title: Laparoscopic Management of Ureteroileal Anastomosis Strictures: Initial Experience.

text: BACKGROUND A ureteroileal anastomosis stricture (UAS) is one of the most frequent complications after radical cystectomy. Open surgical repair is the treatment of choice but is associated with morbidity. OBJECTIVE To describe the efficacy and safety of laparoscopic management for benign secondary UAS. DESIGN, SETTING, AND PARTICIPANTS A review was performed of the 11 initial procedures performed at our academic center from December 2010 to December 2014, with mean follow-up of 38 mo (range 12-169). Patients included had benign ureteroileal strictures longer than 1cm. SURGICAL PROCEDURE A pure laparoscopic approach was systematically used, involving a two-step procedure for left and a one-step procedure for right ureteral stenosis. MEASUREMENTS Perioperative data were collected and complications were assessed using the Clavien-Dindo grading system. Outcomes and follow-up data were analyzed. RESULTS AND LIMITATIONS A descriptive statistical analysis was performed for 11 surgeries in ten patients. The median stricture length was 2.4cm. No conversion to open surgery was required. The mean blood loss was 180ml and the mean hospital stay was 10 d. Early complications included limited lymphorrhea (n=1), limited anastomotic leakage (n=2), and accidental descent of a ureteral catheter (n=1) that was replaced with radiologic intervention. The mean follow-up was 38 mo (range 12-169). No late complications were reported. After 1 yr of follow-up, six patients had good glomerular filtration rates, all patients were asymptomatic, and no stenotic relapses were detected. CONCLUSIONS This laparoscopic technique for the management of benign secondary UAS is feasible, with good results and without long-term complications. This minimally invasive approach reduces the morbidity associated with open surgery while retaining good success rates. PATIENT SUMMARY We describe a novel laparoscopic approach for patients with a ureteroileal anastomosis stricture after radical cystectomy to avoid the complications associated with open surgery. The surgery was found to be viable and safe with good long-term results.


title: Perioperative comparison of robotic assisted laparoendoscopic single-site (LESS) pyeloplasty versus conventional LESS pyeloplasty.

text: BACKGROUND Conventional laparoendoscopic single-site (C-LESS) pyeloplasty is technically challenging due to instrument clashing, loss of triangulation, and difficulty sewing. Application of the da Vinci S or Si robotic platforms could potentially overcome these challenges. OBJECTIVE Compare our initial experience with robotic assisted laparoendoscopic single-site (R-LESS) pyeloplasty to our latter experience with C-LESS pyeloplasty (ie, after the initial 15 patients). DESIGN, SETTING, AND PARTICIPANTS This single-institution retrospective observational cohort study involved consecutive patients who presented with symptomatic ureteropelvic junction obstruction and who were deemed suitable for single-incision pyeloplasty by the treating surgeon. MEASUREMENTS Demographic, clinical, perioperative, and early postoperative comparative outcomes. RESULTS AND LIMITATIONS Ten patients each underwent R-LESS or C-LESS pyeloplasty by a single surgeon between March 2009 and July 2011. For R-LESS and C-LESS groups, age, gender distribution, body mass index, proportion of patients with prior abdominal surgery, estimated blood loss, and hospital length of stay were statistically similar. Mean operative time was significantly longer for R-LESS (226 vs 188 min; p=0.007). C-LESS pyeloplasty alone required an accessory port for the anastomosis in 10 of 10 cases. Two conversions to standard laparoscopy and two postoperative complications occurred in 3 of 10 patients in the C-LESS group, compared with no conversions and one postoperative complication in the R-LESS group (p=0.26). Study limitations are a retrospective design, a modest number of patients, and a lack of quantification of subjective outcomes such as instrument clashing and maneuverability. CONCLUSIONS Adaptation of the da Vinci Si robotic surgical platform to laparoendoscopic single-site pyeloplasty appears to reduce the physical learning curve for this complex procedure. Future prospective, comprehensive evaluation of additional outcomes including subjective parameters, cosmesis, and longer term functional outcomes will help better define its role in minimally invasive dismembered pyeloplasty and better estimate its associated learning curve.


title: Impact of rectopexy on sexual function: a cohort analysis.

text: PURPOSE Laparoscopic ventral rectopexy (LVR) is an established surgical technique for the treatment of both rectal prolapse and symptomatic rectoceles. It is, however, not known whether LVR influences sexual function (SF). The aim of this study was, therefore, to determine the impact of this procedure on the SF of patients. METHODS All female patients after LVR procedure in a single institution were identified and were sent a questionnaire concerning SF. This addressed sexual activity, satisfaction, preoperative SF, and the impact of surgery on SF. Furthermore, the PISQ-12 validated sexual functioning questionnaire was sent to all female patients. RESULTS A total of 217 patients were sent a questionnaire. These patients underwent LVR for rectal prolapse, symptomatic rectocele, or enterocele between 2004 and 2011. Mean age was 62 years (range 22-89). Mean follow-up was 30 months (range 5-83). Response rate was 64 % (139 patients). The number of sexual active patients dropped from 71 to 54 % after surgery. The number of patients being satisfied with their SF remained relatively equal; 91 % of patients before and 85 % of patients after surgery. Forty-three percent of patients stated that the LVR procedure did not influence their sexual function, in 16 % of patients, the procedure positively influenced their SF, and in 13 % of respondents, SF decreased after surgery. The mean PISQ-12 score postoperatively was 34 out of 48. CONCLUSIONS The impact of LVR on SF of patients seems limited in this cross-sectional study in a large cohort of patients.


Systematic review of sleeve gastrectomy as staging and primary bariatric procedure.


title: Ectopic intrapulmonary thyroid: a case report.

text: An ectopic thyroid is caused by abnormalities in migration of the thyroid during development and rarely occurs in the thoracic cavity or the abdominal cavity. We report the case of a 64-year-old female who had abnormal findings from a thyroid hormone test during follow-up after thyroid cancer surgery. Based on the radioisotope diagnostic test, an ectopic thyroid inside the thoracic cavity was suspected. Through surgical treatment, the patient was diagnosed with ectopic intrapulmonary thyroid. Ectopic intrapulmonary thyroid is reported to be very rare and the case is described along with a literature review.


title: Laparoscopic sleeve gastrectomy in ethnic obese Chinese.

text: BACKGROUND The aim of this study was to evaluate the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity in ethnic Chinese in Hong Kong. METHODS Seventy consecutive Chinese patients (49 females; mean age 34.7+/-8.8 [range 18-56] years) received LSG for the treatment of obesity from May 2006 to Nov 2007 as a stand-alone procedure for weight reduction. Mean baseline body weight (BW) and body mass index (BMI) were 108.9+/-22.1 kg (range 71.0-164.9 kg) and 40.7+/-7.8 kg/m(2) (range 27.4-68.4 kg/m(2)), respectively. Outcome measures were collected and assessed in a prospective manner. RESULTS All procedures were performed laparoscopically with no conversion. There was neither mortality nor any postoperative complications that required reoperation. Major complication occurred in two patients (2.9%; esophagogastric junction [EGJ] leak and stomach tube stricture). Mean follow-up was 7.1+/-5.0 months. Mean procedure time was 90.6+/-39.4 min, and mean hospital stay was 3.8+/-2.3 days. Mean BMI loss was 6.3+/-2.5, 9.0+/-3.4 and 12.3+/-4.5 kg/m(2) at 3, 6, and 12 months. Mean percent of excess BW loss was 48.5+/-28.4, 69.7+/-31.7, and 63.5+/-29.4 at 3, 6, and 12 months. CONCLUSION LSG is safe and effective in achieving significant weight loss in obese ethnic Chinese patients.


title: Does the site of anterior tracheal puncture affect the success rate of retrograde intubation? A prospective, manikin-based study.

text: Background. Retrograde intubation is useful for obtaining endotracheal access when direct laryngoscopy proves difficult. The technique is a practical option in the "cannot intubate / can ventilate" scenario. However, it is equally useful as an elective technique in awake patients with anticipated difficult airways. Many practitioners report difficulty successfully advancing the endotracheal tube due to anatomical obstructions and the acute angle of the anterograde guide. The purpose of this study was to test whether a more caudal tracheal puncture would increase the success rate. Methods. Twenty-four anesthesiology residents were randomly assigned to either a cricothyroid or a cricotracheal puncture group. Each was instructed how to perform the technique and then attempted it on a manikin at their assigned site. Data collection included whether the trachea was intubated, the number of attempts required, and the total time. Results. Both groups displayed a high degree of success. While the group assigned to the cricotracheal site required significantly more time to perform the procedure, they accomplished it in fewer attempts than the cricothyroid group. Conclusion. Retrograde intubation performed via a cricotracheal puncture site, while more time consuming, resulted in fewer attempts to advance the endotracheal tube and may reduce in vivo laryngeal trauma.


title: Zero-fragment Nephrolithotomy: A Multi-center Evaluation of Robotic Pyelolithotomy and Nephrolithotomy for Treating Renal Stones.

text: BACKGROUND Robotic pyelolithotomy (RPL) and robotic nephrolithotomy (RNL) may be utilized for treating kidney stones as an alternative to percutaneous nephrolithotomy or flexible ureteroscopy. OBJECTIVE To describe the techniques of RPL and RNL, and present multi-center outcome data for patients undergoing these procedures. DESIGN, SETTING, AND PARTICIPANTS This study was a retrospective analysis of 27 patients undergoing RPL and RNL at five tertiary academic institutions between 2008 and 2014. SURGICAL PROCEDURE RPL and RNL without use of renal ischemia. MEASUREMENTS We assessed stone clearance by visual assessment and postoperative imaging. We also examined other factors, including complications (Clavien grade), estimated blood loss, operative time, and length of stay. RESULTS AND LIMITATIONS Twenty-seven patients underwent 28 procedures for a mean renal stone size of 2.74cm (standard deviation: 1.4, range: 0.8-5.8). The mean stone volume was 10.2cm3. RPL accounted for 26 of these procedures. RNL was performed in one patient, while another underwent combined RPL-RNL. Indications included failed previous endourological management (13), staghorn calculi (five), gas containing stone (one), calyceal diverticulum (one), complex urinary tract reconstruction (two), and patient preference (four). The mean patient age was 35.6 yr and mean body mass index was 25.5kg/m2. Mean operative time/console times were 182min and 128min, respectively. The mean estimated blood loss was 38ml. The mean length of stay was 1.7 d. There was no significant change in preoperative and postoperative serum creatinine levels. The overall complication rate was 18.5% (Clavien 1=3.7%; 2=7.4%; 3b=7.4%). The complete stone-free rate was 96%. CONCLUSIONS RPL and RNL are safe and reasonable options for removing renal stones in select patients. In particular, RPL allows the removal of stones without transgressing the parenchyma, reducing potential bleeding and nephron loss. PATIENT SUMMARY The robotic approach allows for complete removal of the renal stone without fragmentation, thereby maximizing chances for complete stone clearance in one procedure.


[Single-port gastric bypass: technical details of a new approach].


title: Endovascular treatment with flow diverters of recanalized and multitreated aneurysms initially treated by endovascular approach.

text: PURPOSE To evaluate the feasibility, safety and efficacy of endovascular treatment with flow diverters in patients with recanalized and multitreated aneurysms in a retrospective, multicenter, single-arm study. METHODS The study included 29 patients with 29 recanalized aneurysms who were treated by flow diverters (Silk or Pipeline devices). Pre- and post-procedural complications and morbidity and mortality rates were evaluated and functional outcomes (modified Rankin Score (mRS)) at 1 month (short-term) and 3-4 months (mid-term) were compared with preoperative mRS (before the procedure). Mid-term angiographic follow-up was performed assessing aneurysmal occlusion by the Montreal scale (complete occlusion, neck remnant, aneurysm remnant). RESULTS Placement of the flow diverters was achieved in all patients. Two misdeployments of the flow diverters necessitated balloon dilation in two patients, which was associated with stent delivery in one patient. Permanent morbidity related to treatment was 6.9% (2/29), transient morbidity was 10.3% (3/29) and there were no deaths resulting from the treatment. One patient died from a myocardial infarct 4 weeks after the procedure. 25/29 patients (86.2%) had a good final functional outcome, 26/29 (89.7%) had an unchanged functional outcome and 2/29 patients (6.9%) had clinical worsening. Angiographic follow-up showed complete occlusion in 17/28 patients (60.7%), neck remnants in 6/28 patients (21.4%) and residual aneurysms in 5/28 (17.9%). CONCLUSIONS Flow diverter placement is feasible and safe in patients with recanalized and multitreated aneurysms. The procedure is associated with a high percentage of good functional outcomes as well as good mid-term anatomical results (82.1%).


title: Duration of the action of rocuronium in patients with BMI of less than 25: An observational study.

text: BACKGROUND The duration of rocuronium in patients with BMI more than 30 kg m is prolonged. Whether the reverse is true when BMI is less than 18.5 kg m is unclear. OBJECTIVE The objective of this study was to investigate whether a BMI less than 25 kg m affects the duration of rocuronium in doses adjusted for actual body weight. DESIGN A prospective, observational, single-centre study. SETTING The operating room of a teaching hospital from 1 June 2008 to 30 June 2015. PATIENTS Thirty patients with American Society of Anesthesiologists physical status I or II who were scheduled to undergo elective surgery (BMI < 25 kg m, aged 23 to 74 years) maintained by 0.7 minimum alveolar concentration sevoflurane and remifentanil. MAIN OUTCOME MEASURES Repetitive train-of-four stimulation was applied and contractions of the adductor pollicis muscle were recorded. Duration of the initial dose of rocuronium (D1) was defined as the time from injection of rocuronium 0.6 mg kg to return of first twitch height to 25% of the control. Duration of additional doses (D2) was the time from a supplement of 0.15 mg kg rocuronium to return of first twitch height to 25% of the control. The relationship between D1 or D2 and BMI was examined using linear regression analysis. RESULTS Linear regression analysis revealed a significant correlation between duration of initial dose and BMI (R = 0.246; P = 0.00531). A significant correlation between the duration of the additional dose and BMI was also found (R = 0.316; P = 0.00122). CONCLUSION The lower the BMI, the shorter the duration of rocuronium at initial and additional doses determined by the actual body weight in adult patients with a BMI less than 25 kg m. TRIAL REGISTRATION www.umin.ac.jp/ctr/index/htm with registry number UMIN 00009337 and UMIN 000015407.


title: Computational target-based drug repurposing of elbasvir, an antiviral drug predicted to bind multiple SARS-CoV-2 proteins.

text: Coronavirus disease 19 (COVID-19) is a severe acute respiratory syndrome caused by SARS-CoV-2 (2019-nCoV). While no drugs have yet been approved to treat this disease, small molecules effective against other viral infections are under clinical evaluation for therapeutic abatement of SARS-CoV-2 infections. Ongoing clinical trials include Kaletra (a combination of two protease inhibitors approved for HIV treatment), remdesivir (an investigational drug targeting RNA-dependent RNA polymerase [RdRP] of SARS-CoV-2), and hydroxychloroquine (an approved anti-malarial and immuno-modulatory drug). Since SARS-CoV-2 replication depends on three virally encoded proteins (RdRP, papain-like proteinase, and helicase), we screened 54 FDA-approved antiviral drugs and ~3300 investigational drugs for binding to these proteins using targeted and unbiased docking simulations and computational modeling. Elbasvir, a drug approved for treating hepatitis C, is predicted to bind stably and preferentially to all three proteins. At the therapeutic dosage, elbasvir has low toxicity (liver enzymes transiently elevated in 1% of subjects) and well-characterized drug-drug interactions. We predict that treatment with elbasvir, alone or in combination with other drugs such as grazoprevir, could efficiently block SARS-CoV-2 replication. The concerted action of elbasvir on at least three targets essential for viral replication renders viral mutation to drug resistance extremely unlikely.


title: Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review.

text: BACKGROUND One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. METHODS We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. RESULTS The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. CONCLUSION Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.


title: Design and Application of a New Automated Fluidic Visceral Stimulation Device for Human fMRI Studies of Interoception.

text: Mapping the brain centers that mediate the sensory-perceptual processing of visceral afferent signals arising from the body (i.e., interoception) is useful both for characterizing normal brain activity and for understanding clinical disorders related to abnormal processing of visceral sensation. Here, we report a novel closed-system, electrohydrostatically driven master-slave device that was designed and constructed for delivering controlled fluidic stimulations of visceral organs and inner cavities of the human body within the confines of a 3T magnetic resonance imaging (MRI) scanner. The design concept and performance of the device in the MRI environment are described. In addition, the device was applied during a functional MRI (fMRI) investigation of visceral stimulation related to detrusor distention in two representative subjects to verify its feasibility in humans. System evaluation tests demonstrate that the device is MR-compatible with negligible impact on imaging quality [static signal-to-noise ratio (SNR) loss <2.5% and temporal SNR loss <3.5%], and has an accuracy of 99.68% for flow rate and 99.27% for volume delivery. A precise synchronization of the stimulus delivery with fMRI slice acquisition was achieved by programming the proposed device to detect the 5 V transistor-transistor logic (TTL) trigger signals generated by the MRI scanner. The fMRI data analysis using the general linear model analysis with the standard hemodynamic response function showed increased activations in the network of brain regions that included the insula, anterior and mid-cingulate and lateral prefrontal cortices, and thalamus in response to increased distension pressure on viscera. The translation from manually operated devices to an MR-compatible and MR-synchronized device under automatic control represents a useful innovation for clinical neuroimaging studies of human interoception.


Letter to the Editor: In response to "Role of Telehealth in the Management of COVID-19: Lessons Learned from Previous SARS, MERS, and Ebola Outbreaks".


title: Evolution of topical NSAIDs in the guidelines for treatment of osteoarthritis in elderly patients.

text: Increasing age is the primary predictor of osteoarthritis, the most prevalent painful condition in the US. Because there are no disease-modifying therapies for osteoarthritis, relief of symptoms and maintenance of quality of life through improving joint function become the focus of management. Although highly effective for pain relief, oral nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with systemic adverse reactions that are sometimes treatment limiting, especially for older patients. Thus, osteoarthritis management in elderly populations is shifting away from traditional NSAIDs to therapies that provide comparable pain relief with improved safety. Since the approval by the US Food and Drug Administration of the use of topical NSAIDs to manage osteoarthritis pain, current treatment guidelines put forth by several professional societies have begun to recommend topical NSAIDs as an alternative therapy and, most recently, as first-line therapy for osteoarthritis management in the elderly. This review provides an overview of the various treatment guidelines that are available to assist prescribers in making safe and effective decisions in the treatment of osteoarthritis in this high-risk patient population.


title: [Analysis on clinical study protocols of traditional Chinese medicine for coronavirus disease 2019].

text: To analyze the registered clinical trial protocols of traditional Chinese medicine(TCM) for the prevention and treatment of coronavirus disease 2019(COVID-19), in order to provide information for improving the quality of research design. The website of the Chinese Clinical Trial Registry(www.chictr.org.cn) and the American Clinical Trial Registry(clinicaltrials.gov) were searched to collect protocols of TCM for COVID-19. Documents were screened following the inclusion criteria, and data were extracted in regard to registration date, study objective, type of design, sponsor, patient, sample size, intervention, and evaluation index. Descriptive analysis was conducted. A total of 49 clinical trial protocols of TCM for COVID-19 were included. Primary sponsors were mainly hospitals or universities in places like Hubei, Beijing, Zhejiang and other regions. The implementation units are mainly in Hubei, Guangdong, Zhejiang, Henan and other regional hospitals. The types of study design were mainly experimental studies(40), including 30 randomized parallel controlled trials, 7 non-randomized controlled trials, 2 single arm trials and 1 consecutively recruited trial; besides, there were also 6 observational studies, 2 health service studies and 1 preventive study. The sample size reached a total of 30 562 cases, with a maximum of 20 000 for a single study and a minimum of 30. The 49 trials subjects included healthy people(3), isolation and observation cases(1), suspected cases(10),confirmed COVID-19 patients(31) and COVID-19 recovery patients(4). Of the 31 trials planned to include confirmed COVID-19 patients, 16 protocols no definite disease classification, 3 with a clear exclusion of severe subjects, 4 with common subjects, 2 with light, common or severe subjects, 1 with light and common subjects, 1 with common or severe subjects, 3 with severe subjects, and 1 with severe or critical subjects. The experimental interventions included Chinese patent medicine(Lianhua Qingwen Capsules/Granules, Huoxiang Zhengqi Dropping Pills/Oral Liquid, Babao Dan, Gubiao Jiedu Ling, Jinhao Jiere Granules, Compound Yu-xingcao Mixture, Jinye Baidu Granules, Shufeng Jiedu Capsuless, Shuanghuanglian Oral Liquid, Tanreqing Injection, Xuebijing Injection, Reduning Injection, Xiyanping Injection), Chinese medicinal decoction and taichi. The primary evaluation outcomes mainly included antipyretic time, clinical symptom relief, novel coronavirus nucleic acid turning to negative, conversion rate of severe cases and chest CT. There was a quick response of clinical research on the prevention and treatment of COVID-19 with TCM, with the current registered protocols covers the whole process of disease prevention, treatment and rehabilitation. However, issues need to be concerned, including unclear definition of patient's condition, unclear research objectives, unclear intervention process and inappropriate outcomes, etc. In addition, researchers should consider the actual difficulties and workload of doctors in epidemic response environment, and make effort to optimize the process and improve the operability of research protocols under the principle of medical ethics.


Delays in managing neurosurgical patients during the COVID-19 pandemic.


title: In vivo expression profile of the antiviral restriction factor and tumor-targeting antigen CD317/BST-2/HM1.24/tetherin in humans.

text: Human CD317 is an intrinsic immunity factor that restricts the release of enveloped viruses, including the major pathogens HIV and Lassa virus, from infected cells in culture. Its importance for infection control in humans is unclear, due in part to its incompletely defined in vivo expression pattern. CD317 also has been proposed as a selective target for immunotherapy of multiple myeloma. To provide a framework for studies of the biological functions, regulation, and therapeutic potential of CD317, we performed microarray-based expression profiling in 468 tissue samples from 25 healthy organs from more than 210 patients. We found that CD317 protein was expressed to varying degrees in all organs tested and detected in a number of specialized cell types, including hepatocytes, pneumocytes, ducts of major salivary glands, pancreas and kidney, Paneth cells, epithelia, Leydig cells, plasma cells, bone marrow stromal cells, monocytes, and vascular endothelium. Although many of these cell types are in vivo targets for pathogenic viruses, restriction by CD317 or virus-encoded antagonists has been documented in only some of them. Limited cell type-dependent coexpression of CD317 with the IFN biomarker MxA in vivo and lack of responsive stimulation in organ explants suggest that interferons may only partially regulate CD317. This in vivo expression profiling sheds light on the biology and species-specificity of CD317, identifies multiple thus far unknown interaction sites of viruses with this restriction factor, and refutes the concept of its restricted constitutive expression and primary IFN inducibility. CD317's widespread expression calls into question its suitability as a target for immunotherapy.


title: Single-scar laparoscopic colectomy with intracorporeal attachable and detachable instruments.

text: BACKGROUND In single-access laparoscopic colectomy, the number of instruments that can be inserted through the single-access site is limited by instrument collision. To compensate, triangulation is necessary, but the operative field becomes inadequate. To overcome this problem, intracorporeal attachable and detachable instruments can broaden the field of visceral tissue by retracting from at least 2 points. OBJECTIVE We tested this new procedure for colon cancer surgery. DESIGN This is a prospective study. SETTING This study was conducted at a single-center hospital. PATIENTS Ten consecutive patients (3 male and 7 female) with stage II or III colon cancer underwent the procedure. INTERVENTIONS All patients received a 3.0-cm incision at the umbilicus or right iliac fossa. At least 2 clips and a suspending bar were inserted through a 12-mm port in a multiport access device. The clips grasped the mesocolon at different points and were retracted with either an extracorporeal magnet or fine-loop retractors; this broadened the operative field in the mesocolon by at least 2 points. The mesocolon was dissected with a medial to lateral approach. The suspended bar was tied to 2 fine-loop retractors and manipulated to enlarge the operative field in the mesocolon. The roots of the vascular pedicles were isolated and divided during lymph node dissection. After extracting the specimen, an anastomosis was performed. MAIN OUTCOME MEASURES Intra- and postoperative complications due to inadequate access were the primary outcomes measured. RESULTS There were no intraoperative complications and no need for conversions to open surgery or second access ports. The median total surgical time was 182 minutes (range, 122-245). Surgical blood loss was slight (range, 1-20 mL) in all patients. No postoperative complications occurred. The postoperative hospital stay was 5 to 7 days. LIMITATIONS The sample size was small. CONCLUSIONS This study showed that intracorporeal attachable and detachable instruments were safe and feasible for this procedure.


title: T cell responses are required for protection from clinical disease and for virus clearance in severe acute respiratory syndrome coronavirus-infected mice.

text: A dysregulated innate immune response and exuberant cytokine/chemokine expression are believed to be critical factors in the pathogenesis of severe acute respiratory syndrome (SARS), caused by a coronavirus (SARS-CoV). However, we recently showed that inefficient immune activation and a poor virus-specific T cell response underlie severe disease in SARS-CoV-infected mice. Here, we extend these results to show that virus-specific T cells, in the absence of activation of the innate immune response, were sufficient to significantly enhance survival and diminish clinical disease. We demonstrated that T cells are responsible for virus clearance, as intravenous adoptive transfer of SARS-CoV-immune splenocytes or in vitro-generated T cells to SCID or BALB/c mice enhanced survival and reduced virus titers in the lung. Enhancement of the number of virus-specific CD8 T cells by immunization with SARS-CoV peptide-pulsed dendritic cells also resulted in a robust T cell response, earlier virus clearance, and increased survival. These studies are the first to show that T cells play a crucial role in SARS-CoV clearance and that a suboptimal T cell response contributes to the pathological changes observed in SARS. They also provide a new approach to SARS vaccine design.


title: Prospective trial with optical molecular imaging for percutaneous interventions in focal hepatic lesions.

text: PURPOSE To demonstrate the clinical translation of optical molecular imaging (OMI) for the localization of focal hepatic lesions during percutaneous hepatic interventions. MATERIALS AND METHODS Institutional review board approval was obtained for this prospective, single-center, HIPAA-compliant trial. Patients who were suspected of having hepatocellular carcinoma or liver metastases from colorectal cancer and were scheduled for percutaneous liver biopsy or thermal ablation were eligible for this study. Patients (n = 5) received 0.5 mg per kilogram of body weight of indocyanine green (ICG) intravenously 24 hours prior to their scheduled procedure in this study. Intraprocedurally, a handheld device composed of an endoscope that fits coaxially through a standard 17-gauge introducer needle was advanced into the liver, and real-time measurements of ICG fluorescence were obtained. A point-of-care fluorescence imaging system was used to image ICG fluorescence in biopsy samples. Target-to-background ratios (TBRs) were calculated by dividing the mean fluorescence intensity in the lesion by the mean fluorescence intensity in the adjacent liver parenchyma. The reference standard for determination of proper needle positioning in patients undergoing biopsy was final pathologic analysis of biopsy specimens or follow-up imaging. RESULTS Intraprocedural OMI was successfully performed in six lesions (two lesions in patient 3) in five patients. The median size of the targeted lesions was 16 mm (range, 10-21 mm). Four of five biopsies (80%) yielded an accurate pathologic diagnosis, and one biopsy specimen showed benign liver parenchyma; both ablated lesions showed no residual disease 1 month after the procedure. The median overall added procedure time to perform OMI was 2 minutes. ICG was found to localize with TBRs greater than 2.0 (median, 7.9; range, 2.4-13.4) in all target lesions. No trial-related adverse events were reported. CONCLUSION The clinical translation of OMI to percutaneous hepatic interventions was demonstrated.


title: Opportunities for Biomaterials to Address the Challenges of COVID-19.

text: The Coronavirus Disease 2019 (COVID-19) pandemic has revealed major shortcomings in our ability to mitigate transmission of infectious viral disease and provide treatment to patients, resulting in a public health crisis. Within months of the first reported case in China the virus has spread worldwide at an unprecedented rate. COVID-19 illustrates that the biomaterials community was engaged in significant research efforts against bacteria and fungi with relatively little effort devoted to viruses. Accordingly, biomaterials scientists and engineers will have to participate in multidisciplinary antiviral research over the coming years. Although tissue engineering and regenerative medicine have historically dominated the field of biomaterials, current research holds promise for providing transformative solutions to viral outbreaks. To facilitate collaboration, it is imperative to establish a mutual language and adequate understanding between clinicians, industry partners, and research scientists. In this article, clinical perspectives are shared to clearly define emerging healthcare needs that can be met by biomaterials solutions. Strategies and opportunities for novel biomaterials intervention spanning diagnostics, treatment strategies, vaccines, and virus-deactivating surface coatings are discussed. Ultimately this review serves as a call for the biomaterials community to become a leading contributor to the prevention and management of current and future viral outbreaks. This article is protected by copyright. All rights reserved.


docid: priqqhwz

title: A survey of general surgeons regarding laparoscopic inguinal hernia repair: practice patterns, barriers, and educational needs.

text: PURPOSE Practice patterns for inguinal hernia repair vary significantly among surgeons. The purpose of this study was to identify perceived indications for laparoscopic inguinal hernia repair (LIHR), and to identify barriers to its adoption and educational needs for surgeons. METHODS A web-based survey was sent to general surgery members of several North American surgical societies, and to surgical residents through program directors. The 33-item survey was divided in 4 sections: demographics, utilization of techniques, management based on 11 clinical scenarios, reasons for not performing LIHR and educational needs for those who want to learn. RESULTS Six hundred and ninety-seven general surgeons and 206 general surgery residents responded to the survey. Surgeons with MIS fellowships, and surgeons at the beginning of their careers are more likely to perform LIHR. Out of the 11 clinical scenarios, surgeons preferred a laparoscopic approach (totally extraperitoneal or transabdominal preperitoneal) for bilateral (48 %) and recurrent (44 %) hernias. However, 46 % of respondents never perform LIHR. Of these, 70 % consider the benefits of laparoscopy to be minimal, 59 % said they lack the requisite training, and 26 % are interested in learning. Surgeons (70 %) and residents (73 %) agreed that the best educational method would be a course followed by expert proctoring. CONCLUSION Surgeons remain divided on the utility of laparoscopic surgery for inguinal hernia repair. Nearly half of responding surgeons never perform LIHR, and the other half offer it selectively. One quarter of surgeons who do not perform LIHR are interested in learning. This reveals a knowledge gap that could be addressed with educational programs.


docid: dlgqjylw

title: Intraoperative assessment of the umbilicopubic distance: a reliable anatomic landmark for transposition of the umbilicus.

text: BACKGROUND A clear understanding of the anatomic location and the aesthetic traits of the umbilicus is essential for the plastic surgeon repositioning the umbilicus during an abdominoplasty. Currently no consensus exists regarding the ideal location for this unique aesthetic unit of the abdomen. To their interest, the authors noted that the intraoperative distance from the pubic symphysis to midumbilical stalk measured 15 cm for several consecutive patients. They believe the umbilicopubic distance is another clinically useful and reliable anatomic landmark for the plastic surgeon relocating the umbilicus during an abdominoplasty. METHODS A retrospective chart review analysis was performed for 40 consecutive patients who underwent abdominoplasty or panniculectomy between July 2009 and May 2010 at the authors' institution. The intraoperative measurement of the umbilicopubic distance (pubic symphysis to midumbilical stalk) was available for 32 of these patients. The average umbilicopubic distance was calculated. Two separate graphs were generated to evaluate the relationship of the umbilicopubic distance to the patients' height and body mass index (BMI). The data were saved and analyzed using Microsoft Office Excel. RESULTS In the study population, the average intraoperative umbilicopubic distance was found to be 15.05 cm. The results validate the mean umbilicopubic distance of 15.04 cm reported by Dubou and colleagues in 1978. For patients whose stature fell between 145 and 178 cm, the umbilicopubic distance was consistently 15 cm. A tendency toward a higher umbilicus was noted as the patients became taller. The BMI did not seem to influence the location of the umbilicus as measured intraoperatively. CONCLUSION Translocation of the umbilicus to 15 cm from the pubic symphysis in patients with a stature of 145-178 cm is another clinically useful, safe, and expeditious method for relocation of the umbilicus during an abdominoplasty.


The COVID-19 Pandemic-Can open access modeling give us better answers more quickly?


title: External carotid artery flow maintains near infrared spectroscopy-determined frontal lobe oxygenation during ephedrine administration.

text: BACKGROUND Phenylephrine and ephedrine affect frontal lobe oxygenation ([Formula: see text]) differently when assessed by spatially resolved near infrared spectroscopy. We evaluated the effect of phenylephrine and ephedrine on extra- vs intra-cerebral blood flow and on [Formula: see text]. METHODS In 10 healthy males (age 20-54 yr), phenylephrine or ephedrine was infused for an ∼20 mm Hg increase in mean arterial pressure. Cerebral oxygenation (SavO₂) was calculated from the arterial and jugular bulb oxygen saturations. Blood flow in the internal carotid artery (ICAf) and blood flow in the external carotid artery (ECAf) were assessed by duplex ultrasonography. Invos-5100c (SinvosO₂) and Foresight (SforeO₂) determined [Formula: see text] while forehead skin oxygenation (SskinO₂) was assessed. RESULTS Phenylephrine reduced SforeO₂ by 6.9% (95% confidence interval: 4.8-9.0%; P<0.0001), SinvosO₂ by 10.5 (8.2-12.9%; P<0.0001), and ECAf (6-28%; P=0.0001), but increased ICAf (5-21%; P=0.003) albeit with no consequence for SskinO₂ or SavO₂. In contrast, SforeO₂ was maintained with administration of ephedrine while SinvosO₂ and SavO₂ decreased [by 3.1 (0.7-4.5%; P=0.017) and 2.1 (0.5-3.3%; P=0.012)] as arterial carbon dioxide pressure decreased (P=0.003). ICAf was stable and ECAf increased by 11 (4-18%; P=0.005) with administration of ephedrine while SskinO₂ did not change. CONCLUSIONS The effect of phenylephrine on ScO₂ is governed by a decrease in external carotid blood flow since it increases cerebral blood flow as determined by flow in the internal carotid artery. In contrast, ScO₂ is largely maintained with administration of ephedrine because blood flow to extracerebral tissue increases.


docid: atlxswlh

title: COVID-19 pandemic - An African perspective.

text: The recently emerged novel coronavirus, "severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)", caused a highly contagious disease called coronavirus disease 2019 (COVID-19). The virus was first reported from Wuhan city in China in December, 2019, which in less than three months spread throughout the globe and was declared a global pandemic by the World Health Organization (WHO) on 11th of March, 2020. So far, the ongoing pandemic severely damaged the world's most developed countries and is becoming a major threat for low- and middle-income countries. The poorest continent, Africa with the most vulnerable populations to infectious diseases, is predicted to be significantly affected by the ongoing COVID-19 outbreak. Therefore, in this review we collected and summarised the currently available literature on the epidemiology, etiology, vulnerability, preparedness and economic impact of COVID-19 in Africa, which could be useful and provide necessary information on ongoing COVID-19 pandemics in the continent. We also briefly summarised the concomitance of the COVID-19 pandemic and global warming.


title: Evaluation of a thoracoscopic technique using ligating loops to obtain large lung biopsies in standing healthy and heaves-affected horses.

text: OBJECTIVE To evaluate use of pre-tied ligating loop to perform thoracoscopic, large lung biopsy in normal and heaves-affected horses. STUDY DESIGN Prospective clinical study. ANIMALS Normal (n=5) and heaves-affected (n=6) horses. METHODS Lung biopsies, 1 from each hemithorax, were collected thoracoscopically using a pre-tied ligating loop. Horses were either normal (C) or heaves-affected with the latter being in remission (Ha) for the initial biopsy and in exacerbation (Hs) for the 2nd biopsy. Clinical variables, PaO(2), and PaCO(2) were used to determine the effect of surgical biopsy. Postoperative pneumothorax was monitored by serial thoracic radiographic examinations. RESULTS Thoracoscopic lung biopsy (n=29, 22 procedures) was well tolerated by all horses. Complication rate was 31%, including 8 ligature slippage and 1 pulmonary hemorrhage. Intranasal oxygen was administered intraoperatively to 6 horses (2 C, 1 Ha, 3 Hs) with severe hypoxemia or labored breathing. There was a significant decrease in PaO(2) during surgery in horses not supplemented with oxygen. Postoperative pneumothorax (21/22 procedures) detected radiographically resolved within 3 weeks. CONCLUSION Thoracoscopic lung biopsy using pre-tied ligating loops was minimally invasive, relatively inexpensive, and fairly efficient. Heaves-affected horses tolerated the surgery well, even when in exacerbation; however, the technique was associated with non life-threatening complications in 31% of the biopsies, most of which required correction with additional ligating loops or more sophisticated instrumentation. CLINICAL RELEVANCE Using laparoscopic pre-tied ligating loop for thoracoscopically-assisted lung biopsy can be considered in horses with normal and impaired lung function but alternative instrumentation and access to intranasal oxygen must be available to the surgeon in case of complications.


title: Anti-complementary constituents of Houttuynia cordata and their targets in complement activation cascade.

text: Activity-guided fractionation for complement inhibitors led to the isolation of 23 known compounds from Houttuynia cordata Thunb. Seven flavonoids, two alkaloids, one coumarin and two phenols showed anti-complementary activity. Preliminary inhibitory mechanism of four flavonoids, including quercitrin, afzelin, isoquercitrin and quercetin in the complement activation cascade were examined for the first time. The results indicated that the target components of flavonols are different from those of flavonosides, and the glycoside moieties may be necessary to block C3 and C4 components.


title: A laparoscopic approach to benign retrorectal tumors.

text: BACKGROUND Retrorectal tumors (RTs) are rare in adults. Their surgical excision is often difficult because of their anatomic location. The aim of this study was to evaluate the results of straight laparoscopic resection of RTs in our institution. METHODS Eight patients (six women and two men) with benign RTs were treated by laparoscopic resection in our tertiary care center between September 2012 and June 2013. Exclusion criteria included malignant tumors, lesions with fistula formation, and anterior sacral meningoceles. Clinical data, imaging features, operative details, pathological results, and treatment outcomes were reviewed and analyzed. RESULTS Eight cases of benign RT with an average diameter of 8.9 ± 1.7 cm were treated by a straight laparoscopic procedure. The mean operative time was 122 ± 36 min, and the average intraoperative blood loss was 46 ± 33 ml. The median postoperative stay was 5 days (range 3-8 days), and all patients were discharged without serious complications. During a median follow-up of 11 months, no tumor recurrence was observed. CONCLUSIONS In our experience, a laparoscopic approach is safe for removing benign tumors in the retrorectal space. This approach may provide access to this difficult-to-reach space and has the advantages of allowing excellent visualization, meticulous dissection, less morbidities, and fast recuperation.


title: Flocculent Settling of Food Wastes.

text: This study evaluated the flocculent settling in water and municipal wastewater (MWW) in a 10.6 ft deep column. A total of eight runs at three different testing conditions involving MWW alone, food waste (FW) alone, and FW in MWW (FW+MWW) were conducted. Total suspended solid (TSS), total BOD (TBOD), total COD (TCOD), total nitrogen (TN), and total phosphorous (TP) removal efficiencies after 3 hours of settling were 62%, 46%, 49%, 46% and 62% for FW, and 50%, 43%, 39%, 37% and 24% for MWW. Removal efficiencies of particulate COD (PCOD) and particulate BOD (PBOD) at the lowest surface overflow rate (SOR) of 1.1 m3/m2/hr corresponding to the longest settling time of 3 hours were 59% and 64% for FW, and 65% and 70% for FW with MWW samples. On the other hand, no significant variation between FW and FW with MWW was observed for PN removal after 3 hours of settling.


docid: geicgodx

title: Strategies to induce broadly protective antibody responses to viral glycoproteins.

text: INTRODUCTION Currently, several universal/broadly protective influenza virus vaccine candidates are under development. Many of these vaccines are based on strategies to induce protective antibody responses against the surface glycoproteins of antigenically and genetically diverse influenza viruses. These strategies might also be applicable to surface glycoproteins of a broad range of other important viral pathogens. Areas covered: Common strategies include sequential vaccination with divergent antigens, multivalent approaches, vaccination with glycan-modified antigens, vaccination with minimal antigens and vaccination with antigens that have centralized/optimized sequences. Here we review these strategies and the underlying concepts. Furthermore, challenges, feasibility and applicability to other viral pathogens are discussed. Expert commentary: Several broadly protective/universal influenza virus vaccine strategies will be tested in humans in the coming years. If successful in terms of safety and immunological readouts, they will move forward into efficacy trials. In the meantime, successful vaccine strategies might also be applied to other antigenically diverse viruses of concern.


title: Preoperative planning for endovascular aortic repair of abdominal aortic aneurysms: feasibility of nonenhanced MR angiography versus contrast-enhanced CT angiography.

text: PURPOSE To compare vascular measurements to determine stent types and configurations for abdominal endovascular aneurysm repair (EVAR) by comparing results of contrast material-enhanced computed tomographic (CT) angiography and nonenhanced magnetic resonance (MR) angiography. MATERIALS AND METHODS This prospective study was institutional review board approved, and all patients provided written informed consent. Fifty patients (45 men and five women; mean age, 76.0 years) admitted for elective abdominal EVAR underwent preoperative abdominal CT angiography (triplanar reformatted images; section thickness of 1-3 mm) and nonenhanced MR angiography (triplanar two-dimensional single-shot turbo field-echo images; section thickness of 6 mm). Two observers independently completed standard measurement and device selection forms for endovascular stent planning for CT and MR angiography. Pearson and intraclass correlation coefficients were calculated to evaluate intermodality and interobserver differences. RESULTS No significant difference was found in aortic neck diameter (observer 1: CT, 18.5 mm; MR, 19.0 mm; P = .43) (observer 2: CT, 19.6 mm; MR, 19.3 mm; P = .59), aortic neck diameter 15 mm distal to the lowest renal artery (observer 1: CT, 19.2 mm; MR, 19.2 mm; P = .38) (observer 2: CT, 19.6 mm; MR, 19.6 mm; P = .91), aortic neck length (observer 1: CT, 43.6 mm; MR, 43.6 mm; P = .85) (observer 2: CT, 44.4 mm; MR, 44.0 mm; P = .93), or other key vascular measurements (P = .23-.99) for preoperative planning. These included aneurysm diameter, lowest renal artery to aortic bifurcation length, aortic bifurcation diameter, common iliac artery diameters, external iliac artery diameters, length between orifices of lower renal and internal iliac arteries, and iliac artery sealing length. CT and MR angiography measurements showed very strong correlation (r = 0.92-0.99). Intraclass correlation coefficients between observers ranged from 0.90 to 0.98. Stent types and configurations determined with CT measurements remained unaltered when reassessed with MR measurements. CONCLUSION Measurements obtained with nonenhanced MR angiography appear equally accurate to those of CT angiography in the preoperative planning of abdominal EVAR.


COVID-19 and Public Interest in Face Mask Use.


Antibiotic consumption may be linked to exaggeration of COVID-19.


title: Digital technology for management of severe mental disorders in low-income and middle-income countries.

text: PURPOSE OF REVIEW Increasingly, digital technologies, especially mobile telecommunications and smartphone apps, are seen as a novel tool for managing severe mental disorders (SMDs) in low-income and middle-income countries (LMICs). However, there is a need to identify best practices in the use of digital technologies to effectively reach, support, and manage care for patients living with SMDs. In this review, we summarize recent studies using digital technology to manage symptoms and support clinical care for this patient population and discuss new opportunities to advance digital psychiatry research and practice in LMICs. RECENT FINDINGS Studies evaluating digital interventions for clinical populations living with SMDs in LMICs are limited. Yet, across recent articles surveyed, digital technology appears to yield diverse benefits for this at-risk patient population. These benefits include improved medication adherence, appointment adherence, reduced instances of relapse, and fewer re-hospitalizations. SUMMARY Continued rigorous research evaluating effectiveness and cost-effectiveness of digital technologies in reaching, treating, and managing symptoms and supporting clinical care for patients with SMDs in LMICs is vital. The urgency for remote approaches for delivering specialized psychiatric care is particularly pronounced because of the immediate and long-term impact of the coronavirus (COVID-19) pandemic on access to in-person services. Future research should emphasize participatory approaches rooted in a process of codesign with target users, in order to achieve clinically effective remotely delivered digital mental health interventions.


What next for QALYs?


title: New respiratory viruses of humans.

text: Acute respiratory viruses are a major cause of morbidity and mortality in humans worldwide and most acute respiratory infections are caused by viruses. Many of these viruses cause the highest burden of disease in specific risk groups such as young infants, the elderly, and immune-compromised individuals. Although the most important respiratory viruses of humans have been identified in the last century, in the past decade about a dozen "new" viruses have been discovered that may cause a high burden of acute respiratory disease in humans. Not only viruses were discovered that must have been with humans for many decades or centuries, such as human metapneumovirus and 2 different human coronaviruses, but also viruses that are truly new for humans and have emerged as a result of recent interspecies transmissions from other mammalian or avian reservoirs. The latter include highly pathogenic avian influenza viruses, severe acute respiratory syndrome (SARS) coronavirus, and Nipah virus. The discovery, etiologic role, and burden of disease caused by these infections are described.


title: Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion.

text: OBJECT Flow-diversion treatment has been shown to be associated with high rates of angiographic obliteration; however, the treatment is relatively contraindicated in the acute phase following subarachnoid hemorrhage (SAH) as these patients require periprocedural dual antiplatelet therapy. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured complex and giant aneurysms. In this study the authors report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned delayed flow diversion. METHODS This case series includes patients from 2 institutions. All patients underwent standard endovascular coiling in the acute phase after SAH with the intention and plan to proceed with flow diversion at a later date. Outcomes studied included angiographic occlusion, procedure-related complications, and long-term clinical outcome as measured using the modified Rankin Scale. RESULTS A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. The mean aneurysm size was 15.8 ± 7.9 mm. Of the 31 patients undergoing coiling, 4 patients could not undergo further flow-diverter therapy: 3 patients (9.7%) died of complications of subarachnoid hemorrhage and 1 patient had permanent morbidity as a result of perioperative ischemic stroke (3.1%). Twenty-seven patients underwent staged placement of flow diverters after adequate recovery. The median time to treatment was 16 weeks. There was one case of aneurysm rebleeding following coil treatment. There were no cases of permanent morbidity or mortality resulting from flow-diverter treatment. Twenty-four patients underwent imaging follow-up; 18 of these patients had aneurysms that were completely or nearly completely occluded (58.1% on an intent-to-treat basis). At last follow-up (mean 18.3 months), 25 patients had mRS scores ≤ 2 (80.6% on an intent-to-treat basis). CONCLUSIONS Staged treatment of ruptured complex and giant intracranial aneurysms with coiling in the acute phase and flow-diverter treatment following recovery from SAH is both safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. This strategy should be considered as a valid option in patients presenting with these challenging ruptured aneurysms.


docid: tbsenbuj

title: Efficacy and safety of hepatectomy performed with intermittent portal triad clamping with low central venous pressure.

text: BACKGROUND This retrospective study was designed to investigate the efficacy and safety of intermittent portal triad clamping (PTC) with low central venous pressure (CVP) in liver resections. METHODS Between January 2007 and August 2013, 115 patients underwent liver resection with intermittent PTC. The patients' data were retrospectively analyzed. RESULTS There were 58 males and 57 females with a mean age of 55 years (± 13.7). Cirrhosis was found in 23 patients. Resections were performed for malignant disease in 62.6% (n = 72) and for benign disease in 37.4% (n = 43). Major hepatectomy was performed in 26 patients (22.4%). Mean liver ischemia period was 27.1 min (± 13.9). The mortality rate was 1.7% and the morbidity rate was 22.6%. Cumulative clamping time (t = 3.61, P < 0.001) and operation time (t = 2.38, P < 0.019) were significantly correlated with AST alterations (D-AST). Cumulative clamping time (t = 5.16, P < 0.001) was significantly correlated with D-ALT. Operation time (t = 5.81, P < 0.001) was significantly correlated with D-LDH. CONCLUSIONS Intermittent PTC under low CVP was performed with low morbidity and mortality. Intermittent PTC can be safely applied up to 60 minutes in both normal and impaired livers.


title: What can be done for cerebral embolic protection in TAVI? Analysis in the light of 10 years' experience with protected carotid artery stenting.

text: In the last 30 years, development of minimally invasive percutaneous procedures to treat cardiovascular defects has been thriving. Although these techniques present obvious advantages, like avoiding cardiopulmonary bypass, the passage of catheter systems and the deployment of devices in the blood circulation can cause particle embolization that may result in stroke. In carotid artery stenting, cerebral embolic protection devices (CEPD) such as filtering membranes have been available for already 10 years. In transcatheter aortic valve implantation (TAVI), the development of CEPD is starting and three membrane-based devices are in clinical trials. There are controversial discussions about the efficacy of CEPD in TAVI. The experience with CEPD in carotid artery stenting can help to understand some of the technical issues and shortcomings of current devices and thereby ultimately reduce cerebral complication risks during TAVI procedures.


title: Applications for a hybrid operating room in thoracic surgery: from multidisciplinary procedures to --image-guided video-assisted thoracoscopic surgery.

text: The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases. RESUMO O conceito de sala híbrida traduz a união de um aparato cirúrgico de alta complexidade com recursos radiológicos de última geração (ultrassom, TC, radioscopia e/ou ressonância magnética), visando a realização de procedimentos minimamente invasivos e altamente eficazes. Apesar de bem estabelecido em outras especialidades, como neurocirurgia e cirurgia cardiovascular, o uso da sala hibrida ainda é pouco explorado na cirurgia torácica. Nosso objetivo foi discutir as aplicações e as possibilidades abertas por essa tecnologia na cirurgia torácica através do relato de três casos.


Focus on immunocompromised patients.


title: Evaluation of novel 99mTc(I)-labeled homobivalent α-melanocyte-stimulating hormone analogs for melanocortin-1 receptor targeting.

text: Aiming to apply the multivalency concept to melanoma imaging, we have assessed the in vivo melanocortin type 1 receptor (MC1R)-targeting properties of (99m)Tc(I)-labeled homobivalent peptide conjugates which contain copies of the α-melanocyte-stimulating hormone (α-MSH) analog [Ac-Nle(4), Asp(5), D-Phe(7), Lys(11)]α-MSH4-11 separated by linkers of different length (L(2) nine atoms and L(3) 14 atoms). The MC1R-binding affinity of L(2) and L(3) is significantly higher than that of the monovalent conjugate L(1). Metallation of these conjugates yielded the complexes fac-[M(CO)(3)(k(3)-L)](+) (M is (99m)Tc/Re; 1/1a, L is L(1); 2/2a, L is L(2); 3/3a, L is L(3)), with IC(50) values in the subnanomolar and nanomolar range. The MC1R-mediated internalization of 2 and 3 is higher than that of 1 in B16F1 melanoma cells. Biodistribution studies in melanoma-bearing mice have shown low nonspecific accumulation with a tumor uptake that correlates with IC(50) values. However, no correlation between tumor uptake and valency was found. Nevertheless, 2 displayed the highest tumor retention, and the best tumor to nontarget organ ratios.


title: The impact of communications about swine flu (influenza A H1N1v) on public responses to the outbreak: results from 36 national telephone surveys in the UK.

text: OBJECTIVES To assess the association between levels of worry about the possibility of catching swine flu and the volume of media reporting about it; the role of psychological factors in predicting likely uptake of the swine flu vaccine; and the role of media coverage and advertising in predicting other swine flu-related behaviours. DESIGN Data from a series of random-digit-dial telephone surveys were analysed. A time series analysis tested the association between levels of worry and the volume of media reporting on the start day of each survey. Cross-sectional regression analyses assessed the relationships between likely vaccine uptake or behaviour and predictor variables. SETTING Thirty-six surveys were run at, on average, weekly intervals across the UK between 1 May 2009 and 10 January 2010. Five surveys (run between 14 August and 13 September) were used to assess likely vaccine uptake. Five surveys (1-17 May) provided data relating to other behaviours. PARTICIPANTS Between 1047 and 1173 people aged 16 years or over took part in each survey: 5175 participants provided data about their likely uptake of the swine flu vaccine; 5419 participants provided data relating to other behaviours. MAIN OUTCOME MEASURES All participants were asked to state how worried they were about the possibility of personally catching swine flu. Subsets were asked how likely they were to take up a swine flu vaccination if offered it and whether they had recently carried tissues with them, bought sanitising hand gel, avoided using public transport or had been to see a general practitioner, visited a hospital or called NHS Direct for a flu-related reason. RESULTS The percentage of 'very' or 'fairly' worried participants fluctuated between 9.6% and 32.9%. This figure was associated with the volume of media reporting, even after adjusting for the changing severity of the outbreak [chi2(1) = 6.6, p = 0.010, coefficient for log-transformed data = 2.6]. However, this effect only occurred during the UK's first summer wave of swine flu. In total, 56.1% of respondents were very or fairly likely to accept the swine flu vaccine. The strongest predictors were being very worried about the possibility of oneself [adjusted odds ratio (aOR) 4.7, 95% confidence interval (CI) 3.2 to 7.0] or one's child (aOR 8.0, 95% CI 4.6 to 13.9) catching swine flu. Overall, 33.1% of participants reporting carrying tissues with them, 9.5% had bought sanitising gel, 2.0% had avoided public transport and 1.6% had sought medical advice. Exposure to media coverage or advertising about swine flu increased tissue carrying or buying of sanitising hand gel, and reduced avoidance of public transport or consultation with health services during early May 2009. Path analyses showed that media coverage and advertising had these differential effects because they raised the perceived efficacy of hygiene behaviours but decreased the perceived efficacy of avoidance behaviours. CONCLUSIONS During the swine flu outbreak, uptake rates for protective behaviours and likely acceptance rates for vaccination were low. One reason for this may in part be explained by was the low level of public worry about the possibility of catching swine flu. When levels of worry are generally low, acting to increase the volume of mass media and advertising coverage is likely to increase the perceived efficacy of recommended behaviours, which, in turn, is likely to increase their uptake.


title: Endovascular revascularization results in IMS III: intracranial ICA and M1 occlusions.

text: BACKGROUND Interventional Management of Stroke III did not show that combining IV recombinant tissue plasminogen activator (rt-PA) with endovascular therapies (EVTs) is better than IV rt-PA alone. OBJECTIVE To report efficacy and safety results for EVT of intracranial internal carotid artery (ICA) and middle cerebral artery trunk (M1) occlusion. METHODS Five revascularization methods for persistent occlusions after IV rt-PA treatment were evaluated for prespecified primary and secondary endpoints, after accounting for differences in key baselines variables using propensity scores. Revascularization was scored using the arterial occlusive lesion (AOL) and the modified Thrombolysis in Cerebral Ischemia (mTICI) scores. RESULTS EVT of 200 subjects with intracranial ICA or M1 occlusion resulted in 81.5% AOL 2-3 recanalization, in addition to 76% mTICI 2-3 and 42.5% mTICI 2b-3 reperfusion. Adverse events included symptomatic intracranial hemorrhage (SICH) (8.0%), vessel perforations (1.5%), and new emboli (14.9%). EVT techniques used were standard microcatheter n=51; EKOS n=14; Merci n=77; Penumbra n=39; Solitaire n=4; multiple n=15. Good clinical outcome was associated with both TICI 2-3 and TICI 2b-3 reperfusion. Neither modified Rankin scale (mRS) 0-2 (28.5%), nor 90-day mortality (28.5%), nor asymptomatic ICH (36.0%) differed among revascularization methods after propensity score adjustment for subjects with intracranial ICA or M1 occlusion. CONCLUSIONS Good clinical outcome was associated with good reperfusion for ICA and M1 occlusion. No significant differences in efficacy or safety among revascularization methods were demonstrated after adjustment. Lack of high-quality reperfusion, adverse events, and prolonged time to treatment contributed to lower-than-expected mRS 0-2 outcomes and study futility compared with IV rt-PA. TRIAL REGISTRATION NUMBER NCT00359424.


title: Comparison of Hepatic Resection Combined with Intraoperative Radiofrequency Ablation, or Hepatic Resection Alone, for Hepatocellular Carcinoma Patients with Multifocal Tumors Meeting the University of California San Francisco (UCSF) Criteria: A Propensity Score-Matched Analysis.

text: BACKGROUND Whether hepatic resection (HR) combined with radiofrequency ablation (RFA) or HR alone is the treatment of choice for early or moderately advanced multifocal hepatocellular carcinomas (HCCs) is a matter of debate. This study compared the short- and long-term outcomes of patients with multifocal tumors meeting the University of California San Francisco (UCSF) criteria after HR plus intraoperative RFA or HR alone. METHODS A total of 261 consecutive patients with multifocal HCCs meeting the UCSF criteria from January 2010 to January 2018, who underwent combined treatment (n = 51) or HR (n = 210), were included. Propensity score matching was performed to adjust for baseline differences. Overall survival (OS) and recurrence-free survival (RFS) were calculated, and subgroup analysis, along with univariate and multivariate analyses, were performed. RESULTS The 1-, 3-, and 5-year OS rates after combined treatment or HR alone were 86.3%, 66.6%, and 34.2%, and 92.8%, 67.1%, and 37%, respectively (p = 0.423); combined treatment provided similar RFS rates as HR at 1, 3, and 5 years (78.4%, 35.8% and 20.9% vs. 82.6%, 50.4% and 24.5%, respectively; p = 0.076). The propensity matching model showed similar results. Subgroup analysis showed that HR was associated with better RFS than HR plus RFA for patients with two tumors or major tumors ≤ 3 cm. Multivariate analysis revealed that portal hypertension and three tumors are independent risk factors. CONCLUSIONS For multifocal HCC patients meeting the UCSF criteria, combined treatment may offer similar OS and RFS as HR; however, HR may be more suitable than combined treatment for patients with two tumors or major tumors ≤ 3 cm.


title: Single-access laparoscopic "lavage" for purulent diverticulitis in a 96-year-old patient: how to reduce surgical trauma and standardize surgical technique.

text: INTRODUCTION Recently, laparoscopic lavage emerged as an effective alternative for patients with perforated diverticulitis with purulent peritonitis. CASE REPORT A 96-year-old woman, diagnosed with Hinchey 3 diverticulitis after a computed tomography scan, was operated on with a single-access "lavage" to reduce surgical trauma and to avoid stoma. METHODS The procedure was performed under general anesthesia. Tracheal intubation, nasogastric tube, and urethral catheterization were mandatory. The patient was in a modified Lloyd-Davis position, with the table tilted in Trendelenburg position, left side up. Surgeons were on the right side. INSTRUMENTATION The procedure was performed using a surgical technique similar to standard laparoscopy with traditional laparoscopic instruments. SURGICAL STEPS: The surgical procedure involved single-incision laparoscopic surgery (Covidien, Mansfield, MA) insertion, small bowel dissection, abscess opening, and peritoneal washing. RESULTS The procedure was completed in 75 minutes with an estimated blood loss of 120 mL. The patient was kept in the intensive care unit for 1 day. She was on postoperative analgesia for 2 days and was discharged from the hospital on postoperative day 5. The patient was able to drink on day 1 and eat on day 3 after flatus.


docid: rotjzbdc

title: Rewarming Rate During Cardiopulmonary Bypass Is Associated With Release of Glial Fibrillary Acidic Protein.

text: BACKGROUND Rewarming from hypothermia during cardiopulmonary bypass (CPB) may compromise cerebral oxygen balance, potentially resulting in cerebral ischemia. The purpose of this study was to evaluate whether CPB rewarming rate is associated with cerebral ischemia assessed by the release of the brain injury biomarker glial fibrillary acidic protein (GFAP). METHODS Blood samples were collected from 152 patients after anesthesia induction and after CPB for the measurement of plasma GFAP levels. Nasal temperatures were recorded every 15 min. A multivariate estimation model for postoperative plasma GFAP level was determined that included the baseline GFAP levels, rewarming rate, CPB duration, and patient age. RESULTS The mean rewarming rate during CPB was 0.21° ± 0.11°C/min; the maximal temperature was 36.5° ± 1.0°C (range, 33.1°C to 38.0°C). Plasma GFAP levels increased after compared with before CPB (median, 0.022 ng/mL versus 0.035 ng/mL; p < 0.001). Rewarming rate (p = 0.001), but not maximal temperature (p = 0.77), was associated with higher plasma GFAP levels after CPB. In the adjusted estimation model, rewarming rate was positively associated with postoperative plasma log GFAP levels (coefficient, 0.261; 95% confidence intervals, 0.132 to 0.390; p < 0.001). Six patients (3.9%) experienced a postoperative stroke. Rewarming rate was higher (0.3° ± 0.09°C/min versus 0.2° ± 0.11°C/min; p = 0.049) in the patients with stroke compared with those without a stroke. CONCLUSIONS Rewarming rate during CPB was correlated with evidence of brain cellular injury documented with plasma GFAP levels. Modifying current practices of patient rewarming might provide a strategy to reduce the frequency of neurologic complications after cardiac surgery.


title: COSUTI: a protocol for the development of a core outcome set (COS) for interventions for the treatment of uncomplicated urinary tract infection (UTI) in adults.

text: BACKGROUND Urinary tract infections (UTIs) are the second most common infection presenting in the community. Clinical guidelines and decision aids assist health practitioners to treat a UTI; however, treatment practices vary due to patient needs and context of presentation. Numerous trials have evaluated the effectiveness of treatment interventions for UTI; however, it is difficult to compare the results between trials due to inconsistencies between reported outcomes. Poor choice of outcome measures can lead to impairment of evidence synthesis due to the inability to compare outcomes between trials with similar aims. Transparency in selecting and reporting outcomes can be mitigated through the development of an agreed minimum set of outcomes that should be reported in clinical trials, referred to as a core outcome set (COS). This paper presents the protocol for the development of a COS for interventions in the treatment of uncomplicated UTI in adults. METHODS This COS development consists of three phases. Phase 1 is a systematic review, which aims to identify the core outcomes that have been reported in trials and systematic reviews of interventions treating uncomplicated UTI in adults. Phase 2 consists of a three-round online Delphi survey with stakeholders in the area of treatment interventions for UTI. The aim of this online Delphi survey is to achieve consensus on the importance of the outcomes emerging from Phase 1 of this research. Phase 3 is a consensus meeting to finalise the COS that should be reported in trials evaluating the effectiveness of interventions for the treatment of UTI. DISCUSSION It is hoped that the development of a COS for interventions for the treatment of uncomplicated UTI in adults will be adopted as a minimum set of outcomes that should be reported and measured within this context. If the findings from clinical trials related to treatment interventions for UTI are to impact on policy and practice, it is important that the findings from different treatment interventions are comparable across trials.


title: Laparoscopic distal pancreatectomy.

text: After technological advances and increased experiences, more complicated surgeries including distal pancreatectomy can be easily performed with acceptable oncologic results, and decreased mortality and morbidity. Laparoscopic distal pancreatectomy (LDP) has been shown to have several advantages including less blood loss, less hospital stay, less pain. Several studies comparing open distal pancreatectomy (ODP) and LDP resulted that both techniques have similar results according to pancreas fistulas, oncological results, costs and operation indications. Morbidity is very low in high volume centers, for this reason at least ten cases should be performed for the learning curve. Several authors remarked important technical points in LDP in order to perform safe and acceptable LDP in several studies. Here in this review, we aimed to overview the results of previous studies about LDP and discuss the technical points of LDP.


title: First prize: Standard laparoscopic donor nephrectomy versus laparoendoscopic single-site donor nephrectomy: a randomized comparative study.

text: INTRODUCTION The purpose of this study was to compare in a randomized fashion the clinical outcomes following standard laparoscopic and laparoendoscopic single-site (LESS) donor nephrectomies. MATERIALS AND METHODS Fifty voluntary renal donors who met the inclusion and exclusion criteria were randomized to standard laparoscopic (group A) and LESS (group B) donor nephrectomies. The primary end point of the study was patients' postoperative pain. The clinical outcomes, patient's quality of life, body image, and cosmetic scores on follow-up were also compared. RESULTS The operating times were similar in both groups (175.83 ± 47.57 vs. 172.20 ± 38.33 minutes, p = 0.38). The surgeon's difficulty as measured using a visual analog scale was significantly more in group B in 4 of 10 defined steps. The postoperative patient pain scores were similar till 48 hours following surgery (3.84 ± 1.68 vs. 3.68 ± 0.75, p = 0.33), but following which the patients in group B had improved pain scores (2.08 ± 0.91 vs. 1.24 ± 0.72, p = 0.0004). Analgesic requirements were similar in both groups (p = 0.47). The warm ischemia times in group B (5.11 ± 1.01 vs. 7.15 ± 1.84 minutes, p < 0.0001) were longer but the total ischemia times in both groups were similar (62.55 ± 9.46 vs. 62.71 ± 12.14 minutes, p = 0.48). All grafts had on-table urine output in the recipient. Intraoperative (8% vs. 16%, p = 0.2) and postoperative complications (20% vs. 16%, p = 0.99) in both groups were comparable. The patients in group B had shorter hospital stay (4.56 ± 0.82 vs. 3.92 ± 0.76 days, p = 0.003). There was no graft loss in either group except for one recipient in group A who sustained sudden cardiac death. The estimated glomerular filtration rates of recipients at 1 year were comparable for both groups (80.87 ± 22.12 vs. 81.51 ± 29.01 mL/minute, p = 0.46). The donor's quality of life, body image, and cosmetic scores were comparable for both groups. CONCLUSION In this select group of donors, LESS donor nephrectomy, although challenging to the surgeon with longer warm ischemic times, gave early pain relief with shorter hospital stay and comparable graft function.


title: Exhausted Parents: Development and Preliminary Validation of the Parental Burnout Inventory.

text: Can parents burn out? The aim of this research was to examine the construct validity of the concept of parental burnout and to provide researchers which an instrument to measure it. We conducted two successive questionnaire-based online studies, the first with a community-sample of 379 parents using principal component analyses and the second with a community- sample of 1,723 parents using both principal component analyses and confirmatory factor analyses. We investigated whether the tridimensional structure of the burnout syndrome (i.e., exhaustion, inefficacy, and depersonalization) held in the parental context. We then examined the specificity of parental burnout vis-à-vis professional burnout assessed with the Maslach Burnout Inventory, parental stress assessed with the Parental Stress Questionnaire and depression assessed with the Beck Depression Inventory. The results support the validity of a tri-dimensional burnout syndrome including exhaustion, inefficacy and emotional distancing with, respectively, 53.96 and 55.76% variance explained in study 1 and study 2, and reliability ranging from 0.89 to 0.94. The final version of the Parental Burnout Inventory (PBI) consists of 22 items and displays strong psychometric properties (CFI = 0.95, RMSEA = 0.06). Low to moderate correlations between parental burnout and professional burnout, parental stress and depression suggests that parental burnout is not just burnout, stress or depression. The prevalence of parental burnout confirms that some parents are so exhausted that the term "burnout" is appropriate. The proportion of burnout parents lies somewhere between 2 and 12%. The results are discussed in light of their implications at the micro-, meso- and macro-levels.


title: Identification of bioactive molecule from Withania somnifera (Ashwagandha) as SARS-CoV-2 main protease inhibitor.

text: SARS-CoV-2 is the causative agent of COVID-19 and has been declared as pandemic disease by World Health Organization. Lack of targeted therapeutics and vaccines for COVID-2019 have triggered the scientific community to develop new vaccines or drugs against this novel virus. Many synthetic compounds and antimalarial drugs are undergoing clinical trials. The traditional medical practitioners widely use Indian medicinal plant Withania somnifera (Ashwagandha) natural constituents, called withanolides for curing various diseases. The main protease (Mpro) of SARS-CoV-2 plays a vital role in disease propagation by processing the polyproteins which are required for its replication. Hence, it denotes a significant target for drug discovery. In the present study, we evaluate the potential of 40 natural chemical constituents of Ashwagandha to explore a possible inhibitor against main protease of SARS-CoV-2 by adopting the computational approach. The docking study revealed that four constituents of Ashwagandha; Withanoside II (-11.30 Kcal/mol), Withanoside IV (-11.02 Kcal/mol), Withanoside V (-8.96 Kcal/mol) and Sitoindoside IX (-8.37 Kcal/mol) exhibited the highest docking energy among the selected natural constituents. Further, MD simulation study of 100 ns predicts Withanoside V possess strong binding affinity and hydrogen-bonding interactions with the protein active site and indicates its stability in the active site. The binding free energy score also correlates with the highest score of -87.01 ± 5.01 Kcal/mol as compared to other selected compounds. In conclusion, our study suggests that Withanoside V in Ashwagandha may be serve as a potential inhibitor against Mpro of SARS-CoV-2 to combat COVID-19 and may have an antiviral effect on nCoV. Communicated by Ramaswamy H. Sarma.


title: Five-year Study of Viral Etiology and Features of Febrile Respiratory Tract Infections With Prolonged Fever in Japanese Pediatric Outpatients.

text: Over 5 years, we prospectively collected nasopharyngeal aspirate samples from pediatric outpatients with prolonged fever (≥5 days, ≥38.0°C). Real-time polymerase chain reaction assays identifying 13 different respiratory viruses and Mycoplasma pneumoniae were performed on the test samples. Real-time polymerase chain reaction assays identified at least 1 pathogen in 273 (75.4%) of the 362 samples assessed (239 single and 34 multiple infections).


title: Evasion of antiviral immunity through sequestering of TBK1/IKKε/IRF3 into viral inclusion bodies.

text: Cells are equipped with pattern recognition receptors (PRRs) such as the Toll-like and RIG-I-like receptors that mount innate defenses against viruses. However, viruses have evolved multiple strategies to evade or thwart host antiviral responses. Viral inclusion bodies (IBs), which are accumulated aggregates of viral proteins, are commonly formed during the replication of some viruses in infected cells, but their role in viral immune evasion has rarely been explored. Severe fever with thrombocytopenia syndrome (SFTS) is an emerging febrile illness caused by a novel phlebovirus in the Bunyaviridae. The SFTS viral nonstructural protein NSs can suppress host beta interferon (IFN-β) responses. NSs can form IBs in infected and transfected cells. Through interaction with tank-binding kinase 1 (TBK1), viral NSs was able to sequester the IKK complex, including IKKε and IRF3, into IBs, although NSs did not interact with IKKε or IRF3 directly. When cells were infected with influenza A virus, IRF3 was phosphorylated and active phosphorylated IRF3 (p-IRF3) was translocated into the nucleus. In the presence of NSs, IRF3 could still be phosphorylated, but p-IRF3 was trapped in cytoplasmic IBs, resulting in reduced IFN-β induction and enhanced viral replication. Sequestration of the IKK complex and active IRF3 into viral IBs through the interaction of NSs and TBK1 is a novel mechanism for viral evasion of innate immunity.


title: SARS-CoV-2 and HIV protease inhibitors: why lopinavir/ritonavir will not work for COVID-19 infection.

text: Since the beginning of the outbreak of severe acute respiratory syndrome (SARS) coronavirus (CoV) 2 lopinavir/ritonavir was selected for treatment. The recent publication of Cao et al in the NEJM[1] showed that lopinavir/ritonavir treatment did not accelerate clinical improvement compared with standard of care. This raised the question if we in retrospect could have known this. The aim of this paper is to gather all the available evidence and to comprehensively discuss this issue.


title: Absence of severe complications from SARS-CoV-2 infection in children with rheumatic diseases treated with biologic drugs.

text: We read with interest the Editorial by Cron and Chatam (1) suggesting a cytokine storm syndrome (CSS) occurring in response to SARS-CoV-2 infection and, consequently, a possible role for targeted approaches to blocking inflammatory cytokines.


title: Current concepts in hepatobiliary surgery.

text: The most common hepatic procedures performed in companion animals are liver biopsies and partial hepatectomies. Surgery of the biliary tract most often involves the gallbladder, although surgical intervention of the bile duct may also be performed. Hepatobiliary surgery is often challenging, being performed in patients with significant systemic illness and associated with potentially life-threatening complications. An in-depth understanding of the regional anatomy, use of a team concept for patient management, particularly for patients undergoing partial hepatectomy surgery, and provision of intensive perioperative monitoring and support helps minimize complications and maximize outcome.


title: Blood-brain barrier permeation and efflux exclusion of anticholinergics used in the treatment of overactive bladder.

text: Overactive bladder (OAB) is a common condition, particularly in the elderly. Anticholinergic agents are the mainstay of pharmacological treatment of OAB; however, many anticholinergics can cross the blood-brain barrier (BBB) and may cause central nervous system (CNS) effects, including cognitive deficits, which can be especially detrimental in older patients. Many anticholinergics have the potential to cause adverse CNS effects due to muscarinic (M(1)) receptor binding in the brain. Of note, permeability of the BBB increases with age and can also be affected by trauma, stress, and some diseases and medications. Passive crossing of a molecule across the BBB into the brain is dependent upon its physicochemical properties. Molecular characteristics that hinder passive BBB penetration include a large molecular size, positive or negative ionic charge at physiological pH, and a hydrophilic structure. Active transport across the BBB is dependent upon protein-mediated transporter systems, such as that of permeability-glycoprotein (P-gp), which occurs only for P-gp substrates, such as trospium chloride, darifenacin and fesoterodine. Reliance on active transport can be problematic since genetic polymorphisms of P-gp exist, and many commonly used drugs and even some foods are P-gp inhibitors or are substrates themselves and, due to competition, can reduce the amount of the drug that is actively transported out of the CNS. Therefore, for drugs that are preferred not to cross into the CNS, such as potent anticholinergics intended for the bladder, it is optimal to have minimal passive crossing of the BBB, although it may also be beneficial for the drug to be a substrate for an active efflux transport system. Anticholinergics demonstrate different propensities to cross the BBB. Darifenacin, fesoterodine and trospium chloride are substrates for P-gp and, therefore, are actively transported away from the brain. In addition, trospium chloride has not been detected in cerebrospinal fluid assays and does not appear to have significant CNS penetration. This article reviews the properties of anticholinergics that affect BBB penetration and active transport out of the CNS, discusses issues of increased BBB permeability in patients with OAB, and examines the clinical implications of BBB penetration on adverse events associated with anticholinergics.


World Health Organization and emergency health: if not now, when?


COVID-19 highlights the need for a strong health laboratories foundation for infectious disease surveillance and control in the Eastern Mediterranean Region.


title: Epidemiology of eating disorders in Latin America: a systematic review and meta-analysis.

text: PURPOSE OF REVIEW Eating disorders are currently not considered to be limited to Western culture. We systematically reviewed the existing literature on the prevalence of eating disorders in Latin America. RECENT FINDINGS Of 1583 records screened, 17 studies from Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela were included in the analysis. Most studies reported point-prevalence rates and only three studies provided lifetime and 12-month prevalence rates. We found a mean point-prevalence rate of 0.1% for anorexia nervosa, 1.16% for bulimia nervosa, and 3.53% for binge-eating disorder (BED) in the general population. Heterogeneity for bulimia nervosa and BED was large. This meta-analysis indicates that the prevalence of anorexia nervosa seems to be lower, whereas the prevalence of bulimia nervosa and especially of BED seems to be higher in Latin America than in Western countries. SUMMARY Our findings show that eating disorders are common mental disorders in Latin America. However, some facets of Latin American culture might be protective for the development of anorexia nervosa and increase the risk for bulimia nervosa and BED. Further studies investigating the epidemiology of eating disorders and their relation to culture in Latin America are needed. VIDEO ABSTRACT SPANISH ABSTRACT.


docid: njmmavob

title: Patient and public involvement in covid-19 policy making.


title: Laparoscopic component separation reduces postoperative wound complications but does not alter recurrence rates in complex hernia repairs.

text: BACKGROUND The purpose of this study was to evaluate and compare the incidence of wound complications after laparoscopic component separation (LCS) vs open component separation (OCS) in patients with complex abdominal wall hernias. METHODS A retrospective review was performed of all patients who underwent LCS or OCS for repair of a complex abdominal wall hernia at a single institution between 2009 and 2011. Charts were reviewed to identify postoperative wound complications. A computed tomographic scan or physical examination was used for the determination of hernia recurrence. Categoric variables were compared using the Fisher exact test. Univariate and multivariate analyses were performed using linear and Cox regression. Recurrence rates were compared using log-rank tests (Kaplan-Meier method). RESULTS A total of 44 patients underwent LCS (n = 18) or OCS (n = 26). There was no statistically significant difference between categoric variables. Multivariate analysis using wound complications as the dependent variable showed a statistically significantly lower rate of wound complications in the LCS group. CONCLUSIONS LCS is associated with a lower rate of wound complications when compared with OCS but yields comparable recurrence rates.


title: Lessons to learn from MERS-CoV outbreak in South Korea.

text: Since the first identification of Middle Eastern Respiratory Syndrome coronavirus (MERS-CoV) in 2012 the virus has infected 1289 humans with approximately 40% mortalities. Currently South Korea is experiencing the hospital-associated outbreak of MER-CoV that has infected 126 human cases and 13 deaths, as of 12 June 2015, following the return of a MERS infected patient from Middle East. The episode is characterized unique being the largest cluster of patients linked to the single introduction of virus that involves three generations of virus transmission. Human-to-human transmission though was observed on several occasions in past, it is documented as non-sustainable event. The recent outbreak including the healthcare workers, index case's roommates and their caregivers, raises several concerns about the infection control practices and timely diagnosis of MERS.


title: Dumping syndrome following gastric bypass: validation of the dumping symptom rating scale.

text: There is a lack of prevalent data for dumping syndrome (DS) and methods discriminating between different symptoms of the DS. A self-assessment questionnaire, the Dumping Symptom Rating Scale (DSRS), was developed. The aim was to measure the severity and frequency of nine dumping symptoms and to evaluate the construct validity of the DSRS. Pre- and 1 and 2 years after Roux-en-Y gastric bypass surgery, 47 adults and 82 adolescents completed the DSRS. Cognitive interview was performed. Reliability and construct validity were tested. Effect sizes (ES) of changes were calculated. Patients found the questionnaire relevant. A high proportion of the respondents reported no symptoms affecting them negatively at all (floor effects). However, 12 % stated, quite severe, severe, or very severe problems regarding fatigue after meal and half of them were so tired that they needed to lie down. Nearly 7 % reported quite severe, severe, or very severe problems dominated by nausea and 6 % dominated by fainting esteem. The internal consistency reliability was adequate for both severity (0.81-0.86) and frequency (0.76-0.84) scales. ES were small, since some subjects experienced symptoms already preoperatively. Although most patients reported no or mild dumping symptoms 1 and 2 years after gastric bypass surgery, around 12 % had persistent symptoms, in particular, postprandial fatigue, and needed to lie down. Another 7 % had problems with nausea and 6 % had problems with fainting esteem. The DSRS is a reliable screening tool to identify these patients.


title: Current Treatment Strategies for Intracranial Aneurysms: An Overview.

text: Intracranial aneurysm is a leading cause of stroke. Its treatment has evolved over the past 2 decades. This review summarizes the treatment strategies for intracranial aneurysms from 3 different perspectives: open surgery approach, transluminal treatment approach, and new technologies being used or trialed. We introduce most of the available treatment techniques in detail, including contralateral clipping, wrapping and clipping, double catheters assisting coiling and waffle-cone technique, and so on. Data from major trials such as Analysis of Treatment by Endovascular approach of Non-ruptured Aneurysms (ATENA), Internal Subarachnoid Trial (ISAT), Clinical and Anatomical Results in the Treatment of Ruptured Intracranial Aneurysms (CLARITY), and Barrow Ruptured Aneurysm Trial (BRAT) as well as information from other clinical reports and local experience are reviewed to suggest a clinical pathway for treating different types of intracranial aneurysms. It will be a valuable supplement to the current existing guidelines. We hope it could help assisting real-time decision-making in clinical practices and also encourage advancements in managing the disease.


title: Learning curve analysis of transvaginal natural orifice transluminal endoscopic hysterectomy.

text: BACKGROUND No data are available to assess the learning curve for transvaginal natural orifice transluminal endoscopic hysterectomy for non-prolapsed uteri in benign gynecologic diseases. The lack of exposure to transvaginal natural orifice transluminal endoscopic hysterectomy during training, in addition to a poorly defined learning curve, further deters interested physicians from applying this technique to daily practice. The aim of this study was to evaluate the learning curve and perioperative outcome of transvaginal natural orifice transluminal endoscopic hysterectomy by an experienced endoscopist. METHODS A total of 240 cases of transvaginal natural orifice transluminal endoscopic hysterectomies with or without adnexectomy for various benign gynecologic diseases were included. Demographic data and various perioperative parameters were reviewed from the prospectively collected database. Operative time was set as a surrogate marker for surgical competency. The learning curve was evaluated using the cumulative sum method. RESULTS The overall mean operative time (OT) was 76.5 min ± 22.4. Four unique phases of the learning curve were derived using cumulative sum analysis: the mean OT of phase I (the initial learning curve of 20 cases) was 86.3 ± 23.7 min, phase II (acquisition of competence of 80 cases) was 71.0 ± 21.4 min, phase III (proficiency and plateau of 80 cases) was 76.0 ± 20.4 min, and phase IV (post-learning in which more challenging cases were managed) was 81.3 ± 23.6 min. No major complications were encountered. One case in phase III converted to laparoscopy due to difficulty in performing anterior colpotomy. CONCLUSION Our data demonstrated four distinct phases of the learning curve of transvaginal natural orifice transluminal endoscopic hysterectomy. In a well-trained endoscopist, surgical competence in transvaginal natural orifice transluminal endoscopic hysterectomy can be reached after 20 cases.


Feline calicivirus-associated virulent systemic disease: not necessarily a local epizootic problem.


title: Transcatheter aortic valve implantation and left ventricular assist device: a word of caution.

text: Aortic valve disease in the setting of a left ventricular assist device presents unique challenges. We present the case of a patient who underwent transcatheter aortic valve implantation to replace a stenotic aortic valve to facilitate left ventricular assist device explantation. Thirty-three days later, the porcine pericardial valve cusps were fused and a thick pseudomembrane had occluded the left ventricular outflow tract, forcing the explant to be aborted.