title: Steroids in cardiac surgery: a systematic review and meta-analysis.

text: BACKGROUND Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction that may contribute to postoperative complications. Preventing this reaction with steroids may improve outcomes. We performed a systematic review to evaluate the impact of prophylactic steroids on clinical outcomes in patients undergoing on-pump cardiac surgery. METHODS We searched MEDLINE, EMBASE, and Cochrane CENTRAL for randomised controlled trials (RCTs) comparing perioperative corticosteroid administration with a control group in adults undergoing CPB. Outcomes of interest included mortality, myocardial infarction, and new onset atrial fibrillation. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Fifty-six RCTs published between 1977 and 2015 were included in this meta-analysis. Mortality was not significantly different between groups [3.0% (215/7258 patients) in the steroid group and 3.5% (252/7202 patients) in the placebo group; relative risk (RR), 0.85; 95% confidence interval (CI), 0.71-1.01; P=0.07; I2 = 0%]. Myocardial injury was more frequent in the steroid group [8.0% (560/6989 patients), compared with 6.9% (476/6929 patients); RR, 1.17, 95% CI, 1.04-1.31; P=0.008; I2=0%]. New onset atrial fibrillation was lower in the steroid group [25.7% (1792/6984 patients) compared with 28.3% (1969/6964 patients), RR, 0.91, 95% CI, 0.86-0.96, P=0.0005, I2=43%]; this beneficial effect was limited to small trials (P for interaction <0.00001). CONCLUSIONS After randomising 16 013 patients, steroid administration at the time of cardiac surgery had an unclear impact on mortality, increased the risk of myocardial injury, and the impact on atrial fibrillation should be viewed with caution given that large trials showed no effect.


title: The Muffling of Healthcare: Assessing the Impact of Personal Protective Equipment on Speaking Volume in an Endoscopy Centre.

text: Personal protective equipment (PPE) is crucial in the COVID-19 epidemic[1] but muffle speech, with potential for medical error. While wearing Powered Air-Purifying Respirator (PAPR) adds 76 Db of background noise to the user[2], objectively quantifying this effect remains a knowledge gap with implications on human factors[3] and safety.


title: Shortening of the twitch stabilization period by tetanic stimulation in acceleromyography in infants, children and young adults (STSTS-Study): a prospective randomised, controlled trial.

text: Acceleromyography is characterised by an increase of the twitch response T1 (first twitch of the train-of-four [TOF]) during first 30 min of monitoring known as the staircase phenomenon. In adults the staircase phenomenon can be avoided by tetanic prestimulation. This study examined, if tetanic prestimulation eliminates the staircase phenomenon in children. After written informed consent, the neuromuscular function of 80 children, 10 in each age group (< 6 months, 6-12 months, 12-24 months, 2-3 years, 3-6 years, 6-12 years, 12-18 years, and ≥ 18 years) was measured on both arms simultaneously over 30 min under general anaesthesia. The ulnaris nerve was stimulated using the TOF technique every 15 s. The twitch response (T1, TOF ratio [TOFR]) was measured by acceleromyography. Before calibration, tetanic prestimmulation (50 Hz for 5 s) was administered to one randomly selected arm. The effect of tetanic prestimulation and age was analysed using general linear models based on the normalized T1 and TOFRs of both arms. Tetanic prestimulation significantly affected T1 values avoiding the staircase phenomenon (p < 0.0001). After 5.8 min [1.0-17.2 min] the normalized T1 values increased to 117% [102-147%] without prestimulation (p < 0.0001) independent of the age group (p = 0.539). The normalized TOFR was stable throughout the observation period of 30 min 100% [95-107%]. Infants (> 12 weeks), children, and young adults (< 18 years) develop similar characteristics of the staircase phenomenon than adults. Tetanic prestimulation prevents the staircase phenomenon in these age groups. The stability of the TOFR reading confirms its value to monitor neuromuscular function over time.Registration: The study was registered as NCT02552875 on Clinical Trials.gov on July 29, 2014.


title: Physicomechanical evaluation of polypropylene, polyester, and polytetrafluoroethylene meshes for inguinal hernia repair.

text: BACKGROUND For meshes to be used effectively for hernia repair, it is imperative that engineers and surgeons standardize the terminology and techniques related to physicomechanical evaluation of these materials. The objectives of this study were to propose standard techniques, perform physicomechanical testing, and classify materials commonly used for inguinal hernia repair. STUDY DESIGN Nine meshes were evaluated: 4 polypropylene, 1 polyester, 1 polytetrafluoroethylene, and 3 partially absorbable. Physical properties were determined through image analysis, laser micrometry, and density measurements. Biomechanical properties were determined through suture retention, tear resistance, uniaxial, and ball burst testing with specimens tested in 2 different orientations. A 1-way ANOVA with Tukey's post-test or a t-test were performed, with p < 0.05. RESULTS Significant differences were observed due to both mesh type and orientation. Areas of interstices ranged from 0.33 ± 0.01 mm² for ProLite (Atrium Medical Corp) and C-QUR Lite (Atrium Medical Corp) Large to 4.10 ± 0.06 mm² for ULTRAPRO (Ethicon), and filament diameters ranged from 99.00 ±8.1 μm for ProLite Ultra (Atrium Medical Corp) and C-QUR Lite Small to 338.8 ± 3.7 μm for Parietex Flat Sheet TEC (Covidien). These structural characteristics influenced biomechanical properties such as tear resistance and tensile strength. ProLite Ultra, C-QUR Lite Small, ULTRAPRO and INFINIT (WL Gore & Associates) did not resist tearing as effectively as the others. All meshes exhibited supraphysiologic burst strengths except INFINIT and ULTRAPRO. CONCLUSIONS Significant differences exist between the physicomechanical properties of polypropylene, polyester, polytetrafluoroethylene, and partially absorbable mesh prostheses commonly used for inguinal hernia repair. Orientation of the mesh was also shown to be critical for the success of meshes, particularly those demonstrating anisotropy.


title: Laparoscopic surgical box model training for surgical trainees with limited prior laparoscopic experience.

text: BACKGROUND Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown. OBJECTIVES To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013. SELECTION CRITERIA We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training. DATA COLLECTION AND ANALYSIS Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible. MAIN RESULTS We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).None of the trials compared box model training versus animal model training or versus different methods of box model training. AUTHORS' CONCLUSIONS There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.


title: Functional connectivity patterns of medial and lateral macaque frontal eye fields reveal distinct visuomotor networks.

text: It has been previously shown that small- and large-amplitude saccades have different functions during vision in natural environments. Large saccades are associated with reaching movements toward objects, whereas small saccades facilitate the identification of more detailed object features necessary for successful grasping and manual manipulation. To determine whether these represent dichotomous processing streams, we used resting-state functional MRI to examine the functional connectivity patterns of the medial and lateral frontal eye field (FEF) regions that encode large- and small-amplitude saccades, respectively. We found that the spontaneous blood oxygen level-dependent signals of the medial FEF were functionally correlated with areas known to be involved in reaching movements and executive control processes, whereas lateral FEF was functionally correlated with cortical areas involved in object processing and in grasping, fixation, and manipulation of objects. The results provide strong evidence for two distinct visuomotor network systems in the primate brain that likely reflect the alternating phases of vision for action in natural environments.


title: Genioglossus activity available via non-arousal mechanisms vs. that required for opening the airway in obstructive apnea patients.

text: It is generally believed that reflex recruitment of pharyngeal dilator muscles is insufficient to open the airway of obstructive apnea (OSA) patients once it is closed and, therefore, that arousal is required. Yet arousal promotes recurrence of obstruction. There is no information about how much dilator [genioglossus (GG)] activation is required to open the airway (GG Opening Threshold) or about the capacity of reflex mechanisms to increase dilator activity before/without arousal (Non-Arousal Activation). The relationship between these two variables is important for ventilatory stability. We measured both variables in 32 OSA patients (apnea-hypopnea index 74 ± 42 events/h). GG activity was monitored while patients were on optimal continuous positive airway pressure (CPAP). Zopiclone was administered to delay arousal. Maximum GG activity (GG(MAX)) and airway closing pressure (P(CRIT)) were measured. During stable sleep CPAP was decreased to 1 cmH(2)O to induce obstructive events and the dial-downs were maintained until the airway opened with or without arousal. GG activity at the instant of opening (GG Opening Threshold) was measured. GG Opening Threshold averaged only 10.4 ± 9.5% GG(Max) and did not correlate with P(CRIT) (r = 0.04). Twenty-six patients had >3 openings without arousal, indicating that Non-Arousal Activation can exceed GG Opening Threshold in the majority of patients. GG activity reached before arousal in Arousal-Associated Openings was only 5.4 ± 4.6% GG(MAX) below GG Opening Threshold. We conclude that in most patients GG activity required to open the airway is modest and can be reached by non-arousal mechanisms. Arousals occur in most cases just before non-arousal mechanisms manage to increase activity above GG Opening Threshold. Measures to reduce GG Opening Threshold even slightly may help stabilize breathing in many patients.


Vulnerability of people with schizophrenia to COVID-19.


title: Usefulness of Hydrogel-Coated Coils in Embolization of Pulmonary Arteriovenous Malformations.

text: PURPOSE To evaluate the usefulness of hydrogel-coated coils for preventing recanalization after coil embolization of pulmonary arteriovenous malformations (PAVMs). MATERIALS AND METHODS Thirty-seven consecutive patients with 57 untreated PAVMs underwent coil embolization with hydrogel-coated coils between January 2013 and Jun 2017. The mean age was 49 years (range 9-83 years), and there were seven male patients and 30 female patients. The median size of the feeding artery was 3.7 mm (range 1.5-6.1 mm), and the median size of the venous sac was 9.3 mm (range 2.6-36.6 mm). For all PAVM, embolization was attempted using 0.018-in. hydrogel-coated coils with or without other coils (0.0135-0.018-in. bare platinum coils and fibered platinum coils). Technical success rate, recanalization rate, and complications were evaluated. Technical success was defined as completion of embolization using hydrogel-coated coils. Recanalization was evaluated with time-resolved magnetic resonance angiography and/or pulmonary angiography. RESULTS In 56 of 57 PAVMs, embolization was successfully performed with hydrogel-coated coils. Therefore, the technical success rate was 98% (56/57). The number of PAVMs at risk was 56, 42, 18, and 12 at 0, 12, 24, and 36 months, respectively. There was no recanalization with a mean follow-up period of 19 months (range 2-47 months) in 56 PAVMs embolized with hydrogel-coated coils. There were no major complications. As a minor complication, local pain was observed in 8 of 43 sessions (19%) after embolization. CONCLUSIONS Hydrogel-coated coils may be useful for preventing recanalization after the embolization of PAVMs.


title: Clinical Outcomes of Esophagojejunostomy in Totally Laparoscopic Total Gastrectomy: A Multicenter Study.

text: PURPOSE To examine the short-term outcomes of intracorporeal anastomosis during totally laparoscopic total gastrectomy retrospectively at multiple institutions. PATIENTS AND METHODS We collected data of the patients who had undergone totally laparoscopic total gastrectomy at 4 institutions. All patients received an intracorporeal esophagojejunostomy. RESULTS Of the 215 patients evaluated, 147 underwent functional end-to-end anastomosis (FEEA) as the intracorporeal esophagojejunostomy (FEEA group), and 68 patients received a circular stapler anastomosis (Circular group). The rate of tumor invasion to the esophagus was significantly higher in the Circular group than in the FEEA group (33% vs. 6%, respectively; P<0.0001). Univariate and multivariate analyses revealed that the circular stapler anastomosis and high preoperative BMI were statistically significant risk factors for postoperative leakage. However, the rates of complications and mortality were not significantly different between groups. CONSIDERATION Our results showed that each type of esophagojejunostomy is safe and feasible for patients with gastric cancer with acceptable morbidity and mortality.


title: Computed Tomography Angiography in the Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) Study.

text: BACKGROUND The Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) study validated noninvasive imaging tests of intracranial atherosclerosis against catheter angiography in a prospective, blinded, multicenter setting. Critical evaluation of transcranial Doppler (TCD) and magnetic resonance angiography in the SONIA study standardized their performance and interpretation. We performed a similar analysis of computed tomography angiography (CTA) for the detection of intracranial stenosis. METHODS Multicenter standardization of image acquisition and blinded, central interpretation of CTA performance were conducted in concert with the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial. Measurements of the intracranial arterial diameter were obtained to derive stenosis values. Correlation with catheter angiography was used to assess CTA performance characteristics. RESULTS CTA measurements of intracranial stenosis were obtained in 120 vessel segments, with angiographic correlation in 52. CTA was performed as a noninvasive study prior to conventional angiography. CTA stenoses of 50-99% or a flow gap were identified in 15 of 52 vessel segments, stenoses of <50% in 5 of 52, and normal arterial diameters in 32 of 52 vessel segments. Based on the digital subtraction angiography (DSA) stenosis defined as 50-99%, the positive predictive value (PPV) of CTA was only 46.7% (95% CI 21.3-73.4) and the negative predictive value (NPV) was 73.0% (95% CI 55.9-86.2). For DSA stenosis defined as 70-99%, the PPV of CTA was 13.3% (95% CI 1.7-40.5) and the NPV was 83.8% (95% CI 68.0-93.8). CONCLUSIONS CTA can accurately rule out the presence of severe stenosis due to intracranial atherosclerosis and may eliminate the need for angiography in many cases. Further prospective, blinded evaluation of CTA and optimization of cutpoints to predict angiographic disease will facilitate future trials of intracranial atherosclerosis.


docid: vpaxhalf

title: Should Intermittent Mandatory Ventilation Be Abolished?

text: Intermittent mandatory ventilation (IMV) was introduced nearly 50 years ago. Despite the initial fanfare and early adoption by many, the role of IMV continues to be questioned. The use of small tidal volumes complicates the application of IMV, and issues with work of breathing, weaning and lack of clear advantages have many calling for a moratorium on its use. Spontaneous breathing, however, has a number of salutatory effects on gas exchange, the distribution of ventilation, and hemodynamics. These issues will be explored in light of a growing body of evidence.


title: The partial myocutaneous gluteal flap reconstruction of extralevator abdominoperineal defects in irradiated patients.

text: Reconstruction of the irradiated perineum has posed a consistent reconstructive challenge historically. The evolution of reconstructive techniques must mirror advances in neoadjuvant treatment and surgery for low rectal cancer. The purpose of this study was to evaluate the perineal healing in a cohort of patients, of whom a majority had laparoscopic tumor excision and partial myocutaneous gluteal flap reconstruction. There were 11 patients in this cohort; 8 primary reconstructions and 3 salvage cases. Complete healing was measured as the cessation of all dressings. There were no returns to theater for flap-related surgery. Mean postreconstruction inpatient stay was 16.5 days. All patients healed completely. Mean time to healing was 42 days. This method has been successful for primary and salvage reconstruction in patients having laparoscopic or open surgery; thus, averting the major morbidity associated with failed reconstruction as reported for most of other reconstructive modalities in these patients.


title: Thrombus formation in the pulmonary vein stump after left upper lobectomy: a report of four cases.

text: Left upper lobectomy may be followed by complications such as thrombus formation in a stump of the left superior pulmonary vein (LSPV), which may cause systemic embolization. We have encountered four such cases, which account for 3.4% of all left upper lobectomies performed at our institution. Right renal infarction was observed in one of these four cases; the remaining cases were asymptomatic, with the thrombus incidentally detected by enhanced computed tomography (CT). The postoperative duration for the detection of the thrombus varied from 4 days to 24 months. Even in a case in which the superior pulmonary vein (PV) was divided by posterolateral thoracotomy, CT showed that the stump was long enough intrapericardially for thrombus formation. Anticoagulant therapy was administered in all the cases, resulting in dissipation of the thrombus. Therefore, when a thrombus is detected in a pulmonary stump, an anticoagulant should be administered.


title: Photodynamic therapeutic ablation for peripheral pulmonary malignancy via electromagnetic navigation bronchoscopy localization in a hybrid operating room (OR): a pioneering study.

text: Background With the aid of electromagnetic navigation bronchoscopy (ENB), it has become possible to approach peripheral lung tumors from the airway. Meanwhile, local ablation using photodynamic therapy (PDT) has shown increasing promise in the realm of lung cancer treatment. The purpose of this study was to explore an alternative ablation method using PDT with SuperDimension ENB localization in a hybrid operating theater. Methods Our study includes patients with primary or metastatic lung cancer who underwent PDT via ENB in the hybrid operating room (OR) of National Taiwan University Hospital between January 2016 and January 2017. ENB with the SuperDimension Navigation System (7th edition) was performed before PDT ablation to localize the target lesions. PDT ablation was performed with the assistance of intraoperative Dyna-computed tomography (Dyna-CT). Tumor response was evaluated by CT 3 months after the procedure. Results Three patients underwent lung interstitial PDT via the aid of ENB during the study period. The mean size of the nodules was 21.3 mm. The mean navigation time was 14.3 minutes. In all cases, the target pulmonary nodule was ablated by PDT successfully. No major procedure-related complications occurred. One patient suffered from skin hypersensitivity one month after the procedure. The follow-up CT showed significant tumor shrinkage for all the patients. They were all discharged without incident a few days after the procedure as scheduled. Conclusions PDT with SuperDimension ENB guidance in the hybrid OR is a novel and feasible approach to control peripheral lung malignancy.


title: Real-world management of hyperkalemia with patiromer among United States Veterans.

text: Objective: Patiromer is a sodium-free, non-absorbed, potassium (K+) binder approved for the treatment of hyperkalemia (HK). Among US Veterans with HK, this retrospective, observational cohort study evaluated patiromer utilization, RAASi continuation, and K+ concentration change following patiromer initiation.Methods: Using data from the Veterans Affairs Corporate Data Warehouse, Veterans with HK (K+ ≥5.1 mmol/L) were included upon patiromer initiation (index date) during the study period (1/2016-8/2018). All patients had heart failure (HF), diabetes, or chronic kidney disease (CKD). Patients with end-stage renal disease were excluded. The following outcomes were assessed within 6-months post-patiromer initiation: patiromer utilization (using proportion of days covered); K+ concentration change (pre- vs post-initiation); and RAASi continuation.Results: 288 Veterans with HK were included. Baseline characteristics were: median age 70 years, African-American race 24%, diabetes 83%, HF 32%, CKD 95%, and median K+ concentration 5.7 mmol/L. At 1, 3, and 6 months post-index, the median patiromer PDC was 100%, 66%, and 44%, respectively. K+ concentration reductions post-patiromer initiation were, on average, - 1.0 mmol/L (P < 0.001). At 3-6 months, 71% of patiromer initiators had K+ <5.1 mmol/L and 95% had K+ <5.5 mmol/L. RAASi therapy was continued in >80%-90% of patiromer-treated patients.Conclusions: The real-world utilization results suggest patiromer is used for the chronic management of HK. Clinically relevant K+ concentration reductions were observed at all study time points. The successful management of HK may have contributed to the observed high rate of RAASi therapy continuation. Further research is warranted to corroborate and extend these findings.


title: CD59 association with infectious bronchitis virus particles protects against antibody-dependent complement-mediated lysis.

text: CD59 protein functions as a negative regulator of the terminal pathway of the complement system by binding to the C8/C9 factors. To date, little is known about the role of CD59 in coronavirus infectious bronchitis virus (IBV) infection. In this study, we discovered that CD59 was downregulated in IBV-infected cells and was associated with IBV virions. This association protected IBV particles from antibody-dependent complement-mediated lysis. IBV titres in the supernatant were significantly increased when CD59 proteins were overexpressed in cells followed by IBV infection, and this observation was further supported by knockdown or cleavage of CD59. Because no considerable change in IBV N protein and viral RNA levels was detected in total cell lysates prepared from the overexpression, knockdown or cleavage of CD59 groups, our data indicated that CD59 was involved in IBV particle release and that IBV had evolved a mechanism to utilize CD59 to evade complement-mediated destruction.


title: Relationship of A1 segment hypoplasia to anterior communicating artery aneurysm morphology and risk factors for aneurysm formation.

text: OBJECTIVE Hypoplasia of the A1 segment of the anterior cerebral artery is frequently observed in patients with anterior communicating artery (ACoA) aneurysms. The effect of this anatomical variant on ACoA aneurysm morphology is not well understood. METHODS Digital subtraction angiography images were reviewed for 204 patients presenting to the authors' institution with either a ruptured or an unruptured ACoA aneurysm. The ratio of the width of the larger A1 segment to the smaller A1 segment was calculated. Patients with an A1 ratio greater than 2 were categorized as having A1 segment hypoplasia. The relationship of A1 segment hypoplasia to both patient and aneurysm characteristics was then assessed. RESULTS Of 204 patients that presented with an ACoA aneurysm, 34 (16.7%) were found to have a hypoplastic A1. Patients with A1 segment hypoplasia were less likely to have a history of smoking (44.1% vs 62.9%, p = 0.0410). ACoA aneurysms occurring in the setting of a hypoplastic A1 were also found to have a larger maximum diameter (mean 7.7 vs 6.0 mm, p = 0.0084). When considered as a continuous variable, increasing A1 ratio was associated with decreasing aneurysm dome-to-neck ratio (p = 0.0289). There was no significant difference in the prevalence of A1 segment hypoplasia between ruptured and unruptured aneurysms (18.9% vs 10.7%; p = 0.1605). CONCLUSIONS Our results suggest that a hypoplastic A1 may affect the morphology of ACoA aneurysms. In addition, the relative lack of traditional risk factors for aneurysm formation in patients with A1 segment hypoplasia argues for the importance of hemodynamic factors in the formation of ACoA aneurysms in this anatomical setting.


The Coronavirus Epidemic.


title: Health care access of informal waste recyclers in Johannesburg, South Africa.

text: INTRODUCTION Informal waste recyclers contribute significantly to waste removal in South Africa. Waste recyclers face health hazards which are associated with handling and disposal of waste, a lack of personal protective wear and inaccessibility to occupational health care services. Consequently, accessing health care within the public health care sector is important for health outcomes in this population. This study assesses health care access of informal waste recyclers in South Africa to establish baseline information for health planning for potential inclusion of informal waste recyclers into occupational health services. METHODS A cross-sectional study of informal waste recyclers in two landfill sites in Johannesburg was conducted from March 2018. A standardized structured questionnaire was used to collect information on sociodemographic details, health care utilization, barriers to access and acceptability and affordability of health care. Factors associated with health care utilization were assessed using logistic regression. RESULTS A total of 363 informal waste recyclers were included in the study. Less than half of informal waste recyclers (41.0%) used health care facilities in the last 12 months. Those who accessed services chose to use facilities close to where they live (87.0%). Barriers to accessing health care services included long waiting periods (36.6%), being unable to take time off work (26.3%) and transport problems (13%). In the univariate analysis, factors such as gender and being treated well at the clinic and location of the health care facility were associated with health care utilization (OR: 1.97, p = 0.05, OR: 1.94, p = 0.02, OR: 0.65, p = 0.04 respectively). CONCLUSION Informal waste recyclers face numerous challenges to accessing health care. Specific to their informal trade, barriers to health care utilization are related to financial repercussions due to the informal nature of their work.


title: Evaluation of Chilblains as a Manifestation of the COVID-19 Pandemic.

text: Importance During the coronavirus disease 2019 (COVID-19) pandemic, several cases of chilblains have been reported. Objective To determine if chilblains are associated with COVID-19. Design, Setting, and Participants This monocentric case series was conducted at the Department of Dermatology at Cliniques universitaires Saint-Luc, a tertiary care hospital in Brussels, Belgium, between April 10 and April 17, 2020. We evaluated a total of 31 referred patients who had recently developed chilblains. Main Outcomes and Measures Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) was used to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA on nasopharyngeal swabs for all patients and in skin biopsy specimens for 22 patients. Blood samples from all patients were tested for specific anti-SARS-CoV-2 immunoglobulin (Ig) M and IgG antibodies. All patients had extended blood analyses. Histologic (22 patients) and immunofluorescence examinations (15 patients) were performed on the skin biopsy specimens. Results The 31 patients were generally in good health; most were teenagers or young adults, and 19 were women. Histopathologic analysis of skin biopsy specimens (22 patients) confirmed the diagnosis of chilblains and showed occasional lymphocytic or microthrombotic phenomena. Immunofluorescence analyses showed vasculitis of small-diameter vessels in 7 patients. In all patients, SARS-CoV-2 RNA remained undetected by RT-PCR on nasopharyngeal swabs and in biopsy samples of the skin lesions. The IgM and IgG antibody titers were negative for SARS-CoV-2 in all patients (<1.0 arbitrary unit/mL). No significant abnormalities in blood test results were suggestive of systemic disease. Antinuclear antibody titers were low in 7 patients and higher in 1 patient. Conclusions and Relevance Chilblains appeared not to be directly associated with COVID-19 in this case series. Lifestyle changes associated with community containment and lockdown measures are a possible explanation for these lesions.


title: The COVID-19 pandemic in Australia: Lessons learnt.

text: This paper evaluated the unique challenges of Australians in relation to the global novel coronavirus (COVID-19) pandemic. The 2019-2020 bushfires and COVID-19 outbreak have increased rates of anxiety and distress in Australia. On the contrary, unprecedented spending by the Australian Government on health care, employment, and housing has potentially lowered anxiety and stress for some Australians. Research is required to monitor the potential long-term mental health consequences of COVID-19 in Australia. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Pathogen inactivation technologies for cellular blood components: an update.

text: Nowadays patients receiving blood components are exposed to much less transfusion-transmitted infectious diseases than three decades before when among others HIV was identified as causative agent for the acquired immunodeficiency syndrome and the transmission by blood or coagulation factors became evident. Since that time the implementation of measures for risk prevention and safety precaution was socially and politically accepted. Currently emerging pathogens like arboviruses and the well-known bacterial contamination of platelet concentrates still remain major concerns of blood safety with important clinical consequences, but very rarely with fatal outcome for the blood recipient. In contrast to the well-established pathogen inactivation strategies for fresh frozen plasma using the solvent-detergent procedure or methylene blue and visible light, the bench-to-bedside translation of novel pathogen inactivation technologies for cell-containing blood components such as platelets and red blood cells are still underway. This review summarizes the pharmacological/toxicological assessment and the inactivation efficacy against viruses, bacteria, and protozoa of each of the currently available pathogen inactivation technologies and highlights the impact of the results obtained from several randomized clinical trials and hemovigilance data. Until now in some European countries pathogen inactivation technologies are in in routine use for single-donor plasma and platelets. The invention and adaption of pathogen inactivation technologies for red blood cell units and whole blood donations suggest the universal applicability of these technologies and foster a paradigm shift in the manufacturing of safe blood.


title: Mental health outcomes of the CoViD-19 pandemic.

text: The coronavirus disease 2019 (CoViD-19) caused by the novel Coronavirus strain SARS-CoV-2 is currently a pandemic. On January 30, 2020, the World Health Organization declared that the CoViD-19 outbreak is a public health emergency of international concern. The virus has already had a direct impact on the physical health of million people, and besides, it is supposed to pose a mental health threat of great magnitude globally. This review aims at synthesizing mounting evidence concerning the immediate psychological responses during the initial stage of the CoViD-19 pandemic among the general population, the health-care workers, and clinical populations. Experts point out the need to pay specific attention to other groups at risk of further distress that may need tailored interventions. Providing psychological first aid is an essential care component for populations that have been victims of emergencies and disasters, before, during and after the event. With the aim of dealing better with the urgent psychological problems of people involved in the CoViD-19 pandemic, a new psychological crisis intervention model is needed. Given the recommendation to minimize face-to-face interaction, online mental health services have been widely adopted in China and are urged in other countries.


title: Key Ring Fixator: A Novel External Fixation Technique for Avian Long Bone Stabilization.

text: A 12-year-old blue-fronted Amazon parrot (Amazona aestiva) of unknown sex (case 1) and a 14-year-old female hybrid Catalina macaw (Ara ararauna × Ara macao) (case 2) were evaluated and treated for an open tarsometatarsal fracture and a tibiotarsal fracture, respectively. In case 1, 1 month of external coaptation resulted in a delayed union, significant osteolysis, and presumptive osteomyelitis, which led to the decision to treat with a key ring fixator. In case 2, a key ring fixator was chosen for fracture repair because of presumed resistance to destruction by the bird. In both cases, fractures were stabilized with makeshift circular external fixators composed of key rings, K-wires, orthopedic wire, and acrylic resin. After key ring fixator removal, radiographs confirmed complete bone healing. Both patients had acceptable function of the affected limbs 5 years (case 1) and 2 years (case 2) after their procedures. The key ring fixator described in this report is a viable option for fracture repair in pelvic limbs of moderately sized birds (300-1500 g).


docid: aczhotun

title: Life and Death in the Age of COVID-19.


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title: COVID-19 Crisis as a Collective Hero's Journey to Better Public and Global Mental Health.


docid: xgybuovh

title: Differential expression of nuclear factor-kappaB mediates increased pulmonary expression of tumor necrosis factor-alpha and virus-induced asthma.

text: Infections with respiratory pathogens such as respiratory syncytial virus and rhinovirus have been associated with the development of long-term chronic airway disease. To better understand the events responsible for this clinical outcome, a rodent model of virus-induced chronic airway disease has been characterized. Upon infection with Sendai virus (parainfluenza virus type-1), Brown Norway (BN) rats develop an asthma-like clinical syndrome, while Fischer 344 (F344) rats fully recover. Our previous studies demonstrated that after infection, tumor necrosis factor-alpha (TNF-alpha) expression is substantially higher in BN rats compared to F344 rats, and this may at least partially mediate the virus-induced airway abnormalities. To investigate the underlying mechanism(s) for the increased TNF-alpha expression, the role of nuclear factor-kappaB (NF-kappaB), an important regulator of TNF-alpha gene transcription, was examined. Supershift electrophoretic mobility shift assays (EMSAs) indicate that normal F344 rats predominantly express the p65 subunit of NF-kappaB in the lungs, and virus infection temporarily increases expression of the p50 subunit. In contrast, normal BN rats have higher expression of the p50 subunit in the pulmonary tract. Upon infection, p50-subunit expression in BN rats increases to levels higher than those observed in virus-infected F344 rats. Interestingly, treatment of infected BN rats with dexamethasone at doses known to prevent virus-induced airway abnormalities increases pulmonary expression of the p65 subunit, and decreases TNF-alpha mRNA levels in the lungs. Furthermore, direct inhibition of TNF-alpha also increases pulmonary expression of p65 in virus-infected BN, but not F344, rats. Taken together, these results suggest that differential expression of NF-kappaB subunits may play an important role in the development of post-viral chronic airway abnormalities.


title: Brain oxygen saturation assessment in neonates using T2-prepared blood imaging of oxygen saturation and near-infrared spectroscopy.

text: Although near-infrared spectroscopy is increasingly being used to monitor cerebral oxygenation in neonates, it has a limited penetration depth. The T2-prepared Blood Imaging of Oxygen Saturation (T2-BIOS) magnetic resonance sequence provides an oxygen saturation estimate on a voxel-by-voxel basis, without needing a respiratory calibration experiment. In 15 neonates, oxygen saturation measured by T2-prepared blood imaging of oxygen saturation and near-infrared spectroscopy were compared. In addition, these measures were compared to cerebral blood flow and venous oxygen saturation in the sagittal sinus. A strong linear relation was found between the oxygen saturation measured by magnetic resonance imaging and the oxygen saturation measured by near-infrared spectroscopy ( R2 = 0.64, p < 0.001). Strong linear correlations were found between near-infrared spectroscopy oxygen saturation, and magnetic resonance imaging measures of frontal cerebral blood flow, whole brain cerebral blood flow and venous oxygen saturation in the sagittal sinus ( R2 = 0.71, 0.50, 0.65; p < 0.01). The oxygen saturation obtained by T2-prepared blood imaging of oxygen saturation correlated with venous oxygen saturation in the sagittal sinus ( R2 = 0.49, p = 0.023), but no significant correlations could be demonstrated with frontal and whole brain cerebral blood flow. These results suggest that measuring oxygen saturation by T2-prepared blood imaging of oxygen saturation is feasible, even in neonates. Strong correlations between the various methods work as a cross validation for near-infrared spectroscopy and T2-prepared blood imaging of oxygen saturation, confirming the validity of using of these techniques for determining cerebral oxygenation.


docid: exlibszu

title: Evidence-based guideline: Antiepileptic drug selection for people with HIV/AIDS: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Ad Hoc Task Force of the Commission on Therapeutic Strategies of the International League Against Epilepsy.

text: OBJECTIVE To develop guidelines for selection of antiepileptic drugs (AEDs) among people with HIV/AIDS. METHODS The literature was systematically reviewed to assess the global burden of relevant comorbid entities, to determine the number of patients who potentially utilize AEDs and antiretroviral agents (ARVs), and to address AED-ARV interactions. RESULTS AND RECOMMENDATIONS AED-ARV administration may be indicated in up to 55% of people taking ARVs. Patients receiving phenytoin may require a lopinavir/ritonavir dosage increase of ~50% to maintain unchanged serum concentrations (Level C). Patients receiving valproic acid may require a zidovudine dosage reduction to maintain unchanged serum zidovudine concentrations (Level C). Coadministration of valproic acid and efavirenz may not require efavirenz dosage adjustment (Level C). Patients receiving ritonavir/atazanavir may require a lamotrigine dosage increase of ∼50% to maintain unchanged lamotrigine serum concentrations (Level C). Coadministration of raltegravir/atazanavir and lamotrigine may not require lamotrigine dosage adjustment (Level C). Coadministration of raltegravir and midazolam may not require midazolam dosage adjustment (Level C). Patients may be counseled that it is unclear whether dosage adjustment is necessary when other AEDs and ARVs are combined (Level U). It may be important to avoid enzyme-inducing AEDs in people on ARV regimens that include protease inhibitors or nonnucleoside reverse transcriptase inhibitors, as pharmacokinetic interactions may result in virologic failure, which has clinical implications for disease progression and development of ARV resistance. If such regimens are required for seizure control, patients may be monitored through pharmacokinetic assessments to ensure efficacy of the ARV regimen (Level C).


GPs are still available: five minutes with . . . Mohammed Abbas Khaki.


title: Neurologic Involvement in COVID-19: Cause or Coincidence? A Neuroimaging Perspective.

text: The rapid spread of the coronavirus disease 2019 (COVID-19) pandemic has shaken hospitals worldwide. Some authors suggest that neurologic involvement could further complicate the disease. This descriptive study is a cross-sectional review of 103 patients diagnosed with COVID-19 who underwent neuroimaging (of a total of 2249 patients with COVID-19 in our center). Analyzed variables were neurologic symptoms and acute imaging findings. The most frequent symptoms that motivated neuroimaging examinations were mild nonfocal neurologic symptoms, code stroke (refers to patients presenting with signs and symptoms of stroke whose hyperacute assessment and care is prioritized), focal neurologic symptoms, postsedation encephalopathy, and seizures. No cases of encephalitis or direct central nervous system involvement were detected. Thirteen patients presented with acute ischemic events, and 7, with hemorrhagic events; however, most reported multiple vascular risk factors. Despite the large cohort of patients with COVID-19, we found a large number of symptomatic patients with negative neuroimaging findings, and no conclusions can be drawn concerning concrete associations between neuroimaging and COVID-19.


title: Point-Counterpoint: Large Multiplex PCR Panels Should Be First-Line Tests for Detection of Respiratory and Intestinal Pathogens.

text: The first FDA-approved multiplex PCR panel for a large number of respiratory pathogens was introduced in 2008. Since then, other PCR panels for detection of several respiratory and gastrointestinal pathogens have been approved by the FDA and are commercially available, and more such panels are likely to become available. These assays detect 12 to 20 pathogens, and some include pathogens that typically cause different manifestations of infection, although they infect the same organ system. Some of these tests are labor-intensive, while others require little labor, and all of them are expensive, both for the laboratory and for the patient or insurer. They include a bundle of tests with limited or no options for selecting which tests will be performed. Laboratories and hospitals have adopted different strategies for offering these assays. Some have implemented strategies to limit the use of the tests, such as limiting the frequency with which patients can be tested, restricting testing to specific groups of patients (e.g., immunocompromised patients), or providing education to encourage the use of less expensive tests before using large multiplex panels. Others have offered these assays without limiting their use, either relying on the ordering provider to exercise good judgment or because such assays are thought to be appropriate for first-line diagnostic testing. In this Point-Counterpoint, Paul Schreckenberger of Loyola University Medical Center explains why his laboratory offers these assays without restriction. Alex McAdam of Boston's Children Hospital explains the concerns about the use of these assays as first-line tests and why some limitations on their use might be appropriate.


title: Natural transmission of bat-like SARS-CoV-2PRRA variants in COVID-19 patients.

text: BACKGROUND SARS-CoV-2 contains the furin cleavage PRRA motif in the S1/S2 region, which enhances viral pathogenicity but is absent in closely related bat and pangolin coronaviruses. It remains unknown if bat-like coronaviral variants without PRRA (ΔPRRA) can establish natural infection in humans. METHODS Here, we developed a duplex digital PCR assay to examine ΔPRRA variants in Vero-E6-propagated isolates, human organoids, experimentally infected hamsters and COVID-19 patients. RESULTS We found that currently transmitting SARS-CoV-2 contained a quasispecies of wildtype, ΔPRRA variants and upstream variants that have mutations upstream the PRRA motif. Moreover, the ΔPRRA variants were readily detected despite at a low intra-host frequency in transmitted founder viruses in hamsters and in COVID-19 patients including acute cases and a family cluster with a prevalence rate of 52.9%. CONCLUSIONS Our findings demonstrate that bat-like SARS-CoV-2ΔPRRA not only naturally exists but remains transmissible in COVID-19 patients, which have significant implications to zoonotic origin and natural evolution of SARS-CoV-2.


title: Robotic Single-port Surgery: Paving the Way for the Future.

text: Adoption of robotic technology in urology has been widely popularized as it provides considerable advantages over standard techniques, including improved instrument dexterity, three-dimensional high-definition optics, and enhanced ergonomics. As a result, these features have facilitated the adaptation of robotics for laparoendoscopic single-site surgery (LESS) to overcome challenges with clashing, suturing, and intra-abdominal triangulation. Since the inception of robotic LESS by our institution in 2008,(1) many centers have gone on to study this approach in various urologic applications. Herein we discuss the evolution of robotic LESS access, instrumentation, and outcomes with special focus on up-and-coming technology.


The costs of secrecy.


title: Comparing laparoscopic mesh fixation strength between articulated and non-articulated tack devices.

text: AIM The iMESH Tacker™ (IMT) device is a device which simplifies laproscopic hernia repair by enabling an articulation of the device tip. The study compares the strength of mesh fixation between the IMT and another commercial tack (ACT) device - Absorbatack™ (Covidien, Corp, Mansfield, MA, USA). MATERIAL AND METHODS Strips of mesh were installed on the abodminal wall of three pigs. Half of the meshes were fixated by IMT and half by ACT. Euthanasia was done immediately to the first pig, after14 days to the second and after 27 days to the third pig. The mesh strips were pulled while fixation force was measured. Statistical analysis was done using the two tailed t-test. All mesh strips were found to be fixated. Through detachment force test, the average force in the first pig was 17.1N ± 1.9 and 16.5N ± 8.3 (IMT and ACT respectively, n/s). The average force in the second pig was 18.8N ± 7.3 and 8.4N ± 4.1 (IMT and ACT respectively, p < 0.05). The average force in the third pig was 16.3N ± 5.3 and 10.9N ± 5.9 (IMT and ACT respectively, p < 0.05). CONCLUSION The use of IMT is both feasible and easy to learn. The study showed that IMT creates average fixation force which is higher than ACT.


Essential oils.


title: Massive Hemoptysis from a Pulmonary Artery Pseudoaneurysm during Cardiac Surgery.

text: Massive hemoptysis is a life-threatening condition usually related to a pathology of the bronchial arteries. Pulmonary artery pseudoaneurysms represent a relatively rare cause of severe airway bleeding, but are associated with a mortality rate of over 50%. A case of massive intraoperative hemoptysis treated with temporary occlusion of the right pulmonary artery and delayed endovascular occlusion of the feeding segmental artery is described.


docid: knffihxx

title: The power of disruptive technological innovation: Transcatheter aortic valve implantation.

text: We sought to evaluate the principles of disruptive innovation, defined as technology innovation that fundamentally shifts performance and utility metrics, as applied to transcatheter aortic valve implantation (TAVI). In particular, we considered implantation procedure, device design, cost, and patient population. Generally cheaper and lower performing, classical disruptive innovations are first commercialized in insignificant markets, promise lower margins, and often parasitize existing usage, representing unattractive investments for established market participants. However, despite presently high unit cost, TAVI is less invasive, treats a "new," generally high risk, patient population, and is generally done by a multidisciplinary integrated heart team. Moreover, at least in the short-term TAVI has not been lower-performing than open surgical aortic valve replacement in high-risk patients. We conclude that TAVI extends the paradigm of disruptive innovation and represents an attractive commercial opportunity space. Moreover, should the long-term performance and durability of TAVI approach that of conventional prostheses, TAVI will be an increasingly attractive commercial opportunity.


title: Exhaled breath condensate in intubated neonates--a window into the lung's glutathione status.

text: BACKGROUND Analysis of exhaled breath condensates (EBC) is a non-invasive technique to evaluate biomarkers such as antioxidants in the pediatric population, but limited data exists of its use in intubated patients, particularly newborns. Currently, tracheal aspirate (TA) serves as the gold standard collection modality in critically ill newborns, but this method remains invasive. We tested the hypothesis that glutathione status would positively correlate between EBC and TA collections in intubated newborns in the Newborn Intensive Care Unit (NICU). We also hypothesized that these measurements would be associated with alveolar macrophage (AM) glutathione status in the newborn lung. METHODS Reduced glutathione (rGSH), glutathione disulfide (GSSG), and total GSH (rGSH + (2 X GSSG)) were measured in sequential EBC and TA samples from 26 intubated newborns via high performance liquid chromatography (HPLC). Additionally, AM glutathione was evaluated via immunofluorescence. Pearson's correlation coefficient and associated 95% confidence intervals were used to quantify the associations between raw and urea-corrected concentrations in EBC and TA samples and AM staining. Statistical significance was defined as p ≤ 0.05 using two-tailed tests. The sample size was projected to allow for a correlation coefficient of 0.5, with 0.8 power and alpha of 0.05. RESULTS EBC was obtainable from intubated newborns without adverse clinical events. EBC samples demonstrated moderate to strong positive correlations with TA samples in terms of rGSH, GSSG and total GSH. Positive correlations between the two sampling sites were observed in both raw and urea-corrected concentrations of rGSH, GSSG and total GSH. AM glutathione staining moderately correlated with GSSG and total GSH status in both the TA and EBC. CONCLUSIONS GSH status in EBC samples of intubated newborns significantly correlated with the GSH status of the TA sample and was reflective of cellular GSH status in this cohort of neonatal patients. Non-invasive EBC sampling of intubated newborns holds promise for monitoring antioxidant status such as GSH in the premature lung. Further studies are necessary to evaluate the potential relationships between EBC biomarkers in the intubated premature newborn and respiratory morbidities.


Commentary in response to 'Impact of the COVID-19 pandemic on the process and outcome of thrombectomy for acute ischemic stroke'.


title: Histopathological evaluation of a novel radiofrequency surgical ablation system.

text: PURPOSE : Using a porcine model, this feasibility study was undertaken to evaluate the histopathological characteristics of lesions created in the proximity of the pulmonary veins after ablation with a new endoscopic-guided radiofrequency device. METHODS : Five adult female swine underwent endoscopic surgical ablation on the epicardial surface of the beating heart. Histologic sections taken from around the pulmonary vein pedicle, representing 10 separate anatomic sites, underwent independent qualitative histopathological evaluation as well as quantitative histomorphometric measurement of lesion depth and section thickness. RESULTS : Sections from all five animals had histologically identical lesions, with the majority of ablation foci having pronounced thermal injury characterized by deep and extensive zones of acute myocardial necrosis in the absence of tissue charring. Fifty-seven percent (13 of 23) of the lesions were completely transmural and 91% (21 of 23) of the sections demonstrated ≥70% transmurality. No collateral injuries were noted. CONCLUSIONS : This irrigated, suction-stabilized unipolar radiofrequency device can produce histologically transmural lesions around the pulmonary veins and is amenable to endoscopic-guided application on the beating heart.


title: Endovascular management of six simultaneous intracranial dural arteriovenous fistulas in a single patient.

text: A 64-year-old man with a history of traumatic brain injury 4 years previously presented with progressive cognitive decline and gait abnormality. MRI revealed diffusion restriction in the bilateral centrum semiovale and multiple serpiginous flow voids. Cerebral angiogram revealed a total of six intracranial dural arteriovenous fistulas with separate fistulas of the right and left sphenoid bones, left clival plexus, right transverse sinus, right sigmoid sinus, and superior sagittal sinus. A diffuse pseudophlebitic pattern of venous drainage indicating severe venous hypertension was also observed. The patient underwent a series of endovascular treatments over the next 10 months to achieve resolution of all arteriovenous shunting. Repeat MRI showed resolution of the diffusion restriction and marked reduction in T2 vascular flow voids. The patient's clinical status improved significantly over the course of treatment, paralleling the improvement in venous hypertension.


title: Evaluating the detailed position of the subclavian artery to avoid inadvertent subclavian artery puncture during right internal jugular vein catheterization.

text: PURPOSE Central venous catheter placement is useful but is associated with complications. Inadvertent subclavian artery (SCA) puncture is a rare complication associated with internal jugular vein (IJV) catheterization. We determined the position of the SCA by ultrasonography, and propose a needle-insertion position for avoiding inadvertent SCA puncture. METHODS We positioned an ultrasound probe at an angle of 60° to the skin to mimic a puncture needle halfway between the clavicle and the angle of the mandible (center) and moved the probe parallel to the right IJV (RIJV) toward the clavicle until locating the SCA. We measured the distance from the clavicle to the probe 60 and from the probe to the SCA (P60-SCA) where the SCA was visible by ultrasonography. RESULTS For 50 volunteers with a mean age of 27.3 years, the center position was, on average, 67 mm from the clavicle. The image of the SCA appeared within 65 mm of the clavicle. P60-SCA differed significantly between men and women (p = 0.0058). For 45 volunteers, P60-SCA was <25 mm with the probe 65 mm from the clavicle on the skin. RIJVP-SCA averaged 4.4 mm. Only P60-SCA correlated well with BMI for men (r = 0.732, p = 0.0068). CONCLUSION Puncturing the RIJV away from the center should avoid SCA puncture; puncturing it while approaching the clavicle is more dangerous. The exact location of the SCA varies from person to person; thus, confirming SCA position by ultrasonography is recommended every time before puncturing.


docid: gmvvtogn

title: Evaluation of mesorectal fascia in mid and low anterior rectal cancer using endorectal ultrasound is feasible and reliable: a comparison with MRI findings.

text: BACKGROUND Accuracy of MRI in assessing mesorectal fascia and predicting circumferential resection margin decreases in low anterior rectal tumors. OBJECTIVE The purpose of this work was to evaluate the accuracy of endorectal ultrasound in predicting the pathologic circumferential resection margin in low rectal anterior tumors and to compare it with MRI findings. DESIGN This was a prospective series comparing the preoperative circumferential resection margin assessed by endorectal ultrasound and MRI with pathologic examination. SETTINGS The study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital. PATIENTS Between 2002 and 2008, 76 patients with mid to low rectal cancer were preoperatively evaluated by endorectal ultrasound and MRI and underwent total mesorectal excision without neoadjuvant radiochemotherapy. Twenty-seven patients with posterior or postero-lateral tumors were excluded, leaving 49 patients with anterior or antero-lateral tumors for the present subanalysis. We compared preoperative circumferential resection margin status using endorectal ultrasound and MRI with pathologic examination. INTERVENTIONS We conducted a comparison between preoperative circumferential resection margin status and pathologic examination after total mesorectal excision surgery. MAIN OUTCOME MEASURES Accuracy in predicting pathologic circumferential resection margin status was measured. RESULTS Overall accuracy of endorectal ultrasound and MRI in assessing circumferential resection margin status was 83.7% and 91.8%, with negative predictive values of 97.2% and 97.5%. When focusing on low rectal tumors, the overall accuracy of endorectal ultrasound increased to 87.5%, whereas the accuracy of MRI decreased to 87.5%, with a negative predictive value of 95.6% for both diagnostic tests. LIMITATIONS The sample size is small, and interobserver variability in radiologic assessment was not evaluated. CONCLUSIONS Endorectal ultrasound can help MRI in predicting circumferential resection margin involvement in mid to low anterior rectal cancer, especially at the low third of the rectum, with a high negative predictive value.


docid: uyaopwyx

title: The emotional consequences of corticosteroid use in hematology: preliminary findings.

text: This article presents the findings from a pilot study conducted as a first step in understanding the myriad psychological and psychiatric sequelae stemming from the use of steroids for hematology patients. Descriptions of the side effects experienced by 10 hematology patients undergoing steroid treatment are documented and discussed. Steroid usage can have a range of physical and emotional side effects on patients, including hematology patients. The insights are a serious reminder to all who care for hematology patients that the psychological and psychiatric side effects of steroids need to be taken seriously.


title: (6aR,10aR)-6,6,9-Trimethyl-3-pentyl-6a,7,8,10a-tetra-hydro-6H-benzo[c]-chromen-1-yl 4-methyl-benzene-sulfonate.

text: In the crystal structure of the title compound, C(28)H(36)O(4)S, the p-tolyl ring is inclined at 35.8° to the aromatic ring. The cyclohexene ring adopts a boat conformation and the heterocyclic ring is in a slightly distorted screw boat conformation.


title: Endothelial nitric oxide synthase and superoxide mediate hemodynamic initiation of intracranial aneurysms.

text: BACKGROUND Hemodynamic insults at arterial bifurcations are believed to play a critical role in initiating intracranial aneurysms. Recent studies in a rabbit model indicate that aneurysmal damage initiates under specific wall shear stress conditions when smooth muscle cells (SMCs) become pro-inflammatory and produce matrix metalloproteinases (MMPs). The mechanisms leading to SMC activation and MMP production during hemodynamic aneurysm initiation are unknown. The goal is to determine if nitric oxide and/or superoxide induce SMC changes, MMP production and aneurysmal remodeling following hemodynamic insult. METHODS Bilateral common carotid artery ligation was performed on rabbits (n = 19, plus 5 sham operations) to induce aneurysmal damage at the basilar terminus. Ligated animals were treated with the nitric oxide synthase (NOS) inhibitor LNAME (n = 7) or the superoxide scavenger TEMPOL (n = 5) and compared to untreated animals (n = 7). Aneurysm development was assessed histologically 5 days after ligation. Changes in NOS isoforms, peroxynitrite, reactive oxygen species (ROS), MMP-2, MMP-9, and smooth muscle α-actin were analyzed by immunohistochemistry. RESULTS LNAME attenuated ligation-induced IEL loss, media thinning and bulge formation. In untreated animals, immunofluorescence showed increased endothelial NOS (eNOS) after ligation, but no change in inducible or neuronal NOS. Furthermore, during aneurysm initiation ROS increased in the media, but not the intima, and there was no change in peroxynitrite. In LNAME-treated animals, ROS production did not change. Together, this suggests that eNOS is important for aneurysm initiation but not by producing superoxide. TEMPOL treatment reduced aneurysm development, indicating that the increased medial superoxide is also necessary for aneurysm initiation. LNAME and TEMPOL treatment in ligated animals restored α-actin and decreased MMPs, suggesting that eNOS and superoxide both lead to SMC de-differentiation and MMP production. CONCLUSION Aneurysm-inducing hemodynamics lead to increased eNOS and superoxide, which both affect SMC phenotype, increasing MMP production and aneurysmal damage.


title: Clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices.

text: OBJECTIVE The purpose of this study was to evaluate the incidence and clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices (EPDs). METHODS We reviewed the clinical data of 566 patients treated by 836 endovascular femoropopliteal interventions for lower extremity claudication (46%) or critical limb ischemia (54%) from 2002 to 2012. Outcomes were analyzed in 74 patients/87 interventions performed with EPDs (Spider Rx; Covidien, Plymouth, Minn) and 513 patients/749 interventions performed without EPDs. TransAtlantic Inter-Society Consensus (TASC) II classification, runoff scores, and embolic events were analyzed. End points were morbidity, mortality, reintervention, patency, and major amputation rates. RESULTS Both groups had similar demographics, indications, cardiovascular risk factors, and runoff scores, but patients treated with EPDs had significantly (P < .05) longer lesions (109 ± 94 mm vs 85 ± 76 mm) and more often had occlusions (64% vs 30%) and TASC C/D lesions (56% vs 30%). Embolic events occurred in 35 of 836 interventions (4%), including two (2%) performed with EPD and 33 (4%) without EPD (P = .35). Macroscopic debris was noted in 59 (68%) filter baskets. Embolic events were not associated with lesion length, TASC classification, runoff scores, treatment type, or indication but were independently associated with occlusion. Patients who had embolization required more reinterventions (20% vs 3%; P < .001) and major amputations at 30 days (11% vs 3%; P = .02). There was no difference in hospital stay (2.4 ± 4 days vs 1.6 ± 2 days; P = .08), reintervention (2% vs 4%), and major amputation (1% vs 4%) among patients treated with or without EPD, respectively. The two patients who developed embolization with EPDs had no clinical sequela and required no reintervention. Most emboli were successfully treated by catheter aspiration or thrombolysis, but eight patients (24%) treated without EPD required prolonged hospital stay, seven (21%) had multiple reinterventions, one (3%) had unanticipated major amputation, and one (3%) died from hemorrhagic complications of thrombolysis. Median follow-up was 20 months. At 2 years, primary patency and freedom from reintervention was similar for TASC A/B and TASC C/D lesions treated with or without EPDs. CONCLUSIONS Rates of embolization are low in patients undergoing endovascular femoropopliteal interventions with (4%) or without (2%) EPD. Embolization is more frequent in patients with occlusions. While emboli in patients with EPD had no clinical sequel, those treated without EPD required multiple reinterventions in 21% or resulted in major amputation or death in 3%. Late outcomes were similar in patients treated with or without EPDs.


Face masks - a sustainable measure to mitigate COVID-19.


title: A case of left frontal high-grade glioma diagnosed during pregnancy.

text: Background As pregnancy accelerates glioma growth, therapeutic abortion has been recommended prior to tumor resection. Additionally, it has also been suggested that the extent of glioma resection is closely correlated with patient survival. Case presentation A 162-cm, 61.4-kg, 30-year-old, right-handed primigravida was referred to our institution at 21 weeks gestation to obtain a second opinion. At 18 weeks gestation, the patient developed new-onset generalized convulsive seizures (GCSs), which were poorly controlled by anticonvulsant polytherapy, early in the second trimester. A 6-cm lesion located in her left frontal supplementary motor area (SMA) was suspected as a grade III glioma, classified according to the World Health Organization (WHO) guidelines. Due to the limited evidence on the use of adjuvant therapy during pregnancy, tumors causing neurological symptoms and seizures must be treated, in order to stabilize the maternal condition and enable a safe birth. In the case of pregnant patients, awake craniotomy using intraoperative magnetic resonance imaging (iMRI) is considered advantageous, achieving gross total resection with a reduction of direct cortical stimulation, which may induce seizure, and so reducing fetal exposure to anesthetics. The "Asleep-Awake-Asleep" technique was performed at 27 weeks and 2 days gestation. As use of propofol in pregnant patients is prohibited, general anesthesia was maintained through administration of sevoflurane and remifentanil until the first scan of iMRI, and was subsequently re-induced with dexmedetomidine when tumor removal had been accomplished. A supraglottic airway (SGA) was used until the patient's cranium was opened. There were no complications during either the procedure or the post-operative period. At 35 weeks gestation, the patient delivered a healthy baby of 2317 g. Pathological examination of the patient, revealed an anaplastic astrocytoma, thus radiotherapy and chemotherapy began 2 months post-delivery. There is no evidence of tumor recurrence in the patient and the child did not show any medical or developmental concerns at the point of the 17-month follow-up. Conclusions Since evidence on the use of adjuvant therapy during pregnancy is limited, extensive resection with functional monitoring is recommended if a brain tumor is presumed to be malignant. Awake craniotomy is considered advantageous to pregnant patients because subjective movement preserves the patient's motor function and reduces fetal exposure to anesthetics. Therefore, providing multidisciplinary discussion takes place within the decision-making process, as well as careful perioperative preparation, awake craniotomy should be considered, even in the case of pregnant patients.


title: Pandemic planning: plotting a course through the coronawars.

text: The biological motor behind the current coronavirus pandemic has placed microbiology on a global stage, and given its practitioners a role among the architects of recovery. Planning for a return to normality or the new normal is a complex, multi-agency task for which healthcare scientists may not be prepared. This paper introduces a widely used military planning framework known as the Joint Military Appreciation Process, and outlines how it can be applied to deal with the next phase of the COVID-19 pandemic. Recognition of SARS-CoV-2's critical attributes, targetable vulnerabilities, and its most likely and most dangerous effects is a necessary precursor to scoping, framing and mission analysis. From this flows course of action development, analysis, concept of operations development, and an eventual decision to act on the plan. The same planning technique is applicable to the larger scale task of setting a microbiology-centric plan in the broader context of social and economic recovery.


title: The current status and future perspectives of laparoscopic surgery for gastric cancer.

text: Gastric cancer is most common cancer in Korea. Surgery is still the main axis of treatment. Due to early detection of gastric cancer, the innovation of surgical instruments and technological advances, gastric cancer treatment is now shifting to a new era. One of the most astonishing changes is that minimally invasive surgery (MIS) is becoming more dominant treatment for early gastric cancer. These MIS are represented by endoscopic resection, laparoscopic surgery, robotic surgery, single-port surgery and natural orifice transluminal endoscopic surgery. Among them, laparoscopic gastrectomy is most actively performed in the field of surgery. Laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC) has already gained popularity in terms of the short-term outcomes including patient's quality of life. We only have to wait for the long-term oncologic results of Korean Laparoscopic Gastrointestinal Surgery Study Group. Upcoming top issues following oncologic safety of LADG are function-preserving surgery for EGC, application of laparoscopy to advanced gastric cancer and sentinel lymph node navigation surgery. In the aspect of technique, laparoscopic surgery at present could reproduce almost the whole open procedures. However, the other fields mentioned above need more evidences and experiences. All these new ideas and attempts provide technical advances, which will minimize surgical insults and maximize the surgical outcomes and the quality of life of patients.


title: Biological Control of Asparagus Pests Using Synthetic Herbivore-Induced Volatiles.

text: Natural enemies can be important regulators of pests in agroecosystems, and they often rely on volatile chemical cues to find hosts. Herbivore-induced plant volatiles (HIPVs) have been a focal point in many studies that seek to increase the efficacy of biological control programs by increasing recruitment and retention of natural enemies. Our research sought to explore the role of HIPVs in asparagus agroecosystems to answer the following questions: 1) What is the composition of HIPV produced by asparagus ferns following feeding by a chewing herbivore? 2) Do field deployed lures baited with synthetic asparagus HIPVs attract natural enemies? and 3) Can HIPV lures increase biological control of asparagus pests? Volatiles were field collected from the headspace of healthy asparagus ferns, mechanically damaged ferns, and ferns fed upon by asparagus beetle larvae (Crioceris asparagi L.) (Coleoptera: Chrysomelidae). We found that asparagus beetle damaged asparagus had significantly higher concentrations of (E)-β-ocimene, (E,E)-α-farnesene, and (1)-tetradecanol than healthy or mechanically damaged ferns. Field experiments demonstrated that lures baited with isolates of ocimene and farnesene attracted parasitoids without attracting pests, but had no impact on predator recruitment. Finally, we determined that overall parasitism rates were not increased by synthetic HIPV lures but found evidence that lures may increase parasitism of asparagus miner (Ophiomyia simplex Loew) (Diptera: Agromyzidae) by pteromalids.


title: The effect of age and dose number on the risk of collapse (hypotonic-hyporesponsive episode) after pertussis vaccination.

text: The Netherlands vaccination schedule has been advanced by 1 month. The reporting rate of collapse or hypotonic-hyporesponsive episode increased from 5.2 [95% confidence interval (CI): 4.8-5.7] to 8.5 (95% CI: 8.0-9.1) and from 1.2 (95% CI: 1.0-1.4) to 2.5 (95% CI: 2.2-2.8) per 10,000 first and second doses, respectively. At 3 months of age it fell from 5.2 to 2.5. This suggests some protection by the first dose. Different mediators in primary and secondary immune response may play a role.


title: Investigating the European perspective of neonatal point-of-care echocardiography in the neonatal intensive care unit--a pilot study.

text: UNLABELLED Point-of-care functional neonatal echocardiography (fnECHO) is increasingly used to assess haemodynamic status or patency of the ductus arteriosus (PDA). In Australasia, 90 % of neonatal intensive care units (NICUs) practice point-of-care fnECHO. The Australian Society of Ultrasound Medicine offers a training certificate for fnECHO. In Europe, the use and indications of fnECHO and the extent of point-of-care fnECHO training and accreditation are unknown. We aimed to assess utilisation and training of fnECHO in Europe. For this, we conducted an email survey of 45 randomly chosen tertiary NICUs in 17 European countries. The recall rate was 89 % (n = 40). Neonatologists with skills in fnECHO worked in 29 NICUs (74 %), but paediatric cardiologists would routinely perform most fnECHOs. Twenty-four-hour echocardiography service was available in 31 NICUs (78 %). Indications for fnECHO included assessment of haemodynamic volume status (53 %), presence or absence of pulmonary hypertension of the neonate (55 %), indication for and effect of volume replacement therapy (58 %), PDA assessment and monitoring of PDA treatment (80 %). Teaching of fnECHO was offered to trainees in 22 NICUs (55 %). Teaching of fnECHO was provided by paediatric cardiologists (55 %) or by neonatologists (45 %). Only six (15 %) national colleges accredited fnECHO teaching courses. CONCLUSION fnECHO is widely practiced by neonatologists across Europe for a broad range of clinical questions. However, there is a lack of formal training and accreditation of fnECHO skills. This could be addressed by designing a dedicated European fnECHO training programme and by agreeing on a common European certificate of fnECHO.


title: The promise, pitfalls and progress of RNA-interference-based antiviral therapy for respiratory viruses.

text: Advances in the understanding of RNA biological processing and control are leading to new concepts in human therapeutics with practical implications for many human diseases, including antiviral therapy of respiratory viruses. So-called 'non-coding RNA' exerts specific and profound functional control on regulation of protein production and indeed controls the expression of all genes through processes collectively known as RNA interference (RNAi). RNAi is a naturally occurring intracellular process that regulates gene expression through the silencing of specific messenger RNAs (mRNAs). Methods are being developed that allow the catalytic degradation of targeted mRNAs using specifically designed complementary small interfering RNAs (siRNA). siRNAs are now being chemically modified and packaged into advanced delivery systems so as to acquire drug-like properties and the ability to deliver their effects systemically. Recent in vivo studies have provided proofs of the concept that RNAi may be useful therapeutically. Much of the design of these siRNAs can be accomplished bioinformatically, thus potentially expediting drug discovery and opening new avenues of therapy for many uncommon, orphan, or emerging diseases. Theoretically, any disease that can be ameliorated through knockdown of any endogenous or exogenous protein is a potential therapeutic target for RNAi-based therapeutics. Lung diseases in general are attractive targets for RNAi therapeutics, since the location of affected cells increases their accessibility to topical administration of siRNA, and respiratory viral infections are particularly attractive targets for RNAi-based drug discovery and development. RNAi therapeutics have been shown to exert potent antiviral effects against respiratory syncytial virus (RSV), parainfluenza, influenza, coronaviruses, measles and human metapneumoviruses in vitro and in vivo. Recently, a double-blind placebo-controlled clinical trial of an RNAi-based therapeutic against RSV demonstrated that this technology has therapeutic activity, representing the first proof-of-concept test of efficacy for RNAi's therapeutic effect in humans. This review discusses the science behind RNAi and the potential practical issues in applying this technology to various respiratory viral diseases.


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title: Increased human stretch reflex dynamic sensitivity with height-induced postural threat.

text: KEY POINTS Threats to standing balance (postural threat) are known to facilitate soleus tendon-tap reflexes, yet the mechanisms driving reflex changes are unknown. Scaling of ramp-and-hold dorsiflexion stretch reflexes to stretch velocity and amplitude were examined as indirect measures of changes to muscle spindle dynamic and static function with height-induced postural threat. Overall, stretch reflexes were larger with threat. Furthermore, the slope (gain) of the stretch-velocity vs. short-latency reflex amplitude relationship was increased with threat. These findings are interpreted as indirect evidence for increased muscle spindle dynamic sensitivity, independent of changes in background muscle activity levels, with a threat to standing balance. We argue that context-dependent scaling of stretch reflexes forms part of a multisensory tuning process where acquisition and/or processing of balance-relevant sensory information is continuously primed to facilitate feedback control of standing balance in challenging balance scenarios. ABSTRACT Postural threat increases soleus tendon-tap (t-) reflexes. However, it is not known whether t-reflex changes are a result of central modulation, altered muscle spindle dynamic sensitivity or combined spindle static and dynamic sensitization. Ramp-and-hold dorsiflexion stretches of varying velocities and amplitudes were used to examine velocity- and amplitude-dependent scaling of short- (SLR) and medium-latency (MLR) stretch reflexes as an indirect indicator of spindle sensitivity. t-reflexes were also performed to replicate previous work. In the present study, we examined the effects of postural threat on SLR, MLR and t-reflex amplitude, as well as SLR-stretch velocity scaling. Forty young-healthy adults stood with one foot on a servo-controlled tilting platform and the other on a stable surface. The platform was positioned on a hydraulic lift. Threat was manipulated by having participants stand in low (height 1.1 m; away from edge) then high (height 3.5 m; at the edge) threat conditions. Soleus stretch reflexes were recorded with surface electromyography and SLRs and MLRs were probed with fixed-amplitude variable-velocity stretches. t-reflexes were evoked with Achilles tendon taps using a linear motor. SLR, MLR and t-reflexes were 11%, 9.5% and 16.9% larger, respectively, in the high compared to low threat condition. In 22 out of 40 participants, SLR amplitude was correlated to stretch velocity at both threat levels. In these participants, the gain of the SLR-velocity relationship was increased by 36.1% with high postural threat. These findings provide new supportive evidence for increased muscle spindle dynamic sensitivity with postural threat and provide further support for the context-dependent modulation of human somatosensory pathways.


title: Proton pump inhibitor therapy did not increase the prevalence of small-bowel injury: A propensity-matched analysis.

text: BACKGROUND Previous studies have reported that the suppression of acid secretion by using proton pump inhibitors (PPIs) results in dysbiosis of the small-bowel microbiota, leading to exacerbated small-bowel injuries, including erosions and ulcers. This study was designed to assess the association between PPI therapy and small-bowel lesions after adjustment for the differences in baseline characteristics between users and non-users of PPIs. METHODS We retrospectively studied patients suspected to be suffering from small-bowel diseases, who underwent capsule endoscopy between 2010 and 2013. We used propensity matching to adjust for the differences in baseline characteristics between users and non-users of PPIs. The outcomes included the prevalence of small-bowel lesions: erosion, ulcer, angioectasia, varices, and tumor. RESULTS We selected 327 patient pairs for analysis after propensity matching, and found no significant differences in the prevalence of small-bowel injuries, including erosions and ulcers, between users and non-users of PPIs. Two subgroup analyses of the effect of the type of PPI and the effect of PPI therapy in users and non-users of nonsteroidal anti-inflammatory drugs indicated no significant differences in the prevalence of small-bowel injuries in these two groups. CONCLUSION PPI therapy did not increase the prevalence of small-bowel injury, regardless of the type of PPI used and the use of nonsteroidal anti-inflammatory drugs.


title: Mutation of Asn28 disrupts the dimerization and enzymatic activity of SARS 3CL(pro) .

text: Coronaviruses are responsible for a significant proportion of annual respiratory and enteric infections in humans and other mammals. The most prominent of these viruses is the severe acute respiratory syndrome coronavirus (SARS-CoV) which causes acute respiratory and gastrointestinal infection in humans. The coronavirus main protease, 3CL(pro), is a key target for broad-spectrum antiviral development because of its critical role in viral maturation and high degree of structural conservation among coronaviruses. Dimerization is an indispensable requirement for the function of SARS 3CL(pro) and is regulated through mechanisms involving both direct and long-range interactions in the enzyme. While many of the binding interactions at the dimerization interface have been extensively studied, those that are important for long-range control are not well-understood. Characterization of these dimerization mechanisms is important for the structure-based design of new treatments targeting coronavirus-based infections. Here we report that Asn28, a residue 11 A from the closest residue in the opposing monomer, is essential for the enzymatic activity and dimerization of SARS 3CL(pro). Mutation of this residue to alanine almost completely inactivates the enzyme and results in a 19.2-fold decrease in the dimerization K(d). The crystallographic structure of the N28A mutant determined at 2.35 A resolution reveals the critical role of Asn28 in maintaining the structural integrity of the active site and in orienting key residues involved in binding at the dimer interface and substrate catalysis. These findings provide deeper insight into complex mechanisms regulating the activity and dimerization of SARS 3CL(pro).


title: Incidence of postoperative death and acute kidney injury associated with i.v. 6% hydroxyethyl starch use: systematic review and meta-analysis.

text: BACKGROUND Trials suggest that the use of i.v. hydroxyethyl starch (HES) solutions is associ-ated with increased risk of death and acute kidney injury (AKI) in critically ill patients. It is uncertain whether similar adverse effects occur in surgical patients. METHODS Systematic review and meta-analysis of trials in which patients were randomly allocated to 6% HES solutions or alternative i.v. fluids in patients undergoing surgery. Ovid Medline, Embase, Cinhal, and Cochrane Database of Systematic Reviews were searched for trials comparing 6% HES with clinically relevant non-starch comparator. The primary end-point was hospital mortality. Secondary endpoints were requirement for renal replacement therapy (RRT) and author-defined AKI. Pre-defined subgroups were cardiac and non-cardiac surgery. RESULTS Four hundred and fifty-six papers were identified; of which 19 met the inclusion criteria. In total, 1567 patients were included in the analysis. Dichotomous outcomes were expressed as a difference of proportions [risk difference (RD)]. There was no difference in hospital mortality [RD 0.00, 95% confidence interval (CI) -0.02, 0.02], requirement for RRT (RD -0.01, 95% CI -0.04, 0.02), or AKI (RD 0.02, 95% CI -0.02 to 0.06) between compared arms overall or in predefined subgroups. CONCLUSIONS We did not identify any differences in the incidence of death or AKI in surgical patients receiving 6% HES. Included studies were small with low event rates and low risk of heterogeneity. Narrow CIs suggest that these findings are valid. Given the absence of demonstrable benefit, we are unable to recommend the use of 6% HES solution in surgical patients.


title: Exhaled air dispersion and removal is influenced by isolation room size and ventilation settings during oxygen delivery via nasal cannula.

text: BACKGROUND AND OBJECTIVE We compared the exhaled air dispersion distances during oxygen delivery via nasal cannula to a human-patient simulator (HPS) in two different isolation rooms. METHODS Airflow was marked with intrapulmonary smoke for visualization. Oxygen flow was gradually increased from 1 to 5 L/min, with the HPS sitting at 45°. The leakage jet plume was revealed by laser light-sheet and images captured by high-definition video. Smoke concentration in the plume was estimated from the light scattered by smoke particles. The experiments were conducted at a double-door, negative pressure isolation room with a dimension of 4.1 × 5.1 × 2.6 m, pressure of -7.4 Pa and 16 air exchanges/h (ACH) (room A). Results were compared with experiments repeated in a smaller isolation room with a dimension of 2.7 × 4.2 × 2.4 m, pressure of -5 Pa and 12 ACH (room B). RESULTS Room A: an exhalation jet spread almost horizontally outward from the nostrils of the HPS to 0.66 m and 1 m towards the end of bed when oxygen flow was increased from 1 to 5 L/min respectively. Room B: there was interaction between the downward ceiling ventilation current and the exhaled air from the HPS, leading to deflection of exhaled smoke towards the head of the HPS at an oxygen flow rate of 1 L/min. As oxygen flow was increased gradually to 5 L/min, more room contamination with smoke was noted. CONCLUSIONS Substantial exposure to exhaled air occurs within 1 m towards the end of the bed from patients receiving oxygen via nasal cannula. Room dimension and air exchange rate are important factors in preventing contamination in isolation rooms.


Covid-19: New government study aims to track infection and immunity in population.


title: Virulence factor-activity relationships: workshop summary.

text: The concept or notion of virulence factor-activity relationships (VFAR) is an approach for identifying an analogous process to the use of qualitative structure-activity relationships (QSAR) for identifying new microbial contaminants. In QSAR, it is hypothesized that, for new chemical contaminants, their potential acute or chronic toxicity may be reasonably estimated on the basis of structural relationships to other known toxic contaminants. Thus the parallel that is being attempted for pathogenic microorganisms is that known virulence factors may be used as predictors for identifying undiscovered pathogens and microbial causes of emerging diseases. Advances in molecular biology, genomics and proteomics have led the Committee on Drinking Water Contaminants of the National Research Council, as requested by the EPA, to recommend the VFAR approach as a potentially more systematic and scientific process for the selection of microorganisms for inclusion in the Contaminant Candidate List (CCL).


title: Survey of the 2009 commercial optical biosensor literature.

text: We took a different approach to reviewing the commercial biosensor literature this year by inviting 22 biosensor users to serve as a review committee. They set the criteria for what to expect in a publication and ultimately decided to use a pass/fail system for selecting which papers to include in this year's reference list. Of the 1514 publications in 2009 that reported using commercially available optical biosensor technology, only 20% passed their cutoff. The most common criticism the reviewers had with the literature was that "the biosensor experiments could have been done better." They selected 10 papers to highlight good experimental technique, data presentation, and unique applications of the technology. This communal review process was educational for everyone involved and one we will not soon forget.


Telemedicine and e-Health Solutions for COVID-19: Patients' Perspective.


title: Effectiveness and safety of mouthpiece ventilation and nocturnal non-invasive ventilation in patients with kyphoscoliosis: Short and long-term outcomes after an episode of acute respiratory failure.

text: BACKGROUND Kyphoscoliosis is a skeletal condition involving the hyperflexion of the thoracic spine. It is characterized by reduced chest wall compliance and impaired respiratory mechanisms leading to progressive hypo-ventilation. We evaluated the effectiveness and the safety of non-invasive ventilation (NIV) in patients after an episode of acute respiratory failure (ARF). METHODS Eighteen patients with severe kyphoscoliosis who had been hospitalized for an episode of ARF were followed for 4 years. NIV was applied via mouthpiece (MPV) during the daytime and via mask during the night. The primary outcomes were changes in physiological and functional parameters as well as quality of life. Secondary outcomes were considered re-hospitalization and mortality rate after discharge. A set of control subjects was used for comparison. RESULTS All patients showed a significant improvement in several clinical, physiological, functional and quality of life parameters. Four of them (22.2%) died during the four year follow-up period. In the uni-variate analysis patients who died had higher cardiac co-morbidity, lower MIP and SNIP, higher paCO2, and oxygen desaturation index at initial admission. CONCLUSIONS Diurnal MPV associated with nocturnal NIV had significantly improved lung function, clinical outcomes and quality of life. It should be considered as a safe alternative to traditional administering of NIV.


Short-term stress-related increasing cases of alopecia areata during the COVID-19 pandemic.


title: CD44/CD24 expression in recurrent gastric cancer: a retrospective analysis.

text: BACKGROUND To correlate CD44/CD24 expression with gastric cancer recurrence and prognosis. Gastric cancer is the second leading cause of cancer mortality due to the high recurrence rate, of which the molecular signature has not yet been identified. METHODS We retrospectively reviewed the hospital records of patients with gastric cancer. Among 500 patients receiving curative resection, 95 patients had recurrence. Twenty patients from the recurrence group (95 patients) and 20 patients from the non-recurrence group (405 patients) were randomly selected and identified as "study" and "control" groups, respectively. We reviewed patients' histological study of CD44/CD24 expression by performing immunohistochemistry and recurrence rate. RESULTS Study group had higher TNM stage (III-IV) than control group (80% vs. 25%, P = 0.001). Proportion of lymph node metastasis was significantly higher in study group than that in control group (90% vs. 45%, P = 0.002), and proportion of patients with 5 or more metastatic lymph nodes was also significantly higher in study group than in control group (45% vs. 15%, P = 0.007). Univariate analysis revealed no difference in risk of gastric cancer recurrence between CD44+ and CD44- patients (OR = 1.00, 95% CI: 0.29-3.45, P =1.000). CD24+ patients showed no greater significance of gastric cancer recurrence than CD24- patients (OR = 1.86, 95% CI: 0.52-6.61, P = 0.339). After adjusting for other risk factors, the association of CD44 expression (aOR = 0.66, 95% CI: 0.10-4.26, P = 0.658), CD24 expression (aOR = 0.09, 95% CI: 0.01-1.35, P = 0.081) or combined (CD44/CD24) with gastric cancer recurrence were not significant. CONCLUSION Neither individual expression of CD24 or CD44, nor combined expression of CD44/CD24 was associated with recurrence of gastric carcinoma.


title: Partial Sequence of a Novel Virus Isolated from Pelodiscus sinensis Hemorrhagic Disease.

text: Outbreaks of hemorrhagic syndrome-like disease with high mortality rates have frequently occurred in Pelodiscus sinensis farms. The purpose of this study was to investigate the pathogen through challenge infection assays and partial sequencing of the genome of the pathogen. A 453-bp amplicon was obtained by random PCR using the nucleic acid extracted from the tissue homogenate filtrate and showed 32% identity at the amino acid level with the replicase polyprotein of the porcine reproductive and respiratory syndrome virus by Blastx. Multiple alignments indicated the putative protein sequence has some similarities to the replicase polyprotein of Arteriviridae, and the phylogenetic tree showed it was closely related to equine arteritis virus. This sequence was found in the lung of the diseased P. sinensis by in situ hybridization. Dot blot hybridization and quantitative RT-PCR showed that the lung had the highest content of virus. The peak replication of P. sinensis hemorrhagic syndrome virus (TSHSV) in the lung occurred 4 days after infection. The ribonucleic nature of the viral genome was confirmed by RNase A or DNase I treatments. We named the virus TSHSV in this study as P. sinensis is also known as Trionyx sinensis. These results provide a fundamental basis for further understanding the biology and the molecular mechanisms of TSHSV.


title: Advances in multiparametric molecular diagnostics technologies for respiratory tract infections.

text: PURPOSE OF REVIEW Respiratory tract infections (RTIs) are caused by a variety of bacterial, viral, fungal, and other pathogens and cause millions of deaths each year. Current standard microbiological culture-based tests are laborious and time consuming. Thus, patients are initially treated empirically, leading to inappropriate use of antibiotics. The purpose of this article is to provide clinicians and scientists with a review of recently available commercial multiparametric molecular diagnostics tests for the detection of RTIs so that they can be considered for use instead of, or in combination with, traditional culture techniques. RECENT FINDINGS Several technologies have become commercially available for the multiparametric molecular detection of RTIs in the past decade including tests based on PCR-array, PCR-mass spectrometry, and multiplex qPCR technologies. The majority of these tests are for the detection of viruses, but more recently companies have begun to focus on detection of viruses, bacteria, and associated drug resistances in a single product to maximize the information provided to the clinician by a single test. SUMMARY We describe the recent advances in commercial multiparametric molecular diagnostics technologies for the diagnosis of RTIs. Combining the specific and sensitive molecular detection of bacteria, viruses, fungi, and drug resistances is key if molecular methods are to replace traditional culture. The reliability of the molecular drug-resistance markers chosen, the need for the quantitative detection of some organisms, and throughput are also important considerations for new technology developers.