggesting that the roles and contribution of the interface interactions may change upon phase transitions. By comparing the N-terminal-truncated enzymes with the full-length NS5, we collected data to indicate the indispensability to regular polymerase activities of a region that was functionally unclarified previously. Taken together, we provide biochemical evidence and mechanistic insights for the cross talk between the two enzyme modules of flavivirus NS5.


title: Imaging Paradigms in Acute Ischemic Stroke: A Pragmatic Evidence-based Approach.

text: Online supplemental material is available for this article.


title: Complete blood count might help to identify subjects with high probability of testing positive to SARS-CoV-2.

text: The SARS-CoV-2 pandemic has dramatically increased the workload for health systems and a consequent need to optimise resources has arisen, including the selection of patients for swab tests. We retrospectively reviewed consecutive patients presenting to the emergency department with symptoms suggestive of COVID-19 and undergoing swab tests for SARS-CoV-2. Complete blood counts (CBCs) were analysed looking for predictors of test positivity. Eight significant predictors were identified and used to build a 'complete' CBC score with a discriminatory power for COVID-19 diagnosis of AUC 92% (p<0.0001). When looking at the weight of individual variables, mean corpuscular volume (MCV), age, platelets and eosinophils (MAPE: MCV ≤90 fL, 65 points; age ≥45 years, 100 points; platelets ≤180×103/μL, 73 points; eosinophils <0.01/μL, 94 points) gave the highest contribution and were used to build a 'simplified' MAPE score with a discriminatory power of AUC 88%. By setting the cut-off MAPE score at ≥173 points, sensitivity and specificity for COVID-19 diagnosis were 83% and 82%, respectively, and the actual test positivity rate was 60% as compared to 6% of patients with MAPE score <173 points (odds ratio 23.04, 95% confidence interval [CI] 9.1-58.3, p-value <0.0001). In conclusion, CBC-based scores have potential for optimising the SARS-CoV-2 testing process: if these findings are confirmed in the future, swab tests may be waived for subjects with low score and uncertain symptoms, while they may be considered for asymptomatic or oligosymptomatic patients with high scores.


title: The Stanford Hall consensus statement for post-COVID-19 rehabilitation.

text: The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0-10. Substantial agreement (range 7.5-10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes.


title: Saudi association for the study of liver diseases and transplantation position statement on liver transplantation during the COVID-19 pandemic.

text: The World Health Organization (WHO), on March 11th 2020, upgraded the status of the novel coronavirus disease (COVID-19) from epidemic to pandemic. Over two million individuals have been infected with SARS-CoV-2, the virus causing COVID-19, and as of April, 14th 2020, there were over 5000 confirmed cases in Saudi Arabia (SA). Many countries, including SA, have imposed major restrictions on travel, and everyday life, and the implications of these necessary changes are being felt in liver transplant (LT) centers in SA. Concerns remain that there is an increased risk for individuals over 65 years of age, with underlying medical conditions, or for those who are immunocompromised. Therefore, the Saudi Association for the Study of Liver Diseases and Transplantation (SASLT) established an urgent task force to launch a statement that can be utilized by LT centers as a guidance in the management of patients with advanced liver disease from the time of LT listing to the post-operative care of transplanted patients.


title: Does mechanical thrombectomy in acute embolic stroke have long-term side effects on intracranial vessels? An angiographic follow-up study.

text: PURPOSE Mechanical thrombectomy (mTE) proved to be effective treating acute vessel occlusions with an acceptable rate of procedural complications. Potential long-term side effects of the vessel wall trauma caused by mechanical irritation of the endothelium are unknown up to now. METHODS From a retrospectively established database of 640 acute stroke treatments, we selected 261 patients with 265 embolic vessel occlusions treated successfully by mTE without permanent implantation of a stent. Analysis comprised the type of devices used and the number of passes performed. Digital subtraction angiography immediately after treatment was evaluated for vasospasm, dissection, and extravasation. Control angiographic images were evaluated for any morphological change compared to the immediate posttreatment angiographic run. RESULTS Recanalization was achieved with a median of one (range 1-10) mTE maneuvers. Vasospasm occurred in 69 territories (26.0 %) and was treated with glyceroltrinitrate in three. Dissection was observed in one vessel (0.4 %). Intraprocedural hemorrhage in two patients (0.8 %) was either wire or device induced. Follow-up digital subtraction angiography was available for 117 territories after a median of 107 days, revealing target vessel occlusion in one segment (0.9 %) and a de novo stenosis of four segments (3.4 %). All findings were clinically asymptomatic. Posttreatment vasospasm was more frequent in patients with de novo stenosis and occlusion (p = 0.038). CONCLUSION De novo stenoses and occlusions occur in a small proportion of patients after mTE. Because all lesions were clinically asymptomatic, this finding does not affect the overall benefit of the treatment. Vasospasm may predict late vessel wall changes.


The pandemic in pictures: how coronavirus is changing the world.


title: Outcomes with split liver transplantation are equivalent to those with whole organ transplantation.

text: BACKGROUND Split liver transplantation is an excellent option for expansion of the donor organ pool. However, reports of increased morbidity in split liver recipients may limit use of this technique. STUDY DESIGN This was a single center retrospective analysis investigating split liver transplantation. Between August 1, 1995 and March 30, 2012, 53 of 1,261 (4.2%) recipients received split liver grafts. RESULTS The 1-, 5-, and 10-year patient and graft survivals in adult recipients of split grafts were 95.5%, 89.5%, and 89.5%, respectively. Survival was similar to that of whole organ recipients (p = 0.15). Twenty-three adults received split grafts: 18 (78%) were right trisegment grafts, 4 (17.4%) were right lobes, and 1 (4.3%) was a left lobe. The mean cold ischemic time was 5.7 hours (±2.4 hours [SD]) and warm ischemic time was 36 minutes (±5.5 minutes). Four (17%) recipients required hepatic artery reconstruction; 5 (21.7%) required a caval-venous patch, and 5 (21.7%) had Roux-en-Y reconstruction of the bile duct. No venous conduits were required. Thirty children received split grafts (median age 1.2 years, range 0.1 to 16.4 years) and had a median weight of 8.6 kg (range 3.6 to 45 kg). Pediatric split 1-, 5-, and 10-year overall and graft survival rates were 96.7%, 80.0%, 80.0%, and 93.3%, 76.8, and 76.8%, respectively. Complications included retransplantation in 3 (10.0%), bile leak in 5 (16.7%), hepatic arterial thrombosis in 2 (6.7%), bowel perforation in 2 (6.7%), and bleeding in 2 (6.7%). The mean donor age was 22.4 months (±8.9) months and body mass index was 22.8 kg/m(2) (±3.3 kg/m(2)). CONCLUSIONS We demonstrated excellent outcomes in adult and pediatric recipients using carefully selected donors for liver splitting. We recommend escalation of the use of split liver transplants to expand the donor pool for cadaveric liver transplantation.


title: Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery.

text: BACKGROUND Surgical smoke production is inevitable during surgical procedures. Although many workplaces have adopted smoke-free environments, healthcare workers, especially surgeons, continue to be exposed to surgical smoke. METHODS From February 2013 to March 2013, a total of 20 patients underwent transperitoneal laparoscopic nephrectomy for renal cell carcinoma. A 5-L gas sample was collected 30 min after the electrocautery device was first used and was analyzed by gas chromatography and mass spectrometry. Cancer risk was calculated for carcinogenic compounds and hazard quotient was calculated for noncarcinogenic compounds using US Environmental Protection Agency guidelines. RESULTS Twenty patients with a median age of 57.5 years were enrolled in the study. Eighteen volatile organic compounds were detected by Japanese indoor air standards mix analysis. The cancer risks were ethanol, 5.10 × 10(-5) ± 6.35 × 10(-5); 1,2-dichloroethane, 4.75 × 10(-3) ± 7.42 × 10(-4); benzene, 1.09 × 10(-3) ± 4.33 × 10(-4); ethylbenzene, 2.87 × 10(-5) ± 1.32 × 10(-5); and styrene, 2.94 × 10(-6) ± 1.16 × 10(-6). The hazard quotients were acetone, 1.88 × 10(-2) ± 7.63 × 10(-3); hexane, 1.48 × 10(-1) ± 8.70 × 10(-2); benzene, 4.66 ± 1.85; toluene, 2.61 × 10(-2) ± 7.23 × 10(-3); p-xylene, 1.81 × 10(-1) ± 6.45 × 10(-2); o-xylene, 2.40 × 10(-2) ± 3.33 × 10(-2); and styrene, 5.15 × 10(-3) ± 2.03 × 10(-3). CONCLUSIONS For five carcinogenic compounds detected, the cancer risk was greater than negligible. For 1,2-dichloroethane and benzene, the risk was classified as unacceptable. Analysis of noncarcinogenic compounds showed that risk reduction measures are needed for benzene. Even though surgical smoke is not an immediate health hazard, operating room personnel should be aware of the potential long-term health risks associated with exposure.