title: Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT.

text: BACKGROUND Two antiplatelet agents are better than one for preventing recurrent stroke after acute ischaemic stroke or transient ischaemic attack (TIA). Therefore, intensive treatment with three agents might be better still, providing it does not cause undue bleeding. OBJECTIVE To compare the safety and efficacy of intensive therapy with guideline antiplatelet therapy for acute ischaemic stroke and TIA. DESIGN International prospective randomised open-label blinded end-point parallel-group superiority clinical trial. SETTING Acute hospitals at 106 sites in four countries. PARTICIPANTS Patients > 50 years of age with acute non-cardioembolic ischaemic stroke or TIA within 48 hours of ictus (stroke). INTERVENTIONS Participants were allocated at random by computer to 1 month of intensive (combined aspirin, clopidogrel and dipyridamole) or guideline (combined aspirin and dipyridamole, or clopidogrel alone) antiplatelet agents, and followed for 90 days. MAIN OUTCOME MEASURES The primary outcome was the incidence and severity of any recurrent stroke (ischaemic, haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days by blinded telephone follow-up. Analysis using ordinal logistic regression was by intention to treat. Other outcomes included bleeding and its severity, death, myocardial infarction (MI), disability, mood, cognition and quality of life. RESULTS The trial was stopped early on the recommendation of the Data Monitoring Committee after recruitment of 3096 participants (intensive, n = 1556; guideline, n = 1540) from 106 hospitals in four countries between April 2009 and March 2016. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy in 3070 (99.2%) participants with data [93 vs. 105 stroke/TIA events; adjusted common odds ratio 0.90, 95% confidence interval (CI) 0.67 to 1.20; p = 0.47]. Major (encompassing fatal) bleeding was increased with intensive as compared with guideline therapy [39 vs. 17 participants; adjusted hazard ratio (aHR) 2.23, 95% CI 1.25 to 3.96; p = 0.006]. There were no differences between the treatment groups in all-cause mortality, or the composite of death, stroke, MI and major bleeding (aHR 1.02, 95% CI 0.77 to 1.35; p = 0.88). LIMITATIONS Patients and investigators were not blinded to treatment. The comparator group comprised two guideline strategies because of changes in national guidelines during the trial. The trial was stopped early, thereby reducing its statistical power. CONCLUSIONS The use of three antiplatelet agents is associated with increased bleeding without any significant reduction in recurrence of stroke or TIA. FUTURE WORK The safety and efficacy of dual antiplatelet therapy (combined aspirin and clopidogrel) versus aspirin remains to be defined. Further research is required on identifying individual patient response to antiplatelets, and the relationship between response and the subsequent risks of vascular recurrent events and bleeding complications. TRIAL REGISTRATION Current Controlled Trials ISRCTN47823388. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 48. See the NIHR Journal Library website for further project information. The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) vanguard phase was funded by the British Heart Foundation (grant PG/08/083/25779, from 1 April 2009 to 30 September 2012) and indirect funding was provided by the Stroke Association through its funding of the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK. There was no commercial support for the trial and antiplatelet drugs were sourced locally at each site. The trial was sponsored by the University of Nottingham.


title: Mini-Laparoscopic Versus Conventional Laparoscopic Surgery for Benign Adnexal Masses.

text: BACKGROUND Minimally invasive endoscopic surgery has become an acceptable method for gynecologic indications for more than 20 years. We aimed to compare clinical and surgical outcomes between mini-laparoscopic surgery (MLS) and conventional laparoscopic surgery (CLS) for benign adnexal masses. As far as we know, no comparative study exists between these two minimal invasive procedures. METHODS During the period between January 2014 and December 2016, a total number of 132 laparoscopic surgeries were performed for bening adnexal masses in our clinic. Seventy women underwent CLS and 62 women underwent MLS. Pathological results and operating time of procedures, estimated blood loss, preoperative and postoperative complications, patient scale and observer scale (POSAS) and length of hospital stay were recorded. RESULTS There was no difference between the two groups regarding preoperative diagnosis, intraoperative surgical procedure performed, and length of hospital stay. The groups were compared in terms of postoperative pathological diagnosis using the Chi-square test, and there was a statistically significant difference between the two groups. Comparing the operation time and hematocrit change, there were statistically significant differences between the two groups. Both patient and observer PSOAS scar scores were better in MLS group (P < 0.05). CONCLUSIONS Mini-laparoscopy can be safely and effectively used to perform benign adnexal mass surgery.


title: Robot-assisted segmental resection for intralobar pulmonary sequestration.

text: INTRODUCTION Pulmonary sequestration is a rare congenital malformation found most frequently as intralobar sequestration in the left lower lobe. Complete surgical resection is considered the treatment of choice. PRESENTATION We present the case of a 29- year-old woman with intralobar pulmonary sequestration (ILS) diagnosed on chest CT. The sequestration was located in the left lower basal segments (segments 9 and 10) and was treated successfully by robot-assisted segmental resection without complication. DISCUSSION Recently, robot- assisted thoracoscopic lobar resections started to be performed for ILS. The sublobar, segmental resection are reserved mainly for the resection of pulmonary nodules. We report a first case of robot-assisted anatomical segmental resection for ILS. CONCLUSION We highlight the role of robotic technology offering three-dimensional view and excellent dexterity enhancing the surgical performance and getting the surgical procedure more precise and safer. This could be useful especially in case of challenging sublobar resections.


Covid 19: death certification in England and Wales.


title: Comparison of dexmedetomidine and dexamethasone for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy.

text: BACKGROUND Postoperative nausea and vomiting (PONV) are common following laparoscopic cholecystectomy (LC). Dexamethasone has been reported to reduce PONV. However, there is insufficient evidence regarding the effect of dexmedetomidine in decreasing PONV. This study was designed to compare the effects of a single dose of dexmedetomidine to dexamethasone for reducing PONV after LC. METHODS Eighty-six adult patients scheduled for LC were randomized to receive either single dose 1 µg/kg of dexmedetomidine (Dexmed group, N = 43) or 8 mg dexamethasone (Dexa group, N = 43) before skin incision. During the first 24 h postoperatively, the incidence and severity of PONV were assessed. Pain and sedation scores were assessed on arrival in the recovery room and early postoperatively. Analgesic and antiemetic consumption during the 24 h after surgery were calculated. Intra-operative and postoperative hemodynamics were recorded. RESULTS Twenty-one percent of the patients in the Dexmed group developed PONV compared to 28% in the Dexa group (P = 0.6). Severity of PONV was similar between the two groups (P = 0.07). Early postoperatively, pain severity was significantly lower in the Dexmed group, but sedation scores were significantly higher. The first analgesic request was significantly delayed in the Dexmed group (P = 0.02). The total amounts of intraoperative fentanyl and postoperative tramadol administered were significantly lower in the Dexmed group. No difference in ondansetron was noted between the two groups. Mean arterial pressure and heart rate were significantly lower in the Dexmed group after administration of dexmedetomidine. No major side effects were reported. CONCLUSIONS Dexmedetomidine reduces the incidence and severity of PONV, similar to dexamethasone. It is superior to dexamethasone in reducing postoperative pain and total analgesic consumption during the first 24 h after LC.


A Multicenter, Randomized, Controlled Trial Comparing Reinforced Staplers with Bare Staplers During Distal Pancreatectomy (HiSCO-07 Trial).


title: B cell response to herpesvirus infection of the olfactory neuroepithelium.

text: UNLABELLED Viruses commonly infect the respiratory tract. Analyses of host defense have focused on the lungs and the respiratory epithelium. Spontaneously inhaled murid herpesvirus 4 (MuHV-4) and herpes simplex virus 1 (HSV-1) instead infect the olfactory epithelium, where neuronal cilia are exposed to environmental antigens and provide a route across the epithelial mucus. We used MuHV-4 to define how B cells respond to virus replication in this less well-characterized site. Olfactory infection elicited generally weaker acute responses than lung infection, particularly in the spleen, reflecting slower viral replication and spread. Few virus-specific antibody-forming cells (AFCs) were found in the nasal-associated lymphoid tissue (NALT), a prominent response site for respiratory epithelial infection. Instead, they appeared first in the superficial cervical lymph nodes. The focus of the AFC response then moved to the spleen, matching the geography of virus dissemination. Little virus-specific IgA response was detected until later in the bone marrow. Neuroepithelial HSV-1 infection also elicited no significant AFC response in the NALT and a weak IgA response. Thus, olfactory herpesvirus infection differed immunologically from an infection of the adjacent respiratory epithelium. Poor IgA induction may help herpesviruses to transmit via long-term mucosal shedding. IMPORTANCE Herpesviruses are widespread, persistent pathogens against which vaccines have had limited success. We need to understand better how they interact with host immunity. MuHV-4 and HSV-1 inhaled by alert mice infect the olfactory neuroepithelium, suggesting that this is a natural entry route. Its immunology is almost completely unknown. The antibody response to neuroepithelial herpesvirus infection started in the cervical lymph nodes, and unlike respiratory influenza virus infection, did not significantly involve the nasal-associated lymphoid tissue. MuHV-4 and HSV-1 infections also elicited little virus-specific IgA. Therefore, vaccine-induced IgA might provide a defense that herpesviruses are ill-equipped to meet.


title: Cardiac tamponade as a complication of laparoscopic hiatal hernia repair: case report and literature review.

text: We report the case of a 61-year old female with history of gastroesophageal reflux disease and hiatal hernia who developed hemopericardium and tamponade one day after laparoscopic hiatal hernia repair and Toupe fundoplication. The patient underwent emergent pericardiocentesis and subsequent surgical pericardial window. During surgery, a tack that had been used to secure mesh to the inferior aspect of the diaphragm was found to have penetrated the pericardium near the right ventricle. The offending foreign body was trimmed and reduced into the abdomen, and the patient recovered without further complication. A review of the literature reveals that, although rare, tamponade following diaphragmatic hernia repair and fundoplication surgery often results in fatal outcome. Tamponade must be considered in any patient who develops signs of hemodynamic instability following diaphragmatic hernia repair or fundoplication surgery, as rapid diagnosis and definitive intervention can decrease fatality from such an injury.


title: Pivotal Role of Receptor-Interacting Protein Kinase 1 and Mixed Lineage Kinase Domain-Like in Neuronal Cell Death Induced by the Human Neuroinvasive Coronavirus OC43.

text: Human coronaviruses (HCoV) are respiratory pathogens with neuroinvasive, neurotropic, and neurovirulent properties, highlighting the importance of studying the potential implication of these viruses in neurological diseases. The OC43 strain (HCoV-OC43) was reported to induce neuronal cell death, which may participate in neuropathogenesis. Here, we show that HCoV-OC43 harboring two point mutations in the spike glycoprotein (rOC/Us183-241) was more neurovirulent than the wild-type HCoV-OC43 (rOC/ATCC) in mice and induced more cell death in murine and human neuronal cells. To evaluate the role of regulated cell death (RCD) in HCoV-OC43-mediated neural pathogenesis, we determined if knockdown of Bax, a key regulator of apoptosis, or RIP1, a key regulator of necroptosis, altered the percentage of neuronal cell death following HCoV-OC43 infection. We found that Bax-dependent apoptosis did not play a significant role in RCD following infection, as inhibition of Bax expression mediated by RNA interference did not confer cellular protection against the cell death process. On the other hand, we demonstrated that RIP1 and MLKL were involved in neuronal cell death, as RIP1 knockdown and chemical inhibition of MLKL significantly increased cell survival after infection. Taken together, these results indicate that RIP1 and MLKL contribute to necroptotic cell death after HCoV-OC43 infection to limit viral replication. However, this RCD could lead to neuronal loss in the mouse CNS and accentuate the neuroinflammation process, reflecting the severity of neuropathogenesis. IMPORTANCE Because they are naturally neuroinvasive and neurotropic, human coronaviruses are suspected to participate in the development of neurological diseases. Given that the strain OC43 is neurovirulent in mice and induces neuronal cell death, we explored the neuronal response to infection by characterizing the activation of RCD. Our results revealed that classical apoptosis associated with the Bax protein does not play a significant role in HCoV-OC43-induced neuronal cell death and that RIP1 and MLKL, two cellular proteins usually associated with necroptosis (an RCD back-up system when apoptosis is not adequately induced), both play a pivotal role in the process. As necroptosis disrupts cellular membranes and allows the release of damage-associated molecular patterns (DAMP) and possibly induces the production of proinflammatory cytokines, it may represent a proinflammatory cell death mechanism that contributes to excessive neuroinflammation and neurodegeneration and eventually to neurological disorders after a coronavirus infection.


title: Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon.

text: PURPOSE The plane of surgery in colonic cancer has been linked to patient outcome although the optimal extent of mesenteric resection is still unclear. Surgeons in Erlangen, Germany, routinely perform complete mesocolic excision (CME) with central vascular ligation (CVL) and report 5-year survivals of higher than 89%. We aimed to further investigate the importance of CME and CVL surgery for colonic cancer by comparison with a series of standard specimens. METHODS The fresh photographs of 49 CME and CVL specimens from Erlangen and 40 standard specimens from Leeds, United Kingdom, for primary colonic adenocarcinoma were collected. Precise tissue morphometry and grading of the plane of surgery were performed before comparison to histopathologic variables. RESULTS CME and CVL surgery removed more tissue compared with standard surgery in terms of the distance between the tumor and the high vascular tie (median, 131 v 90 mm; P < .0001), the length of large bowel (median, 314 v 206 mm; P < .0001), and ileum removed (median, 83 v 63 mm; P = .003), and the area of mesentery (19,657 v 11,829 mm(2); P < .0001). In addition, CME and CVL surgery was associated with more mesocolic plane resections (92% v 40%; P < .0001) and a greater lymph node yield (median, 30 v 18; P < .0001). CONCLUSION Surgeons in Erlangen routinely practicing CME and CVL surgery remove more mesocolon and are more likely to resect in the mesocolic plane when compared with standard excisions. This, along with the associated greater lymph node yield, may partially explain the high 5-year survival rates reported in Erlangen.


docid: vmcarvyf

title: Direct application of single-port laparoscopic totally extraperitoneal (TEP) inguinal hernia repair by an experienced single-port laparoscopic surgeon who was inexperienced in conventional TEP hernia repair: initial experience with 100 cases.

text: BACKGROUND Single-port laparoscopic surgery (SPLS) has been introduced for totally extraperitoneal (TEP) inguinal hernia repair. The aim of this study was to report our initial experience with SPLS TEP inguinal hernia repair in 100 patients by a single-port laparoscopic surgeon who had no prior experience of conventional TEP hernia repair. PATIENTS AND METHODS Between October 2012 and December 2013, 100 patients underwent SPLS TEP inguinal hernia repair by a single surgeon. The procedures that were performed in the preperitoneal space did not differ from those in conventional TEP repair. Patient demographics, type of hernia, and operative and postoperative outcomes were analyzed. Also, we compared the results of current series with the data of the other studies for single-port TEP inguinal hernia repair. RESULTS Among the 100 patients, SPLS TEP inguinal hernia repair was successful in 99 patients; 1 patient required additional incisions for inserting the trocar. The mean operative time and postoperative length of stay were 97.8 minutes (range, 55-185 minutes) and 1.3 days (range, 1-4 days), respectively. In the current series, the operation time was longer than those in the other studies for SPLS TEP repair. Recurrent hernia, history of lower abdominal surgery, and peritoneal tear during the operation were significantly associated with prolonged operation time. The other data, including perioperative complications, were similar. CONCLUSIONS In our experience, the transition from standard hernioplasty to SPLS TEP inguinal hernia repair by an experienced SPLS surgeon was feasible. However, a learning curve is necessary.


title: Transvaginal appendectomy in morbidly obese patient.

text: Introduction. Laparoscopic appendectomy has significant benefits in obese patients. However, morbid obesity can be accepted as an exclusion criterion for natural orifice transluminal endoscopic surgery (NOTES). Here, we present a transvaginal appendectomy in a 66-year-old morbidly obese (BMI 36 kg/m(2), ASA III) patient. Case and Technique. Acute appendicitis was suspected based on history, physical examination, laboratory tests, and ultrasound findings. During laparoscopic surgery, a 5 mm trocar was inserted through the umbilicus and a 5 mm telescope was placed. A 12 mm trocar and a 5 mm grasper were inserted separately through the posterior fornix of the vagina under laparoscopic guidance. The appendix was divided with an endoscopic stapler through the transvaginal 12 mm trocar and removed from the same trocar. The operating time was 75 minutes with minimal blood loss (<10 mL). The patient was discharged 16 hours after surgery uneventfully and she did not require any analgesic administration. Conclusion. To the best of our knowledge, this is the first clinical case that focuses on the transvaginal appendectomy at morbid obesity. We can say that morbid obesity does not constitute an obstacle for treatment of acute appendicitis by transvaginal endoscopic surgery.


title: Role of gastrointestinal endoscopy in the screening of digestive tract cancers in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

text: In Europe at present, but also in 2040, 1 in 3 cancer-related deaths are expected to be caused by digestive cancers. Endoscopic technologies enable diagnosis, with relatively low invasiveness, of precancerous conditions and early cancers, thereby improving patient survival. Overall, endoscopy capacity must be adjusted to facilitate both effective screening programs and rigorous control of the quality assurance and surveillance systems required. 1 : For average-risk populations, ESGE recommends the implementation of organized population-based screening programs FOR COLORECTAL CANCER: , based on fecal immunochemical testing (FIT), targeting individuals, irrespective of gender, aged between 50 and 75 years. Depending on local factors, namely the adherence of the target population and availability of endoscopy services, primary screening by colonoscopy or sigmoidoscopy may also be recommendable. 2 : In high-risk populations, endoscopic screening FOR GASTRIC CANCER: should be considered for individuals aged more than 40 years. Its use in countries/regions with intermediate risk may be considered on the basis of local settings and availability of endoscopic resources. 3 : For esophageal and pancreatic cancer, endoscopic screening may be considered only in high-risk individuals:- FOR SQUAMOUS CELL CARCINOMA: , in those with a personal history of head/neck cancer, achalasia, or previous caustic injury; - FOR BARRETT'S ESOPHAGUS (BE)-ASSOCIATED ADENOCARCINOMA: , in those with long-standing gastroesophageal reflux disease symptoms (i. e., > 5 years) and multiple risk factors (age ≥ 50 years, white race, male sex, obesity, first-degree relative with BE or esophageal adenocarcinoma [EAC]). - FOR PANCREATIC CANCER SCREENING: , endoscopic ultrasound may be used in selected high-risk patients such as those with a strong family history and/or genetic susceptibility.


title: Propensity score-matched comparison between open and minimal invasive hybrid esophagectomy for esophageal adenocarcinoma.

text: BACKGROUND This study compared the outcome between patients who had an open and those who had a hybrid esophagectomy for T1 or T3 esophageal adenocarcinoma (eAC). No clear data are available concerning this question based on T-category. METHODS Two groups of patients with esophagectomy and high intrathoracic esophagogastrostomy for eAC were analyzed: hybrid (laparoscopy + right thoracotomy) (n = 835) and open (laparotomy + right thoracotomy) (n = 188). Outcome criteria were 30- and 90-day mortality, R0-resection rate (R0), number of resected lymph nodes (rLNs), and 5-year survival rate (5y-SR). For each type of surgery, three patient groups were analyzed: pT1-carcinoma (group-1), cT3Nx and neoadjuvant chemoradiation (group-2), and pT3N0-3 without neoadjuvant therapy (group-3). The comparison was based on a propensity score matching in relation of 1:2 for open versus hybrid. RESULTS In group-1 (38 open vs 76 hybrid) R0-resection (100%), 30-day mortality (0%), 90-day mortality (2.6% vs 0%), and rLNs (median 29.5 vs 28.5) were not significantly different. The pN0-rate was 76% in the open and 92% in the hybrid group (p = 0.036). Accordingly, the 5y-SR was 69% and 87% (p = 0.016), but the prognosis of the subgroups pT1pN0 or pT1pN+ was not significantly different between open or hybrid. In group-2 (68 open vs 135 hybrid) R0-resection (97%), 30-day (0% vs 0.7%) and 90-day (4%) mortality, rLNs (28.5 vs 26), and 5y-SR (36% vs 41%) were not significantly different. In group-3 (37 open vs 75 hybrid) R0, postoperative mortality, rLNs, and 5y-SR were not significantly different. CONCLUSION In a propensity score-matched comparison of patients with an open or hybrid esophagectomy for esophageal adenocarcinoma the quality of oncologic resection, postoperative mortality and prognosis are not different.


title: Distinct clinical characteristics and risk factors for mortality in female COVID-19 inpatients: a sex-stratified large-scale cohort study in Wuhan, China.

text: BACKGROUND As the coronavirus disease 2019 (COVID-19) outbreak accelerates worldwide, it is highly significant to evaluate sex-specific clinical characteristics and outcomes, that may affect public health policies. METHODS COVID-19 patients admitted to Tongji Hospital between January 18and March 27, 2020 were evaluated. Clinical features, laboratory data, complications and outcomes were compared between females and males. Risk factors for mortality in the whole population, females and males were determined respectively. RESULTS There were 1667 (50.38%) females among the3309 patients included in this study. The mortality rate was only 5.9% in females but 12.7% in males. Compared with males, more females had no initial symptoms (11.1% vs 8.3%, p=0.008). Complications including acute respiratory distress syndrome, acute kidney injury, septic shock, cardiac injury and coagulation disorder were less common in females; critical illness was also significant less common in females (31.1% vs 39.4%, p<0.0001). Significantly fewer female patients received antibiotics treatment (p=0.001), antiviral therapy (p=0.025) glucocorticoids treatment (p<0.0001), mechanical ventilation (p<0.0001) and had Intensive Care Unit admission (p<0.0001). A lower risk of death was found in females (odds ratio 0.44, 95% confidence interval 0.34-0.58) after adjusting for age and coexisting diseases. Among females, age, malignancy, chronic kidney disease and days from onset to admission were significant associated with mortality, while chronic kidney disease was not risk factor in males. CONCLUSIONS Significantly more mild illness and fewer deaths were found in female COVID-19 inpatients and risk factors associated with mortality varied among male and female population.


FDA lays out rules for regulating mobile medical apps.


title: Analysis of unique liver volume restoration after laparoscopic fenestration of liver cysts.

text: INTRODUCTION Laparoscopic fenestration is a standard procedure for the treatment of non-parasitic liver cysts. After fenestration, the remnant liver often restores its volume. However, no systematic analysis of the phenomenon exists. In the present study, the pattern of liver volume restoration after laparoscopic fenestration of liver cysts was analyzed, and the mechanism for the unique restoration was investigated. METHODS Seven patients with giant non-parasitic liver cysts underwent laparoscopic fenestration. Liver volume restoration in each section and changes in the diameter of the portal branch were analyzed after fenestration with CT or MRI. In two patients, regional liver volume restoration was assessed in detail using region-growing software, and change in portal flow distribution was estimated using computational fluid dynamics. Then, the regional liver volume restoration rate was compared with the portal hemodynamic changes. RESULTS Liver volume restoration after fenestration was dependent on the size and position of the cysts; it not uniform throughout the remnant liver. The liver volume restoration in sections that had been compressed by giant cysts was significantly greater than in other areas after fenestration. This volume restoration was accompanied by an increase in the diameters of the portal branches in these sections. In addition, a strong correlation between the regional liver volume restoration rate and the changes in portal flow distribution existed in the computationally analyzed cases. CONCLUSION Liver volume restoration after the fenestration of giant liver cysts non-uniformly occurs in the remnant liver. Improved portal vein circulation in the hepatic area adjacent to the excised giant liver cysts most likely regulates the greater regional volume restoration rate in the area.


title: COVID 19 and Spanish flu pandemics: All it changes, nothing changes.

text: The Corona Virus 19 (COVID 19) epidemic is an infectious disease which was declared as a pandemic and hit all the Countries, all over the world, from the beginning of the year 2020. There are many similarities between the COVID 19 epidemic and the Spanish flu epidemic. We considered some preventive measures which do not change in the two epidemics.


title: Impact of multi-professional simulation-based training on the perception of safety and preparedness among health workers caring for COVID-19 patients in Pakistan.

text: It aimed to evaluate the perception of safety and preparedness among health workers caring for coronavirus disease 2019 (COVID-19) patients before and after a multi-professional simulation-based course in Pakistan. Health workers' perception of preparedness, safety, and their willingness to care for COVID-19 patients were measured before after attending a simulation-based training course to prepare them to care for COVID-19 patients, in Combined Military Hospital Landi Kotal Cantt, from 1st March 2020 to 30th April 2020. : The participants' perceived level of safety and preparedness to care for COVID-19 patients before the simulation-based course was low but increased after completing it (P<0.05). They felt confident and were willing to a significantly higher degree to care for patients of COVID-19 or other infections requiring high isolationSimulation-based training is an effective tool to improve the perception of risk and readiness to deal with COVID-19 among medical and non-medical health workers in Pakistan.


title: Link of a ubiquitous human coronavirus to dromedary camels.

text: The four human coronaviruses (HCoVs) are globally endemic respiratory pathogens. The Middle East respiratory syndrome (MERS) coronavirus (CoV) is an emerging CoV with a known zoonotic source in dromedary camels. Little is known about the origins of endemic HCoVs. Studying these viruses' evolutionary history could provide important insight into CoV emergence. In tests of MERS-CoV-infected dromedaries, we found viruses related to an HCoV, known as HCoV-229E, in 5.6% of 1,033 animals. Human- and dromedary-derived viruses are each monophyletic, suggesting ecological isolation. One gene of dromedary viruses exists in two versions in camels, full length and deleted, whereas only the deleted version exists in humans. The deletion increased in size over a succession starting from camelid viruses via old human viruses to contemporary human viruses. Live isolates of dromedary 229E viruses were obtained and studied to assess human infection risks. The viruses used the human entry receptor aminopeptidase N and replicated in human hepatoma cells, suggesting a principal ability to cause human infections. However, inefficient replication in several mucosa-derived cell lines and airway epithelial cultures suggested lack of adaptation to the human host. Dromedary viruses were as sensitive to the human type I interferon response as HCoV-229E. Antibodies in human sera neutralized dromedary-derived viruses, suggesting population immunity against dromedary viruses. Although no current epidemic risk seems to emanate from these viruses, evolutionary inference suggests that the endemic human virus HCoV-229E may constitute a descendant of camelid-associated viruses. HCoV-229E evolution provides a scenario for MERS-CoV emergence.


Pneumonia Without Respiratory Symptoms.


title: Modeling COVID-19 latent prevalence to assess a public health intervention at a state and regional scale.

text: BACKGROUND Emergence of COVID-19 caught the world off-guard and unprepared, initiating a global pandemic. In the absence of evidence, individual communities had to take timely action to reduce the rate of disease spread and avoid overburdening their healthcare systems. Although a few predictive models have been published to guide these decisions, most have not taken into account spatial differences and have included assumptions that do not match the local realities. Access to reliable information that is adapted to local context is critical for policymakers to make informed decisions during a rapidly evolving pandemic. OBJECTIVE The goal of this study was to develop an adapted susceptible-infected-removed (SIR) model to predict the trajectory of the COVID-19 pandemic in North Carolina (NC) and the Charlotte metropolitan region and to incorporate the effect of a public health intervention to reduce disease spread, while accounting for unique regional features and imperfect detection. METHODS Using the software package R, three SIR models were fit to infection prevalence data from the state and the greater Charlotte region and then rigorously compared. One of these models (SIR-Int) accounted for a stay-at-home intervention and imperfect detection of COVID-19 cases. We computed longitudinal total estimates of the susceptible, infected, and removed compartments of both populations, along with other pandemic characteristics (e.g., basic reproduction number). RESULTS Prior to March 26, disease spread was rapid at the pandemic onset with the Charlotte region doubling time of 2.56 days (95% CI: (2.11, 3.25)) and in NC 2.94 days (95% CI: (2.33, 4.00)). Subsequently, disease spread significantly slowed with doubling times increased in the Charlotte region to 4.70 days (95% CI: (3.77, 6.22)) and in NC to 4.01 days (95% CI: (3.43, 4.83)). Reflecting spatial differences, this deceleration favored the greater Charlotte region compared to NC as a whole. A comparison of the efficacy of intervention, defined as 1 - the hazard ratio of infection, gave 0.25 for NC and 0.43 for the Charlotte region. Also, early in the pandemic, the initial basic SIR model had good fit to the data; however, as the pandemic and local conditions evolved, the SIR-Int model emerged as the model with better fit. CONCLUSIONS Using local data and continuous attention to model adaptation, our findings have enabled policymakers, public health officials and health systems to proactively plan capacity and evaluate the impact of a public health intervention. Our SIR-Int model for estimated latent prevalence was reasonably flexible, highly accurate, and demonstrated the efficacy of a stay-at-home order at both the state and regional level. Our results highlight the importance of incorporating local context into pandemic forecast modeling, as well as the need to remain vigilant and informed by the data as we enter into a critical period of the outbreak. CLINICALTRIAL


title: The impact of covid-19 pandemic on urgent endoscopy in Italy: a nation-wide multicenter study.

text: Objective: COVID-19 pandemic has seriously affected Italy. Radical changes occurred in the Italian NHS and thus in GI departments, as only urgent endoscopies were guaranteed. The study aimed to report how the demand for urgent endoscopy changed during the COVID-19 pandemic in Italy and to evaluate the appropriateness of urgent referrals in the Endoscopy Unit.Material and methods: Nation-wide, cross-sectional survey study in 54 Italian GI Units. Data were collected regarding urgent endoscopies (EGD, CS, ERCP) in two different time periods: March 2019 and March 2020.Results: Thirty-five (64.8%) GI endoscopy Units responded to the survey. The entity of reduction of overall urgent EGDs and CSs performed in March 2020 versus March 2019 was statistically significant: 541 versus 974 (-80%), p < .001 for EGD and 171 versus 265 (-55%), p < .008, for CS, respectively. No statistically significant reduction of urgent ERCP performed in March 2020 versus March 2019 was found. The increase in overall diagnostic yield for urgent EGD in March 2020 versus March 2019 was 7.3% (CI [0.028-0.117], p = .001). No statistically significant difference in diagnostic yield for CS between 2019 and 2020 was found.Conclusion: The study showed a statistically significant reduction of urgent EGD and CS performed during the SARS-CoV-2 pandemic, in March 2020, compared to March 2019. The diagnostic yield of urgent EGD performed in March 2020 was significantly higher than that of March 2019. No statistically significant difference was found in terms of diagnostic yield of urgent CS between March 2020 and March 2019.


title: Network pharmacology-based analysis of the role of traditional Chinese herbal medicines in the treatment of COVID-19.

text: BACKGROUND The novel coronavirus named COVID-19, which originated in Wuhan, China, has spread to many countries around the world. Currently, no effective medical treatment exists to combat this disease. Traditional Chinese herbal medicines (CHM) have unique roles in the treatment of viral infections. In this article we analyzed the effectiveness and possible molecular mechanisms of CHM formulas for the prevention of COVID-19. METHODS The active ingredients and action targets of CHM formulas were obtained from the TCMSP database. Genes related to severe acute respiratory syndromes (SARS) and Middle East respiratory syndrome (MERS) were queried on the GeneCards database. The action mechanisms of these genes were predicted using a Gene Ontology (GO)-based functional enrichment and annotation tool and the Kyoto Encyclopedia of Genes and Genomes (KEGG). RESULTS CHM formulas played a positive role in preventing COVID-19 and warrant further application. CONCLUSIONS Our research provides new evidence to support the possible value of CHM formulas for the prevention of COVID-19. However, further clinical studies with large sample sizes are required to verify their effectiveness.


title: The atrial fibrillation epidemic is approaching the physician's door: will mobile technology improve detection?

text: The rising numbers of people with atrial fibrillation (AF) carry a heavy toll on our graying population. Epidemiological data suggest that AF exists in 1 in 10 individuals aged older than 80 years. The risk of embolic stroke increases along with well-known cardiovascular risk factors. Should there be systematic screening for the elderly? Although 1 in 10 is a huge hit rate in screening for any major illness, the initiative for such programs in AF remains in 'research and development'.At present, cardiologists can utilize implantable loop recorders in patients referred for specialist consultation. Novel technologies are also available, including cloud-based, algorithm-assisted, non-invasive monitoring patches, which allow extended observation periods. What about people in the community without a recognized need for cardiologic investigation? Mobile technology has made detection of pulse irregularity possible without medical attention. Smartphone apps enable opportunistic rhythm monitoring, but true arrhythmias need to be medically verified. AF may be the first common disorder to be effectively screened for by mobile technology. In the spirit of proactive campaigns such as 'Know Your Pulse', we should prepare for rapidly increasing reports of various pulse irregularities.


Responding to COVID-19 in Hong Kong.


title: Identification of a noncanonically transcribed subgenomic mRNA of infectious bronchitis virus and other gammacoronaviruses.

text: Coronavirus subgenomic mRNA (sgmRNA) synthesis occurs via a process of discontinuous transcription involving transcription regulatory sequences (TRSs) located in the 5' leader sequence (TRS-L) and upstream of each structural and group-specific gene (TRS-B). Several gammacoronaviruses including infectious bronchitis virus (IBV) contain a putative open reading frame (ORF), localized between the M gene and gene 5, which is controversial due to the perceived absence of a TRS. We have studied the transcription of a novel sgmRNA associated with this potential ORF and found it to be transcribed via a previously unidentified noncanonical TRS-B. Using an IBV reverse genetics system, we demonstrated that the template-switching event during intergenic region (IR) sgmRNA synthesis occurs at the 5' end of the noncanonical TRS-B and recombines between nucleotides 5 and 6 of the 8-nucleotide consensus TRS-L. Introduction of a complete TRS-B showed that higher transcription levels are achieved by increasing the number of nucleotide matches between TRS-L and TRS-B. Translation of a protein from the sgmRNA was demonstrated using enhanced green fluorescent protein, suggesting the translation of a fifth, novel, group-specific protein for IBV. This study has resolved an issue concerning the number of ORFs expressed by members of the Gammacoronavirus genus and proposes the existence of a fifth IBV accessory protein. We confirmed previous reports that coronaviruses can produce sgmRNAs from noncanonical TRS-Bs, which may expand their repertoire of proteins. We also demonstrated that noncanonical TRS-Bs may provide a mechanism by which coronaviruses can control protein expression levels by reducing sgmRNA synthesis.


title: Large uterus: what is the limit for a laparoscopic approach?

text: Hysterectomy is the most common surgical gynecologic procedure, which is frequently related to the treatment of leiomyoma. The laparoscopic hysterectomy is associated with a shorter hospital stay, fewer infection rates, and a faster return to daily activities. Most gynecologists do not recommend a hysterectomy via the vagina or a laparoscopic-assisted vaginal hysterectomy (LAVH) in the case of a uterus weighing more than 300 g. This case report presents the case of an LAVH undertaken in a 43-year-old patient with a uterus weighing 2,800 g. There are no definite guidelines concerning the procedure for a large uterus, and the literature is vague regarding the best surgical procedure for these cases. The size of the uterus does not seem to be an absolute contraindication for endoscopic surgery. This procedure relies entirely on the surgeon's ability.


title: Spontaneous histologic lesions of the adult naked mole rat (Heterocephalus glaber): a retrospective survey of lesions in a zoo population.

text: Naked mole rats (NMRs; Heterocephalus glaber) are highly adapted, subterranean, eusocial rodents from semiarid regions of the eastern horn of Africa and the longest-living rodent known with a maximum life span of up to 30 years. They are a unique model for aging research due to their physiology, extreme longevity, and, when compared to mice and rats, resistance to cancer. Published surveys of disease in NMRs are sparse. Captive colonies in zoological collections provide an opportunity to monitor spontaneous disease over time in a seminatural environment. This retrospective study describes common lesions of a zoo population over a 15-year period during which 138 adult NMRs were submitted for gross and histologic evaluation. Of these, 61 (44.2%) were male, 77 (55.8%) female, 45 (32.6%) died, and 93 (67.4%) were euthanized. The most frequent cause of death or reason for euthanasia was conspecific trauma (bite wounds) and secondary complications. Some common histologic lesions and their prevalence were renal tubular mineralization (82.6%), hepatic hemosiderosis (64.5%), bite wounds (63.8%), chronic progressive nephropathy (52.9%), and calcinosis cutis (10.1%). In sum, 104 (75.4%) NMRs had more than one of the most prevalent histologic lesions. No malignant neoplasms were noted; however, there was a case of renal tubular adenomatous hyperplasia with nuclear atypia and compression that in rats is considered a preneoplastic lesion. This retrospective study confirms the NMR's relative resistance to cancer in spite of development of other degenerative diseases and highlights the utility of zoological databases for baseline pathological data on nontraditional animal models.


title: Possible therapeutic agents for COVID-19: a comprehensive review.

text: INTRODUCTION Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has emerged in China. There are no available vaccines or antiviral drugs for COVID-19 patients. Herein, we represented possible therapeutic agents that may stand as a potential therapy against COVID-19. AREAS COVERED We searched PubMed, Google Scholar, and clinicaltrials.gov for relevant papers. We showed some agents with potentially favorable efficacy, acceptable safety as well as good pharmacokinetic profiles. Several therapies are under assessment to evaluate their efficacy and safety for COVID-19. However, some drugs were withdrawn due to their side effects after demonstrating some clinical efficacy. Indeed, the most effective therapies could be organ function support, convalescent plasma, anticoagulants, and immune as well as antiviral therapies, especially anti-influenza drugs due to the similarities between respiratory viruses regarding viral entry, uncoating, and replication. We encourage giving more attention to favipiravir, remdesivir, and measles vaccine. EXPERT OPINION A combination, at least dual or even triple therapy, of the aforementioned efficacious and safe therapies is greatly recommended for COVID-19. Further, patients should have a routine assessment for their coagulation and bleeding profiles as well as their inflammatory and cytokine concentrations.


title: Multipotent adult progenitor cells decrease cold ischemic injury in ex vivo perfused human lungs: an initial pilot and feasibility study.

text: BACKGROUND Primary graft dysfunction (PGD) is a significant cause of early morbidity and mortality following lung transplantation. Improved organ preservation techniques will decrease ischemia-reperfusion injury (IRI) contributing to PGD. Adult bone marrow-derived adherent stem cells, including mesenchymal stromal (stem) cells (MSCs) and multipotent adult progenitor cells (MAPCs), have potent anti-inflammatory actions, and we thus postulated that intratracheal MAPC administration during donor lung processing would decrease IRI. The goal of the study was therefore to determine if intratracheal MAPC instillation would decrease lung injury and inflammation in an ex vivo human lung explant model of prolonged cold storage and subsequent reperfusion. METHODS Four donor lungs not utilized for transplant underwent 8 h of cold storage (4°C). Following rewarming for approximately 30 min, non-HLA-matched allogeneic MAPCs (1 × 10(7) MAPCs/lung) were bronchoscopically instilled into the left lower lobe (LLL) and vehicle comparably instilled into the right lower lobe (RLL). The lungs were then perfused and mechanically ventilated for 4 h and subsequently assessed for histologic injury and for inflammatory markers in bronchoalveolar lavage fluid (BALF) and lung tissue. RESULTS All LLLs consistently demonstrated a significant decrease in histologic and BALF inflammation compared to vehicle-treated RLLs. CONCLUSIONS These initial pilot studies suggest that use of non-HLA-matched allogeneic MAPCs during donor lung processing can decrease markers of cold ischemia-induced lung injury.


Mission command: applying principles of military leadership to the SARS-Cov-2 (covid-19) crisis.


title: Clarification of the circulatory patho-physiology of anaesthesia - implications for high-risk surgical patients.

text: The paper examines the effects of anaesthesia on circulatory physiology and their implications regarding improvement in perioperative anaesthetic management. Changes to current anaesthetic practice, recommended recently, such as the use of flow monitoring in high risk patients, are already beginning to have an impact in reducing complications but not mortality [1]. Better understanding of the patho-physiology should help improve management even further. Analysis of selected individual clinical trials has been used to illustrate particular areas of patho-physiology and how changes in practice have improved outcome. There is physiological support for the importance of achieving an appropriate rate of oxygen delivery (DO2), particularly following induction of anaesthesia. It is suggested that ensuring adequate DO2 during anaesthesia will avoid development of oxygen debt and hence obviate the need to induce a high, compensatory, DO2 in the post-operative period. In contrast to the usual assumptions underlying strategies requiring a global increase in blood flow [1] by a stroke volume near maximization strategy, blood flow control actually resides entirely at the tissues not at the heart. This is important as the starting point for understanding failed circulatory control as indicated by 'volume dependency'. Local adjustments in blood flow at each individual organ - auto-regulation - normally ensure the appropriate local rate of oxygen supply, i.e. local DO2. Inadequate blood volume leads to impairment of the regulation of blood flow, particularly in the individual tissues with least capable auto-regulatory capability. As demonstrated by many studies, inadequate blood flow first occurs in the gut, brain and kidney. The inadequate blood volume which occurs with induction of anaesthesia is not due to blood volume loss, but probably results from redistribution due to veno-dilation. The increase in venous capacity renders the existing blood volume inadequate to maintain venous return and pre-load. Blood volume shifted to the veins will, necessarily, also reduce the arterial volume. As a result stroke volume and cardiac output fall below normal with little or no change in peripheral resistance. The resulting pre-load dependency is often successfully treated with colloid infusion and, in some studies, 'inotropic' agents, particularly in the immediate post-operative phase. Treatment during the earliest stage of anaesthesia can avoid the build up of oxygen debt and may be supplemented by drugs which maintain or restore venous tone, such as phenylephrine; an alternative to volume expansion. Interpretation of circulatory patho-physiology during anaesthesia confirms the need to sustain appropriate oxygen delivery. It also supports reduction or even elimination of supplementary crystalloid maintenance infusion, supposedly to replace the "mythical" third space loss. As a rational evidence base for future research it should allow for further improvements in anaesthetic management.


docid: qnighzdj

title: Generation of avian influenza virus (AIV) contaminated fecal fine particulate matter (PM(2.5)): genome and infectivity detection and calculation of immission.

text: As a model for aerosol transmission, chicken feces was spiked with avian influenza virus (AIV) subtype H10N7 and used to generate a fine particulate matter aerosol. For this an innovative aerosol chamber was developed, that collected PM(2.5) on quartz microfiber filters. With AIV contaminated PM(2.5) dust-coated filters different incubation times ranging from 0 to 4 days and storage mainly at +4 and +20 degrees C and at different relative humidity (RH) were performed. Embryonic death in inoculated hen's eggs with filter elute was the AIV infectivity read out. To determine viral genome presence quantitative real time RT-PCR was applied. The filter elutes contained AIV genome as well as viable virus whereby +20 degrees C indicated a borderline temperature for infectious virus stability. In addition, high relative humidity was critical for AIV viability in PM(2.5). The results allowed a dispersion calculation of infectious AIV in aerosols assuming a worst case scenario for an AIV outbreak in poultry farms. Thus exposure to AIV associated with PM(2.5) is possible near to infected farms and may be a serious risk for fatal influenza disease in both man and animals. Airborne transmission should be effectively preventable by dispersion of water combined with disinfection into the inside air as well as the exhaust air stream of AIV infected farms.


Implications for COVID-19 triage from the ICNARC report of 2204 COVID-19 cases managed in UK adult intensive care units.


SHATTUCK LECTURE: The Future of Public Health.


title: Facts and reflections on COVID-19 and anti-hypertensives drugs.

text: Based on some publications that associate SARS-CoV-2 infection with the use of anti-hypertensive drug groups such as angiotensin-converting-enzyme inhibitors (e.g. enalapril) or angiotensin II receptor blockers (e.g. losartan), many patients from South America, Central America or Spain, have stopped or intend to interrupt their treatments with these drugs. Hence, it may exist ominous consequences due to this drop out. For this reason, it is necessary to quickly warn about this situation and the risks associated with it.


Supporting the UK National Health Service during the COVID-19 crisis from an academic perspective.


title: Mycophenolic acid inhibits replication of Japanese encephalitis virus.

text: BACKGROUND Japanese encephalitis is a major public health problem in several parts of Asia, particularly India, Nepal, Sri Lanka and Myanmar (Burma). Despite its public health implications, there are no effective antiviral drugs available. METHODS The present study evaluated the effect of mycophenolic acid on Japanese encephalitis virus (JEV) using an in vitro cytopathic effect inhibition assay, plaque reduction assay and virus yield reduction assay, and its therapeutic potential was also assessed in vivo in a mouse model. RESULTS Analysis of the results obtained in the in vitro and in vivo experiments suggests that mycophenolic acid has significant antiviral activity against JEV, with an IC(50) of 3.1 μg/ml, a therapeutic index of 16 and a 75% protection against lethal challenge of JEV. CONCLUSION The study concludes that this compound significantly inhibited the replication of JEV in vitro and protected mice in vivo.


title: Pilates for breast cancer: A systematic review and meta-analysis.

text: INTRODUCTION Breast cancer is the leading type of cancer causing death in women worldwide. The incidence of the disease is expected to grow worldwide due to the aging of the population and risk factors related to lifestyle behaviors. Considering the lifestyle of women with breast cancer before or after surgery, pilates exercise may be a complementary intervention additionally to standard treatment. OBJECTIVE To analyze the efficacy of pilates compared to other exercises and to no exercise for women with breast cancer diagnosis. METHOD We searched Medline via Pubmed, Embase via Ovid, Amed via EBSCO, Biosis via Ovid, Lilacs and the Cochrane Library for relevant publications until March 2017. The keywords used were pilates and "breast cancer," and only randomized controlled trials were included. Critical appraisal was done using Risk of Bias Tool and GRADE score for assessing the quality of evidence. RESULTS A total of five studies were included in our review. Our results demonstrate that pilates or home-based exercises are better than no exercise in each individual study. We observed significant improvements in the pilates groups compared to home-based exercises. Additionally, in the individual studies, we observed improvements in range of motion, pain and fatigue. CONCLUSION The evidence shows that pilates or home-based exercise should be encouraged to women with breast cancer.


title: Comparative evaluation of colonoscopy-assisted transanal minimally invasive surgery via glove port and endoscopic submucosal dissection for early rectal tumor.

text: BACKGROUND Early rectal tumor is usually managed by local excision. A novel method-colonoscopy-assisted transanal minimally invasive surgery via glove port (CA-TAMIS-GP)-for resecting early rectal tumor was developed and compared with endoscopic submucosal dissection (ESD). MATERIALS AND METHODS We performed CA-TAMIS-GP surgery on 26 patients from January 2014 to February 2016. For better analysis, we retrospectively collected data from 31 patients who underwent ESD between October 2012 and December 2013; overall, 57 patients diagnosed with early rectal tumor were included in this study. Perioperative conditions and long-term outcomes of both groups were compared. RESULTS All lesions were dissected completely and successfully without conversion to open surgery or major complications. On histopathologic examination, all specimens in this study had negative margins. All patients had uneventful postoperative recoveries, except 3 patients of CA-TAMIS-GP with minor hematochezia, which resolved spontaneously; 7 ESD patients had late-onset bleeding and 3 needed colonoscopic hemostasis; 2 patients in each group had mild fever. The CA-TAMIS-GP group had a shorter operation time, less hemorrhage, and a lower average consumable cost than the ESD group (P < 0.05); moreover, the CA-TAMIS-GP group had no recurrence or long-term complications during a follow-up of 10-32 months, whereas3 patients in the ESD group developed local recurrence during a follow-up of 24-36 months. CONCLUSIONS The CA-TAMIS-GP is a new method that is safe and effective in patients with early rectal tumor and appears to have a shorter operation time and less blood loss as compared with ESD.


title: Non-crosslinked porcine acellular dermal matrix in pediatric abdominal wall reconstruction: a case series.

text: INTRODUCTION The use of biologic mesh where native tissue deficiencies limit reconstructive options has been well documented in the adult population, with increasing use to address the special requirements of complex abdominal wall reconstruction. There is, however, little documented evidence as to the safety and efficacy of these products in the pediatric population. METHODS This retrospective case series details 5 pediatric cases of complicated abdominal hernia repair with Strattice®, a non-crosslinked porcine acellular dermal matrix. Outcomes measured include recurrence, infection, seroma formation, symptomatic bulging, and need for mesh removal. Defect size, mesh size, and history of prior abdominal operations and infection were also recorded. RESULTS Patients received Strattice® with an average area of 132.2 (24-250)cm2 and primary closure was achieved over a mesh underlay in three (60%) patients, while the remaining required a bridging approach secondary to lateral defects. Complications included suture extrusion, requiring suture removal, hernia recurrence without bulge, noted incidentally, and seroma formation, requiring placement of drains. DISCUSSION/CONCLUSIONS In conclusion, the use of porcine ADM in pediatric patients appears to be potentially safe and efficacious in the context of complex abdominal wall defects, including those with substantial contamination. Our small series builds on previous reports in this difficult patient population. Although additional study, with larger subject pools, would assist in solidifying the observations seen in this and other series, initial findings suggest that porcine ADM is a valuable tool in the treatment of these complex patients. LEVEL OF EVIDENCE Case series: Treatment study, Level IV.


title: Advances in laparoscopic techniques and instrumentation in standing equine surgery.

text: Equine standing surgery and laparoscopy are becoming increasingly important aspects of equine surgery. Laparoscopic advancements lag behind the human medical field, mainly due to decreased access to appropriate training and instrumentation. It is nearly impossible to cover the topic of equine standing surgery without discussing advances in laparoscopy, because without such advances, equine standing surgery lacks potential for forward progress. Although novel standing techniques continue to be published, the addition of minimally invasive laparoscopic techniques adds an entirely new dimension and provides a plethora of procedures to surgeons practicing equine standing surgery.


title: Looking after yourself and others.

text: The global Covid-19 outbreak is having a profound impact on everyone, including people in the veterinary profession. Public health and government advice for some to self isolate and for all of us to increase social distancing poses huge challenges for the industry and its people, as well as clients and patients. Here, Vetlife Helpline manager.


SARS-CoV-2 in the Employees of a Large University Hospital.


title: Infectious Bronchitis Coronavirus Inhibits STAT1 Signaling and Requires Accessory Proteins for Resistance to Type I Interferon Activity.

text: UNLABELLED The innate immune response is the first line of defense against viruses, and type I interferon (IFN) is a critical component of this response. Similar to other viruses, the gammacoronavirus infectious bronchitis virus (IBV) has evolved under evolutionary pressure to evade and counteract the IFN response to enable its survival. Previously, we reported that IBV induces a delayed activation of the IFN response. In the present work, we describe the resistance of IBV to IFN and the potential role of accessory proteins herein. We show that IBV is fairly resistant to the antiviral state induced by IFN and identify that viral accessory protein 3a is involved in resistance to IFN, as its absence renders IBV less resistant to IFN treatment. In addition to this, we found that independently of its accessory proteins, IBV inhibits IFN-mediated phosphorylation and translocation of STAT1. In summary, we show that IBV uses multiple strategies to counteract the IFN response. IMPORTANCE In the present study, we show that infectious bronchitis virus (IBV) is resistant to IFN treatment and identify a role for accessory protein 3a in the resistance against the type I IFN response. We also demonstrate that, in a time-dependent manner, IBV effectively interferes with IFN signaling and that its accessory proteins are dispensable for this activity. This study demonstrates that the gammacoronavirus IBV, similar to its mammalian counterparts, has evolved multiple strategies to efficiently counteract the IFN response of its avian host, and it identifies accessory protein 3a as multifaceted antagonist of the avian IFN system.


title: Bikini Line Sleeve Gastrectomy: Initial Report.

text: BACKGROUND/INTRODUCTION Several reports have discussed the potential for reducing port access in laparoscopic sleeve gastrectomy (LSG); however, each approach had its innate setbacks. Aiming at improving the aesthetic outcome, we report a novel approach to the LSG where we place the trocars at the bikini line in what we described as bikini line sleeve gastrectomy (BLSG). METHODS The present work is a prospective, pilot study on the use of BLSG in patients, during the period between April and October 2016. Exclusion criteria included the following: large hiatal hernia, upper abdominal surgery, and xiphi-umbilical, xiphi-symphysis pubis, and xiphi-anterior superior iliac spine distances of > 25,36 and 33 cm, respectively. Four trocars were used: one at the umbilicus and three at the bikini line. All laparoscopic graspers were bariatric length instruments (43 cm). However, camera telescope, endoscopic stapler, and bipolar dissectors were standard length. RESULTS Twenty eight patients underwent BLSG. The mean age was 34.6 ± 3.7 years with a mean BMI of 42.46 kg/m2 ± 3. There were no major intra- or postoperative complications and no conversion to conventional port site placement. Patient's scar satisfaction was favorable. The mean postoperative BMI and weight at 6 m were 28.5 ± 1 kg/m2 and 79.8 kg ± 2, respectively. The mean percentage excess weight loss at 3, 6, and 12 months were 39.5 ± 4.6, 64.5 ± 5, and 69.8 ± 6%, respectively. CONCLUSION BLSG was found to be potentially safe, feasible, and effective with a favorable aesthetic outcome; it could possibly be offered to a select group of patients that are conscious about their scar appearance.


title: A prospective study of sentinel lymph node detection in vulval carcinoma: is it time for a change in clinical practice?

text: OBJECTIVES To determine the accuracy of sentinel lymph node (SLN) detection in vulval carcinoma and to report the reliability and safety of this procedure. METHODS/MATERIALS For a period of 6 years, we recruited women undergoing surgery for vulval carcinoma. All women had a preoperative biopsy confirming the depth of invasion greater than 1 mm. Sentinel lymph node detection was performed using the combined method (Tc-99m and methylene-blue dye). The standard management included complete inguinofemoral lymphadenectomy. When inguinofemoral lymph nodes were found grossly to be enlarged, these nodes were debulked, and the women subsequently treated with radiotherapy with or without chemotherapy. During the last 2 years of the study, a selected group of women had an SLN dissection alone. The SLNs were ultrastaged when they were negative on routine hematoxylin and eosin examination. RESULTS Among 60 women undergoing SLN detection, SLN was detected in 59 women (98.3%) with combined method. Blue dye did not detect an SLN in 3 women resulting in a 93.3% detection rate. The median SLN count was 2 nodes (range, 1-9). Of the 60 women, 41 had inguinofemoral lymphadenectomy, 4 had only enlarged inguinofemoral nodes debulked, and 15 had the SLN only removed. The non-SLN count was 9 nodes (range, 3-17). There were no false-negative SLNs. Twenty-one women (35%) had positive nodes on final histology. Ultrastaging increased detection of metastases in 6.9% of nodes relative to routine hematoxylin and eosin examination and upstaged 12% of women. The median follow-up was 24 months (range, 2-66 months). CONCLUSIONS Sentinel lymph node detection is safe and accurate in assessing lymph node status in women with vulval cancer undergoing staging. The combined method using Tc-99m and methylene blue dye injection for SLN detection has the best detection rate. Routine ultrastaging of negative SLN improves the detection of nodal metastases.


Response to: 'Severe COVID-19 associated pneumonia in 3 patients with systemic sclerosis treated with rituximab' by Avouac et al.


Evaluation of a Real-Time Reverse Transcription-PCR (RT-PCR) Assay for Detection of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in Clinical Samples from an Outbreak in South Korea in 2015.


title: Ustekinumab for Crohn's disease: results of the ICC Registry, a nationwide prospective observational cohort study.

text: BACKGROUND AND AIMS Ustekinumab is approved for the treatment of Crohn's disease (CD). Systematically registered prospective real-world data is scarce. We therefore aimed to study the effectiveness, safety and usage of ustekinumab for CD in everyday practise. METHODS We prospectively enrolled CD patients initiating ustekinumab in regular care between December 2016 and January 2019. Clinical (Harvey Bradshaw Index (HBI)), biochemical (C-reactive protein (CRP) and faecal calprotectin (FCP)), extra-intestinal manifestations, and peri-anal fistula activity, ustekinumab dosage, concomitant medication use, and adverse events were documented at week 0, 12, 24, and 52. The primary outcome was corticosteroid-free clinical remission. RESULTS In total, 221 CD patients were included (98.6% anti-TNF and 46.6% vedolizumab exposed) with a median follow-up of 52.0 weeks (IQR 49.3-58.4). The corticosteroid-free clinical remission rates at week 24 and 52 was 38.2% and 37.1%, respectively. An initial dosing schedule of 8 weeks, compared to 12 weeks, correlated with a lower discontinuation rate (20.0% vs. 42.6%, p=0.01), but comparable corticosteroid-free clinical remission at week 52 (46.3% (q8w) vs. 34.6% (q12w), p=0.20). There was no clinical benefit of combination therapy after 52 weeks when compared to ustekinumab monotherapy (combi 40.6% vs. mono 36.0% p=0.64). At baseline, 28 patients had active peri-anal fistula, of which 35.7% showed complete clinical resolution after 24 weeks. During follow-up we encountered six severe infections (3.5 per 100 patient years), all patients were on concomitant immunosuppressant therapies. Ustekinumab treatment discontinuation was observed in 75 (33.9%) patients mainly due to lack of response. CONCLUSION Ustekinumab is relatively safe and effective treatment option for CD patients with prior failure of anti-TNF and anti-integrin therapies.


title: Hand-Assisted Robotic Surgery for Staging of Ovarian Cancer and Uterine Cancers With High Risk of Peritoneal Spread: A Retrospective Cohort Study.

text: OBJECTIVE This study aimed to determine surgical outcomes related to hand-assisted robotic surgery (HARS) for staging of ovarian cancer and uterine cancers with high risk of peritoneal spread and compare them to laparotomy and standard robotic-assisted surgery. METHODS A retrospective cohort study of women undergoing staging for uterine and ovarian cancer between January 2011 and July 2013 at a major metropolitan teaching hospital was reviewed. Patients undergoing HARS were matched with patients undergoing staging laparotomy [exploratory laparotomy (XLAP)] for the same indications and with patients undergoing traditional robotic surgery (RS) for staging of endometrioid endometrial cancer. In HARS, a longer incision is used to allow palpation of the peritoneal surfaces, to exteriorize the small bowel, to examine the mesentery, and to perform omentectomy. RESULTS One hundred five patients were analyzed (15 HARS, 45 RS, 45 XLAP). Compared with XLAP, HARS was associated with decreased blood loss (200 vs 400 mL, P = 0.011) and shorter hospital stay (1 vs 4 days, P < 0.001). Patients who had undergone HARS had fewer major complications, but those results did not reach statistical significance (0% vs 27%, P = 0.063). Hand-assisted robotic surgery was associated with higher blood loss and length of stay as compared to robotic staging of endometrioid endometrial cancer (RS). Minor wound complications were also more common (27% vs 2%, P = 0.012). CONCLUSIONS Hand-assisted robotic surgery allows for thorough visual and tactile assessment of peritoneal surfaces. It represents a safe alternative to laparotomy for staging of ovarian and uterine cancers with high risk of peritoneal spread. Long-term follow-up study is needed to determine oncologic adequacy of HARS.


title: Fetal bovine serum inhibits hepatitis C virus attachment to host cells.

text: Fetal bovine serum (FBS), used normally as a basic cell culture supplement, inhibits influenza virus growth. However, the role of FBS in the regulation of hepatitis C virus (HCV) infection has not been studied extensively and remains largely unclear. We adopted the established cell-cultured HCV (HCVcc) isolated from the JFH-1 strain and two sets of solutions (cDMEM7.4 and cDMEM6.8; RHMNB6.8 and RHMN6.8) to investigate the effect of FBS on HCV infection. Our data indicate that FBS blocks HCV infection in a dose-dependent manner. The infectivity of HCV diluted in the RHMNB solution was more susceptible to the addition of FBS than that diluted in the cDMEM solution. In addition, FBS-mediated blocking of HCV infection occurred at the step of virus attachment to the target cells, suggesting that FBS contains factors that interfere with the early steps in HCV infection.


COVID-19: What implications for sexual and reproductive health and rights globally?


title: Factors affecting capsular volume changes and association with outcomes after Bankart repair and capsular shift.

text: BACKGROUND Capsular laxity is a main contributing factor in recurrent shoulder instability and is suggested to be correlated with increased capsular volume. Arthroscopic capsular shift combined with Bankart repair can reduce the capsular volume and reinforce the redundant capsule; however, as the capsuloligamentous structure has viscoelastic properties, it is possible for the shifted and tensioned capsule of the glenohumeral joint to slowly stretch out again over time, resulting in an increase in capsular volume. PURPOSE To analyze changes in capsular volume of the glenohumeral joint over time after arthroscopic Bankart repair and capsular shift, the factors associated with these changes, and their relevance to outcomes. STUDY DESIGN Case series; Level of evidence, 4. METHODS Included in this study were 105 patients (mean age, 25.8 ± 8.2 years) who underwent arthroscopic Bankart repair and capsular shift for anterior shoulder instability and computed tomography arthrography (CTA) at 3 months and 1 year postoperatively and whose various functional outcomes were evaluated preoperatively and at the last follow-up (>12 months). Among these patients, 27 also had preoperative CTA. These 27 patients were used to make comparisons between preoperative and 3-month postoperative CTA measurements, and all 105 patients were used for all other comparisons. Two raters measured the separate anterior and posterior capsular volume and cross-sectional area at the 5-o'clock position using 3-dimensional (3D) Slicer software. These measurements were subsequently adjusted for each glenoid size. The changes in capsular volume and cross-sectional area at the 5-o'clock position over time, the factors related to higher change in anterior capsular volume, and their correlation with outcomes were evaluated. RESULTS Three months postoperatively, the total and anterior capsular volume and anterior cross-sectional area significantly decreased; however, these values increased again at 1 year postoperatively (all P < .01). The inter- and intraobserver reliabilities of the measurements were excellent (interclass correlation coefficient = 0.717-0.945). Female sex, being an elite athlete, and more dislocations before surgery were related to a higher increase in anterior capsular volume at 1 year (all P < .05). Eight patients had redislocation, and 18 exhibited positive apprehension test postoperatively, and these patients showed significantly higher increases in anterior and total capsular volume at 1 year than did those without redislocation or positive apprehension sign (all P < .01). However, with the exception of Rowe score, a higher increase in anterior capsular volume was not related to functional outcome measures. CONCLUSION Surgeons should be aware of the re-increase in anterior capsular volume or restretching trait of the anterior capsule over time, even after successful arthroscopic Bankart repair and capsular shift. In this study, women, elite athletes, and those with frequent dislocations were at high risk of capsular restretching. An increase in capsular volume was related to redislocation and positive apprehension sign as well as with Rowe score.


How to Get Your Paper Published in JVIR.


Covid-19: excess all cause mortality in domiciliary care.


title: Bipolar disorder and resembling special psychopathological manifestations in multiple sclerosis: a review.

text: PURPOSE OF REVIEW The higher prevalence of psychiatric disorders in multiple sclerosis (MS) compared with the general population is well documented, with depression being the leading disorder. Apart from depression, other psychiatric disorders and symptoms such as bipolar disorder, pseudobulbar affect, euphoria sclerotica, anxiety and personality changes are also reported to be overpresented in MS patients. Psychiatric disorders in MS lead to significant disruption in patients' family, work and social life, affecting patients' quality of life in general. Moreover, they are reported to be associated with poorer adherence to MS medication. The literature concerning bipolar disorder and affect disorders in MS is rather scarce. The purpose of this article is to provide a critical review on the latter subject. RECENT FINDINGS This review focuses upon the recent findings with regard to the epidemiology and the comorbidity rates of bipolar and affect disorders in MS, questions raised about the potential underlying mechanisms that could explain such a high comorbidity, diagnostic issues and the recent developments in the treatment of those psychiatric disorders in MS. SUMMARY Despite the fact that the higher prevalence of psychiatric disorders in MS is well established, such disorders still remain underdiagnosed and undertreated. A shift in the clinical suspicion towards the psychiatric morbidity in MS patients and the optimal treatment of those disorders is fundamental.


title: Expert review on the VenaSeal® system for endovenous cyano-acrylate adhesive ablation of incompetent saphenous trunks in patients with varicose veins.

text: INTRODUCTION The treatment of incompetent truncal veins has been innovated by the introduction of minimally invasive non-thermal non-tumescent (NTNT) techniques. One of these consists of the use of cyanoacrylate glue to occlude the vein lumen by means of the VenaSeal device. Areas covered: This expert-review aims to evaluate NTNT ablation of incompetent saphenous trunks using the VenaSeal device. Expert commentary: Cyanoacrylate adhesive embolization of incompetent truncal veins using the VenaSeal device is a safe and efficacious innovative technique. Further studies are needed to evaluate anatomical and clinical outcomes at long term.


title: A novel duplex real time quantitative reverse transcription polymerase chain reaction for rubella virus with armored RNA as a noncompetitive internal positive control.

text: The objective of this study was to build and apply a duplex real time quantitative reverse transcription-polymerase chain reaction (RT-PCR) for rubella virus. Firstly, a 60-bp-long armored RV RNA was constructed in the laboratory. Secondly, a duplex real time RT-PCR assay was established. Thirdly, the 60-bp-long armored RV RNA was used as an internal positive control (IPC) for the duplex real time RT-PCR. And finally the duplex real time RT-PCR assay was applied to detect RV RNA in clinical specimens. The in-house assay has a high amplification efficiency (0.99), a high analytical sensitivity (200 copies/mL), and a good reproducibility. The diagnostic specificity and sensitivity of the in-house assay were both 100%, due to the monitoring of the armored RV RNA IPC. Therefore, the in-house duplex real time quantitative RT-PCR assay is a specific, sensitive, reproducible and accurate assay for quantitation of RV RNA in clinical specimens. And noncompetitive armored RV RNA IPC can monitor RT-PCR inhibition and prevent false-negative and inaccurate results in the real time detection system.


title: The Relationship Between Physical Fitness Qualities and Sport-Specific Technical Skills in Female, Team-Based Ball Players: A Systematic Review.

text: BACKGROUND Understanding the relationships between physical fitness attributes and sport-specific technical skills may assist with the establishment of beneficial training interventions. The aim of this systematic review was to determine if physical fitness qualities were associated with performance of sport-specific technical skills in female, team-based ball players. METHODS Five databases (MEDLINE, EMBASE, SPORTDiscus, ProQuest, and Scopus) were searched for relevant studies up to April 15, 2019. Full-text articles investigating relationships between physical fitness and sport-specific technical skills in female, team-based ball players were included. Methodological quality of included studies was appraised using a modified Downs and Black checklist. Data synthesis was conducted to determine the summary of evidence based on the number of significantly associated relationships divided by the total relationships assessed. An individual relationship was defined as a reported result examining the association between a single physical fitness variable and a single sport-specific technical skill. RESULTS Data synthesis of grouped female ball players from 41 included studies revealed three clear associations: (i) body composition and defensive technical skills (19/29; 66%), (ii) agility and movement with a ball (4/6; 67%), and (iii) coordination and movement with a ball (3/5; 60%). An uncertain association exists between cardiorespiratory fitness and defensive technical skills (2/5; 40%). No association or an unknown conclusion (< 5 relationships reported) exists between all remaining physical fitness attributes and sport-specific technical skills. Sub-analyses revealed clear associations between body composition and throwing/shooting (using hands) in junior ball players (15/15; 100%) and with movement with a ball in elite (6/9; 67%) and senior (6/6; 100%) ball players. Three uncertain associations were found between offensive technical skills and agility in elite ball players (3/8; 38%), and with speed in elite (6/14; 43%) and junior (7/18; 39%) female ball players. CONCLUSION There is limited evidence available to demonstrate relationships between physical fitness qualities and sport-specific technical skills in female, team-based ball players. This lack of association is possibly due to reductionist methods in available literature and a lack of research in female ball players globally. REGISTRATION CRD42017065339 (PROSPERO on 12 May 2017).


title: Deception Improves Time Trial Performance in Well-trained Cyclists without Augmented Fatigue.

text: PURPOSE To investigate the effects of feedback, in the form of a virtual avatar paced at 100% and 102% of baseline performance, on neuromuscular fatigue after a 4-km cycling time trial (TT). We hypothesized that improved cycling performance would occur because of the participants exceeding a previously established critical threshold and experiencing greater neuromuscular fatigue. METHODS After familiarization, 10 well-trained cyclists performed a baseline 4-km TT without feedback (BASE), followed by two 4-km TT where they raced against an avatar (set at 100% accurate [ACC] and 102% deception [DEC] of baseline power output) in a randomized and counterbalanced order. Before and after each TT, neuromuscular fatigue was assessed using maximal isometric voluntary contractions (MVC) of the quadriceps, and supramaximal electrical stimulation of the femoral nerve, during and 2 s after MVCs to assess voluntary activation and potentiated twitch force. Blood lactate was taken pretrials and posttrials and RPE was taken throughout each TT. RESULTS Time trial performance improved after deception of feedback compared with baseline performance (-5.8 s, P = 0.019). Blood lactate increased after DEC compared with BASE (+1.37 mmol·L, P = 0.019). Despite this, there was no difference in any measures of exercise-induced neuromuscular fatigue (P > 0.05). Similarly, RPE was not different between trials. CONCLUSIONS Well-trained male cyclists can improve cycling TT performance when competing against an avatar increased to 102% of a previously established best effort. However, this improvement is not associated with a measurable augmentation of neuromuscular fatigue.


title: Clinical Features of E-cigarette, or Vaping, Product Use-Associated Lung Injury in Teenagers.

text: BACKGROUND In the United States in 2019, there was an outbreak of electronic cigarette, or vaping, product use-associated lung injury (EVALI). The manifestations of EVALI in adolescents are not well characterized. We describe the diagnosis, evaluation, and management of EVALI in adolescents hospitalized at a tertiary care, university-affiliated children's hospital. METHODS A multidisciplinary committee developed an EVALI algorithm on the basis of guidelines from the Centers for Disease Control and Prevention. A retrospective chart review was conducted on patients diagnosed with EVALI. Descriptive analyses included sociodemographic characteristics, clinical presentation, laboratory and imaging results, pulmonary function testing, oxygen requirements, and clinic follow-up. RESULTS Thirteen hospitalized adolescents were diagnosed with confirmed or probable EVALI. The majority were female (54%) with a mean age of 15.9 years. Sixty-nine percent of patients presented with respiratory symptoms, whereas gastrointestinal symptoms were prominent in 85% of patients. Vaping Δ-9-tetrahydrocannabinol was reported in 92% of patients, and vaping nicotine was reported in 62% of patients. All had bilateral ground-glass opacities on the chest computed tomography (CT) scan. Treatment with glucocorticoids led to clinical improvement in 11 of 12 patients. Treatment with glucocorticoids led to improvement in both forced expiratory volume in 1 second and forced vital capacity (P < .05). Four patients required home oxygen on the basis of 6-minute walk test results. CONCLUSIONS Diagnosis of EVALI should be suspected on the basis of vaping history and clinical presentation. Glucocorticoid treatment led to an improvement in symptoms and lung function. The 6-minute walk test may help determine oxygen needs at discharge.


title: New respiratory viral infections.

text: PURPOSE OF REVIEW The first era in the discoveries of respiratory viruses occured between 1933 and 1965 when influenza virus, enteroviruses, adenovirus, respiratory syncytial virus, rhinovirus, parainfluenza virus and coronavirus (CoV) were found by virus culture. In the 1990s, the development of high throughput viral detection and diagnostics instruments increased diagnostic sensitivity and enabled the search for new viruses. This article briefly reviews the clinical significance of newly discovered respiratory viruses. RECENT FINDINGS In 2001, the second era in the discoveries of respiratory viruses began, and several new respiratory viruses and their subgroups have been found: human metapneumovirus, CoVs NL63 and HKU1, human bocavirus and human rhinovirus C and D groups. SUMMARY Currently, a viral cause of pediatric respiratory illness is identifiable in up to 95% of cases, but the detection rates decrease steadily by age, to 30-40% in the elderly. The new viruses cause respiratory illnesses such as common cold, bronchitis, bronchiolitis, exacerbations of asthma and chronic obstructive pulmonary disease and pneumonia. Rarely, acute respiratory failure may occur. The clinical role of other new viruses, KI and WU polyomaviruses and the torque teno virus, as respiratory pathogens is not clear.


Malta's healthcare escalation for COVID-19.


title: In Silico Investigation of the SARS CoV2 Protease with Thymoquinone Major Constituent of Nigella Sativa.

text: The COVID-19 caused by a new type of coronavirus has emerged from China and led to thousands of deaths globally. Despite many groups engaged in studying the newly emerged virus and searching for the treatment, the understanding of the SARS-CoV2 target ligand interactions represents a key challenge. Several studies are being conducted to identify potential treatment. Alternatively, the results of numerous studies have shown that protease inhibitors can be a genuine leader in research. The antiviral activity and beneficial effect against respiratory disorders of thymoquinone have been largely demonstrated. The aim of this study is to testing In Silico the inhibition of the replication of SARS CoV2 by thymoquinone. This is a molecular simulation study using SARS CoV2 protease and thymoquinone structures provided by Protein Data Bank. The preliminary results have shown that thymoquinone may have inhibitory activities against SARS CoV2 protease. Furthermore, given the demonstrated results of thymoquinone, we can conclude that it may be considered as an effective or adjuvant treatment for SARS CoV2 infection.


title: Accuracy and efficacy of percutaneous biopsy and ablation using robotic assistance under computed tomography guidance: a phantom study.

text: OBJECTIVE To compare the accuracy of a robotic interventional radiologist (IR) assistance platform with a standard freehand technique for computed-tomography (CT)-guided biopsy and simulated radiofrequency ablation (RFA). METHODS The accuracy of freehand single-pass needle insertions into abdominal phantoms was compared with insertions facilitated with the use of a robotic assistance platform (n = 20 each). Post-procedural CTs were analysed for needle placement error. Percutaneous RFA was simulated by sequentially placing five 17-gauge needle introducers into 5-cm diameter masses (n = 5) embedded within an abdominal phantom. Simulated ablations were planned based on pre-procedural CT, before multi-probe placement was executed freehand. Multi-probe placement was then performed on the same 5-cm mass using the ablation planning software and robotic assistance. Post-procedural CTs were analysed to determine the percentage of untreated residual target. RESULTS Mean needle tip-to-target errors were reduced with use of the IR assistance platform (both P < 0.0001). Reduced percentage residual tumour was observed with treatment planning (P = 0.02). CONCLUSION Improved needle accuracy and optimised probe geometry are observed during simulated CT-guided biopsy and percutaneous ablation with use of a robotic IR assistance platform. This technology may be useful for clinical CT-guided biopsy and RFA, when accuracy may have an impact on outcome. KEY POINTS • A recently developed robotic intervention radiology assistance platform facilitates CT-guided interventions. • Improved accuracy of complex needle insertions is achievable. • IR assistance platform use can improve target ablation coverage.


title: Pressures delivered by nasal high flow oxygen during all phases of the respiratory cycle.

text: BACKGROUND Nasal high flow (NHF) oxygen therapy and CPAP are modes of noninvasive respiratory support used to improve respiratory function in multiple patient groups. Both therapies provide positive pressure, although this varies during the respiratory cycle. The purpose of this study was to measure and compare the airway pressure generated during different phases of the respiratory cycle in patients receiving NHF at various gas flows. METHODS Patients scheduled for elective cardiac surgery were invited to participate. Nasopharyngeal pressure measurements were performed using NHF with gas flows of 30, 40, and 50 L/min. All measurements were performed in random order, with the subject breathing with mouth closed. RESULTS During NHF the mean ± SD nasopharyngeal airway pressures were 1.5 ± 0.6, 2.2 ± 0.8, and 3.1 ± 1.2 at 30, 40, and 50 L/min using NHF. Analyses also determined the mean peak expiratory and mean expiratory plateau pressures. CONCLUSIONS The expiratory pressure during NHF was higher than the mean pressure previously reported for NHF. This may account in part for the disproportional clinical effects seen with NHF. (Australian Clinical Trials Registry www.anzctr.org.au ACTRN12609000305224).


title: Clinical Practice Guideline for Enteroscopy.

text: Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.


title: Stigma for common mental disorders in racial minorities and majorities a systematic review and meta-analysis.

text: BACKGROUND There is a strong stigma attached to mental disorders preventing those affected from getting psychological help. The consequences of stigma are worse for racial and/or ethnic minorities compared to racial and/or ethnic majorities since the former often experience other social adversities such as poverty and discrimination within policies and institutions. This is the first systematic review and meta-analysis summarizing the evidence on the impact of differences in mental illness stigma between racial minorities and majorities. METHODS This systematic review and meta-analysis included cross-sectional studies comparing mental illness stigma between racial minorities and majorities. Systematic searches were conducted in the bibliographic databases of PubMed, PsycINFO and EMBASE until 20th December 2018. Outcomes were extracted from published reports, and meta-analyses, and meta-regression analyses were conducted in CMA software. RESULTS After screening 2787 abstracts, 29 studies with 193,418 participants (N = 35,836 in racial minorities) were eligible for analyses. Racial minorities showed more stigma than racial majorities (g = 0.20 (95% CI: 0.12 ~ 0.27) for common mental disorders. Sensitivity analyses showed robustness of these results. Multivariate meta-regression analyses pointed to the possible moderating role of the number of studies with high risk of bias on the effect size. Racial minorities have more stigma for common mental disorders when compared with majorities. Limitations included moderate to high risk of bias, high heterogeneity, few studies in most comparisons, and the use of non-standardized outcome measures. CONCLUSIONS Mental illness stigma is higher among ethnic minorities than majorities. An important clinical implication of these findings would be to tailor anti-stigma strategies related with mental illnesses according to specific racial and/or ethnic backgrounds with the intention to improve mental health outreach.


title: Timing-specific transfer of adapted muscle activity after walking in an elastic force field.

text: Human locomotion results from interactions between feedforward (central commands from voluntary and automatic drive) and feedback (peripheral commands from sensory inputs) mechanisms. Recent studies have shown that locomotion can be adapted when an external force is applied to the lower limb. To better understand the neural control of this adaptation, the present study investigated gait modifications resulting from exposure to a position-dependent force field. Ten subjects walked on a treadmill before, during, and after exposure to a force field generated by elastic tubing that pulled the foot forward and up during swing. Lower limb kinematics and electromyographic (EMG) activity were recorded during each walking period. During force field exposure, peak foot velocity was initially increased by 38%. As subjects adapted, peak foot velocity gradually returned to baseline in <or=125 strides. In the adapted state, hamstring EMG activity started earlier (16% before toe off) and remained elevated throughout swing. After force field exposure, foot velocity was initially reduced by 22% and returned to baseline in 9-51 strides. Aftereffects in hamstring EMGs consisted of increased activity around toe off. Contrary to the adapted state, this increase was not maintained during the rest of swing. Together, these results suggest that while the neural control of human locomotion can adapt to force field exposure, the mechanisms underlying this adaptation may vary according to the timing in the gait cycle. Adapted hamstring EMG activity may rely more on feedforward mechanisms around toe off and more on feedback mechanisms during the rest of swing.


Impact of COVID-19 as a vertical infection in late pregnancy.


Mitigating and learning from the impact of COVID-19 infection on addictive disorders.


title: The Role of Iron in Type 1 Diabetes Etiology: A Systematic Review of New Evidence on a Long-Standing Mystery.

text: BACKGROUND The incidence of type 1 diabetes (T1D) is rising, which might be due to the influence of environmental factors. Biological and epidemiological evidence has shown that excess iron is associated with beta-cell damage and impaired insulin secretion. AIM In this review, our aim was to assess the association between iron and the risk of T1D. METHODS A systematic literature search was performed in PubMed and EMBASE in July 2016. Studies investigating the effect of iron status/intake on the risk of developing T1D later were included, and study quality was evaluated. The results have been summarized in narrative form. RESULTS From a total of 931 studies screened, we included 4 observational studies evaluating iron intake from drinking water or food during early life and the risk of T1D. The quality of the studies was moderate to high assessed via the nine-star Newcastle Ottawa Scale. One out of the four studies included in this review found estimates of dietary iron intake to be associated with risk of T1D development, whereas three studies found no such relationship for estimates of iron in drinking water. CONCLUSIONS The limited number of studies included found dietary iron, but not iron in drinking water, to be associated with risk of T1D. Further studies are needed to clarify the association between iron and risk of T1D, especially studies including measurements of body iron status.


title: Transvesical robotic radical prostatectomy.

text: OBJECTIVE To report the technical feasibility of performing transvesical robotic radical prostatectomy (TRRP) in a cadaver. MATERIALS AND METHODS TRRP was performed in two fresh male cadavers (prostate volume 46 and 30 mL). In the first procedure we used four laparoscopic transvesical trocars and in the second a single-port device was placed percutaneously into the bladder. Pneumovesicum was established in both cases and the da Vinci-S robotic system (Intuitive Surgical, Sunnyvale, CA, USA) was used for the TRRP. All steps of the procedure, including dissection of the seminal vesicles and vas deferens, ligation of prostatic pedicles, release of neurovascular bundles, apical dissection, urethral transection, and urethro-vesical anastomosis, were done transvesically and robotically. Real time transrectal ultrasonography monitoring was used in the first cadaver. RESULTS Both procedures were technically successful transvesically with no need for additional ports or conversion to standard laparoscopy. The operative duration for the multi-port procedure was 3 h and for the single-port procedure was 4.2 h. Clashing of the da Vinci arms was the primary technical difficulty with the single-port procedure, but did not occur in the multi-port procedure. CONCLUSIONS TRRP under pneumovesicum is technically feasible using multiple-port or a single-port approach in the cadaver. The clinical application of this novel approach is imminent. Further refinement of technique and instruments might lead to an increasing role of percutaneous intraluminal surgery in various surgical disciplines.