title: Posterior wall capture and femoral artery stenosis following use of StarClose closing device: diagnosis and therapy.

text: A case of femoral artery obstruction following application of a StarClose type arterial puncture closing device (APCD) is presented. Ultrasonographic and angiographic imaging of this complication was obtained. The posterior wall of the vessel was accidentally caught in the anchoring element of the nitinol clip. This complication was successfully resolved by endovascular treatment and the implantation of a stent.


title: Endoscopic ultrasound-guided inoculation of transmissible venereal tumor in the colon: A large animal model for colon neoplasia.

text: BACKGROUND To develop and evaluate the feasibility of emerging interventions, animal models with accurate anatomical environment are required. OBJECTIVES We aimed to establish a clinically relevant colorectal tumor model with canine transmissible venereal tumor (CTVT) utilizing endoscopic ultrasound (EUS) imaging guidance. DESIGN Survival study using a canine model. SETTING Endoscopic animal research laboratory at a tertiary cancer center. MATERIALS AND METHODS This study involved five canines. INTERVENTIONS A colorectal tumor model was established and evaluated in five canines under cyclosporine immune suppression. Under endoscopic imaging guidance, saline was injected into the submucosal layer forming a bleb. Subsequently, CTVT was inoculated into the bleb under EUS guidance. Endoscopy was the primary method of assessing tumor growth. Tumors developed in 60-130 days. Upon detection of lesions >1 cm, the animals were euthanized and the tumors were harvested for histopathological characterization. MAIN OUTCOME MEASUREMENTS Success rate of tumor growth. The presence or absence of vasculature inside tumors. RESULTS Colorectal tumor successfully developed in three out of the five animals (60%). Among the ones with tumor growth, average inoculated CTVT volume, incubation time, and tumor size was 1.8 cc, 65.7 days, and 2.0 cm, respectively. The two animals without tumor growth were observed for >100 days. In all the tumors, vascular structure was characterized with CD31 imunohistochemical stain. LIMITATIONS Small number of animals. CONCLUSION We succeeded in creating a new colorectal tumor canine model with CTVT utilizing EUS.


title: Evidence mapping based on systematic reviews of therapeutic interventions for gastrointestinal stromal tumors (GIST).

text: BACKGROUND Gastrointestinal Stromal Tumours (GISTs) are the most common mesenchymal tumours. Currently, different pharmacological and surgical options are used to treat localised and metastatic GISTs, although this research field is broad and the body of evidence is scattered and expanding. Our objectives are to identify, describe and organise the current available evidence for GIST through an evidence mapping approach. METHODS We followed the methodology of Global Evidence Mapping (GEM). We searched Pubmed, EMBASE, The Cochrane Library and Epistemonikos in order to identify systematic reviews (SRs) with or without meta-analyses published between 1990 and March 2016. Two authors assessed eligibility and extracted data. Methodological quality of the included systematic reviews was assessed using AMSTAR. We organised the results according to identified PICO questions and presented the evidence map in tables and a bubble plot. RESULTS A total of 17 SRs met eligibility criteria. These reviews included 66 individual studies, of which three quarters were either observational or uncontrolled clinical trials. Overall, the quality of the included SRs was moderate or high. In total, we extracted 14 PICO questions from them and the corresponding results mostly favoured the intervention arm. CONCLUSIONS The most common type of study used to evaluate therapeutic interventions in GIST sarcomas has been non-experimental studies. However, the majority of the interventions are reported as beneficial or probably beneficial by the respective authors of SRs. The evidence mapping is a useful and reliable methodology to identify and present the existing evidence about therapeutic interventions.


title: Screening of FDA-Approved Drugs for Treatment of Emerging Pathogens.

text: The current outbreaks of Middle East Respiratory Syndrome (MERS) and Ebolavirus (EboV) have revealed a gap in the development and availability of drugs to treat these infections. To date, there are no approved treatments for patients infected with MERS coronavirus (MERS-CoV), a virus that continues to infect new patients and that has now spread from the Middle East to Asia. Despite a downward trend in the number of new EboV cases in West Africa, new infections are still occurring, and many patients continue to suffer from this illness. People infected with MERS and Ebola viruses receive only supportive care in hopes of recovery. Investigation into repurposing drugs approved by the FDA is gaining interest. To identify better treatment strategies, several groups have used drug screens to repurpose FDA-approved drugs as inhibitors of MERS-CoV and EboV.


title: Outcomes Are Not Different between Patients with Intermediate and High DWI-ASPECTS after Stent-Retriever Embolectomy for Acute Anterior Circulation Stroke.

text: BACKGROUND AND PURPOSE Questions remain as to what benefits embolectomy provides to patients presented with considerable early ischemic changes on baseline imaging studies. This study aimed to investigate the impact of the Alberta Stroke Program Early CT Score applied to DWI on treatment outcomes in patients with acute stroke undergoing stent-retriever embolectomy. MATERIALS AND METHODS We retrospectively analyzed the clinical and DWI data from 171 patients with acute anterior circulation stroke who were treated with stent-retriever embolectomy within 6 hours of symptom onset. DWI-ASPECTS scores were analyzed with the full scale or were dichotomized (4-6 versus 7-10). Patients with DWI-ASPECTS ≤3 were excluded from the study. Associations between outcome and clinical and radiologic factors were determined with a multivariate logistic regression analysis. A good outcome was defined as a modified Rankin Scale score of 0-2 at 3 months. RESULTS The median DWI-ASPECTS was 7 (interquartile range, 6-8). The rates of good outcome, symptomatic hemorrhage, and mortality were not different between high DWI-ASPECTS (scores of 7-10) and intermediate DWI-ASPECTS (scores of 4-6) groups. In patients with an intermediate DWI-ASPECTS, good outcome was achieved in 46.5% (20/43) of patients with successful revascularization, whereas no patients without successful revascularization had a good outcome (P = .016). In multivariate logistic regression analysis, independent predictors of good outcome were age and successful revascularization. CONCLUSIONS Our study suggested that there were no differences in outcomes between patients with a high DWI-ASPECTS and those with an intermediate DWI-ASPECTS who underwent stent-retriever embolectomy for acute anterior circulation stroke. Thus, patients with an intermediate DWI-ASPECTS otherwise eligible for endovascular therapy may not be excluded from stent-retriever embolectomy or stroke trials.


title: Outcome Following Partial Unilateral Hysterectomy by Standing Flank Approach in Dairy Cattle.

text: OBJECTIVE To describe the clinical findings, surgical treatment, and long-term outcome of dairy cattle undergoing partial hysterectomy with or without unilateral ovariectomy. STUDY DESIGN Retrospective case series. ANIMALS Dairy cattle (n = 7). METHODS Medical records (June 2007-June 2014) of dairy cattle that had partial hysterectomy with or without ipsilateral ovariectomy were reviewed. Follow-up data were obtained by telephone interviews with owners and referring veterinarians between 6 months and 7 years following discharge. RESULTS Seven dairy cattle met the inclusion criteria. Diagnoses made intra- or postoperatively were ovarian abscess with multiorgan adhesions (4 cows), segmental aplasia of the uterus (2 cows), and uterine lymphosarcoma (1 cow). Partial hysterectomy with or without unilateral ovariectomy was performed without surgical complications by standing flank approach. All cows were successfully discharged from the hospital (short-term prognosis). Five cows became pregnant, and 4 delivered live calves and had a satisfactory productive life without long-term complications. CONCLUSION Partial hysterectomy by standing flank approach should be considered as a viable treatment option for unilateral ovarian or uterine problems in dairy cattle. Cattle undergoing partial hysterectomy with or without ipsilateral ovariectomy are capable of satisfactory reproduction and milk production after surgery with no short- or long-term complications.


title: A direct aspiration first pass technique for retrieval of a detached coil.

text: A 64-year-old man was referred to our hospital for treatment of a cerebral aneurysm that was incidentally found. The aneurysm was 7 mm in size and located on the left anterior communicating artery. Using a balloon assisted technique, we performed coil embolization. During the second coil insertion, the first coil was dislodged into the anterior communicating artery. We attempted coil retrieval using a snare, which was unsuccessful. We applied a direct aspiration first pass technique (ADAPT) and advanced a Penumbra 4MAX immediately proximal to the dislodged coil; the dislodged coil was then successfully retrieved. ADAPT is a simple procedure for retrieval of a detached coil, and it can be used as an alternative to the snare technique.


title: The impact of maternal prenatal and postnatal anxiety on children's emotional problems: a systematic review.

text: Maternal mental health problems during pregnancy and the postnatal period are a major public health issue. Despite evidence that symptoms of both depression and anxiety are common during pregnancy and the postpartum, the impact of maternal anxiety on the child has received relatively less attention than the impact of maternal depression. Furthermore, the evidence base for the direct impact of maternal anxiety during pregnancy and the postpartum on children's emotional outcomes lacks cohesion. The aim of this systematic review is to summarise the empirical evidence regarding the impact of maternal prenatal and postnatal anxiety on children's emotional outcomes. Overall, both maternal prenatal and postnatal anxiety have a small adverse effect on child emotional outcomes. However, the evidence appears stronger for the negative impact of prenatal anxiety. Several methodological weaknesses make conclusions problematic and replication of findings is required to improve the identification of at-risk parents and children with appropriate opportunities for intervention and prevention.


title: FIRST CASE OF CORONAVIRUS DISEASE 2019 IN CHILDHOOD LEUKEMIA IN CHINA.

text: We report the first case of coronavirus disease 2019 (COVID-19) comorbid with leukemia in a patient hospitalized in Beijing, China. The patient showed a prolonged manifestation of symptoms and a protracted diagnosis period of COVID-19. It is necessary to extend isolation time, increase the number of nucleic acid detections and conduct early symptomatic treatment for children with both COVID-19 and additional health problems.


title: Tinkering with translation: protein synthesis in virus-infected cells.

text: Viruses are obligate intracellular parasites, and their replication requires host cell functions. Although the size, composition, complexity, and functions encoded by their genomes are remarkably diverse, all viruses rely absolutely on the protein synthesis machinery of their host cells. Lacking their own translational apparatus, they must recruit cellular ribosomes in order to translate viral mRNAs and produce the protein products required for their replication. In addition, there are other constraints on viral protein production. Crucially, host innate defenses and stress responses capable of inactivating the translation machinery must be effectively neutralized. Furthermore, the limited coding capacity of the viral genome needs to be used optimally. These demands have resulted in complex interactions between virus and host that exploit ostensibly virus-specific mechanisms and, at the same time, illuminate the functioning of the cellular protein synthesis apparatus.


title: Detection of respiratory viruses among pilgrims in Saudi Arabia during the time of a declared influenza A(H1N1) pandemic.

text: BACKGROUND The objectives of this study were to determine whether pilgrim attendance at the Hajj was associated with an increased risk of acquiring influenza, and other respiratory viruses, and to evaluate the compliance of pilgrims with influenza vaccination and other recommended preventive measures. METHODS A cross-sectional survey was conducted among pilgrims as they arrived at the King Abdulaziz International Airport in Jeddah for the 2009 Hajj and as they departed from the same airport during the week after the Hajj. Nasopharyngeal and throat swabs were tested for 18 respiratory virus types and subtypes using the xTAG Respiratory Viral Panel FAST assay. RESULTS A total of 519 arriving pilgrims and 2,699 departing pilgrims were examined. Their mean age was 49 years and 58% were male. In all, 30% of pilgrims stated that they had received pandemic influenza A(H1N1) vaccine before leaving for the Hajj and 35% of arriving pilgrims reported wearing a face mask. Only 50% of arriving pilgrims were aware of preventive measures such as hand hygiene and wearing a mask. The prevalence of any respiratory-virus infection was 14.5% (12.5% among arriving pilgrims and 14.8% among departing pilgrims). The main viruses detected (both groups combined) were rhinovirus-enterovirus (N = 414, 12.9%), coronaviruses (N = 27, 0.8%), respiratory syncytial virus (N = 8, 0.2%), and influenza A virus (N = 8, 0.2%) including pandemic influenza A(H1N1) (N = 3, 0.1%). The prevalence of pandemic influenza A(H1N1) was 0.2% (N = 1) among arriving pilgrims and 0.1% (N = 2) among departing pilgrims. The prevalence of any respiratory virus infection was lower among those who said they received H1N1 vaccine compared to those who said they did not receive it (11.8% vs 15.6%, respectively, p = 0.009). CONCLUSION We found very low pandemic influenza A(H1N1) prevalence among arriving pilgrims and no evidence that amplification of transmission had occurred among departing pilgrims.


title: Single-layer versus double-layer closure of the vaginal cuff with barbed sutures in laparoscopic hysterectomy.

text: OBJECTIVES The utilization of barbed sutures in laparoscopic hysterectomy has become popular among gynecologic sur-geons. Our aim was to compare the outcomes of two different techniques for closing the vaginal cuff with barbed sutures in laparoscopic hysterectomies. MATERIAL AND METHODS A retrospective study was completed on 202 patients who underwent laparoscopic hysterectomy for benign diseases at Istanbul Kanuni Sultan Suleyman Training and Research Hospital from April 2014 through June 2016. In group 1 (n = 139), a single-layer continuous suturing method was used; each bite contained the pubocervical fascia and vaginal mucosa anteriorly, and vaginal mucosa and rectovaginal fascia posteriorly. In group 2 (n = 63), a double-layer continuous suturing method was used; only vaginal mucosa was included in the first layer, and a second layer incorporated the pubocervical and rectovaginal fascias. RESULTS Patient characteristics (age, body mass index, parity, previous abdominal surgery, smoking, comorbidity) were similar between the two groups. There were also no differences in total operation time, length of hospitalization, intraop-erative complications, and perioperative change in hemoglobin levels. There was no difference between the two groups in terms of vaginal cuff dehiscence, which was the primary outcome measure of the study. Secondary outcome measures (presence of granulation tissue, spotting, cuff cellulitis) were also similar between the two groups. CONCLUSIONS We observed no differences in outcomes between single- or double-layer vaginal closure techniques with barbed sutures.


title: Initial experience with the AXERA 2 Femoral Access System in neurovascular procedures.

text: INTRODUCTION Conventional cerebral angiography is a commonly performed procedure in medicine. Vascular closure devices have been developed as alternatives to manual compression at the arteriotomy site and prolonged bed rest. The risks of using these devices include arterial dissection, groin hematoma, and device failure. Herein, we describe our experience with the use of a novel device used for arterial access and closure, the AXERA 2 Access System. METHODS A total of 13 patients underwent vascular access and closure with the AXERA 2 Access System. RESULTS Arterial access using the AXERA 2 Access System was achieved in 11 of 13 patients. Amongst the patients with successful access, one patient experienced a groin hematoma requiring manual compression and two patients suffered occlusions of the common femoral artery due to dissections, with both patients requiring femoral artery thromboendarterectomies. CONCLUSIONS This small series highlights a heretofore underreported serious complication rate of the AXERA 2 Access System. Additional studies are warranted to provide further insight into risk factors for device failure and complication development.


title: Endovascular Thrombectomy for Acute Ischemic Stroke.

text: PURPOSE OF REVIEW To review the current evidence supporting the use of endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO). RECENT FINDINGS Recent advances in AIS management by EVT have led to significant reduction in morbidity and mortality in selected patients with LVO within the anterior circulation. Until recently, use of EVT was strictly based on time criteria, within 4.5 to 12 h of symptom onset with many patients presenting with "wake-up" stroke who were not considered for EVT. The positive results of the DAWN and DEFUSE-3 trials have shown benefit in extending the therapeutic window for EVT to 24 and 16 h, respectively, after last known normal (LKN) time in the setting of large ischemic penumbra. These trials represent a paradigm shift in contemporary treatment of AIS, changing from a purely time-based decision to treat to an individualized decision based on clinical and radiographic findings of salvageable tissue. Overall, acute stroke management has evolved considerably over the years from intravenous thrombolysis to include EVT, with paralleled improvements in patient selection and thrombectomy devices. Since the results of the DAWN and DEFUSE-3, EVT is now considered the standard of care in select patients with anterior circulation LVO up to 24 h from LKN time. Despite these developments, post-stroke disability remains pervasive and further studies are warranted in establishing the role of EVT in posterior circulation and distal vessel occlusions, with need for development of new and effective techniques for revascularization of small vessels.


title: Robotic valvuloplastic esophagogastrostomy using double flap technique following proximal gastrectomy: technical aspects and short-term outcomes.

text: BACKGROUND Valvuloplastic esophagogastrostomy by double flap technique (VEG-DFT) is a promising procedure to prevent reflux after proximal gastrectomy (PG), and is achieved by the burial of the abdominal esophagus into the gastric submucosa; however, laparoscopic VEG-DFT is technically demanding due to complicated suturing and ligation maneuvers. The present study was designed to determine the feasibility and safety of robotic VEG-DFT. METHODS After robotic PG, seromuscular flaps were extracorporeally created at the anterior wall of the remnant stomach through a small umbilical incision. Then, using a robot, the posterior wall of the esophagus was fixed to the cranial end of the mucosal window, and layer-to-layer sutures were placed between the anterior aspects of esophagus and the remnant stomach. Finally, the anastomosis was covered by seromuscular flaps. Short-term outcomes of 12 consecutive patients who underwent VEG-DFT between January 2014 and December 2015 were assessed. RESULTS Operations were successfully completed using robotic assistance in all patients. Median operative, surgeon console, and anastomosis times were 406 (324-613 min), 267 (214-483), and 104 (76-186) min, respectively, and median estimated blood loss was 31 (5-130) ml. The first six cases were required to reach a learning plateau. Both mortality and morbidity rates within 30 days after surgery were 0%. Postoperative hospital stay was 10 (9-30) days. No postoperative reflux esophagitis was observed, whereas anastomotic stenosis, which required endoscopic balloon dilation, developed in three patients (25%) in postoperative month 2. There was a significant association between the total number of stitches used for VEG-DFT and anastomotic stenosis (p < 0.001). CONCLUSIONS Robotic assistance may be useful for VEG-DFT with a short learning curve. Attention is required to prevent postoperative anastomotic stenosis possibly caused by an excessive number of stitches for esophagogastrostomy.


title: Parastomal hernia repair outcomes in relation to stoma site with diisocyanate cross-linked acellular porcine dermal collagen mesh.

text: PURPOSE Biologic meshes are increasingly used in parastomal hernia repair. This study evaluates the efficacy and safety of diisocyanate cross-linked acellular porcine dermal collagen mesh for parastomal hernia repair, with particular reference to the relationship of the stoma site to the rectus sheath. METHODS Hernias were repaired via a lateral approach, with onlay placement of the biologic mesh. A retrospective case note review and analysis of clinical outcomes was performed. The relationship of the stoma to the rectus sheath was determined by abdominal computed tomography (CT) and intraoperative findings. RESULTS Over a 16-month period, 27 consecutive patients, median age 72 years, underwent parastomal hernia repair utilising onlay biologic mesh to reinforce the external oblique aponeurosis. There were 20 paracolostomy and seven paraileostomy hernias. Eleven stomas passed through the rectus sheath and 16 were lateral to it. Recurrences occurred in 3 of 11 stomas within and 12 of 16 stomas lateral to the rectus sheath (P = 0.022). The median time to recurrence was 10.1 months. The median follow up of patients without recurrence was 16.6 months (range 0.2-39.3). There was one perioperative death. One patient developed a superficial post-operative abscess that was managed conservatively, but there were no complications related to the biologic mesh and no mesh required removal. CONCLUSIONS For parastomal hernias within the rectus sheath, diisocyanate cross-linked porcine dermal collagen mesh onlay repair gives good results and is safe to use. Repair of a parastomal hernia where the stoma is lateral to the rectus sheath has a significantly higher risk of recurrence and is not recommended.


Debrief: Joining the cult.


title: Everolimus Plus Endocrine Therapy for Postmenopausal Women With Estrogen Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer: A Clinical Trial.

text: Importance Cotargeting the mammalian target of rapamycin pathway and estrogen receptor may prevent or delay endocrine resistance in patients receiving first-line treatment for advanced breast cancer. Objective To investigate the combination of everolimus plus endocrine therapy in first-line and second-line treatment settings for postmenopausal women with estrogen receptor-positive, human epidermal growth receptor 2-negative advanced breast cancer. Design, Setting, and Participants In the multicenter, open-label, single-arm, phase 2 BOLERO-4 (Breast Cancer Trials of Oral Everolimus) clinical trial, 245 patients were screened for eligibility; 202 were enrolled between March 7, 2013, and December 17, 2014. A median follow-up of 29.5 months had been achieved by the data cutoff date (December 17, 2016). Interventions Patients received first-line treatment with everolimus, 10 mg/d, plus letrozole, 2.5 mg/d. Second-line treatment with everolimus, 10 mg/d, plus exemestane, 25 mg/d, was offered at the investigator's discretion upon initial disease progression. Main Outcomes and Measures The primary end point was investigator-assessed progression-free survival in the first-line setting per Response Evaluation Criteria in Solid Tumors, version 1.0. Safety was assessed in patients who received at least 1 dose of study medication and at least 1 postbaseline safety assessment. Results A total of 202 women treated in the first-line setting had a median age of 64.0 years (interquartile range, 58.0-70.0 years) with metastatic (194 [96.0%]) or locally advanced (8 [4.0%]) breast cancer. Median progression-free survival was 22.0 months (95% CI, 18.1-25.1 months) with everolimus and letrozole. Median overall survival was not reached; 24-month estimated overall survival rate was 78.7% (95% CI, 72.1%-83.9%). Fifty patients started second-line treatment; median progression-free survival was 3.7 months (95% CI, 1.9-7.4 months). No new safety signals were observed. In the first-line setting, the most common all-grade adverse event was stomatitis (139 [68.8%]); the most common grade 3 to 4 adverse event was anemia (21 [10.4%]). In the second-line setting, the most common adverse events were stomatitis and decreased weight (10 [20.0%] each); the most common grade 3 to 4 adverse event was hypertension (5 [10.0%]). There were 50 (24.8%) deaths overall during the study; 40 were due to study indication (breast cancer). Conclusions and Relevance The results of this trial add to the existing body of evidence suggesting that everolimus plus endocrine therapy is a good first-line treatment option for postmenopausal women with estrogen receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer. Trial Registration clinicaltrials.gov Identifier: NCT01698918.


title: Contrast media use in the operating room.

text: Iodinated contrast media is frequently used in the OR, but often is not well understood by health care providers who are administering it. Although used for diagnosis rather than treatment, contrast media is classified as a drug by the FDA, and has indications, contraindications, adverse effects, drug interactions, disease interactions, and laboratory interference issues related to its use. Iodinated contrast media is classified according to osmolarity and ionicity, and these characteristics contribute to potential for adverse effects and choice of agent. Financial and safety concerns are factors to be considered when selecting an appropriate agent. Adverse effects can range from mild and self-limited to severe and life threatening; potentially the most serious of these are anaphylactoid reactions and contrast-induced acute renal failure. Knowledge of risk factors and preventive strategies is vital, as are issues related to substitution of gadolinium-based contrast, an off-label use. It is important for the perianesthesia nurse to become familiar with these commonly used imaging medications.


title: Effect of IV alteplase on the ischemic brain lesion at 24-48 hours after ischemic stroke.

text: OBJECTIVE To determine whether alteplase alters the development of ischemic lesions on brain imaging after stroke. METHODS The Third International Stroke Trial (IST-3) was a randomized controlled trial of IV alteplase for ischemic stroke. We assessed CT or brain MRI at baseline (pretreatment) and 24 to 48 hours posttreatment for acute lesion visibility, extent, and swelling, masked to all other data. We analyzed associations between treatment allocation, change in brain tissue appearances between baseline and follow-up imaging, and 6-month functional outcome in IST-3. We performed a meta-analysis of randomized trials of alteplase vs control with pre- and postrandomization imaging. RESULTS Of 3,035 patients recruited in IST-3, 2,916 had baseline and follow-up brain imaging. Progression in either lesion extent or swelling independently predicted poorer 6-month outcome (adjusted odds ratio [OR] = 0.92, 95% confidence interval [CI] 0.88-0.96, p < 0.001; OR = 0.73, 95% CI 0.66-0.79, p < 0.001, respectively). Patients allocated alteplase were less likely than controls to develop increased lesion visibility at follow-up (OR = 0.77, 95% CI 0.67-0.89, p < 0.001), but there was no evidence that alteplase reduced progression of lesion extent or swelling. In meta-analysis of 6 trials including IST-3 (n = 4,757), allocation to alteplase was associated with a reduction in ischemic lesion extent on follow-up imaging (OR = 0.85, 95% CI 0.76-0.95, p = 0.004). CONCLUSION Alteplase was associated with reduced short-term progression in lesion visibility. In meta-analysis, alteplase reduced lesion extent. These findings may indicate that alteplase improves functional outcome by reducing tissue damage. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that IV alteplase impedes the progression of ischemic brain lesions on imaging after stroke.


docid: caqxrcaz

title: The "Infodemic" of Journal Publication Associated with the Novel Coronavirus Disease.


title: Evolution and outcomes of sentinel lymph node mapping in vulvar cancer.

text: OBJECTIVES To characterize our institutional experience with sentinel lymph node (SLN) biopsy in patients with vulvar cancer. We describe the oncologic outcomes of these patients and the utilization of SLN detection techniques over time. METHODS A retrospective analysis of all patients who underwent inguinofemoral SLN biopsy as part of their treatment for vulvar cancer at Memorial Sloan Kettering Cancer Center from January 1, 2000 to April 1, 2019. Patients were included in this analysis if they underwent inguinofemoral SLN biopsy for vulvar cancer, irrespective of presenting factors such as histology, tumor size or laterality. An "at-risk groin" was defined as either the right or left groin for which SLN biopsy of inguinofemoral lymph nodes was performed. RESULTS A total of 160 patients were included in our analysis, representing 265 at-risk groins. 114 patients had squamous cell histology representing 195 at-risk groins. Of the 169 negative groins in patients with squamous cell carcinoma, the 2 year isolated groin recurrence rate was 1.2%. SLN detection rate, irrespective of modality, was 96.2%. Technetium-99 (TC-99) + blue dye detected SLNs in 91.8% of groins; TC-99 + indocyanine green detected SLNs in 100% of groins (p=0.157). Among the 110 groins that underwent mapping with TC-99 and blue dye, 4 patients had failed mapping with blue dye and mapped with TC-99 alone (3.6%). Among the 96 groins that underwent mapping with TC-99 and ICG, 14 patients failed to map with TC-99 and mapped with indocyanine green alone (14.6%). CONCLUSIONS SLN mapping in vulvar cancer is reliable and oncologically effective. The utilization of indocyanine green for mapping has increased over the past decade and is associated with high rates of SLN detection.


title: Differential Gene Expression in Coiled versus Flow-Diverter-Treated Aneurysms: RNA Sequencing Analysis in a Rabbit Aneurysm Model.

text: BACKGROUND AND PURPOSE The biologic mechanisms leading to aneurysm healing or rare complications such as delayed aneurysm ruptures after flow-diverter placement remain poorly understood. We used RNA sequencing following implantation of coils or flow diverters in elastase aneurysms in rabbits to identify genes and pathways of potential interest. MATERIALS AND METHODS Aneurysms were treated with coils (n = 5) or flow diverters (n = 4) or were left untreated for controls (n = 6). Messenger RNA was isolated from the aneurysms at 4 weeks following treatment. RNA samples were processed by using RNA-sequencing technology and were analyzed by using the Ingenuity Pathway Analysis tool. RESULTS With RNA sequencing for coiled versus untreated aneurysms, 464/9990 genes (4.6%) were differentially expressed (58 down-regulated, 406 up-regulated). When we compared flow-diverter versus untreated aneurysms, 177/10,041 (1.8%) genes were differentially expressed (8 down-regulated, 169 up-regulated). When we compared flow-diverter versus coiled aneurysms, 13/9982 (0.13%) genes were differentially expressed (8 down-regulated, 5 up-regulated). Keratin 8 was overexpressed in flow diverters versus coils. This molecule may potentially play a critical role in delayed ruptures due to plasmin production. We identified overregulation of apelin in flow diverters, supporting the preponderance of endothelialization, whereas we found overexpression of molecules implicated in wound healing (dectin 1 and hedgehog interacting protein) for coiled aneurysms. Furthermore, we identified metallopeptidases 1, 12, and 13 as overexpressed in coiled versus untreated aneurysms. CONCLUSIONS We observed different physiopathologic responses after endovascular treatment with various devices. Flow diverters promote endothelialization but express molecules that could potentially explain the rare delayed ruptures. Coils promote wound healing and express genes potentially implicated in the recurrence of coiled aneurysms.


title: Microscope transsphenoidal surgery.

text: BACKGROUND The transsphenoidal approach to the pituitary using the microscope has undergone continuous modification since its introduction by Hardy over 50 years ago. It is one of the most effective and safest of major neurosurgical procedures with excellent outcomes and low complication rates. METHODS Although being displaced by the endoscopic approach, it remains the 'gold standard' for a number of pituitary conditions such as Cushing's tumours, and for the majority of the remainder, has yet to be overtaken in outcome results by the endoscopic approach. CONCLUSION This description of the endonasal 'septal pushover' technique is from an author with experience in nearly 4,000 cases. The anatomy is described, and the step-by-step approach and tumour removal for micro- and pituitary macroadenomas are given. Complications and their avoidance are overviewed.


title: An Effective Case for Chyluria by Retroperitoneoscopic Lymphatic Disconnection.

text: BACKGROUND Chyluria is a rare disease in Japan. Lymphatic disconnection is the most effective treatment for patients with Chyluria, and laparoscopic approach is performed as a minimally invasive technique. CASE PRESENTATION We present a case of a 40-year-old man who referred to our hospital because of recurrence of chyluria. Chyluria had continued for 20 years, and the patient had received retrograde instillations of silver nitrate three times. The patient underwent retroperitoneoscopic nephrolympholysis, and the chyluria disappeared immediately. One year after surgery, chyluria has not recurred. CONCLUSION We treated a patient with chyluria by performing retroperitoneoscopic lymphatic disconnection and this procedure is less invasive and easy to perform.


ANNALS EXPRESS: Electrolyte Imbalances in Patients with Severe Coronavirus Disease 2019 (COVID-19).


docid: vklncncu

title: Aspergillus fumigatus and pan-azole resistance: who should be concerned?

text: PURPOSE OF REVIEW Although clinical outcomes in the treatment of aspergillosis have markedly improved with the availability of newer triazoles, the development of resistance to these antifungals, especially in Aspergillus fumigatus, is a growing concern. The purpose of this review is to provide an update on azole resistance mechanisms and their epidemiology in A. fumigatus, the clinical implications of azole resistance, and to discuss future treatment options against azole-resistant aspergillosis. RECENT FINDINGS Resistance may develop through either patient or environmental azole exposure. Environmental exposure is the most prevalent means of resistance development, and these isolates can cause disease in various at-risk groups, which now include those with influenza, and potentially COVID-19. Although current treatment options are limited, newer therapies are in clinical development. These include agents with novel mechanisms of action which have in vitro and in vivo activity against azole-resistant A. fumigatus. SUMMARY Azole-resistant A. fumigatus is an emerging threat that hampers our ability to successfully treat patients with aspergillosis. Certain geographic regions and patient populations appear to be at increased risk for this pathogen. As new patient groups are increasingly recognized to be at increased risk for invasive aspergillosis, studies to define the epidemiology and management of azole-resistant A. fumigatus are critically needed. While treatment options are currently limited, new agents under clinical development may offer hope.


title: The addition of capnography to standard monitoring reduces hypoxemic events during gastrointestinal endoscopic sedation: a systematic review and meta-analysis.

text: Background The use of capnography monitoring devices has been shown to lower the rates of hypoxemia via early detection of respiratory depression, and facilitate more accurate titration of sedatives during procedures. The aim of the current meta-analysis was to compare the incidence of hypoxemia associated with standard monitoring alone during gastrointestinal endoscopy to that associated with standard monitoring with the addition of capnography. Methods The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials scientific databases were searched to identify relevant studies. We performed a meta-analysis of randomized controlled trials undertaken up to January 2018 that met our predefined inclusion criteria. The study outcome measures were incidence of hypoxemia, severe hypoxemia, apnea, the use of assisted ventilation, the use of supplemental oxygen, and change in vital signs. Results We included nine trials assessing a total of 3,088 patients who underwent gastrointestinal procedural sedation. Meta-analysis of study outcome revealed that capnography significantly reduced the incidence of hypoxemia (odds ratio 0.61, 95% CI 0.49-0.77) and severe hypoxemia (odds ratio 0.53, 95% CI 0.35-0.81). However, there were no significant differences in other outcomes including incidence of apnea, assisted ventilation, supplemental oxygen, and changes in vital signs. Early procedure termination and patient satisfaction-related outcomes did not differ significantly in the capnography group and the standard monitoring group. Conclusion This study indicates that capnography monitoring is an important addition with regard to the detection of hypoxemia during gastrointestinal procedural sedation, and should be considered in routine monitoring during gastrointestinal endoscopy.


title: (18)F-FDG PET patterns and BAL cell profiles in pulmonary sarcoidosis.

text: PURPOSE Bronchoalveolar lavage (BAL) and (18)F-fluorodeoxyglucose ((18)F-FDG) PET can both demonstrate sarcoid activity. To assess whether metabolic activity imaged by (18)F-FDG PET represents signs of disease activity as reflected by BAL, (18)F-FDG PET patterns were compared with BAL cell profiles. METHODS In this retrospective analysis, 77 newly diagnosed pulmonary sarcoidosis patients underwent BAL and (18)F-FDG PET. Based on (18)F-FDG PET, patients were diagnosed with exclusively mediastinal/hilar activity (group A) and activity in the lung parenchyma (group B). Per group, BAL lymphocytes (%), CD4/CD8 ratio, CD103(+)CD4(+)/CD4(+) ratio and neutrophils (%) were compared with the extent of metabolic activity expressed as the maximum standardized uptake value (SUV(max)). Additionally, SUV(max) and BAL parameters per radiographic stage were analysed. RESULTS Overall, the SUV(max) in the lung parenchyma correlated with neutrophils and SUV(max) of the mediastinum/hila correlated with the CD4/CD8 ratio. In both groups, a significant, negative correlation between the SUV(max) of the mediastinum/hila and the CD103(+)CD4(+)/CD4(+) ratio was found. In group B, the SUV(max) of the mediastinum/hila correlated with the CD4/CD8 ratio, while the SUV(max) in the lung parenchyma correlated with the CD103(+)CD4(+)/CD4(+) ratio and neutrophils. Significant differences were found in the SUV(max), CD4/CD8 ratio, CD103(+)CD4(+)/CD4(+) ratio and neutrophils between the radiographic stages. The SUV(max) of the lung parenchyma was positively related to the radiographic stage, while the SUV(max) of the mediastinum/hila and CD4/CD8 ratio were inversely related. CONCLUSION (18)F-FDG PET correlates with the CD4/CD8 ratio and neutrophils, suggesting that (18)F-FDG PET represents this specific cell profile in BAL. High SUV(max) values of the lung parenchyma may therefore correlate with more severe parenchymal involvement, particularly when accompanied by a low SUV(max) of the mediastinum/hila.


Face masks could raise pollution risks.


docid: zgxuktuc

title: Development of a novel transgenic rat overexpressing the P2Y(2) nucleotide receptor using a lentiviral vector.

text: The G protein-coupled P2Y(2) nucleotide receptor (P2Y(2)R) is upregulated in response to stress and tissue injury and has been postulated to play a role in chronic inflammation seen in atherosclerosis, Alzheimer's disease and Sjogren's syndrome. The role of P2Y(2)R upregulation in vivo is poorly understood, in part due to the lack of a P2Y(2)R overexpressing animal model. The P2Y(2)R overexpressing transgenic rat was generated using a lentiviral vector. Rats overexpressing P2Y(2)R showed a significant increase in P2Y(2)R mRNA levels in all tissues screened as compared to nontransgenic rats. Fura 2 imaging of smooth muscle cells (SMCs) isolated from aorta indicated that the percentage of cells exhibiting increases in the intracellular free calcium concentration in response to P2Y(2)R agonists was significantly greater in freshly isolated SMCs from transgenic rats than wild-type controls. Histopathological examination of tissues revealed that P2Y(2)R overexpressing rats develop lymphocytic infiltration in lacrimal glands and kidneys as early as at 3 months of age. These rats show similarities to patients with Sjogren's syndrome who display lymphocyte-mediated tissue damage. This transgenic rat model of P2Y(2)R overexpression may prove useful for linking P2Y(2)R upregulation with chronic inflammatory diseases, neurodegenerative diseases and Sjogren's syndrome.


title: Endoluminal suturing of an anastomotic leak.

text: An anastomotic leak can be one of the most morbid and complex complications after esophagectomy. Typically, management can entail repair, stenting, or diversion. The leak complicates a patient's postoperative course and delays initiation of any adjuvant therapy. Novel minimally invasive tools created to expedite healing of the anastomotic leak may potentially limit additional procedures traditionally used to treat the leak. We present the case of a 49-year-old man who sustained an anastomotic leak 5 days after undergoing esophagectomy for cancer. He was initially managed with drainage, and when this failed, he was transferred to our hospital. An endoscopic suturing device was used to close the leak and pexy a partially covered self-expanding metal stent that was left in place for 2 weeks. At the end of 2 weeks, the leak healed and there was no stent migration.


title: Smartphone-Based Self-Testing of COVID-19 Using Breathing Sounds.

text: Telemedicine could be a key to control the world-wide disruptive and spreading novel coronavirus disease (COVID-19) pandemic. The COVID-19 virus directly targets the lungs, leading to pneumonia-like symptoms and shortness of breath with life-threatening consequences. Despite the fact that self-quarantine and social distancing are indispensable during the pandemic, the procedure for testing COVID-19 contraction is conventionally available through nasal swabs, saliva test kits, and blood work at healthcare settings. Therefore, devising personalized self-testing kits for COVID-19 virus and other similar viruses is heavily admired. Many e-health initiatives have been made possible by the advent of smartphones with embedded software, hardware, high-performance computing, and connectivity capabilities. A careful review of breathing sounds and their implications in identifying breathing complications suggests that the breathing sounds of COVID-19 contracted users may reveal certain acoustic signal patterns, which is worth investigating. To this end, acquiring respiratory data solely from breathing sounds fed to the smartphone's microphone strikes as a very appealing resolution. The acquired breathing sounds can be analyzed using advanced signal processing and analysis in tandem with new deep/machine learning and pattern recognition techniques to separate the breathing phases, estimate the lung volume, oxygenation, and to further classify the breathing data input into healthy or unhealthy cases. The ideas presented have the potential to be deployed as self-test breathing monitoring apps for the ongoing global COVID-19 pandemic, where users can check their breathing sound pattern frequently through the app.


title: Novel Coronavirus (COVID-19): What You Need to Know.

text: Much remains unknown about COVID-19. Occupational health nurses must use reliable sources to control misinformation and prevent widespread panic.


title: International palliative care research priorities: A systematic review.

text: BACKGROUND There has been increasing evidence and debate on palliative care research priorities and the international research agenda. To date, however, there is a lack of synthesis of this evidence, examining commonalities, differences, and gaps. To identify and synthesize literature on international palliative care research priorities originating from Western countries mapped to a quality assessment framework. METHODS A systematic review of several academic and grey databases were searched from January 2008-June 2019 for studies eliciting research priorities in palliative care in English. Two researchers independently reviewed, critically appraised, and conducted data extraction and synthesis. RESULTS The search yielded 10,235 articles (academic databases, n = 4108; grey literature, n = 6127), of which ten were included for appraisal and review. Priority areas were identified: service models; continuity of care; training and education; inequality; communication; living well and independently; and recognising family/carer needs and the importance of families. Methodological approaches and process of reporting varied. There was little representation of patient and caregiver driven agendas. The priorities were mapped to the Donabedian framework for assessing quality reflecting structure, process and outcomes and key priority areas. CONCLUSIONS Limited evidence exists pertaining to research priorities across palliative care. Whilst a broad range of topics were elicited, approaches and samples varied questioning the credibility of findings. The voice of the care provider dominated, calling for more inclusive means to capture the patient and family voice. The findings of this study may serve as a template to understand the commonalities of research, identify gaps, and extend the palliative care research agenda.


title: Endoscopic cyclophotocoagulation (ECP) for open angle glaucoma and primary angle closure.

text: BACKGROUND Glaucoma is a leading cause of irreversible blindness. A number of minimally invasive surgical techniques have been introduced as a treatment to prevent glaucoma progressing. Among them, endoscopic cyclophotocoagulation (ECP) is a cyclodestructive procedure developed by Martin Uram in 1992. OBJECTIVES To evaluate the efficacy and safety of ECP in people with open angle glaucoma (OAG) and primary angle closure whose condition is inadequately controlled with drops. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 12 July 2018. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) of ECP compared to other surgical treatments (other minimally invasive glaucoma device techniques, trabeculectomy), laser treatment or medical treatment. We also planned to include trials where these devices were combined with phacoemulsification compared to phacoemulsification alone. DATA COLLECTION AND ANALYSIS Two review authors planned to independently extract data from reports of included studies using a data collection form and analyse data based on methods expected by Cochrane. Our primary outcome was proportion of participants who were drop-free (not using eye drops). Secondary outcomes included mean change in IOP; proportion of participants who achieved an IOP of 21 mmHg or less, 17 mmHg or less or 14 mmHg or less; and proportion of participants experiencing intra- and postoperative complications, We planned to measure all outcomes in the short-term (six to 18 months), medium-term (18 to 36 months), and long-term (36 months onwards). MAIN RESULTS We found one ongoing study that met our inclusion criteria (ChiCTR-TRC-14004233). The study compares combined phacoemulsification with ECP to phacoemulsification alone in people with primary angle closure glaucoma. The primary outcome is intraocular pressure (IOP) and number of IOP-lowering drugs. A total of 50 people have been enrolled. The study started in February 2014 and the trialists have completed recruitment and are in the process of collecting data. AUTHORS' CONCLUSIONS There is currently no high-quality evidence for the effects of ECP for OAG and primary angle closure. Properly designed RCTs are needed to assess the medium and long-term efficacy and safety of this technique.


title: Online estimation of the case fatality rate using a run-off triangle data approach: An application to the Korean MERS outbreak in 2015.

text: This work is motivated by the recent Korean Middle East respiratory syndrome outbreak. We propose an easy online estimation procedure for the case fatality rate, ie, the proportion of deaths among the total cases during the course of an epidemic disease, which is an important indicator of the severity of a disease. The key step in our procedure is representing the data with the run-off triangle, which simultaneously takes into account two time axes, namely, the calendar and disease-duration times. We restructure the original data into run-off triangle data, where the cells contain the numbers of cured patients, deceased patients, and patients still having the disease at a given combination of calendar and disease-duration times. Based on the restructured run-off triangle data, we propose an online estimator of the case fatality rate. We numerically show the advantages of the proposed estimator compared to the existing estimators in the literature. Finally, we apply our procedure to the 2015 Korean Middle East respiratory syndrome outbreak data.


Covid-19 in Peru: from supervised walks for children to the first case of Kawasaki-like syndrome.


title: Contraction intensity and sex differences in knee-extensor fatigability.

text: Females are less fatigable than males during isometric contractions across various muscles and intensities. However, sex differences in knee-extensor fatigability remain relatively unexplored. PURPOSE To determine the sex difference in performance fatigability for intermittent, isometric contractions of the knee-extensor muscles. METHODS Eighteen participants (10 males, 8 females) performed intermittent, isometric, knee-extensor contractions at 30% of their maximal voluntary force (MVC) for 30min and in a separate session at 50% MVC until task-failure. During both fatiguing protocols a MVC was performed every 60s and electromyography (EMG) was recorded during all contractions. RESULTS At task completion males had a larger reduction in MVC force for the 30% MVC task (-32±15% vs. -15±16%, P=0.042) and the 50% MVC task (-34±8% vs. -24±1%, P=0.045). Furthermore, for the 50% MVC task, females had a longer task duration (937±525svs. 397±153s, P=0.007). The rise in EMG activity and force fluctuations were more rapid for the males than females (P<0.05). When participants were matched for strength post hoc (n=10), a sex difference in fatigability for both tasks was still evident. CONCLUSIONS Females were less fatigable than males during intermittent, isometric, knee-extensor contractions at moderate relative forces and this difference was independent of strength.


Single-incision laparoscopic surgery.


title: Robotic-assisted laparoendoscopic single-site surgery in gynecology: initial report and technique.

text: Robotic surgery has greatly improved surgeon dexterity and ergonomics but has substantially increased the number and size of ports required. The typical robotic surgical procedure will use three 8-mm ports and two 12-mm ports. Single-port laparoscopy, also known as Laparo-Endoscopic Single Site (LESS) surgery, is an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery.We present our initial clinical experience and technique with robotic-assisted single-port surgery in gynecology.


Wuhan: Britons to be evacuated as scientists estimate 44 000 cases of 2019-nCOV in the city.


title: The central role of renal microcirculatory dysfunction in the pathogenesis of acute kidney injury.

text: Acute kidney injury (AKI) is a rapidly developing condition often associated with critical illness, with a high degree of morbidity and mortality, whose pathophysiology is ill understood. Recent investigations have identified the dysfunction of the renal microcirculation and its cellular and subcellular constituents as being central to the etiology of AKI. Injury is caused by inflammatory activation involving endothelial leucocyte interactions in combination with dysregulation of the homeostatis between oxygen, nitric oxide, and reactive oxygen species. Effective therapies expected to resolve AKI will have to control inflammation and restore this homeostasis. In order to apply and guide these therapies effectively, diagnostic tools aimed at physiological biomarkers of AKI for monitoring renal microcirculatory function in advance of changes in pharmacological biomarkers associated with structural damage of the kidney will need to be developed.


title: [Experience of teaching and training for medical students at gastrointestinal surgery department under COVID-19 epidemic situation].

text: In hospitals and medical schools as densely populated sites with high risk of coronavirus disease 2019 (COVID-19), it is vital to adjust the teaching and training strategy for medical students to ensure curriculum completion with safety. This article aims to introduce the experience of teaching and training for medical students under the epidemic situation at Department of Surgery, Shanghai Medical College, Fudan University and Zhongshan Hospital. The content includes exploring diversified online teaching models for undergraduate surgery courses and clinical practice, carrying out online graduate education and dissertation plans, and strengthening comprehensive education of medical humanity combined with knowledge of COVID-19 prevention. Through implementation of the above teaching strategies, scheduled learning plans of medical students can be well completed in an orderly, safe and quality-ensured manner. Our experience provides practical solution of medical teaching and could be advisable for other medical colleges and teaching hospitals.


title: Coronavirus Disease (COVID-19) Outbreak and Its Impact on Spinal Daily Practice : Preliminary Report from a Single (Regional) University Hospital in Republic of Korea.

text: Objective Since the first discovery of the 2019 novel coronavirus (COVID-19), rapid and wide spread of the disease has been reported and the World Health Organization announced that a 'pandemic' has started. Up to date there is little known regarding the impact of this outbreak on spinal specialists' daily clinical practice. We intended to evaluate how COVID-19 has affected the number of spinal disease patients we meet and operate in daily practice. Methods The de-identified data regarding number of patients visiting the spine clinic at a tertiary referral hospital and a secondary level hospital from January, February and March of 2017 to 2020 were retrospectively reviewed. The number of out-patient department (OPD) visits, number of emergency room (ER) visits as well as number of surgeries performed during the reviewed period were collected and analyzed, comparing 2020 to the previous 3 years. Results The number of daily OPD visits showed a steady decrease starting from January, and presented a statistically significant decrease by early March 2020, compared to the previous 3 years. During the same period, decrease in number of daily ER visits was statistically significant as well. The number of elective surgeries or number of surgeries for patients admitted via ER during COVID-19 outbreak remained similar to that of 2017-2019 suggesting, despite the decrease of patients visiting the hospital for spinal diseases, those whom required surgery still visited the hospital. The results were consistant among other hospital level. Conclusion The outbreak of COVID-19 affected our daily practice as OPD and ER visits reduced but did not affect the number of surgeries. We believe that this report will be informative to spinal specialists worldwide fighting the COVID-19 pandemic.


Chikungunya outbreak, French Polynesia, 2014.


Erratum to: The introduction of mid-urethral slings: an evaluation of literature.


title: Internet Use, Risk Awareness, and Demographic Characteristics Associated with Engagement in Preventive Behaviors and Testing: A Cross-sectional Survey on COVID-19 in the U.S.

text: BACKGROUND During the COVID-19 pandemic, engagement in preventive behaviors and getting tested for the virus play a crucial role in protecting people from contracting the new coronavirus. OBJECTIVE This study aims to examine how Internet use, risk awareness, and demographic characteristics are associated with engagement in preventative behaviors and testing during the COVID-19 pandemic in the United States. METHODS A cross-sectional survey was conducted on Amazon Mechanical Turk from April 10, 2020 to April 14, 2020. Participants' Internet use (in terms of the extent of receiving information pertaining to COVID-19), risk awareness (whether any immediate family members, close friends or relatives, or people in local communities tested positive for COVID-19), demographics (sex, age, ethnicity, income, education level, marital status, employment status), as well as their engagement in preventative behaviors and testing were assessed. RESULTS Our data included 979 valid responses from the U.S. Participants who received more COVID-19-related health information online reported more frequent effort to engage in all types of preventive behaviors: wearing a facemask in public (odds ratio [OR] 1.55, 95% CI 1.34-1.79，P < .001), washing hands (OR 1.58, 95% CI 1.35-1.85, P < .001), covering nose and mouth when sneezing and coughing (OR 1.78, 95% CI 1.52-2.10, P < .001), keeping social distance with others (OR 1.41, 95% CI 1.21-1.65, P < .001), staying home (OR 1.40, 95% CI 1.20-1.62, P < .001), avoiding using public transportation (OR 1.57, 95% CI 1.32-1.88, P < .001), and cleaning frequently used surfaces (OR 1.55, 95% CI 1.34-1.79, P < .001). Compared with participants who did not have positive cases in their social circles, those who had immediate family members (OR 1.48, 95% CI 8.28-2.64, P < .001), or close friends and relatives (OR 2.52, 95% CI 1.58, 4.03, P < .001) who tested positive were more likely to get tested. Participants' sex, age, ethnicity, marital status, and employment status were also associated with preventive behaviors and testing. CONCLUSIONS Our findings revealed that the extent of receiving COVID-19-related information online, risk awareness, and demographic characteristics including sex, ethnicity, age, marital status, and employment status are key factors associated with U.S. residents' engagement in various preventive behaviors and testing for COVID-19. CLINICALTRIAL


docid: ilgfuozv

title: GERD and acid reduction medication use following gastric bypass and sleeve gastrectomy.

text: BACKGROUND Gastroesophageal reflux disease is a common comorbid medical condition of obesity. Laparoscopic sleeve gastrectomy has been associated with de novo and worsening GERD following surgery. For this reason, patients who suffer from GERD and are considering bariatric surgery are often counseled to undergo gastric bypass. Given this practice, we sought to determine acid reduction medication (ARM) utilization in bariatric surgical patients who undergo one of these procedures prior to surgery and at 1 year following surgery. METHODS A retrospective review of prospectively maintained data on patients to undergo gastric bypass or sleeve gastrectomy between November 2012 and December 2014 was conducted after IRB approval. ARM utilization and Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) scores [range 0 (no symptoms)-50 (severe GERD)] were compared prior to surgery and at 1 year postoperatively. RESULTS 334 patients underwent an eligible procedure in the study interval. 147 patients (44 %) had data on both preoperative and 1 year postoperative ARM use (93 gastric bypass and 54 sleeve gastrectomy). ARM utilization prior to surgery in gastric bypass patients did not reach statistical significance when compared to sleeve gastrectomy (40.9 vs. 26 %, p = 0.07). GERD-HRQL scores were greater prior to surgery in gastric bypass patients (GERD-HRQL 8.2 vs. 1.9; p < 0.01). At 12 months postoperatively, sleeve gastrectomy patients had a significantly higher rate of overall ARM use (48.1 vs. 16.1 %, p < 0.01), new ARM use (35 vs. 7.3 %, p < 0.01), and persistent ARM use (78.6 vs. 21.9 %, p < 0.01) when compared to gastric bypass patients. GERD-HRQL scores were similar overall at 12 months postoperatively (4.4 bypass vs. 4.8 sleeve; p = 0.72). CONCLUSION Laparoscopic sleeve gastrectomy is associated with a significantly increased likelihood that acid reduction medications will be necessary for GERD symptom control 12 months postoperatively when compared to gastric bypass.


docid: kypyhuzy

title: Effectiveness of mechanical endovascular thrombectomy in a model system of cerebrovascular occlusion.

text: BACKGROUND AND PURPOSE A number of thrombectomy devices are currently undergoing clinical evaluation; meanwhile, various novel devices are under investigation. The aims of this study were to quantify flow restoration and the particle size distribution of the effluent pursuant to MET in an in vitro occlusion model. MATERIALS AND METHODS The model system was composed of 3 elements: an ICA/MCA replica, a clot model with mechanical properties similar to those of thrombi found in patients at risk of stroke, and a pulsatile flow loop. Different thrombectomy mechanisms including mechanical retrieval, aspiration, and waveguide induced cavitation were used. The efficacy end points were recanalization rate and amount of flow restoration. The risk of the embolic shower was assessed to evaluate device safety. RESULTS The recanalization rates were the following: Merci, 67%; Solitaire, 100%; Penumbra, 83%; Enterprise, 17%; and the waveguide, 0%. In experiments in which recanalization was achieved, the amount of flow restoration for the Merci, Solitaire, and Enterprise devices was 100%, 92%, and 86%, respectively. The mean sizes of generated small and large clot fragments were between 23 and 37 and 215 and 285 μm, respectively, depending on the device used. The Merci device generated the fewest number of large fragments compared with the Penumbra system (P < .05) and Solitaire (not significant). CONCLUSIONS The risk of embolic shower was influenced by the mechanism of action for the thrombectomy device. Clinically reported recanalization rates for the Solitaire, Penumbra, and Merci devices were nearly identical in this model system, suggesting that this model may provide a predictive tool for preclinical evaluation of MET.


title: Environmental degradation, economic growth, and energy innovation: evidence from European countries.

text: This study aims to explore the relationship of environmental degradation with economic growth and energy innovation by utilizing the panel data of 33 European countries by covering the period of 1996 to 2017. We use the cross-sections independence and control the heterogeneity between cross-sections by using the second-generation econometric of panel data. The Westerlund bootstrap co-integration, CIPS unit root test, Pedroni co-integration, panel causality techniques, and FMOLS have been used to analyze the relationship. The result of the study shows that all the variables are integrated in the long run. Energy innovation has a negative and significant impact on environmental degradation. On the other hand, gross domestic product has a U-shape and significant relationship with environmental degradation by supporting Kuznets curve. Therefore, this study helps not only the policymaker and government but also the people and businessmen on how they can increase the growth of the business and economy without effecting the environment.


title: miRNA targeting and alternative splicing in the stress response - events hosted by membrane-less compartments.

text: Stress can be temporary or chronic, and mild or acute. Depending on its extent and severity, cells either alter their metabolism, and adopt a new state, or die. Fluctuations in environmental conditions occur frequently, and such stress disturbs cellular homeostasis, but in general, stresses are reversible and last only a short time. There is increasing evidence that regulation of gene expression in response to temporal stress happens post-transcriptionally in specialized subcellular membrane-less compartments called ribonucleoprotein (RNP) granules. RNP granules assemble through a concentration-dependent liquid-liquid phase separation of RNA-binding proteins that contain low-complexity sequence domains (LCDs). Interestingly, many factors that regulate microRNA (miRNA) biogenesis and alternative splicing are RNA-binding proteins that contain LCDs and localize to stress-induced liquid-like compartments. Consequently, gene silencing through miRNAs and alternative splicing of pre-mRNAs are emerging as crucial post-transcriptional mechanisms that function on a genome-wide scale to regulate the cellular stress response. In this Review, we describe the interplay between these two post-transcriptional processes that occur in liquid-like compartments as an adaptive cellular response to stress.


Circumcision to prevent HPV infection.


title: Individualised oxygen delivery targeted haemodynamic therapy in high-risk surgical patients: a multicentre, randomised, double-blind, controlled, mechanistic trial.

text: BACKGROUND Morbidity after major surgery is associated with low oxygen delivery. Haemodynamic therapy aimed at increasing oxygen delivery in an effort to reduce oxygen debt, tissue injury, and morbidity, is controversial. The most appropriate target for this strategy is unclear and might have several off-target effects, including loss of neural (parasympathetic)-mediated cellular protection. We hypothesised that individualised oxygen delivery targeted haemodynamic therapy (goal-directed therapy) in high-risk surgical patients would reduce postoperative morbidity, while secondarily addressing whether goal-directed therapy affected parasympathetic function. METHODS In this multicentre, randomised, double-blind, controlled trial, adult patients undergoing major elective surgery were allocated by computer-generated randomisation to a postoperative protocol (fluid, with and without dobutamine) targeted to achieve their individual preoperative oxygen delivery value (goal-directed therapy) or standardised care (control). Patients and staff were masked to the intervention. The primary outcome was absolute risk reduction (ARR) in morbidity (defined by Clavien-Dindo grade II or more) on postoperative day 2. We also assessed a secondary outcome focused on parasympathetic function, using time-domain heart rate variability measures. Analyses were done on an intention-to-treat basis. The trial was registered with Controlled Clinical Trials (number ISRCTN76894700). FINDINGS We enrolled 204 patients between May 20, 2010, and Feb 12, 2014. Intention-to-treat analysis of the 187 (92%) patients who completed the trial intervention period showed that early morbidity was similar between goal-directed therapy (44 [46%] of 95 patients) and control groups (49 [53%] of 92 patients) (ARR -7%, 95% CI -22 to 7; p=0·30). Prespecified secondary analysis showed that 123 (66%) of 187 patients achieved preoperative oxygen delivery (irrespective of intervention). These patients sustained less morbidity (ARR 19%, 95% CI 3-34; p=0·016), including less infectious complications. Goal-directed therapy reduced parasympathetic activity postoperatively (relative risk 1·33, 95% CI 1·01-1·74). INTERPRETATION Achievement of preoperative oxygen delivery values in the postoperative phase was associated with less morbidity, but this was not affected by the use of an oxygen delivery targeted strategy. Reduced parasympathetic activity after goal-directed therapy was associated with the failure of this intervention to reduce postoperative morbidity. FUNDING Academy of Medical Sciences and Health Foundation Clinician Scientist Award.


title: Change in Pain and Physical Function Following Bariatric Surgery for Severe Obesity.

text: IMPORTANCE The variability and durability of improvements in pain and physical function following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) are not well described. OBJECTIVES To report changes in pain and physical function in the first 3 years following bariatric surgery, and to identify factors associated with improvement. DESIGN, SETTING, AND PARTICIPANTS The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study at 10 US hospitals. Adults with severe obesity undergoing bariatric surgery were recruited between February 2005 and February 2009. Research assessments were conducted prior to surgery and annually thereafter. Three-year follow-up through October 2012 is reported. EXPOSURES Bariatric surgery as clinical care. MAIN OUTCOMES AND MEASURES Primary outcomes were clinically meaningful presurgery to postsurgery improvements in pain and function using scores from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (ie, improvement of ≥5 points on the norm-based score [range, 0-100]) and 400-meter walk time (ie, improvement of ≥24 seconds) using established thresholds. The secondary outcome was clinically meaningful improvement using the Western Ontario McMaster Osteoarthritis Index (ie, improvement of ≥9.7 pain points and ≥9.3 function points on the transformed score [range, 0-100]). RESULTS Of 2458 participants, 2221 completed baseline and follow-up assessments (1743 [78.5%] were women; median age was 47 years; median body mass index [BMI] was 45.9; 70.4% underwent RYGB; 25.0% underwent LAGB). At year 1, clinically meaningful improvements were shown in 57.6% (95% CI, 55.3%-59.9%) of participants for bodily pain, 76.5% (95% CI, 74.6%-78.5%) for physical function, and 59.5% (95% CI, 56.4%-62.7%) for walk time. Additionally, among participants with severe knee or disability (633), or hip pain or disability (500) at baseline, approximately three-fourths experienced joint-specific improvements in knee pain (77.1% [95% CI, 73.5%-80.7%]) and in hip function (79.2% [95% CI, 75.3%-83.1%]). Between year 1 and year 3, rates of improvement significantly decreased to 48.6% (95% CI, 46.0%-51.1%) for bodily pain and to 70.2% (95% CI, 67.8%-72.5%) for physical function, but improvement rates for walk time, knee and hip pain, and knee and hip function did not (P for all ≥.05). Younger age, male sex, higher income, lower BMI, and fewer depressive symptoms presurgery; no diabetes and no venous edema with ulcerations postsurgery (either no history or remission); and presurgery-to-postsurgery reductions in weight and depressive symptoms were associated with presurgery-to-postsurgery improvements in multiple outcomes at years 1, 2, and 3. CONCLUSIONS AND RELEVANCE Among a cohort of participants with severe obesity undergoing bariatric surgery, a large percentage experienced improvement, compared with baseline, in pain, physical function, and walk time over 3 years, but the percentage with improvement in pain and physical function decreased between year 1 and year 3. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00465829.


title: Letter to the Editor: Assessing the Long-Term Potential of Relaxing Regulations: Should We Go Back to Business as Usual?

text: The response to the COVID-19 pandemic resulted in reallocation of health care resources and removal of barriers to deliver expedited care to those in need. This might be a unique moment in history to reconsider the regulations within our health care system that significantly increase its cost.


title: Is There Any Difference in Risk Factors between Male and Female Patients in New-Onset Atrial Fibrillation after Coronary Artery Bypass Grafting?

text: BACKGROUND We aimed to investigate the risk factors of post-coronary artery bypass grafting (CABG) atrial fibrillation (AF) in male and female patients without any history of AF, to identify the sex-specific risk factors, and to examine the effect of sex-specific risk factors on the overall population. METHODS This retrospective study was conducted using the hospital database with 4,758 patients who underwent CABG surgery. Among them, 2,836 patients with complete data participated in this study. The female patients were divided into two groups as patients who developed new-onset AF after CABG and those who did not. The relationship between the patients' variables and risk factors of post-CABG AF was examined. RESULTS The overall incidence of post CABG AF was 12.9% (386/2,836). Sex-specific incidence of AF was similar: 3.2% (91/690) and 12.9% (277/2146) in female and male patients, respectively (p = 0.849). Multiple analysis revealed the independent risk factors for male and female patients, respectively: mean age (odds ratio [OR] = 1.057, OR = 1,076), age over 65 years (OR = 2.156, OR = 2.736), the European System For Cardiac Operative Risk Evaluation Scores (EuroSCORE) (OR = 1.13, OR = 1.218), COPD (OR = 1.589, OR = 1.789), BUN level (OR = 1.026, OR = 1.019), mean cardiopulmonary bypass (CPB) time (OR = 1.007, OR = 1.010), prolonged CPB time (OR = 1.604, OR = 2.309), mean cross-clamp time (OR = 1.009, OR = 1.017), need of inotropic support (OR = 2.249, OR = 2.731), and mean mechanical ventilation time (VT) (OR = 1.026, OR = 1.027).Low left ventricular ejection fraction (LVEF) (OR = 1.419), left ventricular (LV) aneurysm repair (OR = 1.533), carotid artery disease (OR = 1.750), prolonged VT (OR = 1.729), and use of intra-aortic balloon pump (IABP) (OR = 2.436) were found to be the risk factors only for male AF patients.Unstable angina (OR = 1.969), right coronary artery (RCA) disease (OR = 2), prolonged cross-clamp time (OR = 2.152), and the number of grafts per operation (OR = 1.298) were found to be the risk factors only for female AF patients. CONCLUSION This study suggests that predictors of AF in the overall population may be due to isolated patient groups. Multiple regression analysis and artificial intelligence modelling should be performed on large-scale, isolated groups to make strong AF prediction.


docid: xzspheca

title: COVID-19 in a remote village in a tropical forest - a note.


title: rSILS: initial clinical experience with single-port robotic (SPr) right colectomy.

text: BACKGROUND The da Vinci Single-Port (SP) robot is a novel platform designed to facilitate single-incision robotic surgery (rSILS). The objective of this study was to describe our initial experience using this platform for SP robotic (SPr) right colectomy. METHODS Under a Food and Drug Administration-regulated feasibility study and Institutional Review Board approval, a patient with cecal adenocarcinoma underwent an SPr right colectomy. The primary endpoint was the safety and feasibility of the first SPr right colectomy performed in the USA. Secondary endpoints included perioperative metrics, morbidity and mortality. RESULTS An SPr Standard right colectomy was performed through a 4-cm single incision without the need for conversion or additional port placement. Estimated blood loss was 100 mL and there were no intraoperative complications. The robot was docked once with a docking time of 19 min. Total console time was 116 min and operative time was 219 min. The patient tolerated clear liquids on postoperative day (POD) 0 and a low-residue diet on POD 1. The patient had flatus and a bowel movement on POD 1. She was discharged home on POD 3. Final pathology showed pT3N0 cecal adenocarcinoma with negative margins and 0/24 lymph nodes positive for disease. CONCLUSIONS Our initial experience demonstrates that an SPr right colectomy is feasible and can be safely completed. We completed an oncologic resection of a cecal adenocarcinoma without complications. The SP robot facilitates the utilization of robotic technology in a single-incision platform to perform colorectal procedures and offers promising benefits in the advancement of robotic surgery.


title: Bartonella dromedarii sp. nov. isolated from domesticated camels (Camelus dromedarius) in Israel.

text: Bartonella spp. are fastidious, Gram-negative bacilli that cause a wide spectrum of diseases in humans. Most Bartonella spp. have adapted to a specific host, generally a domestic or wild mammal. Dromedary camels (Camelus dromedarius) have become a focus of growing public-health interest because they have been identified as a reservoir host for the Middle East respiratory syndrome coronavirus. Nevertheless, data on camel zoonoses are limited. We aimed to study the occurrence of Bartonella bacteremia among dromedaries in Israel. Nine of 51 (17.6%) camels were found to be bacteremic with Bartonella spp.; bacteremia levels ranged from five to >1000 colony-forming units/mL. Phylogenetic reconstruction based on the concatenated sequences of gltA and rpoB genes demonstrated that the dromedary Bartonella isolates are closely related to other ruminant-derived Bartonella spp., with B. bovis being the nearest relative. Using electron microscopy, the novel isolates were shown to be flagellated, whereas B. bovis is nonflagellated. Sequence comparisons analysis of the housekeeping genes ftsZ, ribC, and groEL showed the highest homology to B. chomelii, B. capreoli, and B. birtlesii, respectively. Sequence analysis of the gltA and rpoB revealed ∼96% identity to B. bovis, a previously suggested cutoff value for sequence-based differentiation of Bartonella spp., suggesting that this approach does not have sufficient discriminatory power for differentiating ruminant-related Bartonella spp. A comprehensive multilocus sequence typing (MLST) analysis based on nine genetic loci (gltA, rpoB, ftsZ, internal transcribed spacer (ITS), 16S rRNA, ribC, groEL, nuoG, and SsrA) identified seven sequence types of the new dromedary isolates. This is the first description of a Bartonella sp. from camelids. On the basis of a distinct reservoir and ecological niche, sequence analyses, and expression of flagella, we designate these isolates as a novel Bartonella sp. named Bartonella dromedarii sp. nov. Further studies are required to explore its zoonotic potential.


title: Increasing handwashing in young children: A brief review.

text: Personal hygiene is critical for preventing the spread of infection. One important component of personal hygiene is handwashing. This review summarizes research on behavioral strategies to address handwashing in children, offers areas for additional research, and suggests a treatment package to teach handwashing to young children.


Predictor of poor prognosis of COVID-19 patients----liver injury.


title: Robot-Assisted Laparoscopic Prostatectomy in a Prostate Cancer Patient Undergoing Continuous Ambulatory Peritoneal Dialysis.

text: Background: Robot-assisted laparoscopic prostatectomy (RALP) has become the gold standard treatment for organ-confined prostate cancer. However, no proper surgical approach or appropriate postsurgical management of RALP has been established for a patient undergoing peritoneal dialysis. Here, we present a case of a peritoneal dialysis patient who underwent RALP and reinstated peritoneal dialysis with no trouble associated with peritoneal dialysis. Case Presentation: The patient was a 61-year-old man with organ-confined prostate cancer. He had been on peritoneal dialysis for 2 years. The peritoneal dialysis catheter was routed subcutaneously from the left lateral region into the abdominal cavity at the paramedian region. RALP was performed by the transperitoneal anterior approach. The surgical maneuver was not influenced by the peritoneal dialysis catheter at all. At the end of surgery, the incised peritoneum was sutured and closed tightly. After surgery, peritoneal dialysis was temporarily interrupted for 2 weeks. Then it was safely reinitiated with no complications. Conclusion: Transperitoneal RALP with complete peritoneal repair can be a standard treatment option for a prostate cancer patient undergoing peritoneal dialysis.


title: Intentional Omission of Ureteral Stents During Robotic-assisted Intracorporeal Ureteroenteric Anastomosis: Is It Safe and Feasible?

text: OBJECTIVE To describe the surgical technique we used to perform a stentless intracorporeal ureteroenteric anastomosis and to determine the outcomes in this initial series. METHODS We performed a retrospective review of a prospective database of all patients undergoing robotic-assisted intracorporeal urinary diversion with stentless ureteroenteric anastomosis between March 2014 and July 2016. Diversions were performed at the time of either robotic-assisted laparoscopic cystectomy for bladder cancer or urinary diversion for other indications. RESULTS A total of 10 patients underwent implantation of 20 ureters into the intestine via a robotic-assisted approach with intentional omission of stents. Median body mass index was 29.57 (first quartile 23.68, third quartile 34.69). Median American Society of Anesthesiologists score was 3 (range 2-3). Seven patients had intracorporeal ileal conduit reconstruction and 3 patients had an intracorporeal neobladder creation. There were no patients who developed a stricture of the ureter nor did any patient develop a leak at the ureteroenteric anastomosis. All patients had normal serum creatinine at least 4 weeks after surgery, and all patients had follow-up computed tomography of the kidneys, which were normal. The median follow-up was 8 months (first quartile = 3 months, third quartile = 17 months). CONCLUSION Robotic intracorporeal urinary diversion with intentional omission of ureteral stents is a safe and feasible option when establishing continuity of the genitourinary and gastrointestinal tracts.


title: Correction: Identification of feature risk pathways of smoking-induced lung cancer based on SVM.

text: [This corrects the article DOI: 10.1371/journal.pone.0233445.].


How swamped preprint servers are blocking bad coronavirus research.


Keeping current on patient safety.


Immunization for vaccine-preventable diseases: why aren't we protecting our students?


title: Disappearance of a small intracranial aneurysm as a result of vessel straightening and in-stent stenosis following use of an Enterprise vascular reconstruction device.

text: In-stent stenosis after stent-assisted coil embolization is a rare but well-known complication. A 32-year-old woman with an unruptured wide-necked left internal carotid artery (ICA) terminus aneurysm and an ipsilateral very small anterior choroidal artery aneurysm underwent stent-assisted coil embolization for the ICA terminus aneurysm. The 4-month follow-up angiography revealed diffuse in-stent stenosis and disappearance of the untreated anterior choroidal artery aneurysm, retaining the patency of the anterior choroidal artery. To our knowledge, this is the first report to demonstrate the course of in-stent stenosis and disappearance of an untreated small intracranial aneurysm as a result. We report this unique case and discuss the interesting mechanism underlying this phenomenon, and also provide a review of the relevant literature.


Critical illness myopathy as a consequence of Covid-19 infection.


title: CD8+ T cell immunity to 2009 pandemic and seasonal H1N1 influenza viruses.

text: A novel strain of H1N1 influenza A virus (pH1N1) emerged in 2009, causing a worldwide pandemic. Several studies suggest that this virus is antigenically more closely related to human influenza viruses that circulated prior to 1957 than viruses of more recent seasonal influenza varieties. The extent to which individuals who are naïve to the 2009 pH1N1 virus carry cross-reactive CD8+ T cells is not known, but a certain degree of reactivity would be expected since there is substantial conservation among the internal proteins of the virus. In the present study, we examined the production of multiple cytokines in response to virus from CD8+ T cells in healthy adult subjects, between 18 and 50 years of age (born post 1957), who had no evidence of exposure to the 2009 pH1N1 virus, and had blood collected prior to the emergence of the pandemic in April of 2009. Human peripheral blood mononuclear cells (PBMCs) were stimulated in vitro with a panel of live viruses, and assayed by intracellular cytokine staining and flow cytometry. Although results were variable, most subjects exhibited cytokine positive CD8+ T cells in response to pH1N1. Cytokine producing cells were predominantly single positive (IL2, IFNγ, or TNFα); triple-cytokine producing cells were relatively rare. This result suggests that although many adults carry cross-reactive T cells against the emergent pandemic virus, these cells are in a functionally limited state, possibly because these subjects have not had recent exposure to either seasonal or pandemic influenza strains.


title: Changes in topographic electroencephalogram during deepening levels of propofol sedation based on alertness/sedation scale under bispectral index guidance.

text: BACKGROUND Sedation has been associated with numerous changes on electroencephalogram (EEG) but there is a need to clarify specific alterations in relation to deepening levels of sedation with different agents. We aimed to evaluate the effect of deepening levels of sedation induced by propofol and how they compare to natural sleep. METHODS Fifty consecutive neurologically normal patients who underwent upper gastrointestinal endoscopy while sedated with propofol were included. Topographic EEG spectral maps and the bispectral index (BIS) values were obtained at four time points: wakefulness, mild sedation, deep sedation and recovery. Observer's Assessment of Alertness and Sedation (OAA/S) score was used to assess sedation levels. RESULTS Propofol induced increased delta (0.5-3.5 Hz) and gamma (25-40 Hz) power throughout sedation. In addition, there was decreased alpha power (9-11.5 Hz) in the occipital area and increased global beta (12-25 Hz)/gamma (25-40 Hz) power during mild sedation. Deep sedation was associated with increased theta (4-7 Hz)/alpha (9-11.5 Hz)/beta (12-25 Hz) power, which was maximal frontally. CONCLUSION There are distinct changes associated with deepening levels of propofol induced sedation that distinguish it from natural sleep. This suggests that different mechanisms are involved in them and warrants further investigations to clarify the nature of these changes.


title: Safety and efficacy of single incision laparoscopic surgery for total extraperitoneal inguinal hernia repair.

text: Almost 20 years after the first laparoscopic inguinal hernia repair was performed, single incision laparoscopic surgery (SILS™) is set to revolutionize minimally invasive surgery. However, the loss of triangulation must be overcome before the technique can be popularized. This study reports the first 100 laparoscopic total extraperitoneal hernia repairs using a single incision. The study cohort comprised 68 patients with a mean age of 44 (range, 18 to 83): 36 unilateral and 32 bilateral hernias. Twelve patients also underwent umbilical hernia repair with the Ventralex patch requiring no additional incisions. A 2.5-cm to 3-cm crescentic incision within the confines of the umbilicus was performed. Standard dissecting instruments and 52-cm/5.5-mm/30(0) laparoscope were used. Operation times were 50 minutes for unilateral and 80 minutes for bilateral. There was one conversion to conventional 3-port laparoscopic repair and none to open surgery. Outpatient surgery was achieved in all (except one). Analgesic requirements were minimal: 8 Dextropropoxyphene tablets (range, 0 to 20). There were no intraoperative or postoperative complications with a high patient satisfaction score. Single-incision laparoscopic hernia repair is safe and efficient simply by modifying dissection techniques (so-called "inline" and "vertical"). Comparable success can be obtained while negating the risks of bowel and vascular injuries from sharp trocars and achieving improved cosmetic results.


Functionally assessing coronavirus entry.


title: Prediction of Early Arterial Recanalization and Tissue Fate in the Selection of Patients With the Greatest Potential to Benefit From Intravenous Tissue-Type Plasminogen Activator.

text: BACKGROUND AND PURPOSE Our objective is to determine the performance of the combination of likelihood of arterial recanalization and tissue fate to predict functional clinical outcome in patients with acute stroke. METHODS Clinical, imaging, and outcome data were collected in 173 patients with acute ischemic stroke who presented within 4.5 hours from symptom onset, in the time window eligible for intravenous tissue-type plasminogen activator. Imaging data included Alberta Score Program Early Computed Tomographic Score (ASPECTS), site of occlusion, volume of ischemic core and penumbra, and recanalization. Outcome data consisted of modified Rankin Scale score at 90 days. We classified patients based on their baseline imaging characteristics and treatment with intravenous tissue-type plasminogen activator (yes/no) according to 5 different hypothetical prognostic algorithms: (1) based on whether patients received intravenous tissue-type plasminogen activator, (2) based on ASPECTS, (3) based on the site of occlusion, (4) based on volume of ischemic core and penumbra, and (5) based on a matrix of predicted recanalization and volume of ischemic core and penumbra. We compared the performance of such algorithms to predict good clinical outcome, defined as modified Rankin Scale score of ≤2 at 90 days. RESULTS One hundred and twenty-four patients received intravenous tissue-type plasminogen activator; 49 did not. In the group that was treated, 46 (37%) had good outcome as opposed to 38.7% in the nontreated. The algorithm that combined the prediction of recanalization with the volume of ischemic core and penumbra showed the highest accuracy to predict good outcome (77.7%) as opposed to others (range, 43.9%-57.2%) CONCLUSIONS The combination of predicted recanalization and tissue fate proved superior to prognosticate good clinical outcome when compared with other usual predictors.


COVID: How to explain differences in lethality between different populations?


title: Combination therapy with single incision laparoscopic surgery and double-balloon endoscopy for small intestinal bleeding: report of three cases.

text: The clinical introduction of double-balloon endoscopy (DBE) has brought about a revolution in the diagnosis and the treatment of diseases of the small intestine. DBE allows not only direct observation of the entire small intestine, but also interventional therapies, tissue sampling and India ink marking (tattooing). Single incision laparoscopic surgery (SILS) was developed from conventional laparoscopic surgery to further reduce the degree of invasiveness. SILS requires only one umbilical incision, thus resulting in almost scarless surgery. This report presents three cases of small intestinal bleeding successfully treated by SILS following tattooing under DBE. The average operative time was 67 min and average blood loss was 5 ml. All patients immediately recovered without any complications. SILS, in conjunction with presurgical tattooing by DBE for small intestinal bleeding is considered to be an ideal approach in terms of minimal surgical trauma and aesthetics.


title: The relationship between chronotype and intelligence: the importance of work timing.

text: Sleep-wake patterns show substantial biological determination, but they are also subject to individual choice and societal pressure. Some evidence suggests that high IQ is associated with later sleep patterns. However, it is unclear whether the relationship between IQ and later sleep is due to biological or social effects, such as the timing of working hours. We investigated the association between habitual sleep timing during work days and work-free days, working time and membership in Mensa, an organization of highly intelligent individuals (IQ ≥130) using a sample of 1,172 adults split between Mensa members and age- and sex-matched volunteers from a large web-based database. We found no difference in chronotype, and the later sleep timing of Mensa members on work days was fully accounted for by later work start times. Our results indicate that later sleep timing in those with higher IQs is not due to physiological differences, but rather due to later work schedules. Later working times and the resulting lower social jetlag may be one of the reasons why higher IQ is associated with lower prospective morbidity and mortality.


title: Mobile field hospitals, an effective way of dealing with COVID-19 in China: sharing our experience.

text: During the COVID-19 outbreak, China made great progress in controlling the epidemic, and the number of confirmed and suspected cases continues to decrease thanks to the various efforts employed. Mobile field hospitals have played a huge role in the centralized management of patients and they have effectively reduced transmission. This article describes some of our experiences operating mobile field hospitals in order to provide a reference and to better inform countries that are dealing with this crisis.


title: Mammalian innate resistance to highly pathogenic avian influenza H5N1 virus infection is mediated through reduced proinflammation and infectious virus release.

text: Respiratory epithelial cells and macrophages are the key innate immune cells that play an important role in the pathogenesis of influenza A virus infection. We found that these two cell types from both human and pig showed comparable susceptibilities to initial infection with a highly pathogenic avian influenza (HPAI) H5N1 virus (A/turkey/Turkey/1/05) and a moderately pathogenic human influenza H1N1 virus (A/USSR/77), but there were contrasting differences in host innate immune responses. Human cells mounted vigorous cytokine (tumor necrosis factor alpha [TNF-α] and interleukin-6 [IL-6]) and chemokine (CXCL9, CXCL10, and CXCL11) responses to H5N1 virus infection. However, pig epithelial cells and macrophages showed weak or no TNF-α and chemokine induction with the same infections. The apparent lack of a strong proinflammatory response, corroborated by the absence of TNF-α induction in H5N1 virus-challenged pigs, coincided with greater cell death and the reduced release of infectious virus from infected pig epithelial cells. Suppressor of cytokine signaling 3 (SOCS3), a protein suppressor of the JAK-STAT pathway, was constitutively highly expressed and transcriptionally upregulated in H5N1 virus-infected pig epithelial cells and macrophages, in contrast to the corresponding human cells. The overexpression of SOCS3 in infected human macrophages dampened TNF-α induction. In summary, we found that the reported low susceptibility of pigs to contemporary Eurasian HPAI H5N1 virus infections coincides at the level of innate immunity of respiratory epithelial cells and macrophages with a reduced output of viable virus and an attenuated proinflammatory response, possibly mediated in part by SOCS3, which could serve as a target in the treatment or prevention of virus-induced hypercytokinemia, as observed for humans.


Addressing mental health care for bereavements during COVID-19 pandemic.


title: MRGPR-mediated activation of local mast cells clears cutaneous bacterial infection and protects against reinfection.

text: Mast cells (MCs) are strategically distributed at barrier sites and prestore various immunocyte-recruiting cytokines, making them ideal targets for selective activation to treat peripheral infections. Here, we report that topical treatment with mastoparan, a peptide MC activator (MCA), enhances clearance of Staphylococcus aureus from infected mouse skins and accelerates healing of dermonecrotic lesions. Mastoparan functions by activating connective tissue MCs (CTMCs) via the MRGPRX2 (Mas-related G protein-coupled receptor member X2) receptor. Peripheral CTMC activation, in turn, enhances recruitment of bacteria-clearing neutrophils and wound-healing CD301b+ dendritic cells. Consistent with MCs playing a master coordinating role, MC activation also augmented migration of various antigen-presenting dendritic cells to draining lymph nodes, leading to stronger protection against a second infection challenge. MCAs therefore orchestrate both the innate and adaptive immune arms, which could potentially be applied to combat peripheral infections by a broad range of pathogens.


title: Original technique to close the transrectal viscerotomy access in a NOTES transrectal and transgastric segmental colectomy.

text: Segmental colectomy is an ideal procedure for natural orifice transluminal endoscopic surgery (NOTES). Transanal endoscopic approaches have enabled rectosigmoid colectomy through a viscerotomy that is resected with the specimen. To extend NOTES segmental colectomy to the entire colon and beyond, a rectal viscerotomy will have to be safely and effectively closed at the end of the procedure. A new technique for rectal viscerotomy closure using a circular EEA hemorrhoid and prolapse stapler with DST series technology (Covidien) is described.