docid: wosqleyp

title: Monitoring respiration and oxygen saturation in patients during the first night after elective bariatric surgery: A cohort study.

text: Background: Obstructive sleep apnoea and obese hypoventilation is not uncommon in patients with obesity. Residuals effect from surgery/anaesthesia and opioid analgesics may worsen respiration during the first nights after bariatric surgery. The aim of this observational study was to monitor respiration on the first postoperative night following elective bariatric surgery. Methods: This observational study aimed to determine the incidence and severity of hypo/apnoea in low risk obsess patients undergoing elective bariatric surgery in general anesthaesia. Patients with known or suspected sleep respiratory disturbances was not included. ESS was scored prior to surgery. Oxygen desaturation was analyzed by continuous respiratory monitoring. Mean oxygen saturation (SpO2), nadir SPo2, apnoea/hypopnea index and oxygen desaturation index was assess by standard tools. Results: 45 patients were monitored with portable polygraphy equipment (Embletta, ResMed) during the first postoperative night at the general ward following elective laparoscopic bariatric surgery. The prop ESS was 0-5 in 22, 6-10 in 14 and 11-16 in 6 of the patients studied (missing data 3). Mean SpO2 was 93%; 10 patients had a mean SpO2 of less than 92% and 4 of less than 90%. The lowest mean SpO2 was 87%. There were 16 patients with a nadir SpO2 of less than 85%, lowest nadir SpO2 being 63%. An Apnoea Hypo/apnoea Index (AHI) > 5 was found in 2 patients only (AHI 10 and 6), and an Oxygen Desaturation index (ODI) > 5 was found in 3 patients (24, 10 and 6, respectively). 3 patients had more prolonged (> 30 seconds) apnoea with nadir SpO2 81%, 83% and 86%. ESS score and type of surgery did not impact on respiration/oxygenation during the observation period. Conclusions: A low mean SpO2 and episodes of desaturation were not uncommon during the first postoperative night following elective bariatric surgery in patients without history of night time breathing disturbance. AHI and/or ODI of more than 5 were only rarely seen. Night-time respiration monitoring provided seemingly sparse additional information. Further studies are need to assess risk factors and potential impact of the desaturation episodes that occurs during sleep.


title: Outcome after mechanical thrombectomy using a stent retriever under conscious sedation: comparison between tandem and single occlusion of the anterior circulation.

text: BACKGROUND AND PURPOSE In acute ischemic stroke patients, internal carotid artery/middle cerebral artery (ICA/MCA) occlusion in tandem predicts a poor outcome after systemic thrombolysis. This study aimed to compare outcomes after mechanical thrombectomy for tandem and single occlusions of the anterior circulation. MATERIALS AND METHODS This prospective study included consecutive patients with acute ischemic stroke of the anterior circulation who had undergone mechanical thrombectomy performed with a stent retriever under conscious sedation within 6h of symptom onset. Data on clinical, imaging and endovascular findings were collected. In cases of tandem occlusion, distal thrombectomy (retrograde approach) was performed first whenever possible. Tandem and single occlusions were compared in terms of functional outcome and mortality at 3 months. RESULTS From May 2010 to April 2012, 42 patients with acute ischemic stroke attributable to MCA and/or ICA occlusion were treated. Eleven patients (26.2%) presented with tandem occlusions and 31 patients (73.8%) had a single anterior circulation occlusion. Baseline characteristics were similar between the two groups. Recanalization status also did not differ significantly (P=0.76), but patients with tandem occlusions had poorer functional outcomes (18.2% vs. 67.7% for single occlusions; P=0.01), a higher mortality rate at 3 months (45.5% vs. 12.9%, respectively; P=0.03) and more symptomatic intracranial hemorrhages at 24h (9.7% vs. 0%, respectively; P=0.01). A high rate of early proximal re-occlusion or severe residual stenosis (66%) was also observed in the tandem group. CONCLUSION Tandem occlusions had poor clinical outcomes after mechanical thrombectomy compared with single occlusions. The retrograde approach (treatment of distal occlusion first) used in patients under conscious sedation may have contributed to these poor outcomes.


title: Two-stage laparoscopic biliopancreatic diversion with duodenal switch as treatment of high-risk super-obese patients: analysis of complications.

text: INTRODUCTION The aim of this study is to retrospectively analyze the incidence of complications after two-stage laparoscopic biliopancreatic diversion with duodenal switch (Lap BPD-DS) in high-risk super-obese patients and explore the possible predictive factors of specific complications after laparoscopic sleeve gastrectomy (SG). METHODS High-risk patients--body mass index (BMI) > 50 kg/m(2) with at least two major comorbidities: type 2 diabetes, obstructive sleep apnea syndrome (OSAS), hypertension--undergoing two-stage laparoscopic BPD-DS were retrospectively analysed. The SG pouch volume was 100-150 ml; in the second stage, the common channel and the alimentary loop were 100 cm and 150 cm, respectively. RESULTS Eighty-seven patients (50 female, 57.5%) underwent SG (two open). The mean age was 41.8 +/- 10.22 years with BMI of 55.2 +/- 6.69 kg/m(2). Four patients had Prader-Willy syndrome. Fourteen (16.46%) patients (6 female, 42.8%) had postoperative complications such as bleeding, fistula, pulmonary embolism, transitory acute renal failure, and abdominal abscess. One patient died at postoperative day 5 of pulmonary embolism. One patient was reoperated for hemoperitoneum by laparoscopy. The risk of complications after SG was lower in patients where reinforcement of the suture line was used (0.492), while it was higher in men (1.780). Neither difference was statistically significant [p = not significant (NS)]. After 9-24 months, 27 patients (BMI 43 +/- 8 kg/m(2)) underwent a second stage of BPD-DS (two open). Major postoperative complications were registered in eight patients (29.6%): three bleeding, four duodeno-ileal stenosis and one rhabdomyolysis. Two cases of internal hernia required laparoscopic reoperation. The reoperation rate was 1/85 (1.2%) after SG and 2/27 (7.4%) after second stage. CONCLUSIONS Complications after SG greatly decrease after the learning curve period and can be successfully managed without need of reoperation. Suture-line reinforcement, at least selectively in the middle-upper portion of the staple line and in super-super-obese patients, is recommended to decrease the incidence of specific complications.


title: "Obama system:" a new easy, safe, and economical technique for laparoscopic single-port surgery.

text: INTRODUCTION Various approaches to laparoscopic single-site surgery (LESS) have been developed to reduce pain and other complications, promote recovery, and improve cosmetic outcomes, particularly relative to conventional open or laparoscopic surgery. Three-port procedures for LESS have been reported to be superior to single-port access, but they usually require expensive, technically sophisticated instruments. To avoid these problems, we have developed a modified procedure for performing LESS with a single port, referred to as the "Obama system." METHODS From January 2009 through December 2010, we performed laparoscopic cholecystectomy (LC) in 61 patients. Conventional LC with three ports was performed in 39 patients, LESS with a SILS Port was performed in 4 patients, and modified LESS was performed using the Obama system in 18 patients. The operative results were compared. RESULTS LC was successfully completed in all 61 patients, with no postoperative complications. The mean operating time was 102.3 min (C-reactive protein [CRP] ≤ 2) and 160.1 min (CRP > 2) in the 39 patients who underwent conventional LC, 108.3 min (CRP ≤ 2) in the 4 patients who underwent LESS with a SILS Port, and 116.5 min (CRP ≤ 2) and 186.5 min (CRP > 2) in the 18 patients who underwent LESS using the Obama system. No morbidity or mortality was associated with any technique. CONCLUSION The Obama system is easier to use and more efficient and reliable than any other technique currently available for LESS. This system is expected to greatly contribute to the further development and wider acceptance of LESS.


Sweet signals - gut-brain circuit for sugar identified.


title: Computed Tomography Features of Coronavirus Disease 2019 (COVID-19): A Review for Radiologists.

text: Coronavirus Disease 2019 (COVID-19) pneumonia has become a global pandemic. Although the rate of new infections in China has decreased, currently, 169 countries report confirmed cases, with many nations showing increasing numbers daily. Testing for COVID-19 infection is performed via reverse transcriptase polymerase chain reaction, but availability is limited in many parts of the world. The role of chest computed tomography is yet to be determined and may vary depending on the local prevalence of disease and availability of laboratory testing. A common but nonspecific pattern of disease with a somewhat predictable progression is seen in patients with COVID-19. Specifically, patchy ground-glass opacities in the periphery of the lower lungs may be present initially, eventually undergoing coalescence, consolidation, and organization, and ultimately showing features of fibrosis. In this article, we review the computed tomography features of COVID-19 infection. Familiarity with these findings and their evolution will help radiologists recognize potential COVID-19 and recognize the significant overlap with other causes of acute lung injury.


Coping with Covid-19.


title: Revisional versus primary Roux-en-Y gastric bypass: a case-matched analysis.

text: BACKGROUND Laparoscopic adjustable gastric banding (LAGB) has been a widely performed bariatric procedure. Unfortunately, revisional surgery is required in 20-30% of cases. Data comparing revisional and primary gastric bypass procedures are scarce. This study compared revisional malabsorptive laparoscopic very very long limb (VVLL) Roux-en-Y gastric bypass (RYGB) with primary VVLL RYGB and tested the hypothesis that one-stage revisional laparoscopic VVLL RYGB is an effective procedure after failed LAGB. METHODS In this study, 48 revisional VVLL RYGBs were matched one-to-one with 48 primary VVLL RYGBs. The outcome measures were operating time, conversion to open surgery, excess weight loss (EWL), and early and late morbidity. RESULTS Surgical and medical morbidities did not differ significantly. No conversions occurred. The revisional group showed an EWL of 41.8% after 12 months of follow-up evaluation and 45.1% after 24 months based on the pre-revisional weight. The total EWL based on the weight before the LAGB was calculated to be 54.3% after 12 months and 57.2% after 24 months. The EWL in the primary RYGB group was significantly higher for both types of calculation: 41.8%/54.3% versus 64.1 % (p < 0.001 and <0.01) after 12 months and 45.1%/57.2% versus 70.4% (p < 0.001 and <0.002) after 24 months. CONCLUSIONS Revisional laproscopic VVLL RYGB can be performed as a one-stage procedure by experienced bariatric surgeons but shows less effective EWL than primary RYGB procedures.


title: Recommendations for the emergency management of complications associated with the new direct oral anticoagulants (DOACs), apixaban, dabigatran and rivaroxaban.

text: Dabigatran, apixaban, and rivaroxaban have been approved for primary and secondary stroke prevention in patients with atrial fibrillation. However, questions have arisen about how to manage emergency situations, such as when thrombolysis would be required for acute ischemic stroke or for the managing intracranial or gastrointestinal bleedings. We summarize the current literature and provide recommendations for the management of these situations. Peak plasma levels of the direct oral anticoagulants (DOACs) apixaban, dabigatran, or rivaroxaban are observed about 2-4 h after intake. Elimination of dabigatran is mainly dependent on renal function. Consequently, if renal function is impaired, there is a risk of drug accumulation that is highest for dabigatran followed by rivaroxaban and then apixaban and thus dosing recommendations are different. To date, no bedside tests are available that reliably assess the anticoagulatory effect of DOACs, nor are specific antidotes available. We recommend performing the following tests if DOAC intake is unknown: dabigatran-associated bleeding risk is minimized or can be neglected if thrombin time, Hemoclot test, or Ecarin clotting time is normal. Apixaban and rivaroxaban effects can be ruled out if findings from the anti-factor Xa activity test are normal. High plasma levels of DOAC are also mostly excluded if PTT and PTZ are normal four or more hours after DOAC intake. However, normal values of global coagulation tests are not sufficient if thrombolysis is indicated for treating acute stroke. The decision for or against thrombolysis is an individual decision; in these cases, thrombolysis use is off-label. In case of bleeding, prothrombin complex concentrates seems to be the most plausible treatment. For severe gastrointestinal bleeding with life-threatening blood loss, the bleeding source needs to be identified and treated by invasive measures. Use of procoagulant drugs (antifibrinolytics) might also be considered. However, there is very limited clinical experience with these products in conjunction with DOAC.


title: Ganglioside-linked terminal sialic acid moieties on murine macrophages function as attachment receptors for murine noroviruses.

text: Noroviruses are the major cause of nonbacterial gastroenteritis in humans. However, little is known regarding the norovirus life cycle, including cell binding and entry. In contrast to human noroviruses, the recently discovered murine norovirus 1 (MNV-1) readily infects murine macrophages and dendritic cells in culture. Many viruses, including the related feline calicivirus, use terminal sialic acids (SA) as receptors for infection. Therefore, we tested whether SA moieties play a role during MNV-1 infection of murine macrophages. Competition with SA-binding lectins and neuraminidase treatment led to a reduction in MNV-1 binding and infection in cultured and primary murine macrophages, suggesting a role for SA during the initial steps of the MNV-1 life cycle. Because SA moieties can be attached to glycolipids (i.e., gangliosides), we next determined whether MNV-1 uses gangliosides during infection. The gangliosides GD1a, GM1, and asialo-GM1 (GA1) are natural components of murine macrophages. MNV-1 bound to ganglioside GD1a, which is characterized by an SA on the terminal galactose, but not to GM1 or asialo-GM1 in an enzyme-linked immunosorbent assay. The depletion of gangliosides using an inhibitor of glycosylceramide synthase (d-threo-P4) led to a reduction of MNV-1 binding and infection in cultured and primary murine macrophages. This defect was specifically rescued by the addition of GD1a. A similar phenotype was observed for MNV field strains WU11 (GV/WU11/2005/USA) and S99 (GV/Berlin/2006/DE). In conclusion, our data indicate that MNV can use terminal SA on gangliosides as attachment receptors during binding to murine macrophages.


title: Performance of current intensive care unit ventilators during pressure and volume ventilation.

text: BACKGROUND Intensive-care mechanical ventilators regularly enter the market, but the gas-delivery capabilities of many have never been assessed. METHODS We evaluated 6 intensive-care ventilators in the pressure support (PS), pressure assist/control (PA/C), and volume assist/control (VA/C) modes, with lung-model mechanics combinations of compliance and resistance of 60 mL/cm H(2)O and 10 cm H(2)O/L/s, 60 mL/cm H(2)O and 5 cm H(2)O/L/s, and 30 mL/cm H(2)O and 10 cm H(2)O/L/s, and inspiratory muscle effort of 5 and 10 cm H(2)O. PS and PA/C were set to 15 cm H(2)O, and PEEP to 5 and 15 cm H(2)O in all modes. During VA/C, tidal volume was set at 500 mL and inspiratory time was set at 0.8 second. Rise time and termination criteria were set at the manufacturers' defaults, and to an optimal level during PS and PA/C. RESULTS There were marked differences in ventilator performance in all 3 modes. VA/C had the greatest difficulty meeting lung model demand and the greatest variability across all tested scenarios and ventilators. From high to low inspiratory muscle effort, pressure-to-trigger, time for pressure to return to baseline, and triggering pressure-time product decreased in all modes. With increasing resistance and decreasing compliance, tidal volume, pressure-to-trigger, time-to-trigger, time for pressure to return to baseline, time to 90% of peak pressure, and pressure-time product decreased. There were large differences between the default and optimal settings for all the variables in PS and PA/C. Performance was not affected by PEEP. CONCLUSIONS Most of the tested ventilators performed at an acceptable level during the majority of evaluations, but some ventilators performed inadequately during specific settings. Bedside clinical evaluation is needed.


title: Caring for critically ill patients with ebola virus disease. Perspectives from West Africa.

text: The largest ever Ebola virus disease outbreak is ravaging West Africa. The constellation of little public health infrastructure, low levels of health literacy, limited acute care and infection prevention and control resources, densely populated areas, and a highly transmissible and lethal viral infection have led to thousands of confirmed, probable, or suspected cases thus far. Ebola virus disease is characterized by a febrile severe illness with profound gastrointestinal manifestations and is complicated by intravascular volume depletion, shock, profound electrolyte abnormalities, and organ dysfunction. Despite no proven Ebola virus-specific medical therapies, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings. With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigm shift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen.


title: Development of new equipment for intra-arrest brain cooling that uses cooled oxygen in the lungs: volunteer study.

text: Aims Many experimental studies have reported that intra-arrest cooling during cardiac arrest is a promising treatment to mitigate brain injury. However, there is no clinically established method for cooling the brain during cardiac arrest. We hypothesized that, as blood flow in the lungs must be very slow during cardiopulmonary resuscitation, the blood could be cooled by ventilating the lungs with cooled oxygen like a radiator, and that this cooled blood would in turn cool the brain. The aim of this study was to develop equipment to cool oxygen for this purpose and to confirm its safety on a group of volunteers. Methods We developed new equipment that cools oxygen by running it through a vinyl chloride coil submerged in a bottle of water and frozen at -80°C. Using this equipment, seven volunteers were given oxygen by mask, and their blood pressure, heart rate, and peripheral saturation of oxygen were measured. The temperature in the mask was also measured. Results This equipment was able to decrease the temperature in the mask to -5°C at the Jackson Rees circuit for an oxygen flow of 10 L/min. Among the volunteer group, vital signs were unchanged and the temperature in the mask decreased from 30.1 ± 2.6°C (mean ± standard deviation) to 15.9 ± 9.6°C. No adverse effects were observed in the volunteers after experimentation. Conclusion We successfully developed new equipment to cool oxygen and established its safety in a volunteer study.


title: Single-incision video-assisted thoracoscopic resection of a pedunculated solitary fibrous tumor of the pleura: case report.

text: In this report, we describe the surgical resection of a pedunculated solitary fibrous tumor of the pleura (SFTP) by single-incision thoracoscopic surgery (SITS). SITS may be a suitable surgical option for pedunculated SFTPs.


title: Single-dose protection against Plasmodium berghei by a simian adenovirus vector using a human cytomegalovirus promoter containing intron A.

text: Human adenovirus serotype 5 (AdH5) vector vaccines elicit strong immune responses to the encoded antigen and have been used in various disease models. We designed AdH5 vectors expressing antigen under the control of a human cytomegalovirus (HCMV) immediate-early promoter containing its intron A sequence. The transcriptional levels of antigen and immune responses to antigen for vectors with the HCMV promoter with the intron A sequence (LP) were greater than those for AdH5 vectors using the HCMV promoter sequence without intron A (SP). We compared an E1E3-deleted AdH5 adenoviral vector, which affords more space for insertion of foreign sequences, and showed it to be as immunogenic as an E1-deleted AdH5 vector. Neutralizing antibodies to AdH5 limit the efficacy of vaccines based on the AdH5 serotype, and simian adenoviral vectors offer an attractive option to overcome this problem. We constructed E1E3-deleted human and simian adenoviral vectors encoding the pre-erythrocytic-stage malarial antigen Plasmodium berghei circumsporozoite protein. We compared the immunogenicity and efficacy of AdC6, a recombinant simian adenovirus serotype 6 vector, in a murine malaria model to those of AdH5 and the poxviral vectors MVA and FP9. AdC6 induced sterile protection from a single dose in 90% of mice, in contrast to AdH5 (25%) and poxviral vectors MVA and FP9 (0%). Adenoviral vectors maintained potent CD8(+) T-cell responses for a longer period after immunization than did poxviral vectors and mainly induced an effector memory phenotype of cells. Significantly, AdC6 was able to maintain protection in the presence of preexisting immunity to AdH5.


Benzodiazepines in long-term opioid therapy.


docid: npmplthj

title: Community-acquired respiratory viral infections in lung transplant recipients: a single season cohort study.

text: BACKGROUND The impact of community-acquired respiratory virus (CARV) infections on bronchiolitis obliterans syndrome (BOS) and outcome after lung transplantation (LTx) and diagnostic techniques were prospectively evaluated. METHODS A single-center prospective cohort study was performed in LTx-outpatients between October 31, 2005 and April 30, 2006. Symptoms of respiratory tract infections were recorded and nasopharyngeal and oropharyngeal swabs were obtained. Lower respiratory sampling was performed when indicated. Immunofluorescence testing, cultures, and polymerase chain reaction for 12 different CARV were applied. Patients were followed up until December 31, 2007. New onset and BOS-stage was recorded 1 year after presentation. RESULTS Three hundred eighty-eight LTx-recipients were screened. Fifty-one percent reported of symptoms of respiratory tract infection. Seven hundred seventy upper and 180 lower respiratory samples were obtained. Thirty-four CARV were detected in 30 patients (7.7%): 12 parainfluenza, 7 respiratory syncytial virus, 6 metapneumovirus, 5 coronavirus, 3 rhinovirus, and 1 influenza virus. At 1 year, 43 new cases of BOS developed. One-year incidence of BOS was 25.0% in CARV-positive versus 9.0% in CARV-negative patients (log-rank P=0.01). Symptomatic CARV-infection proved to be a significant covariate for 1-year BOS-free survival in multivariate analysis (P=0.002, adjusted hazard ratio 4.13). CARV-infection did not influence BOS progression in 88 patients with prior BOS (P 0.45). After paramyxovirus infection, 8 of 24 patients developed new-onset BOS, whereas no case was recorded after rhinovirus and coronavirus infection. DISCUSSION Surveillance detected CARV in LTx outpatients infrequently. Symptomatic CARV-infection increases the risk for new onset of BOS, but not progression. Risk to develop BOS was especially increased after paramyxovirus infection.


Teleconsultation and Diabetes Care Amid COVID-19 Pandemic in India: Scopes and Challenges.


CT Diagnosis of Coronavirus Infection.


title: Procalcitonin-guided antibiotic therapy for chronic obstructive pulmonary disease exacerbations.

text: The aim of this article is to review the current literature examining the use of procalcitonin-guided antibiotic therapy for management of chronic obstructive pulmonary disease (COPD) exacerbations. Procalcitonin is a serum marker that rises in response to bacterial infections, but remains low in nonbacterial infections and other proinflammatory conditions. To date, there are four randomized clinical trials which compare procalcitonin-guided antibiotic therapy to standard therapy in patients with COPD exacerbations. In all four trials the use of procalcitonin was associated with a reduction in antibiotic use (prescription and/or duration) without an increase in the rates of adverse patient outcomes including death, admission to the intensive care unit, re-exacerbation and readmission to the hospital. This data is clinically significant and suggests that the use of procalcitonin-guided antibiotic therapy has the potential to decrease unnecessary antibiotic use in nonbacterial COPD exacerbations, thereby curtailing the spread of antibiotic-resistant bacteria, reducing antibiotic-related adverse reactions, including Clostridium difficile infection, and potentially reducing healthcare costs.


title: Laparoscopic robot-assisted versus open total pancreatectomy: a case-matched study.

text: BACKGROUND The enhanced dexterity offered by robotic assistance could be excessive for distal pancreatectomy but not enough to improve the outcome of laparoscopic pancreaticoduodenectomy. Total pancreatectomy retains the challenges of uncinate process dissection and digestive reconstruction, but avoids the risk of pancreatic fistula, and could be a suitable operation to highlight the advantages of robotic assistance in pancreatic resections. METHODS Eleven laparoscopic robot-assisted total pancreatectomies (LRATP) were compared to 11 case-matched open total pancreatectomies. All operations were performed by one surgeon during the same period of time. Robotic assistance was employed in half of the patients, based on robot availability at the time of surgery. Variables examined included age, sex, American Society of Anesthesiologists score, body mass index, estimated blood loss, need for blood transfusions, operative time, tumor type, tumor size, number of examined lymph nodes, margin status, post-operative complications, 90-day or in-hospital mortality, length of hospital stay, and readmission rate. RESULTS No LRATP was converted to conventional laparoscopy, hand-assisted laparoscopy or open surgery despite two patients (18.1 %) required vein resection and reconstruction. LRATP was associated with longer mean operative time (600 vs. 469 min; p = 0.014) but decreased mean blood loss (220 vs. 705; p = 0.004) than open surgery. Post-operative complications occurred in similar percentages after LRATP and open surgery. Complications occurring in most patients (5/7) after LRATP were of mild severity (Clavien-Dindo grade I and II). One patient required repeat laparoscopic surgery after LRATP, to drain a fluid collection not amenable to percutaneous catheter drainage. One further patient from the open group required repeat surgery because of bleeding. No patient had margin positive resection, and the mean number of examined lymph nodes was 45 after LRATP and 36 after open surgery. CONCLUSIONS LRATP is feasible in selected patients, but further experience is needed to draw final conclusions.


title: Is the use of ACE inb/ARBs associated with higher in-hospital mortality in Covid-19 pneumonia patients?

text: INTRODUCTION The present research aimed to determine the relation between the use of angiotensin-converting enzyme inhibitors (ACE inh) and angiotensinogen receptor blockers (ARBs) and in-hospital mortality of hypertensive patients diagnosed with Covid-19 pneumonia. MATERIAL AND METHOD In this retrospective study, we included 113 consecutive hypertensive patients admitted due to Covid-19 infection. In all patients, Covid-19 infection was confirmed with using reverse-transcription polymerase chain reaction. All patients were on ACE inh/ARBs or other antihypertensive therapy unless no contraindication was present. The primary outcome of the study was the in-hospital all-cause mortality. RESULTS In total, 113 hypertensive Covid-19 patients were included, of them 74 patients were using ACE inh/ARBs. During in-hospital follow up, 30.9% [n = 35 patients] of patients died. The frequency of admission to the ICU and endotracheal intubation were significantly higher in patients using ACE inh/ARBs. In a multivariable analysis, the use of ACE inh/ARBs was an independent predictor of in-hospital mortality (OR: 3.66; 95%CI: 1.11-18.18; p= .032). Kaplan-Meir curve analysis displayed that patients on ACE inh/ARBs therapy had higher incidence of in-hospital death than those who were not. CONCLUSION The present study has found that the use of ACE inh/ARBs therapy might be associated with an increased in-hospital mortality in patients who were diagnosed with Covid-19 pneumonia. It is likely that ACE inh/ARBs therapy might not be beneficial in the subgroup of hypertensive Covid-19 patients despite the fact that there might be the possibility of some unmeasured residual confounders to affect the results of the study.


Prevention and treatment of venous thromboembolism: international consensus statement (guidelines according to scientific evidence).


title: Robot-assisted subtotal pancreas-preserving duodenectomy.

text: BACKGROUND Angiodysplasia of the duodenum is a rare disorder, often requiring surgical resection. Technical difficulties have made the use of the minimally invasive approach uncommon. Herein, we present a subtotal pancreas-preserving duodenectomy using robotic assistance. METHODS The patient is a 60-y-old female with a long medical history including chronic gastrointestinal bleeding due to angiodysplasia with intermittent melena, and requiring multiples blood transfusions. A capsule endoscopy and double-balloon upper endoscopy showed angiectasis, which appeared to be limited to the third and fourth portion of the duodenum and the proximal loops of the jejunum. Despite multiple endoscopic cauterizations, the patient continued to require blood transfusion for several years. The patient underwent a robot-assisted subtotal pancreas-preserving duodenectomy. RESULTS The operation lasted 420 min with minimal blood loss. The postoperative course was uneventful. The pathology report showed multiple small bowel mucosal and submucosal distorted and dilated vasculature, consistent with angiodysplasia. At 2-mo follow-up, the patient was totally asymptomatic. A barium swallow study showed contrast passed antegrade through the duodenojejunostomy with no evidence of obstruction, stricture, or leakage. CONCLUSION The use of robotic assistance to perform a subtotal pancreas-preserving duodenectomy for the treatment of benign duodenal disease, such as angiodysplasia, is feasible and safe. The technical advantages include a high degree of freedom offered by the robotic instruments, as well as enhanced visualization, which allows for precise microdissection and microsuture, thereby preserving the benefits of minimally invasive surgery. The use of robotic technology allows for a wider range of indications for minimally invasive surgery.


title: HEALTH STATUS OF REINTRODUCED WOOD BISON ( BISON BISON ATHABASCAE): ASSESSING THE CONSERVATION VALUE OF AN ISOLATED POPULATION IN NORTHWESTERN CANADA.

text: A central goal for reintroduced populations of threatened wood bison ( Bison bison athabascae) is to maintain them free of diseases of concern, particularly bovine tuberculosis (caused by Mycobacterium bovis) and brucellosis (caused by Brucella abortus). A wood bison population in southwestern Yukon, Canada was reintroduced into the wild in 1988, but no health assessment has been done since then. To provide an initial assessment of the health status and, hence, the conservation value of this population, we serologically tested 31 wood bison (approximately 3% of the population) for pathogens of interest and obtained histopathology results for select tissues. We found no evidence of exposure to M. bovis or Brucella spp., but antibodies were present to bovine parainfluenza virus 3, bovine coronavirus, Leptospira interrogans, and Neospora caninum, with seroprevalences of 87, 7, 61, and 7% of the tested animals, respectively. Reintroduced wood bison in southwestern Yukon may be of high value for wood bison recovery because it is a large and geographically isolated population with no bacteriologic, histopathologic, or serologic evidence of exposure to Brucella spp. or M. bovis.


title: Surveillance using serological and molecular methods for the detection of infectious agents in captive Brazilian neotropic and exotic felids.

text: The aim of the current study was to investigate the exposure of captive wild felids to various infectious pathogens using serological and molecular methods. One hundred and fifty-nine neotropic felids and 51 exotic felids from 28 captive settings in Brazil were tested. While antibodies against Feline parvovirus and Feline coronavirus (FCoV), Feline calicivirus and Bartonella spp. were frequently detected by serologic tests, antibodies against Felid herpesvirus 1 or infection with hemotropic mycoplasmas were less prevalent. Serologic evidence of exposure to Ehrlichia spp., Feline immunodeficiency virus, and Feline leukemia virus (FeLV) was detected rarely, and infections with FeLV, Ehrlichia spp., and Cytauxzoon spp. were found infrequently. The detected Bartonella sequence was molecularly similar to B. koehlerae and B. henselae; for Cytauxzoon, the sequence resembled those from domestic cats. No Anaplasma phagocytophilum and Theileria spp. infections were detected. The positive test results varied significantly among different facilities and species. Additionally, FCoV seropositivity was more prevalent in captivity than in free-ranging populations. Results suggest that testing is appropriate prior to relocation of felids.


title: Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis.

text: BACKGROUND Previous studies comparing open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) have found advantages related to minimal-access surgery. Few studies have compared direct and associated costs after LDP versus ODP. The purpose of the current study was to compare perioperative outcomes of patients undergoing LDP and ODP and to assess whether LDP was a cost-effective procedure compared with the traditional ODP. METHODS A retrospective analysis of a prospectively maintained database of 52 distal pancreatic resections that were performed during a 10-year period was performed. RESULTS Patients included in the analysis were 16 in the LDP group and 29 in the ODP. Tumors operated laparoscopically were smaller than those removed at open operation, but the length of pancreatic resection was similar. The mean operating time for LDP was longer than ODP (204 ± 31 vs. 160 ± 35; P < 0.0001), whereas blood loss was higher in the open group (365 ± 215 vs. 160 ± 185, P < 0.0001). Morbidity (25 vs. 41; P = 0.373) and pancreatic fistula (18 vs. 20%; P = 0.6) rates were similar after LDP and ODP, as was 30-day mortality (0 vs. 2%; P = 0.565). LDP had a shorter mean length of hospital stay than ODP (6.4 (2.3) vs. 8.8 (1.7) days; P < 0.0001). Operative cost for LDP was higher than ODP (2889 vs. 1989; P < 0.0001). The entire cost of the associated hospital stay was higher in the ODP group (8955 vs. 6714; P < 0.043). The total cost was comparable in LDP and ODP groups (9603 vs. 10944; P = 0.204). CONCLUSIONS Laparoscopic distal pancreatectomy for left-sided lesions can be performed safely and effectively in selected patients, with reduced hospital stay and operative blood loss. Major complications, including pancreatic leak, were not reduced, whereas total cost was comparable between LDP and ODP. A selective use of LDP seems to be an effective and cost-efficient alternative to ODP.


title: Mortality from HIV-associated meningitis in sub-Saharan Africa: a systematic review and meta-analysis.

text: INTRODUCTION HIV-associated cryptococcal, TB and pneumococcal meningitis are the leading causes of adult meningitis in sub-Saharan Africa (SSA). We performed a systematic review and meta-analysis with the primary aim of estimating mortality from major causes of adult meningitis in routine care settings, and to contrast this with outcomes from clinical trial settings. METHODS We searched PubMed, EMBASE and the Cochrane Library for published clinical trials (defined as randomized-controlled trials (RCTs) or investigator-managed prospective cohorts) and observational studies that evaluated outcomes of adult meningitis in SSA from 1 January 1990 through 15 September 2019. We performed random effects modelling to estimate pooled mortality, both in clinical trial and routine care settings. Outcomes were stratified as short-term (in-hospital or two weeks), medium-term (up to 10 weeks) and long-term (up to six months). RESULTS AND DISCUSSION Seventy-nine studies met inclusion criteria. In routine care settings, pooled short-term mortality from cryptococcal meningitis was 44% (95% confidence interval (95% CI):39% to 49%, 40 studies), which did not differ between amphotericin (either alone or with fluconazole) and fluconazole-based induction regimens, and was twofold higher than pooled mortality in clinical trials using amphotericin based treatment (21% (95% CI:17% to 25%), 17 studies). Pooled short-term mortality of TB meningitis was 46% (95% CI: 33% to 59%, 11 studies, all routine care). For pneumococcal meningitis, pooled short-term mortality was 54% in routine care settings (95% CI:44% to 64%, nine studies), with similar mortality reported in two included randomized-controlled trials. Few studies evaluated long-term outcomes. CONCLUSIONS Mortality rates from HIV-associated meningitis in SSA are very high under routine care conditions. Better strategies are needed to reduce mortality from HIV-associated meningitis in the region.


title: Using the relationship between brain tissue regional saturation of oxygen and mean arterial pressure to determine the optimal mean arterial pressure in patients following cardiac arrest: A pilot proof-of-concept study.

text: INTRODUCTION Prospectively assess cerebral autoregulation and optimal mean arterial pressure (MAPOPT) using the dynamic relationship between MAP and regional saturation of oxygen (rSO2) using near-infrared spectroscopy. METHODS Feasibility study of twenty patients admitted to the intensive care unit following a cardiac arrest. All patients underwent continuous rSO2 monitoring using the INVOS(®) cerebral oximeter. ICM+(®) brain monitoring software calculates the cerebral oximetry index (COx) in real-time which is a moving Pearson correlation coefficient between 30 consecutive, 10-s averaged values of MAP and correspond rSO2 signals. When rSO2 increases with increasing MAP (COx ≥0.3), cerebral autoregulation is dysfunctional. Conversely, when rSO2 remains constant or decreases with increasing MAP (COx <0.3), autoregulation is preserved. ICM+(®) fits a U-shaped curve through the COx values plotted vs. MAP. The MAPOPT is nadir of this curve. RESULTS The median age was 59 years (IQR 54-67) and 7 of 20 were female. The cardiac arrest was caused by myocardial infarction in 12 (60%) patients. Nineteen arrests were witnessed and return of spontaneous circulation occurred in a median of 15.5min (IQR 8-33). Patients underwent a median of 30h (IQR 23-46) of monitoring. COx curves and MAPOPT were generated in all patients. The mean overall MAP and MAPOPT were 76mmHg (SD 10) and 76mmHg (SD 7), respectively. MAP was outside of 5mmHg from MAPOPT in 50% (SD 15) of the time. Out of the 7672 5-min averaged COx measurements, 1182 (15%) were at 0.3 or above, indicating absence of autoregulation. Multivariable polynomial fractional regression demonstrated an increase in COx with increasing temperature (P=0.008). CONCLUSIONS We demonstrated the feasibility to determine a MAPOPT using cerebral oximetry in patients after cardiac arrest.


title: Laparoscopic gastroscopic transgastric cystogastrostomy and cholecystectomy for pseudopancreatic cyst after gallstone pancreatitis in children.

text: A 15-year-old girl presented with gallstone pancreatitis. Subsequently, a pseudopancreatic cyst developed that was diagnosed on computed tomographic scan. She underwent a laparoscopic and gastroscopic transgastric cystogastrostomy. In the following report, we describe our novel approach and technique for the above condition.


Biological mesh extrusion months after laparoscopic ventral rectopexy.


title: Altered DNA methylation profile in Norwegian patients with Autoimmune Addison's Disease.

text: Autoimmune Addison's Disease (AAD) is an endocrine and immunological disease of uncertain pathogenesis resulting from the immune system's destruction of the hormone producing cells of the adrenal cortex. The underlying molecular mechanisms are largely unknown, but it is commonly accepted that a combination of genetic susceptibility and environmental impact is critical. In the present study, we identified multiple hypomethylated gene promoter regions in patients with isolated AAD using DNA isolated from CD4+ T cells. The identified differentially methylated regions were distributed evenly across the 10.5-kb-promoter regions covered by the array, and a substantial number localized to promoters of genes involved in immune regulation and autoimmunity. This study reveals a hypomethylated status in CD4+ T cells from AAD patients and indicates differential methylation of promoters of key genes involved in immune responses.


title: The Importance of Psychodynamic Approach during COVID-19 Pandemic.

text: The coronavirus (COVID-19) outbreak was labeled a global pandemic by the WHO in March of 2020. Understanding how crisis influence an individual's reactions to stressful events (and vice versa) is important in order to create meaningful and effective interventions. Our literature search have revealed lack of the papers related to psychodynamic approach to recent crisis. Psychodynamic places a large emphasis on defense mechanisms and unconscious mind, where upsetting feelings, urges, and thoughts that are too painful for us to directly look at are housed. Even though these painful feelings and thoughts are outside of our awareness, they still influence our behavior in many ways. Optimal application of psychodynamic approach offers the frame for acceptance of psychological stress in a more positive way and benefits psychological growth. We believe that including psychodynamic approach in the national public and mental health emergency system will empower Croatia and the world during (and after) COVID-19 pandemic crisis.


title: Choice of Estimated Glomerular Filtration Rate Equation Impacts Drug-Dosing Recommendations and Risk Stratification in Patients With Chronic Kidney Disease Undergoing Percutaneous Coronary Interventions.

text: BACKGROUND Multiple equations exist to estimate glomerular filtration rate (GFR); however, there is no consensus on which is superior for risk classification in patients with chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI). OBJECTIVES The goals of this study were to identify which equation to estimate GFR is superior for predicting adverse outcomes after PCI and to examine how equation selection would impact drug-dosing recommendations. METHODS Estimated GFR (eGFR) was calculated with the Cockcroft-Gault, Modification of Diet in Renal Disease Study (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations for 128,805 patients undergoing PCI in the state of Michigan. Agreement between patient pre-PCI eGFR estimates and resultant CKD stage classifications, their ability to discriminate post-procedural in-hospital clinical outcomes, and the impact of equation choice on dosing recommendations for commonly used antiplatelet and antithrombotic medications were investigated. RESULTS CKD-EPI best discriminated post-PCI mortality by receiver operator characteristic analysis. There was wide variability in eGFR, which persisted after grouping by CKD stages. Reclassification by CKD-EPI resulted in net reclassification index improvement for acute kidney injury and new requirement for dialysis. Equation choice affected drug-dosing recommendations, with the formulas agreeing for only 50.3%, 40.0%, and 34.3% of potentially impacted patients for eGFR cutoffs of <60, <50, and <30 ml/min/1.73 m(2), respectively. CONCLUSIONS Different eGFR equations result in CKD stage reclassification that has major clinical implications for predicting adverse outcomes after PCI and drug-dosing recommendations. Our results support the use of CKD-EPI for risk stratification among patients undergoing PCI.


docid: narwwdxb

title: Aminopeptidase N (EC 3.4.11.2) inhibitors (2006 - 2010): a patent review.

text: INTRODUCTION Aminopeptidase N (APN/CD13) acts as an exopeptidase and has been studied for decades. In recent years, it has been seen not only as a tumor-related target but also as a potential functional protein in various other physiological or pathological processes, such as analgesia, virus infection and inflammation. AREAS COVERED In this review, APN inhibitors in the patents publicized during 2006 - 2010 are introduced. Readers will gain information on the patent inhibitors, including chemical structures, original sources or synthetic methods, biological assays and application potential. EXPERT OPINION It is difficult to identify compounds that interact with the function not relevant with peptide-hydrolysis of APN in the enzyme activity assay, and such compounds have not been reported in the patents during the past 5 years. The progress of protein-small molecule interaction detecting means, such as surface plasmon resonance, will possibly help develop such compounds for the treatment of relevant diseases or new molecular probes in mechanism investigation.


title: Thromboelastometry: studying hemostatic profile in small for gestational age neonates-a pilot observational study.

text: Scarce data exists about the hemostatic status of small for gestational age (SGA) neonates. We aimed at evaluating the hemostatic profile of SGA neonates, using thromboelastometry (TEM). This is an observational study performed in a Greek tertiary General Hospital during an 18-month period. Ninety-three neonates were included in the study: 48 appropriate for gestational age weight (AGA) neonates and 45 SGA neonates Extrinsically activated TEM (ex-TEM) parameters, such as clotting time, clot formation time, amplitude recorded at 5 and 10 min, a angle, maximum clot firmness, lysis index at 60 min, and also platelet count, were used for the evaluation of the hemostatic profile in all neonates. No statistically significant differences were noticed regarding all ex-TEM parameters between AGA and SGA neonates, while no event of hemorrhage or thrombosis was noticed in the study population.Conclusions: The coagulation system of SGA neonates seems to be fully functional, with no evident tendency toward coagulopathy or thrombosis, when compared with AGA neonates. TEM seems to provide a promising and valid assessment of coagulation and fibrinolysis systems and may be used as a valuable biomarker, in the future. Further studies, with large samples, are necessary to confirm our results. What is Known: • SGA neonates may present coagulation disorders mainly due to hepatic dysfunction, polycythemia, and thrombocytopenia owing to long-term intrauterine hypoxia. • In the literature, despite the statistically significant differences in laboratory results between SGA and AGA neonates, no clinical manifestations of significantly altered hemostasis were recorded. Data of TEM interpretation of hemostasis in SGA neonates are not available. What is New: • TEM seems to interpret coagulation mechanism of preterm and full-term SGA neonates and confirm previous relevant literature findings regarding hemostasis in these neonates.


title: Carotid revascularization and medical management for asymptomatic carotid stenosis: Protocol of the CREST-2 clinical trials.

text: Rationale Trials conducted decades ago demonstrated that carotid endarterectomy by skilled surgeons reduced stroke risk in asymptomatic patients. Developments in carotid stenting and improvements in medical prevention of stroke caused by atherothrombotic disease challenge understanding of the benefits of revascularization. Aim Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) will test whether carotid endarterectomy or carotid stenting plus contemporary intensive medical therapy is superior to intensive medical therapy alone in the primary prevention of stroke in patients with high-grade asymptomatic carotid stenosis. Methods and design CREST-2 is two multicenter randomized trials of revascularization plus intensive medical therapy versus intensive medical therapy alone. One trial randomizes patients to carotid endarterectomy plus intensive medical therapy versus intensive medical therapy alone; the other, to carotid stenting plus intensive medical therapy versus intensive medical therapy alone. The risk factor targets of centrally directed intensive medical therapy are LDL cholesterol <70 mg/dl and systolic blood pressure <140 mmHg. Study outcomes The primary outcome is the composite of stroke and death within 44 days following randomization and stroke ipsilateral to the target vessel thereafter, up to four years. Change in cognition and differences in major and minor stroke are secondary outcomes. Sample size Enrollment of 1240 patients in each trial provides 85% power to detect a treatment difference if the event rate in the intensive medical therapy alone arm is 4.8% higher or 2.8% lower than an anticipated 3.6% rate in the revascularization arm. Discussion Management of asymptomatic carotid stenosis requires contemporary randomized trials to address whether carotid endarterectomy or carotid stenting plus intensive medical therapy is superior in preventing stroke beyond intensive medical therapy alone. Whether carotid endarterectomy or carotid stenting has favorable effects on cognition will also be tested. Trial registration United States National Institutes of Health Clinicaltrials.gov NCT02089217.


title: Analyzing 2,589 child neurology telehealth encounters necessitated by the COVID-19 pandemic.

text: OBJECTIVE To assess the rapid implementation of child neurology telehealth outpatient care with the onset of the COVID-19 pandemic in March 2020. METHODS This was a cohort study with retrospective comparison of 14,780 in-person encounters and 2,589 telehealth encounters including 2,093 audio-video telemedicine and 496 scheduled telephone encounters between 10/1/19 and 4/24/2020. We compared in-person and telehealth encounters for patient demographics and diagnoses. For audio-video telemedicine encounters, we analyzed questionnaire responses addressing provider experience, follow-up plans, technical quality, need for in-person assessment, and parent/caregiver satisfaction. We performed manual reviews of encounters flagged as concerning by providers. RESULTS There were no differences in patient age and major ICD10 codes before and after transition. Clinicians considered telemedicine satisfactory in 93% (1200/1286) of encounters and suggested telemedicine as a component for follow-up care in 89% (1144/1286) of encounters. Technical challenges were reported in 40% (519/1314) of encounters. In-person assessment was considered warranted following 5% (65/1285) of encounters. Patients/caregivers indicated interest in telemedicine for future care in 86% (187/217) of encounters. Participation in telemedicine encounters compared to telephone encounters was less frequent amongst patients in racial or ethnic minority groups. CONCLUSIONS We effectively converted most of our outpatient care to telehealth encounters, including mostly audio-video telemedicine encounters. Providers rated the vast majority of telemedicine encounters to be satisfactory, and only a small proportion of encounters required short-term in-person follow-up. These findings suggest telemedicine is feasible and effective for a large proportion of child neurology care. Additional strategies are needed to ensure equitable telemedicine utilization.


Late Coronary Stent Thrombosis in a Patient With Coronavirus Disease 2019.


Becoming anti-racist for the benefit of our patients.


title: A modified intrascleral intraocular lens fixation technique with fewer anterior segment manipulations: 27-gauge needle-guided procedure with built-in 8-0 absorbable sutures.

text: BACKGROUND To report a modified surgical technique for intrascleral intraocular lens (IOL) fixation with fewer anterior segment manipulations in eyes lacking sufficient capsular support. METHODS Eyes from 14 patients who underwent 27-gauge needle-guided intrascleral IOL fixation with built-in 8-0 absorbable sutures were studied. The 8-0 absorbable sutures were inserted into 27-gauge round needles and used to create sclerotomies at the 4 o'clock and 10 o'clock positions under the scleral flap. The sutures were used to tie knots at the end of each haptic and guide haptic externalization through the sclerotomy. After externalization, a sufficient flange was created at the end of each haptic and fixed under the scleral flaps. The best corrected visual acuity (BCVA), corneal endothelial cell density (ECD), IOL tilt and decentration, previous surgery history, and complications were determined. RESULTS Fourteen cases were analyzed. The majority of eyes exhibited an improvement in the BCVA after surgery. When comparing the last follow-up to preoperative visual acuity, the mean change in BCVA was + 26.32 letters (p = 0.011). Postoperative complications included postoperative hypotony in 3 eyes, ocular hypertension in 2 eyes. No cases of postoperative cystoid macular edema (CME), vitreous hemorrhage (VH), IOL dislocation, or endophthalmitis were observed. CONCLUSIONS The 27-gauge needle-guided intrascleral IOL fixation technique with built-in 8-0 absorbable sutures is easy to perform with fewer anterior chamber manipulations and achieves both anatomical and optical stability.


Images in clinical medicine. Coughing and aerosols.


title: Constitutively active glutaminase variants provide insights into the activation mechanism of anthranilate synthase.

text: The glutamine amidotransferase (GATase) family comprises enzyme complexes which consist of glutaminase and synthase subunits that catalyze in a concerted reaction the incorporation of nitrogen within various metabolic pathways. An important feature of GATases is the strong stimulation of glutaminase activity by the associated synthase. To understand the mechanism of this tight activity regulation, we probed by site-directed mutagenesis four residues of the glutaminase subunit TrpG from anthranilate synthase that are located between the catalytic Cys-His-Glu triad and the synthase subunit TrpE. In order to minimize structural perturbations induced by the introduced exchanges, the amino acids from TrpG were substituted with the corresponding residues of the closely related glutaminase HisH from imidazole glycerol phosphate synthase. Steady-state kinetic characterization showed that, in contrast to wild-type TrpG, two TrpG variants with single exchanges constitutively hydrolyzed glutamine in the absence of TrpE. A reaction assay performed with hydroxylamine as a stronger nucleophile replacing water and a filter assay with radiolabeled glutamine indicated that the formation of the thioester intermediate is the rate-limiting step of constitutive glutamine hydrolysis. Molecular dynamics simulations with wild-type TrpG and constitutively active TrpG variants suggest that the introduced amino acid exchanges result in a distance reduction between the active site Cys-His pair, which facilitates the deprotonation of the sulfhydryl group of the catalytic cysteine and thus enables its nucleophilic attack onto the carboxamide group of the glutamine side chain. We propose that native TrpG in the anthranilate synthase complex is activated by a similar mechanism.


title: Tumor-induced rickets in a child with a central giant cell granuloma: a case report.

text: Tumor-induced osteomalacia/rickets is a rare paraneoplastic disorder associated with a tumor-producing fibroblast growth factor 23 (FGF23). We present a child with symptoms of rickets as the first clinical sign of a central giant cell granuloma (CGCG) with high serum levels of FGF23, a hormone associated with decreased phosphate resorption. A 3-year-old boy presented with a limp and 6 months later with painless growth of the jaw. On examination gingival hypertrophy and genu varum were observed. Investigations revealed hypophosphatemia, normal 1,25 and 25 (OH) vitamin D, and high alkaline phosphatase. An MRI showed an osteolytic lesion of the maxilla. Radiographs revealed typical rachitic findings. Incisional biopsy of the tumor revealed a CGCG with mesenchymal matrix. The CGCG was initially treated with calcitonin, but the lesions continued to grow, making it necessary to perform tracheostomy and gastrostomy. One year after onset the hyperphosphaturia worsened, necessitating increasing oral phosphate supplements up to 100 mg/kg per day of elemental phosphorus. FGF23 levels were extremely high. Total removal of the tumor was impossible, and partial reduction was achieved after percutaneous computed tomography-guided radiofrequency, local instillation of triamcinolone, and oral propranolol. Compassionate use of cinacalcet was unsuccessful in preventing phosphaturia. The tumor slowly regressed after the third year of disease; phosphaturia improved, allowing the tapering of phosphate supplements, and FGF23 levels normalized. Tumor-induced osteomalacia/rickets is uncommon in children and is challenging for physicians to diagnose. It should be suspected in patients with intractable osteomalacia or rickets. A tumor should be ruled out if FGF23 levels are high.


title: Methods for monitoring construction off-road vehicle emissions: a critical review for identifying deficiencies and directions.

text: The paper reviews the existing applications of sensing technologies for measuring construction off-road vehicle emissions (COVE) such as earthmoving equipment. The current literature presented different measurement methods and reported the results of utilisation of new technologies for measuring COVE. However, previous papers used different technology applications covering only a part of the monitoring process with its own limitations. Since technologies are advancing and offering novel solutions, there is an urgent need to identify the gaps, re-evaluate the current methods, and develop a critical agenda for automating the entire process of collecting emissions data from construction sites, and monitoring the emission contributors across cities. This paper systematically identifies relevant papers through a search of three key databases-Web of Science, Engineering Valley and Scopus-covering the publications in the last decade from 2008 to 2017. An innovative robust research method was designed to select and analyse the relevant papers. The identified papers were stored in a data set, and a thematic algorithm employed to find the clusters of papers which might be potentially relevant. The selected papers were used for further micro-thematic analysis to find key relevant papers on COVE, and the gap in the literature. A sample of relevant papers was found relevant to COVE and critically reviewed by coding and content analysis. This paper critically reviews the selected papers and also shows that there is a considerable gap in the applications of new technologies for measuring in-use COVE in real time based on real activities toward automated methods. This review enables practitioners and scholars to gain a concrete understanding of the gap in measuring COVE and to provide a significant agenda for future technology applications.


title: Differential and directional effects of perfusion on electrical and thermal conductivities in liver.

text: Two different measurement probes--an electrical probe and a thermal conductivity probe--were designed, fabricated, calibrated, and used in experimental studies on a pig liver model that was designed to control perfusion rates. These probes were fabricated by photolithography and mounted in 1.5-mm diameter catheters. We measured the local impedance and thermal conductivity, respectively, of the artificially perfused liver at different flow rates and, by rotating the probes, in different directions. The results show that both the local electrical conductivity and the thermal conductivity varied location to location, that thermal conductivity increased with decreased distance to large blood vessels, and that significant directional differences exist in both electrical and thermal conductivities. Measurements at different perfusion rates demonstrated that both the local electrical and local thermal conductivities increased linearly with the square root of perfusion rate. These correlations may be of great value to many energy-based biomedical applications.


title: Running barbed suture quilting reduces abdominal drainage in perforator-based breast reconstruction.

text: Prolonged abdominal drainage after perforator-based breast reconstruction is a common problem that can result in seroma formation, patient morbidity, and increased duration of hospital stay. Abdominal quilting with progressive tension sutures has been effective in reducing abdominal drainage in abdominoplasty patients prompting a change of practice in our unit. We studied consecutive unilateral mastectomy patients undergoing breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap. The initial 27 patients underwent breast reconstruction without any form of abdominal flap plication. The subsequent 26 patients underwent an identical DIEP flap raise procedure after which the abdominal flap was progressively tensioned using a running barbed suture quilting technique. All patients had closed suction drains inserted bilaterally until daily drain output was <40 ml in 2 consecutive days. Primary outcome measures were total volume of abdominal drainage and length of hospital stay. Independent statistical analyses were performed using Welch's t-test. There were no demographic differences between the two groups. A statistically significant decrease in the mean total abdominal drainage was found after quilting (238 ml vs. 528 ml; p = 0.0005). Patients in the quilting group also showed a reduction in mean duration of hospital stay. Quilting of the abdominal flap helps to reduce abdominal drainage not only in abdominoplasty patients but also in patients undergoing breast reconstruction with DIEP flap.


title: Percutaneous closure of patent foramen ovale in cryptogenic embolism.

text: BACKGROUND The options for secondary prevention of cryptogenic embolism in patients with patent foramen ovale are administration of antithrombotic medications or percutaneous closure of the patent foramen ovale. We investigated whether closure is superior to medical therapy. METHODS We performed a multicenter, superiority trial in 29 centers in Europe, Canada, Brazil, and Australia in which the assessors of end points were unaware of the study-group assignments. Patients with a patent foramen ovale and ischemic stroke, transient ischemic attack (TIA), or a peripheral thromboembolic event were randomly assigned to undergo closure of the patent foramen ovale with the Amplatzer PFO Occluder or to receive medical therapy. The primary end point was a composite of death, nonfatal stroke, TIA, or peripheral embolism. Analysis was performed on data for the intention-to-treat population. RESULTS The mean duration of follow-up was 4.1 years in the closure group and 4.0 years in the medical-therapy group. The primary end point occurred in 7 of the 204 patients (3.4%) in the closure group and in 11 of the 210 patients (5.2%) in the medical-therapy group (hazard ratio for closure vs. medical therapy, 0.63; 95% confidence interval [CI], 0.24 to 1.62; P=0.34). Nonfatal stroke occurred in 1 patient (0.5%) in the closure group and 5 patients (2.4%) in the medical-therapy group (hazard ratio, 0.20; 95% CI, 0.02 to 1.72; P=0.14), and TIA occurred in 5 patients (2.5%) and 7 patients (3.3%), respectively (hazard ratio, 0.71; 95% CI, 0.23 to 2.24; P=0.56). CONCLUSIONS Closure of a patent foramen ovale for secondary prevention of cryptogenic embolism did not result in a significant reduction in the risk of recurrent embolic events or death as compared with medical therapy. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT00166257.).


title: Laparoscopic tension-free abdominal wall repair: impact of mesh size and of different fixation devices in a consecutive series of 120 patients.

text: PURPOSE To assess the impact of mesh size and fixation devices on short-term outcomes in a consecutive series of tension-free laparoscopic abdominal wall repairs. METHODS Data for 120 consecutive, unselected patients undergoing tension-free laparoscopic incisional (n=63) or umbilical (n=57) hernia repair were prospectively collected. A multivariate analysis was performed to evaluate variables influencing outcomes. RESULTS Persistent seromas were observed in 13 patients (10.83%) and 2 recurrences (1.98%) occurred. Mesh size >300 cm was associated with increased hospital stay [odds ratio (OR) 4.83; 95% confidence interval (CI), 1.5-15.53; P=0.008], increased postoperative day 1 (POD1) pain assessed with visual analog scale (OR 5.51; 95% CI, 1.76-17.2; P=0.003), and the presence of complications (OR 10.4; 95% CI, 1.85-58.96; P=0.007). Body mass index >30 resulted in increased hospital stay (OR 3.05; 95% CI, 1.23-7.57; P=0.01) and increased POD1 visual analog scale (OR 2.28; 95% CI, 1-5.18; P=0.04). CONCLUSIONS Mesh size and obesity were the main factors influencing postoperative outcomes.


title: Assessment of Postural Ergonomics and Surgical Performance in Laparoendoscopic Single-Site Surgery Using a Handheld Robotic Device.

text: PURPOSE New laparoscopic devices are being continuously developed to overcome some of the technical and ergonomic limitations of laparoendoscopic single-site (LESS) surgery. This study aims to assess the surgeon's surgical performance and ergonomics during the use of a handheld, robotic-driven, articulating laparoscopic instrument during LESS surgery. METHODS Seven right-handed experienced surgeons took part in this study. A set of basic suturing tasks and digestive and urological procedures in a porcine model were performed. Surgeons used both a conventional laparoscopic needle holder and a robotic device. The learning curve, execution time, and precision using the surgical needle were assessed. The surgeon's posture was analyzed using a motion tracking system and a data glove. RESULTS After the training period, execution time on the intracorporeal suturing was significantly shorter using the conventional needle holder. The precision was higher using the conventional instrument in the horizontal plane, but the number of attempts to position the needle was lower using the robotic device (1.625 ± 0.250 vs 1.188 ± 0.375 attempts). The extension of the elbow (134.681 ± 14.35° vs 120.631 ± 13.134°) and the flexion of the shoulder (26.122 ± 7.411° vs 18.475 ± 14.166°) were significantly lower using the robotic instrument. The wrist posture using the robotic device was ergonomically acceptable during both surgical procedures. CONCLUSIONS Results show a positive learning curve in ergonomics and surgical performance using the robotic instrument during LESS surgery. This instrument improves the surgeon's body posture and the needle positioning errors. The use of the robotic instrument is feasible and safe during LESS partial nephrectomy and sigmoidectomy procedures.


title: Study design and protocol for investigating social network patterns in rural and urban schools and households in a coastal setting in Kenya using wearable proximity sensors.

text: Background: Social contact patterns shape the transmission of respiratory infections spread via close interactions. There is a paucity of observational data from schools and households, particularly in developing countries. Portable wireless sensors can record unbiased proximity events between individuals facing each other, shedding light on pathways of infection transmission. Design and methods: The aim is to characterize face-to-face contact patterns that may shape the transmission of respiratory infections in schools and households in Kilifi, Kenya. Two schools, one each from a rural and urban area, will be purposively selected. From each school, 350 students will be randomly selected proportional to class size and gender to participate. Nine index students from each school will be randomly selected and followed-up to their households. All index household residents will be recruited into the study. A further 3-5 neighbouring households will also be recruited to give a maximum of 350 participants per household setting. The sample size per site is limited by the number of sensors available for data collection. Each participant will wear a wireless proximity sensor lying on their chest area for 7 consecutive days. Data on proximal dyadic interactions will be collected automatically by the sensors only for participants who are face-to-face. Key characteristics of interest include the distribution of degree and the frequency and duration of contacts and their variation in rural and urban areas. These will be stratified by age, gender, role, and day of the week. Expected results: Resultant data will inform on social contact patterns in rural and urban areas of a previously unstudied population. Ensuing data will be used to parameterize mathematical simulation models of transmission of a range of respiratory viruses, including respiratory syncytial virus, and used to explore the impact of intervention measures such as vaccination and social distancing.


title: Public Health Response to the Initiation and Spread of Pandemic COVID-19 in the United States, February 24-April 21, 2020.

text: From January 21 through February 23, 2020, a total of 14 cases of coronavirus disease 2019 (COVID-19) were diagnosed in six U.S. states, including 12 cases in travelers arriving from China and two in household contacts of persons with confirmed infections. An additional 39 cases were identified in persons repatriated from affected areas outside the United States (1). Starting in late February, reports of cases with no recent travel to affected areas or links to known cases signaled the initiation of pandemic spread in the United States (2). By mid-March, transmission of SARS-CoV-2, the virus that causes COVID-19, had accelerated, with rapidly increasing case counts indicating established transmission in the United States. Ongoing traveler importation of SARS-CoV-2, attendance at professional and social events, introduction into facilities or settings prone to amplification, and challenges in virus detection all contributed to rapid acceleration of transmission during March. Public health responses included intensive efforts to detect cases and trace contacts, and implementation of multiple community mitigation strategies. Because most of the population remains susceptible to infection, recognition of factors associated with amplified spread during the early acceleration period will help inform future decisions as locations in the United States scale back some components of mitigation and strengthen systems to detect a potential transmission resurgence. U.S. circulation of SARS-CoV-2 continues, and sustained efforts will be needed to prevent future spread within the United States.


title: Correspondence: Laparoscopic repair of abdominal wall hernia--"How I do it"--synopsis of a seemingly straightforward technique.

text: Abdominal wall hernia repairs are commonly performed worldwide in general surgery. There is still no agreed consensus on the optimal surgical approach. Since the turn of the twenty-first century, minimally invasive techniques have gained in popularity as they combine the advantages of limited abdominal wall dissection, reduced post-operative pain and risk of complications, and shorter hospital stay. Although the added cost incurred by using sophisticated laparoscopic instruments may be quite substantial, it is precisely counterbalanced by an improved morbidity rate, faster discharge home and time to return to work. Laparoscopic abdominal wall hernia repair is often challenging, as it requires good anatomical knowledge, eye-hand coordination and diversified laparoscopic skills. The objective of this article is not to present another set of personal data and to compare it with already published results on this matter, but simply to offer comprehensive guidelines on the practical aspects of this relatively new technique. Some of these steps have already been discussed but most of the time in a scattered way in the surgical literature, while others are the fruit of a personal expertise grasped over the years.


COVID-19: How Do We Stay Safe?


docid: wwwlzknl

title: Hereditary Haemorrhagic Telangiectasia: a disease not to be forgotten during the COVID-19 pandemic.

text: From November 2019 to date, almost six thousand papers have been published on COVID-19, the disease caused by SARS-CoV-2 infection. As physicians working in a multidisciplinary centre for the cure of Hereditary Haemorrhagic Telangiectasia (HHT) in a country (Italy) that has been severely affected by COVID-19, we are surprised that, among this impressive amount of publications, there is none on HHT. Indeed, we performed our last PubMed search on 22 April 2020, using the keywords "Hereditary Haemorrhagic Telangiectasia" OR "Hereditary Hemorrhagic Telangiectasia" OR "HHT" OR "Rendu-Osler-Weber" AND "COVID-19" OR "coronavirus", and found no papers. This is surprising, because, although HHT is a rare disease, there are many reasons why we believe that it deserves special attention during the COVID-19 pandemic.


Palivizumab Prophylaxis for Healthy Preterm Infants: More Data Supporting American Academy of Pediatrics Guidelines.


title: Quantification of Improvements in Static and Dynamic Ventilatory Measures Following Lung Volume Reduction Surgery for Severe COPD.

text: Rationale: This study quantitatively measured the effects of lung volume reduction surgery (LVRS) on spirometry, static and dynamic lung and chest wall volume subdivision mechanics, and cardiopulmonary exercise measures. Methods: Patients with severe COPD (mean FEV1 = 23 ± 6% predicted) undergoing LVRS evaluation were recruited. Spirometry, plethysmography and exercise capacity were obtained within 6 months pre-LVRS and again within 12 months post- LVRS. Ventilatory mechanics were quantified using stationary optoelectronic plethysmography (OEP) during spontaneous tidal breathing and during maximum voluntary ventilation (MVV). Statistical significance was set at P< 0.05. Results:Ten consecutive patients met criteria for LVRS (5 females, 5 males, age: 62±6yrs). Post -LVRS (mean follow up 7 months ± 2 months), the group showed significant improvements in dyspnea scores (pre 4±1 versus post 2 ± 2), peak exercise workload (pre 37± 21 watts versus post 50 ± 27watts ), heart rate (pre 109±19 beats per minutes [bpm] versus post 118±19 bpm), duty cycle (pre 30.8 ± 3.8% versus post 38.0 ± 5.7%), and spirometric measurements (forced expiratory volume in 1 second [FEV1] pre 23 ± 6% versus post 32 ± 13%, total lung capacity / residual lung volume pre 50 ± 8 versus 50 ± 11) . Six to 12 month changes in OEP measurements were observed in an increased percent contribution of the abdomen compartment during tidal breathing (41.2±6.2% versus 44.3±8.9%, P=0.03) and in percent contribution of the pulmonary ribcage compartment during MVV (34.5±10.3 versus 44.9±11.1%, P=0.02). Significant improvements in dynamic hyperinflation during MVV occurred, demonstrated by decreases rather than increases in end expiratory volume (EEV) in the pulmonary ribcage (pre 207.0 ± 288.2 ml versus post -85.0 ± 255.9 ml) and abdominal ribcage compartments (pre 229.1 ± 182.4 ml versus post -17.0 ± 136.2 ml) during the maneuver. Conclusions: Post-LVRS, patients with severe COPD demonstrate significant favorable changes in ventilatory mechanics, during tidal and maximal voluntary breathing. Future work is necessary to determine if these findings are clinically relevant, and extend to other environments such as exercise.


title: Surface microbes in the neonatal intensive care unit: changes with routine cleaning and over time.

text: Premature infants in neonatal intensive care units (NICUs) are highly susceptible to infection due to the immaturity of their immune systems, and nosocomial infections are a significant risk factor for death and poor neurodevelopmental outcome in this population. To investigate the impact of cleaning within a NICU, a high-throughput short-amplicon-sequencing approach was used to profile bacterial and fungal surface communities before and after cleaning. Intensive cleaning of surfaces in contact with neonates decreased the total bacterial load and the percentage of Streptococcus species with similar trends for total fungal load and Staphylococcus species; this may have clinical relevance since staphylococci and streptococci are the most common causes of nosocomial NICU infections. Surfaces generally had low levels of other taxa containing species that commonly cause nosocomial infections (e.g., Enterobacteriaceae) that were not significantly altered with cleaning. Several opportunistic yeasts were detected in the NICU environment, demonstrating that these NICU surfaces represent a potential vector for spreading fungal pathogens. These results underline the importance of routine cleaning as a means of managing the microbial ecosystem of NICUs and of future opportunities to minimize exposures of vulnerable neonates to potential pathogens and to use amplicon-sequencing tools for microbial surveillance and hygienic testing in hospital environments.


title: Five-year experience with modified Fogli (Loré's fascia fixation) platysmaplasty.

text: Over a 5-year period, my technique of approaching and modifying the aging neck has changed from direct suturing of the medial platysma bands and strong posterior traction of the platysma to superior elevation of the posterior platysma and strong fixation to the tympanoparotid fascia. When indicated, redundant anterior platysmal bands are resected instead of approximated. Evaluation of these anterior bands preoperatively for thickness and degree of descent allows more precise decision-making regarding the need to resect redundant and excessively thick or long anterior platysmal bands. The added advantage of the strong fixation of the platysma in a vertical fashion to Loré's fascia (the tympanoparotid fascia) leads not only to an improvement in the contour of the jawline and submental area but also to the undervalued aesthetic feature of a defined contour and visually increased length of the sternomastoid muscle.


title: Zbtb7a induction in alveolar macrophages is implicated in anti-HLA-mediated lung allograft rejection.

text: Chronic rejection significantly limits long-term success of solid organ transplantation. De novo donor-specific antibodies (DSAs) to mismatched donor human leukocyte antigen after human lung transplantation predispose lung grafts to chronic rejection. We sought to delineate mediators and mechanisms of DSA pathogenesis and to define early inflammatory events that trigger chronic rejection in lung transplant recipients and obliterative airway disease, a correlate of human chronic rejection, in mouse. Induction of transcription factor zinc finger and BTB domain containing protein 7a (Zbtb7a) was an early response critical in the DSA-induced chronic rejection. A cohort of human lung transplant recipients who developed DSA and chronic rejection demonstrated greater Zbtb7a expression long before clinical diagnosis of chronic rejection compared to nonrejecting lung transplant recipients with stable pulmonary function. Expression of DSA-induced Zbtb7a was restricted to alveolar macrophages (AMs), and selective disruption of Zbtb7a in AMs resulted in less bronchiolar occlusion, low immune responses to lung-restricted self-antigens, and high protection from chronic rejection in mice. Additionally, in an allogeneic cell transfer protocol, antigen presentation by AMs was Zbtb7a-dependent where AMs deficient in Zbtb7a failed to induce antibody and T cell responses. Collectively, we demonstrate that AMs play an essential role in antibody-induced pathogenesis of chronic rejection by regulating early inflammation and lung-restricted humoral and cellular autoimmunity.


University professor Géza Illyés, the first chairman of the 1st urology department in Hungary was born 150 years ago


Ventilator-induced lung injury.


title: Severe adenovirus community-acquired pneumonia in immunocompetent adults: chest radiographic and CT findings.

text: BACKGROUND Severe adenovirus pneumonia and its associated imaging features are well-described in immunocompromised patients but are rare and poorly understood in immunocompetent adults. We sought to describe the radiographic and CT findings of severe adenovirus community-acquired pneumonia (CAP) in eight immunocompetent adults. METHODS We reviewed systematically chest imaging manifestations of laboratory-confirmed severe adenovirus pneumonia in eight immunocompetent adults from April 2012 to April 2014. RESULTS All patients showed abnormal results on initial chest radiograph and CT, with the exception of one normal initial chest radiograph. The abnormalities of the initial chest radiographs were unilateral (n=4) or bilateral (n=3), including consolidation (n=4), dense patchy opacity (n=3), ground glass opacity (GGO) (n=1), and pleural effusion (n=1). The initial CT findings consisted of unilateral (n=5) and bilateral (n=3) abnormalities, including consolidation (n=8), GGO (n=2), pleural effusion (n=3) and small nodules (n=1). Focal consolidation was the predominant finding in six patients whose initial CT scans were examined within one week after illness onset. Follow-up radiologic findings showed rapid development of bilateral consolidation within ten days after illness onset, usually accompanied by adjacent ground-glass opacity and pleural effusion. The parenchymal abnormalities began to absorb around two weeks after illness onset, with no appearances of fibrosis. CONCLUSIONS Severe adenovirus CAP in immunocompetent adults mainly appears as focal consolidation followed by rapid progression to bilateral consolidation, usually accompanied by adjacent GGO and pleural effusion, which may resemble bacterial pneumonia. Adenovirus should be considered in severe pneumonia cases with negative cultures and failure to respond to antibiotics.


title: Evaluation of unmet clinical needs in prophylaxis and treatment of venous thromboembolism in high-risk patient groups: cancer and critically ill.

text: Background Clinical practice shows that venous thromboembolism (VTE) presents a substantial burden in medical patients, and awareness and advocacy for its primary and secondary prevention remains inadequate. Specific patient populations, such as those with cancer and the critically ill, show elevated risk for VTE, bleeding or both, and significant gaps in VTE prophylaxis and treatment exist in these groups. Objective To present novel insights and consolidated evidence collected from experts, clinical practice guidelines and original studies on the unmet needs in thromboprophylaxis, and on the treatment of VTE in two high-risk patient groups: patients with cancer and the critically ill. Methodology To identify specific unmet needs in the management of VTE, a methodology was designed and implemented that assessed gaps in prophylaxis and treatment of VTE through interviews with 44 experts in the field of thrombosis and haemostasis, and through a review of current guidelines and seminal studies to substantiate the insights provided by the experts. The research findings were then analysed, discussed and consolidated by a multidisciplinary group of experts. Results The gap analysis methodology identified shortcomings in the VTE risk assessment tools, patient stratification approaches for prophylaxis, and the suboptimal use of anticoagulants for primary prophylaxis and treatment. Conclusions Specifically, patients with cancer need better VTE risk assessment tools to tailor primary thromboprophylaxis to tumour types and disease stages, and the potential for drug-drug interactions needs to be considered. In critically ill patients, unfractionated heparin is not advised as a first-line treatment option, and the strength of evidence is increasing for direct oral anticoagulants as a treatment option over low-molecular-weight heparins.


title: Laparoscopic versus open abdominoperineal rectoplasty for infants with high-type anorectal malformation.

text: BACKGROUND/PURPOSE There has not been any study comparing laparoscopic abdominoperineal rectoplasty (ARP) with open ARP. This study investigated the true benefits of the laparoscopic approach in infants with high anorectal malformation. PATIENTS AND METHODS A retrospective analysis was performed in 28 infants with high anorectal malformation treated between 1990 and 2007. Fifteen were treated by open ARP, and 13 were treated by laparoscopic ARP. Surgical durations, amount of bleeding, complications, anorectal pressure measurements, barium enema study, and clinical assessment were compared between the 2 groups. RESULTS The amount of intraoperative bleeding was significantly less in laparoscopic ARP (12 ± 11 g) than in open ARP (65 ± 44 g) (P = .003). Anal resting pressure was 34 ± 9 cm H(2)O after laparoscopic ARP and 31 ± 14 cm H(2)O after open ARP. Anorectal reflex was positive in 1 (7%) of 15 after open ARP and 3 (23%) of 13 after laparoscopic ARP. There was no significant difference in barium enema study and clinical assessment between the 2 groups. With regard to postoperative complications, mucosal prolapse occurred in 10 (67%) of 15 after open ARP and in none of 13 after laparoscopic ARP (P = .003). CONCLUSION Benefits of the laparoscopic approach were reduced intraoperative bleeding and a lower incidence of postoperative anal mucosal prolapse. These results indicate that minimal dissection of the mesorectum in laparoscopic ARP may provide those better outcomes.


title: Effectiveness and versatility of biological prosthesis in transplanted patients.

text: AIM To emphasize the effectiveness and versatility of prosthesis, and good tolerance by patients with incisional hernia (IH). METHODS From December 2001 to February 2016, 270 liver transplantations were performed at San Camillo Hospital. IH occurred in 78 patients (28.8%). IH usually appeared early within the first year post-orthotopic liver transplantation. In the first era, fascial defect was repaired by primary closure for defects smaller than 2.5 cm or with synthetic mesh for greater defects. Recently, we started using biological mesh (Permacol™, Covidien). We present a series of five transplanted patients submitted to surgery for abdominal wall defect correction repaired with biological mesh (Permacol™, Covidien). RESULTS In our cases, the use of biological prosthesis (Permacol™, Covidien) have proven to be effective and versatile in repairing hernia defects of different kinds; patients did not suffer infections of the prosthesis and no recurrence was observed. Furthermore, the prosthesis remains intact even in the years after surgery. CONCLUSION The cases that we presented show that the use of biological mesh (Permacol™, Covidien) in transplanted patients may be safe and effective, being careful in the management of perioperative immunosuppression and renal and graft function, although the cost of the product itself has been the main limiting factor and there is need for prospective studies for further evaluations.


title: CTA collateral status and response to recanalization in patients with acute ischemic stroke.

text: BACKGROUND AND PURPOSE Collateral status at baseline is an independent determinant of clinical outcome among patients with acute ischemic stroke. We sought to identify whether the association between recanalization after intra-arterial acute stroke therapy and favorable clinical response is modified by the presence of good collateral flow assessed on baseline CTA. MATERIALS AND METHODS Data are from the Keimyung Stroke Registry, a prospective cohort study of patients with acute ischemic stroke from Daegu, South Korea. Patients with M1 segment MCA with or without intracranial ICA occlusions on baseline CTA from May 2004 to July 2009 who also had baseline MR imaging were included. Two readers blinded to all clinical information assessed baseline and follow-up imaging. Leptomeningeal collaterals on baseline CTA were assessed by consensus by use of the regional leptomeningeal score. RESULTS Among 84 patients (mean age, 65.2 ± 13.2 years; median NIHSS score, 14; interquartile range, 8.5), median time from stroke onset to initial MR imaging was 164 minutes. TICI 2b-3 recanalization was achieved in 38.1% of patients and mRS 0-2 at 90 days in 35.8% of patients. In a multivariable model, the interaction between collateral status and recanalization was significant. Only patients with intermediate or good collaterals who recanalized showed a statistically significant association with good clinical outcome (rate ratio = 3.8; 95% CI, 1.2-12.1). Patients with good and intermediate collaterals who did not achieve recanalization and patients with poor collaterals, even if they achieved recanalization, did not do well. CONCLUSIONS Patients with good or intermediate collaterals on CTA benefit from intra-arterial therapy, whereas patients with poor collaterals do not benefit from treatment.


Preventing psychological injury during the covid-19 pandemic.


Intracoronary and noninvasive imaging for prediction of distal embolization and periprocedural myocardial infarction during native coronary artery percutaneous intervention.


docid: smvcbgeg

title: [A pathological report of three COVID-19 cases by minimally invasive autopsies].

text: Objective: To investigate the pathological characteristics and the clinical significance of novel coronavirus (2019-nCoV)-infected pneumonia (termed by WHO as corona virus disease 2019, COVID-19). Methods: Minimally invasive autopsies from lung, heart, kidney, spleen, bone marrow, liver, pancreas, stomach, intestine, thyroid and skin were performed on three patients died of novel coronavirus pneumonia in Chongqing, China. Hematoxylin and eosin staining (HE) and histochemical staining were performed to investigate the pathological changes of indicated organs or tissues. Immunohistochemical staining was conducted to evaluate the infiltration of immune cells as well as the expression of 2019-nCoV proteins. Real time PCR was carried out to detect the RNA of 2019-nCoV. Results: Various damages were observed in the alveolar structure, with minor serous exudation and fibrin exudation. Hyaline membrane formation was observed in some alveoli. The infiltrated immune cells in alveoli were majorly macrophages and monocytes. Moderate multinucleated giant cells, minimal lymphocytes, eosinophils and neutrophils were also observed. Most of infiltrated lymphocytes were CD4-positive T cells. Significant proliferation of type II alveolar epithelia and focal desquamation of alveolar epithelia were also indicated. The blood vessels of alveolar septum were congested, edematous and widened, with modest infiltration of monocytes and lymphocytes. Hyaline thrombi were found in a minority of microvessels. Focal hemorrhage in lung tissue, organization of exudates in some alveolar cavities, and pulmonary interstitial fibrosiswere observed. Part of the bronchial epithelia were exfoliated. Coronavirus particles in bronchial mucosal epithelia and type II alveolar epithelia were observed under electron microscope. Immunohistochemical staining showed that part of the alveolar epithelia and macrophages were positive for 2019-nCoV antigen. Real time PCR analyses identified positive signals for 2019-nCoV nucleic acid. Decreased numbers of lymphocyte, cell degeneration and necrosis were observed in spleen. Furthermore, degeneration and necrosis of parenchymal cells, formation of hyaline thrombus in small vessels, and pathological changes of chronic diseases were observed in other organs and tissues, while no evidence of coronavirus infection was observed in these organs. Conclusion: s The lungs from novel coronavirus pneumonia patients manifest significant pathological lesions, including the alveolar exudative inflammation and interstitial inflammation, alveolar epithelium proliferation and hyaline membrane formation. While the 2019-nCoV is mainly distributed in lung, the infection also involves in the damages of heart, vessels, liver, kidney and other organs. Further studies are warranted to investigate the mechanism underlying pathological changes of this disease.


title: Development of a novel rapid immunochromatographic test specific for the H5 influenza virus.

text: Three anti-H5 influenza virus monoclonal antibody (mAb) clones, IFH5-26, IFH5-115 and IFH5-136, were obtained by immunising a BALB/C mouse with inactivated A/duck/Hokkaido/Vac-1/04 (H5N1). These mAbs were found to recognise specifically the haemagglutinin (HA) epitope of the influenza H5 subtypes by western blotting with recombinant HAs; however, these mAbs have no neutralising activity for A/duck/Hokkaido/84/02 (H5N3) or A/Puerto Ric/8/34 (H1N1). Each epitope of these mAbs was a conformational epitope that was formed from the regions located between 46 to 60 amino acids (aa) and 312 to 322 aa for IFH5-115, from 101 to 113 aa and 268 to 273 aa for IFH5-136 and from 61 to 80 aa and 290 to 300 aa for IFH5-26. The epitopes were located in the loop regions between the receptor region and alpha-helix structure in haemagglutinin 1 (HA1). Influenza A virus H5-specific rapid immunochromatographic test kits were tested as solid phase antibody/alkaline phosphate-conjugated mAb in the following three combinations: IFH5-26/IFH5-115, IFH5-136/IFH5-26 and IFH5-136/IFH5-115. In every combination, only influenza A H5 subtypes were detected. For effective clinical application, rapid dual discrimination immunochromatographic test kits in combination with H5 HA-specific mAb, IFA5-26 and IFA5-115 and the influenza A NP NP-specific mAb, FVA2-11, were developed. The dual discrimination immunochromatographic tests kits detected influenza A virus H5 subtypes as H5 line-positive and all influenza A subtypes as A line-positive simultaneously. The dual discrimination immunochromatographic test kits may be useful for discriminating highly pathogenic avian influenza A H5N1 viruses from seasonal influenza A virus, as well as for confirming influenza infection status in human, avian and mammalian hosts.


title: 2020 AAFP Feline Retrovirus Testing and Management Guidelines.

text: CLINICAL IMPORTANCE Feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV) infections are found in cats worldwide. Both infections are associated with a variety of clinical signs and can impact quality of life and longevity. SCOPE This document is an update of the 2008 American Association of Feline Practitioners' feline retrovirus management guidelines and represents current knowledge on pathogenesis, diagnosis, prevention and treatment of retrovirus infections in cats. TESTING AND INTERPRETATION Although vaccines are available for FeLV in many countries and for FIV in some countries, identification of infected cats remains an important factor for preventing new infections. The retrovirus status of every cat at risk of infection should be known. Cats should be tested as soon as possible after they are acquired, following exposure to an infected cat or a cat of unknown infection status, prior to vaccination against FeLV or FIV, and whenever clinical illness occurs. It might not be possible to determine a cat's infection status based on testing at a single point in time; repeat testing using different methods could be required. Although FeLV and FIV infections can be associated with clinical disease, some infected cats, especially those infected with FIV, can live for many years with good quality of life. MANAGEMENT OF INFECTED CATS There is a paucity of data evaluating treatments for infected cats, especially antiretroviral and immunomodulatory drugs. Management of infected cats is focused on effective preventive healthcare strategies, and prompt identification and treatment of illness, as well as limiting the spread of infection.


title: Primary obesity surgery endoluminal.

text: INTRODUCTION Primary obesity surgery, endoluminal (POSE) is a promising procedure for weight loss surgery because it is outpatient, is incisionless and has short recovery time. We demonstrate the POSE procedure as a potential option for the bariatric patient. MATERIALS AND METHODS Using an endoluminal camera, we videotaped one of our surgeons performing the POSE procedure. With rows of sutures in the fundus and antrum, the stomach's volume is reduced. RESULTS We demonstrate a successful POSE procedure in its entirety. CONCLUSIONS The POSE procedure is a promising option for the bariatric patient. Long-term studies are needed to show its efficacy.


Pneumonia in the elderly: whose friend is it anyway?


Letter by Pilz et al Regarding Article, "Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Elevation Myocardial Infarction Care in Hong Kong, China".