title: Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy.

text: In the current global home confinement situation due to the COVID-19 outbreak, most individuals are exposed to an unprecedented stressful situation of unknown duration. This may not only increase daytime stress, anxiety and depression levels but also disrupt sleep. Importantly, because of the fundamental role that sleep plays in emotion regulation, sleep disturbance can have direct consequences upon next day emotional functioning. In this paper we summarize what is known about the stress-sleep link and confinement as well as effective insomnia treatment. We discuss those effects of the current home confinement situation that can disrupt sleep but also those that could benefit sleep quality. We suggest adaptions of cognitive behavioral therapy elements that are feasible to implement for those facing changed work schedules and requirements, those with health anxiety and those handling childcare and homeschooling, whilst also recognizing the general limitations imposed on physical exercise and social interaction. Managing sleep problems as best as possible during home confinement can limit stress and possibly prevent disruptions of social relationships.


title: Effect of position and positive pressure ventilation on functional residual capacity in morbidly obese patients: a randomized trial.

text: PURPOSE In morbidly obese patients, the position and ventilation strategy used during pre-oxygenation influence the safe non-hypoxic apnea time and the functional residual capacity (FRC). In awake morbidly obese volunteers, we hypothesized that the FRC would be higher after a five-minute period of positive pressure ventilation compared with spontaneous ventilation at zero inspiratory pressure. METHODS Using a prospective crossover randomized trial design, obese subjects underwent, in a randomized order, a combination of one of three positions, supine (S), beach chair (BC), and reverse Trendelenburg (RT), and one of two ventilation strategies, spontaneous ventilation at zero inspiratory pressure (ZEEP-SV) or with positive pressure (PP-SV) set to an inspiratory pressure of 8 cmH2O, positive end-expiratory pressure of 10 cmH2O, and fraction of inspired oxygen of 0.21. RESULTS Seventeen obese volunteers with a mean (standard deviation; SD) body mass index of 50 (8) kg·m-2 were included. Mean (SD) FRC in the three positions (S, BC, RT) was significantly higher using PP-SV compared with ZEEP-SV [2571 (477) vs 2215 (481) mL, respectively; mean difference, 356; 95% confidence interval (CI), 209 to 502; P < 0.001]. Mean (SD) FRC was significantly higher in the RT compared with BC position [2483 (521) vs 2338 (469) mL, respectively; mean difference, 145; 95% CI, 31 to 404; P = 0.01], while there was no difference between S and BC [2359 (519) mL vs 2338 (469) mL, respectively; mean difference, 21; 95% CI, -93 to 135; P = 0.89]. CONCLUSION In awake morbidly obese volunteers, an increase in the FRC is observed when spontaneous ventilation at zero inspiratory pressure is switched to positive pressure. Compared with S positioning, the BC position had no measurable impact on the FRC. The RT position resulted in an optimal FRC. TRIAL REGISTRATION clinicaltrials.gov (NCT02121808). Registered 24 April 2014.


title: Characterizing the Structural Integrity of Endotracheal Tube Taping Techniques: A Simulation Study.

text: BACKGROUND Endotracheal tubes (ETTs) are commonly secured with tape to prevent undesirable tube migration. Many methods of taping have been described, although little has been published comparing various methods of taping to one another. In this study, we evaluated several methods for securing ETTs with tape. We hypothesized a difference in mean peak forces between the methods studied during forced extubation. METHODS Five methods of securing an ETT with tape were studied in a variety of contexts including cadaver and simulation lab settings. Testing included measurement of peak force (Newton [N]) during forced extubation, durability of taping following mechanical stress, effects of tape length-width variation, and characterization of failure mechanisms. RESULTS We found several significant differences in mean peak extubation forces between the 5 methods of taping, with mean peak forces during forced extubation ranging from 20 N to 156 N. In separate tests, we found an association between mean peak forces and total surface area as well as geometric configuration of tape on the face. Long thin strips of tape appeared to provide surprising durability against forced extubation, a phenomenon that was associated with minimization of the "peel angle" as tape was removed. CONCLUSIONS We found evidence of differential structural integrity between the 5 taping methods studied. More generally, we found that increased peak extubation forces were associated with increased total surface area of tape and that minimization of the "peel angle" by lateral application of tape is associated with surprisingly high relative peak extubation forces.


title: Whole-mount Confocal Microscopy for Adult Ear Skin: A Model System to Study Neuro-vascular Branching Morphogenesis and Immune Cell Distribution.

text: Here, we present a protocol of a whole-mount adult ear skin imaging technique to study comprehensive three-dimensional neuro-vascular branching morphogenesis and patterning, as well as immune cell distribution at a cellular level. The analysis of peripheral nerve and blood vessel anatomical structures in adult tissues provides some insights into the understanding of functional neuro-vascular wiring and neuro-vascular degeneration in pathological conditions such as wound healing. As a highly informative model system, we have focused our studies on adult ear skin, which is readily accessible for dissection. Our simple and reproducible protocol provides an accurate depiction of the cellular components in the entire skin, such as peripheral nerves (sensory axons, sympathetic axons, and Schwann cells), blood vessels (endothelial cells and vascular smooth muscle cells), and inflammatory cells. We believe this protocol will pave the way to investigate morphological abnormalities in peripheral nerves and blood vessels as well as the inflammation in the adult ear skin under different pathological conditions.


COVID-19 and cardiovascular injury: A role for oxidative stress and antioxidant treatment?


title: Impact of a rapid respiratory panel test on patient outcomes.

text: CONTEXT Evolution of polymerase chain reaction testing for infectious pathogens has occurred concurrent with a focus on value-based medicine. OBJECTIVE To determine if implementation of the FilmArray rapid respiratory panel (BioFire Diagnostics, Salt Lake City, Utah) (hereafter RRP), with a shorter time to the test result and expanded panel, results in different outcomes for children admitted to the hospital with an acute respiratory tract illness. DESIGN Patient outcomes were compared before implementation of the RRP (November 1, 2011, to January 31, 2012) versus after implementation of the RRP (November 1, 2012, to January 31, 2013). The study included inpatients 3 months or older with an acute respiratory tract illness, most admitted through the emergency department. Testing before RRP implementation used batched polymerase chain reaction analysis for respiratory syncytial virus and influenza A and B, with additional testing for parainfluenza 1 through 3 in approximately 11% of patients and for human metapneumovirus in less than 1% of patients. The RRP tested for respiratory syncytial virus, influenza A and B, parainfluenza 1 through 4, human metapneumovirus, adenovirus, rhinovirus/enterovirus, and coronavirus NL62. RESULTS The pre-RRP group had 365 patients, and the post-RRP group had 771 patients. After RRP implementation, the mean time to the test result was shorter (383 minutes versus 1119 minutes, P < .001), and the percentage of patients with a result in the emergency department was greater (51.6% versus 13.4%, P < .001). There was no difference in whether antibiotics were prescribed, but the duration of antibiotic use was shorter after RRP implementation (P = .003) and was dependent on receiving test results within 4 hours. If the test result was positive, the inpatient length of stay (P = .03) and the time in isolation (P = .03) were decreased after RRP implementation compared with before RRP implementation. CONCLUSIONS The RRP decreases the duration of antibiotic use, the length of inpatient stay, and the time in isolation.


title: A comparative study of handsewn versus stapled gastrojejunal anastomosis in laparoscopic Roux-en-Y gastric bypass.

text: BACKGROUND The two basic techniques available in which to perform the gastrojejunal (GJ) anastomosis during a laparoscopic Roux-en-Y gastric bypass (LRYGBP) are stapled and handsewn. Few outcomes differences have been noted between the two to recommend one as a superior approach. We present our findings in comparison of the two methods. METHODS This is a retrospective review of all patients who underwent LRYGBP at a single institution during a 3-year period. The two different techniques that were used were a linear stapled and handsewn anastomosis with an anastomotic diameter of 18 mm. The groups were compared for postoperative complications, including stricture, anastomotic leak, and the need for early reoperation. All patients were followed up for a minimum period of 8 months. RESULTS A total of 222 patients were analyzed after excluding 4 patients: 3 for revisional surgery and 1 for conversion to open. There were 99 patients in the stapled group and 123 in the handsewn group. In both groups, patients were predominantly female. The average age was 42.63 in the stapled group and 44.33 in the handsewn group (P = 0.218). Body mass index was 48.23 in the stapled group and 47.91 in the handsewn group (P = 0.733). Stricture rate in the stapled group was 10.1% (10/99) and 4.1% (5/123) in the handsewn group (P = 0.076). Four patients from the stapled group (4.08%) and six from the handsewn group (4.88%) needed early reoperation. One patient in each group had a GJ anastomotic leak (0.9%). There were no deaths. CONCLUSIONS The incidence of anastomotic stricture tends to be lower with a handsewn technique with lower operative time. No difference was appreciated in the anastomotic leak or reexploration rate with either technique.


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title: A novel, non-adhesive, precipitating liquid embolic implant with intrinsic radiopacity: feasibility and safety animal study.

text: OBJECTIVES To evaluate a novel, ready-to-use, iodinated polyvinyl alcohol polymer embolic implant. METHODS Under good laboratory practice conditions, 26 pigs were investigated. A complex arteriovenous malformation (AVM) model was created in 16 animals, and a simple rete model was used in the remaining 10 animals. The novel material was used for embolization in 22 animals, and a commercially available liquid embolic material in 4 animals as a control group. Animals were killed at 2 days, 3 months and 6 months. Feasibility, efficacy and safety were evaluated radiologically, clinically and histologically. RESULTS Preparation was easy, without risk of catheter clogging or adhesiveness. Embolic delivery was well controlled under subtracted fluoroscopy. Visibility was homogeneous throughout the injection and the material behaved cohesively upon delivery. Best lesion penetration was obtained with the use of proximal microballoon occlusion. Unforeseen over-dilution of the test material by DMSO prefilled in the microballoon hub changed the material properties and caused inadvertent cerebral embolization leading to death in five animals. This phenomenon was avoided by practical measures. The casts produced no beam-hardening artefacts on CT scans. Histology showed excellent biocompatibility. CONCLUSIONS Embolization with this novel, iodinated, precipitating polymer was feasible and effective. Care should be taken during delivery to avoid over-dilution of the material by prefilled DMSO. The material is promising for embolization of AVMs and hypervascular lesions. KEY POINTS • The intrinsically opaque precipitating polymer has adequate fluoroscopic visibility • The polymer does not induce shading or beam-hardening artefacts on CT • The novel liquid embolic material does not require lengthy preparation • Lack of implant adherence reduces the risk of entrapment of the delivery catheter.


title: A double-blind controlled trial of polyglytone 6211 versus poliglecaprone 25 for use in body contouring.

text: The use of absorbable sutures to obtain secure dermal closure in surgeries such as body contouring is common. The risk of complications based on the absorption rate of these materials is unknown. This study attempts to determine whether a faster absorbing suture material such as polyglytone 6211 will lead to fewer complications such as extrusion and granuloma formation as compared with less rapidly absorbing materials such as poliglecaprone 25. Concomitantly, this study also attempts to explore the possible negative outcomes that may be due to faster loss of strength, such as dehiscence and poor scar aesthetics. We found that extrusion occurs less frequently with the rapidly absorbed polyglytone 6211 suture material, without increase in granuloma formation, infection, dehiscence, cellulitis, necrosis, seroma formation, and hematoma formation. We also observed no clinical difference in the cosmetic appearance of scars at the 12-week postoperative follow-up visit.


Cutaneous Manifestations of Coronavirus Disease 2019 (COVID-19) Infection-What Do We Know So Far?


title: A mouse model of cochlear implantation with chronic electric stimulation.

text: OBJECTIVES Cochlear implants provide an effective treatment option for those with severe hearing loss, including those with preserved low frequency hearing. However, certain issues can reduce implant efficacy including intracochlear tissue response and delayed loss of residual acoustic hearing. We describe a mouse model of cochlear implantation with chronic electric stimulation that can be used to study cochlear implant biology and related pathologies. METHODS Twelve normal hearing adult CBA/J mice underwent unilateral cochlear implantation and were evenly divided into one group receiving electric stimulation and one not. Serial impedance and neural response telemetry (NRT) measurements were made to assess implant functionality. Functionality was defined as having at least one electrode with an impedance ≤ 35 kOhms. Mouse cochleae were harvested for histology and 3D x-ray microscopy 21 days post-operatively, or, in case the implant was still functional, at a later time point when the implant failed. A separate experiment measured the hearing preservation rate in 7 adult CBA/J mice undergoing unilateral cochlear implantation with serial auditory brainstem response (ABR) and distortion product otoacoustic emissions (DPOAE). RESULTS Implants maintained functionality for a mean of 35 days in the non-stimulated group and 19.8 days in the stimulated group. Reliable NRT and behavioral responses to electric stimulation were recorded. A robust intracochlear peri-implant tissue response with neo-ossification was seen in all cochleae. Six of seven mice maintained intact low frequency hearing up to 6 weeks following cochlear implantation. CONCLUSIONS We demonstrate the feasibility of cochlear implantation and behaviorally significant electric stimulation in the mouse, with the potential for hearing preservation. This model may be combined with established mouse models of hearing loss and the large genetic and molecular research toolkit unique to the mouse for mechanistic and therapeutic investigations of cochlear implant biology.


title: Alternative routes to oral opioid administration in palliative care: a review and clinical summary.

text: OBJECTIVE A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. METHODS We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. RESULTS Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. CONCLUSIONS This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.


title: Robot assisted thoracoscopic resection of giant esophageal leiomyoma.

text: INTRODUCTION Esophageal leiomyoma represents the most common benign esophageal tumor. Robot-assisted thoracoscopic surgery has provided ability to remove it successfully using a minimally invasive approach. PRESENTATION OF CASE A 63-year old female with history of chronic chest pain presented with an esophageal mass on chest CT and endoscopic ultrasound. Robot-assisted surgery was performed using three robot arms, a camera and an assistant port. A 10cm leiomyoma was enucleated and removed through a 2cm myotomy. Completion endoscopy confirmed integrity of the esophagus. Patient's chest pain resolved postoperatively, and she was discharged on postoperative day 3. DISCUSSION Our case describes successful removal of the giant esophageal leiomyoma (10cm) by robot assisted minimally invasive resection through a 2cm myotomy. CONCLUSION Use of robot allows for removal of large esophageal leiomyoma. The improved dexterity and patient outcome offered by robot suggests its potential as the mainstay technique for giant esophageal leiomyoma removal.


title: Achieving Accreditation Council for Graduate Medical Education duty hours compliance within advanced surgical training: a simulation-based feasibility assessment.

text: BACKGROUND Certain operative cases occur unpredictably and/or have long operative times, creating a conflict between Accreditation Council for Graduate Medical Education (ACGME) rules and adequate training experience. METHODS A ProModel-based simulation was developed based on historical data. Probabilistic distributions of operative time calculated and combined with an ACGME compliant call schedule. RESULTS For the advanced surgical cases modeled (cardiothoracic transplants), 80-hour violations were 6.07% and the minimum number of days off was violated 22.50%. There was a 36% chance of failure to fulfill any (either heart or lung) minimum case requirement despite adequate volume. CONCLUSIONS The variable nature of emergency cases inevitably leads to work hour violations under ACGME regulations. Unpredictable cases mandate higher operative volume to ensure achievement of adequate caseloads. Publically available simulation technology provides a valuable avenue to identify adequacy of case volumes for trainees in both the elective and emergency setting.


title: Acute hypoxia in a simulated high-altitude airdrop scenario due to oxygen system failure.

text: High-Altitude High Opening (HAHO) is a military operational procedure in which parachute jumps are performed at high altitude requiring supplemental oxygen, putting personnel at risk of acute hypoxia in the event of oxygen equipment failure. This study was initiated by the Norwegian Army to evaluate potential outcomes during failure of oxygen supply, and to explore physiology during acute severe hypobaric hypoxia. A simulated HAHO without supplemental oxygen was carried out in a hypobaric chamber with decompression to 30,000 ft (9,144 m) and then recompression to ground level with a descent rate of 1,000 ft/min (305 m/min). Nine subjects were studied. Repeated arterial blood gas samples were drawn throughout the entire hypoxic exposure. Additionally, pulse oximetry, cerebral oximetry, and hemodynamic variables were monitored. Desaturation evolved rapidly and the arterial oxygen tensions are among the lowest ever reported in volunteers during acute hypoxia. PaO2 decreased from baseline 18.4 (17.3-19.1) kPa, 138.0 (133.5-143.3) mmHg, to a minimum value of 3.3 (2.9-3.7) kPa, 24.8 (21.6-27.8) mmHg, after 180 (60-210) s, [median (range)], N = 9. Hyperventilation with ensuing hypocapnia was associated with both increased arterial oxygen saturation and cerebral oximetry values, and potentially improved tolerance to severe hypoxia. One subject had a sharp drop in heart rate and cardiac index and lost consciousness 4 min into the hypoxic exposure. A simulated high-altitude airdrop scenario without supplemental oxygen results in extreme hypoxemia and may result in loss of consciousness in some individuals.NEW & NOTEWORTHY This is the first study to investigate physiology and clinical outcome of oxygen system failure in a simulated HAHO scenario. The acquired knowledge is of great value to make valid risk-benefit analyses during HAHO training or operations. The arterial oxygen tensions reported in this hypobaric chamber study are among the lowest ever reported during acute hypoxia.


title: Retroprosthetic seroma after laparoscopic ventral hernia repair: incidence, risk factors and clinical significance.

text: BACKGROUND The seroma generated between the abdominal viscera and the prosthesis (retroprosthetic seroma), after laparoscopic ventral hernia repair (LVHR) with the implant of an intraperitoneal mesh is an unknown entity with few references in the literature. Our objective is to analyze its incidence, clinical repercussions and course of retroprosthetic seroma during the first 3 months post-operation and the factors related to its appearance, such as the relationship to preprosthetic seroma, the size of the prosthesis and the patient BMI. MATERIALS AND METHODS Prospective, descriptive study in patients undergoing LVHR using the double crown technique. After surgery, the patients had follow-ups on the seventh day and the first and third months post-operation with clinical examination and abdominal CT scan. The study endpoints were: incidence and volume of retroprosthetic seroma, clinical repercussions, relationship to body mass index (BMI), prosthesis size and the existence of preprosthetic seroma. RESULTS Fifty patients underwent LVHR using the double crown technique and were included in the study. The incidence of retroprosthetic seroma during the 3-month follow-up was 46%, there being a progressive process of spontaneous reabsorption. In just one patient (2%) there were clinical repercussions as a result of the seroma. No statistically significant relationship was found with BMI and preprosthetic seroma. A statistical relationship was found between the size of the prosthesis and the risk of suffering retroprosthetic seroma in the third month post-operation (p = 0.048). CONCLUSIONS Retroprosthetic seroma is an entity produced in 46% of patients undergoing LVHR with few clinical repercussions (2%). In most cases it develops in the first week post-operation and then undergoes a reabsorption process that is usually complete by the third month post-operation. The size of the prosthesis delays the reabsorption process.


title: Real-time isothermal detection of Shiga toxin-producing Escherichia coli using recombinase polymerase amplification.

text: Shiga toxin-producing Escherichia coli (STEC) are a major family of foodborne pathogens of public health, zoonotic, and economic significance in the United States and worldwide. To date, there are no published reports on use of recombinase polymerase amplification (RPA) for STEC detection. The primary goal of this study was to assess the potential application of RPA in detection of STEC. This study focused on designing and evaluating RPA primers and fluorescent probes for isothermal (39°C) detection of STEC. Compatible sets of candidate primers and probes were designed for detection of Shiga toxin 1 and 2 (Stx1 and 2), respectively. The sets were evaluated for specificity and sensitivity against STEC (n=12) of various stx genotypes (stx1/stx2, stx1, or stx2, respectively), including non-Stx-producing E. coli (n=28) and other genera (n=7). The primers and probes that were designed targeted amplification of the subunit A moiety of stx1 and stx2. The assay detected STEC in real time (within 5-10 min at 39°C) with high sensitivity (93.5% vs. 90%; stx1 vs. stx2), specificity (99.1% vs. 100%; stx1 vs. stx2), and predictive value (97.9% for both stx1 vs. stx2). Limits of detection of ∼ 5-50 colony-forming units/mL were achieved in serially diluted cultures grown in brain heart infusion broth. This study successfully demonstrated for the first time that RPA can be used for isothermal real-time detection of STEC.


title: Quantifying Anatomic Deformations During Laryngoscopy.

text: For a variety of head and neck cancers, specifically those of the oropharynx, larynx, and hypopharynx, minimally invasive trans-oral approaches have been developed to reduce perioperative and long-term morbidity. However, in trans-oral surgical approaches anatomical deformation due to instrumentation, specifically placement of laryngoscopes and retractors, present a significant challenge for surgeons relying on preoperative imaging to resect tumors to negative margins. Quantifying the deformation due to instrumentation is needed in order to develop predictive models of operative deformation. In order to study this deformation, we used a CT/MR-compatible laryngoscopy system in concert with intraoperative CT imaging. 3D models of preoperative and intraoperative anatomy were generated. Mandible and hyoid displacements as well as tongue deformations were quantified for eight patients undergoing diagnostic laryngoscopy. Across patients, we found on average 1.3 cm of displacement for these anatomic structures due to laryngoscope insertion. On average, the maximum displacement for certain tongue regions exceeded 4 cm. The anatomical deformations quantified here can serve as a reference for describing how the upper aerodigestive tract anatomy changes during instrumentation and may be helpful in developing predictive models of intraoperative upper aerodigestive tract deformation.


Donor site healing dynamics: molecular, histological, and noninvasive imaging assessment in a porcine model.


title: Delineating and preventing plastic waste leakage in the marine and terrestrial environment.

text: Plastics are nowadays considered to be the workhorse material of our modern society with an ubiquitous presence that has increased manifold over the past 60 years, providing several benefits to the global economy. However, inappropriate and/or uncontrolled disposal practices, poor waste management infrastructure and application of insufficient recycling technologies, coupled with a lack of public awareness and incentives, have rendered plastic waste omnipresent, littering both the marine and the terrestrial environment with multi-faceted impacts. This short communication/commentary aims at delineating the plastic litter global challenge providing, at the same time, scientific views and perspectives on properly dealing with this material type, both upstream and downstream.


title: Impact of earplugs and eye mask on sleep in critically ill patients: a prospective randomized study.

text: BACKGROUND Poor sleep is common in intensive care unit (ICU) patients, where environmental factors contribute to reduce and fragment sleep. The objective of this study was to evaluate the impact of earplugs and eye mask on sleep architecture in ICU patients. METHODS A single-center randomized controlled trial of 64 ICU patients was conducted from July 2012 to December 2013. Patients were randomly assigned to sleep with or without earplugs and an eye mask from inclusion until ICU discharge. Polysomnography was performed on the first day and night following inclusion. The primary outcome was the proportion of stage N3 sleep over total sleep time. Secondary outcomes were other descriptors of sleep and major outcome variables. RESULTS In the intervention group, nine (30%) patients did not wear earplugs all night long. The proportion of N3 sleep was 21 [7-28]% in the intervention group and 11 [3-23]% in the control group (p = 0.09). The duration of N3 sleep was higher among the patients in the intervention group who wore earplugs all night long than in the control group (74 [32-106] vs. 31 [7-76] minutes, p = 0.039). The number of prolonged awakenings was smaller in the intervention group (21 [19-26] vs. 31 [21-47] in the control group, p = 0.02). No significant difference was observed between the two groups in terms of clinical outcome variables. CONCLUSIONS Earplugs and eye mask reduce long awakenings and increase N3 duration when they are well tolerated. TRIAL REGISTRATION ClinicalTrials.gov, NCT02292134 . Registered on 21 Nov 2013.


title: Essential items for reporting of scaling studies of health interventions (SUCCEED): protocol for a systematic review and Delphi process.

text: BACKGROUND The lack of a reporting guideline for scaling of evidence-based practices (EBPs) studies has prompted the registration of the Standards for reporting studies assessing the impact of scaling strategies of EBPs (SUCCEED) with EQUATOR Network. The development of SUCCEED will be guided by the following main steps recommended for developing health research reporting guidelines. METHODS Executive Committee. We established a committee composed of members of the core research team and of an advisory group. Systematic review. The protocol was registered with the Open Science Framework on 29 November 2019 (https://osf.io/vcwfx/). We will include reporting guidelines or other reports that may include items relevant to studies assessing the impact of scaling strategies. We will search the following electronic databases: EMBASE, PsycINFO, Cochrane Library, CINAHL, Web of Science, from inception. In addition, we will systematically search websites of EQUATOR and other relevant organizations. Experts in the field of reporting guidelines will also be contacted. Study selection and data extraction will be conducted independently by two reviewers. A narrative analysis will be conducted to compile a list of items for the Delphi exercise. CONSENSUS PROCESS We will invite panelists with expertise in: development of relevant reporting guidelines, methodologists, content experts, patient/member of the public, implementers, journal editors, and funders. We anticipated that three rounds of web-based Delphi consensus will be needed for an acceptable degree of agreement. We will use a 9-point scale (1 = extremely irrelevant to 9 = extremely relevant). Participants' response will be categorized as irrelevant (1-3), equivocal (4-6) and relevant (7-9). For each item, the consensus is reached if at least 80% of the participants' votes fall within the same category. The list of items from the final round will be discussed at face-to-face consensus meeting. Guideline validation. Participants will be authors of scaling studies. We will collect quantitative (questionnaire) and qualitative (semi-structured interview) data. Descriptive analyses will be conducted on quantitative data and constant comparative techniques on qualitative data. DISCUSSION Essential items for reporting scaling studies will contribute to better reporting of scaling studies and facilitate the transparency and scaling of evidence-based health interventions.


title: Intraperitoneal onlay mesh repair (IPOM) plus technique using a hybrid procedure of open laparotomy and laparoscopic approach (hybrid IPOM plus) for incarceration of umbilical hernia in a severely obese patient: a case report.

text: BACKGROUND A standard procedure for the treatment of incarcerated umbilical hernia among severely obese patients has yet to be established. We used the hybrid intraperitoneal onlay mesh repair (IPOM) plus method, which combines open and laparoscopic surgery to treat incarcerated umbilical hernia in a severely obese patient. CASE PRESENTATION A 46-year-old man presented in our department with a chief complaint of a painful mass in the umbilical region. Incarcerated umbilical hernia was diagnosed on the basis of abdominal computed tomography, and the decision was made to perform emergency surgery. The patient was severely obese (body mass index, 53.8 kg/m2), and the incarcerated portion of the hernia was therefore first addressed by open surgery. As bowel resection was unnecessary, the risk of infection was considered low, and after direct closure of the hernia orifice, IPOM was performed laparoscopically using the hybrid IPOM plus method. CONCLUSION Among severely obese patients, first trocar insertion is difficult and the wound site tends to come under strain, meaning that simple closure of the hernia orifice results in a high recurrence rate. The hybrid IPOM plus method used in this case combines open surgery and laparoscopy and appears useful for treating uninfected incarcerated umbilical hernia in severely obese patients safely and with an anticipated low rate of postoperative recurrence.


title: A protocol for a systematic review of process evaluations of interventions investigating sedentary behaviour in adults.

text: INTRODUCTION Sedentary behaviour is defined as any waking behaviour characterised by low energy expenditure ≤1.5 metabolic equivalents while in a sitting, lying or reclining posture. The expanding evidence base suggests that sedentary behaviour may have a detrimental effect on health, well-being and is associated with an increased risk of all-cause mortality. We aim to review process evaluations of randomised controlled trials (RCTs) which included a measure of sedentary behaviour in adults in order to develop an understanding of intervention content, mechanisms of impact, implementation and delivery approaches and contexts, in which interventions were reported to be effective or effective. A secondary aim is to summarise participants, family and staff experiences of such interventions. METHODS AND ANALYSIS Ten electronic databases and reference lists from previous similar reviews will be searched. Eligible studies will be process evaluations of RCTs that measure sedentary behaviour as a primary or secondary outcome in adults. As this review will contribute to a programme to develop a community-based intervention to reduce sedentary behaviour in stroke survivors, interventions delivered in schools, colleges, universities or workplaces will be excluded. Two reviewers will perform study selection, data extraction and quality assessment. Disagreements between reviewers will be resolved by a third reviewer. Process evaluation data to be extracted include the aims and methods used in the process evaluation; implementation data; mechanisms of impact; contextual factors; participant, family and staff experiences of the interventions. A narrative approach will be used to synthesise and report qualitative and quantitative data. Reporting of the review will be informed by Preferred Reporting Items for Systematic Review and Meta-Analysis guidance. ETHICS AND DISSEMINATION Ethical approval is not required as it is a protocol for a systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER CRD42018087403.


title: Preoperative frailty and its association with postsurgical pain in an older patient cohort.

text: BACKGROUND AND OBJECTIVES Chronic postsurgical pain in patients over 65 negatively impacts recovery, quality of life and physical functioning. In the community setting, chronic pain has been shown to be related to frailty, a syndrome more commonly seen in older adults and characterized by limited physiologic reserve and ability to withstand stressors. While frailty is an important preoperative risk factor for poor surgical outcomes in older adults, the relationship between frailty and postsurgical pain in this population has not been investigated. We hypothesized that preoperative frailty would be associated with greater odds of postsurgical chronic pain. METHODS We conducted a prospective cohort study of 116 patients older than 65 years old who underwent major elective non-cardiac surgery. Patients were assessed for frailty within 30 days prior to surgery using the FRAIL Scale assessment and pain was evaluated before surgery and at 3 months after surgery using the Geriatric Pain Measure. RESULTS After adjusting for baseline characteristics, we found that frail patients were almost five times more likely to have intrusive postsurgical pain compared with patients who were not frail (OR 4.73, 95% CI 1.24 to 18.09). Intrusive preoperative pain and spine surgery were also associated with increased postsurgical pain (OR 10.13, 95% CI 2.81 to 36.57 and OR 4.02, 95% CI 1.22 to 13.17, respectively). CONCLUSION Although future studies are needed to establish a causal relationship between preoperative frailty and postsurgical pain, our findings suggest that older patients should have preoperative frailty assessments and frail older adults may need additional resources to improve postsurgical pain outcomes. TRIAL REGISTRATION NUMBER NCT02650687.


title: Meal replacements followed by topiramate for the treatment of adolescent severe obesity: A pilot randomized controlled trial.

text: OBJECTIVE To assess the safety and efficacy of short-term meal replacement therapy followed by topiramate for body mass index (BMI) reduction in adolescents with severe obesity. METHODS Adolescents (ages 12-18 years) with severe obesity (BMI ≥1.2 times the 95th percentile or BMI ≥35 kg/m2 ) were recruited for this double-blind, randomized, placebo-controlled trial. Participants completed 4 weeks of meal replacement therapy followed by randomization (1:1) to either 24 weeks of topiramate 75 mg/day or placebo. Mean changes were compared between groups. RESULTS Thirty adolescents (mean age 15.2 ± 1.7 years, mean BMI 40.3 ± 4.6 kg/m2 ) completed the meal replacement phase and were randomized; 21 completed the study. The difference in mean percent change in BMI between the topiramate and placebo groups was not significant (-1.9%; 95% CI: -5.2% to +1.5%; P = 0.291). Significant improvements in visceral fat and very-low-density lipoprotein cholesterol were observed in the topiramate compared with the placebo group. There were no concerning changes in neurocognitive function or bone health. CONCLUSIONS In this pilot study, 4 weeks of meal replacement therapy followed by 24 weeks of low-dose topiramate compared with meal replacement therapy alone did not result in significant BMI reduction for adolescents with severe obesity.


title: Panel 8: Complications and sequelae.

text: BACKGROUND AND OBJECTIVES Although serious complications of otitis media (OM) such as brain abscess are rare, sequelae of OM such as tympanic membrane perforation and atelectatic tympanic membrane are quite common. Inner ear sequelae can cause hearing loss and speech and language problems. The objectives of this article are to provide a state-of-the-art review on recent articles on complications and sequelae of OM in different anatomic locations, from the tympanic membrane to intracranial sites, as well as hearing loss and speech and language development. DATA SOURCES Primarily PubMed supplemented by Ovid MEDLINE and the Cochrane Database. REVIEW METHODS All types of articles related to OM complications and sequelae published in English between January 2007 and June 2011 were identified. A total of 127 relevant quality articles are summarized and included in this report. RESULTS Key findings are summarized based on the following major anatomic locations and categories: tympanic membrane; cholesteatoma; ossicular problems; mucosal sequelae; inner ear sequelae; speech and language development; extracranial areas, including mastoiditis and facial nerve paralysis; intracranial complications; and future research goals. New information and insights were gained to prevent complications and sequelae. CONCLUSION AND IMPLICATIONS FOR PRACTICE Over the past 4 years, progress has been made in advancing the knowledge on the complications and sequelae of OM, which can be used to prevent and treat them effectively. Areas of potential future research have been identified and outlined.


Coronavirus nixes conference, twilight zone beckons and a faded star brightens.


title: Fixed and Modifiable Correlates of Drug-Eluting Stent Thrombosis From a Large All-Comers Registry: Insights From ADAPT-DES.

text: BACKGROUND Previous studies evaluating correlates of stent thrombosis (ST) have included mostly patients with bare metal stents and early-generation drug-eluting stents (DES) and have not systematically evaluated the role of intravascular ultrasound-guided stenting and high platelet reactivity on clopidogrel. The purpose of this study was to evaluate the frequency and correlates of ST in patients receiving DES, specifically examining the impact of risk factors modifiable by physician and patient behavior. METHODS AND RESULTS Assessment of Dual Anti-platelet Therapy With Drug-Eluting Stents (ADAPT-DES) was a multicenter, prospective study in patients undergoing successful coronary intervention with DES in whom routine platelet reactivity testing was performed. Definite or probable ST occurred in 92 (1.1%) of 8582 patients within 2 years. Independent baseline correlates of ST included presentation with an acute coronary syndrome (hazard ratio [HR]=1.81, P=0.01), insulin-treated diabetes mellitus (HR=1.91, P=0.02), previous myocardial infarction (HR=1.75, P=0.02), and peripheral arterial disease (HR=2.01, P=0.01). Independent treatment-related correlates included use of early generation DES (HR=1.75, P=0.02), no procedural intravascular ultrasound guidance (HR=1.75, P=0.04), and premature discontinuation of dual antiplatelet therapy (HR=2.67, P=0.003); high platelet reactivity on clopidogrel trended as a correlate of ST (HR=1.49, P=0.08). The 2-year risk of ST ranged from 0.3% to 10.0% when 0 to 3 modifiable risk factors were present. CONCLUSIONS After successful DES implantation, ST occurred within 2 years in 1.1% of patients and was strongly associated with fixed and modifiable risk factors. The frequency of ST may be reduced with intravascular ultrasound -guided stenting, assiduous adherence to dual antiplatelet therapy, and adequate P2Y12 platelet receptor inhibition. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794.


title: Prior fundoplication does not improve safety or efficacy outcomes of radiofrequency ablation: results from the U.S. RFA Registry.

text: BACKGROUND Ongoing gastroesophageal reflux may impair healing and re-epithelialization after radiofrequency ablation (RFA) of Barrett's esophagus (BE). Because prior fundoplication may improve reflux control, our aim was to assess the relationship between prior fundoplication and the safety/efficacy of RFA. METHODS We assessed the U.S. RFA Registry, a nationwide registry of BE patients receiving RFA at 148 institutions, to compare the safety and efficacy of ablation between those with prior fundoplication and those with medical management (proton pump inhibition). RESULTS Among 5,537 patients receiving RFA, 301 (5.4 %) had prior fundoplication. Of fundoplication subjects, 1.0 % developed stricture and 1.0 % were hospitalized after RFA. Rates of stricture, bleeding, and hospitalization were not statistically different (p = ns) between patients with and without prior fundoplication. Complete eradication of intestinal metaplasia and complete eradication of dysplasia were achieved in 71 % and 87 % of fundoplication patients, and 73 % and 87 % of patients without fundoplication, respectively (p = ns for both). Patients with prior fundoplication needed similar numbers of RFA sessions for eradication compared with those without fundoplication. CONCLUSIONS Radiofrequency ablation, with or without prior fundoplication, is safe and effective in eradicating BE. Prior fundoplication was associated with similar adverse event and efficacy rates when compared with medical management.


title: Feasibility of cerebral blood flow and oxygenation monitoring by continuous transcranial Doppler combined with cerebral oximetry in a patient with refractory cardiac arrest treated by extracorporeal life support.

text: The adequacy of cerebral blood flow and the level of regional oxygen saturation during CPR and early post-resuscitation phases assuring favorable neurological outcome are not known. We demonstrate the feasibility of cerebral blood flow and oxygenation monitoring by a continuous transcranial Doppler combined with cerebral oximetry in a patient with refractory cardiac arrest treated by extracorporeal life support.


title: Esthetic neck dissection using an endoscope via retroauricular incision: a report of two cases.

text: Various surgical techniques, such as endoscopic surgery and robotic surgery, are developed to optimize the esthetic outcome even in operations for malignancy. A modified face-lift or retroauricular approach are used to minimize postoperative scarring. Recently, robot-assisted surgery is being done in various fields and considered as favorable treatment method by many surgeons. However its high cost is a nonnegligible fraction for many patients. On the other hand, endoscopic surgery, which is cheaper than robotic surgery, is minimally invasive with contentable neck dissection. Although it is a difficult technique for a beginner surgeon due to its limited operation view, we suppose it as an alternative method for robotic surgery. Herein, we report two cases of endoscopic neck dissection via retroauricular incision with a discussion regarding the pros and cons of endoscopic neck dissection.


title: Single-port Laparoscopic Reversal of Hartmann's Procedure: Technique and Results.

text: In general, reversal of Hartmann's procedure is associated with a high morbidity and therefore leads to a low rate of intestinal restoration. Reversal of Hartmann's procedure has to be seen as a complex abdominal operation with the same possible complications as in other colorectal resections. By using the laparoscopic technique, operative access trauma by laparotomy can be minimized. After introducing single-port access into laparoscopic surgery beginning with cholecystectomies and sigmoid resections, we started with the first single-port laparoscopic reversal of Hartmann's procedure in January 2010. After excision of the colostoma, mobilization, and reponing into the abdominal cavity, the single-port trocar was placed at the stoma incision without any extra scar. We investigated whether the single-port laparoscopic reversal is as safely feasible as the "conventional" laparoscopic procedure. Till December 2010, single-port reversal operation was performed in 8 patients 2-4 months after Hartmann's procedure because of complicated diverticulitis. No conversion to "conventional" laparoscopic or open procedure was necessary in 1 patient one extra 5 mm trocar was used. The average operation time was 74 min. Except for one wound complication, the postoperative course was uncomplicated. The patients were discharged after 4 to 8 postoperative days. Single-port reversal of Hartmann's procedure has showed as a new method for minimizing the access trauma even further than "conventional" laparoscopic surgery.


Abdominal Wall "Closure".


title: Use of permacol in parietal and general surgery: a bibliographic review.

text: BACKGROUND The use of synthetic meshes on infected incisional hernias often fails and is therefore contraindicated. Biological meshes offer a novel solution. Among them, Permacol requires a bibliographic analysis of its efficacy and tolerance. DESIGN A bibliographic analysis was carried out on the efficacy and tolerance of Permacol in parietal and general surgery. RESULTS A total of 22 publications described the use of Permacol in digestive surgery. The advantages of Permacol would be usability in contaminated surgical fields, biocompatibility, no erosion of intestinal wall, and less risk of adhesions. The main drawback of Permacol is its high cost. CONCLUSION Even so, Permacol can play an important part in the short-term management of complex or contaminated abdominal wall defects. The lack of long-term studies and the high cost of the implant call for a medical cost-effectiveness assessment to determine the indications for Permacol in parietal and general surgery.


title: Retroperitoneoscopic nephrectomy with a modified hand-assisted approach.

text: OBJECTIVES To present the first experience with a 3-port technique for retroperitoneoscopic (HARP) radical nephrectomy, radical nephroureterectomy, and total and live donor nephrectomy. We believe that the retroperitoneoscopic (RP) approach to nephrectomy is advantageous, as it avoids mobilization of intraperitoneal organs and provides direct access to the renal artery. Nonetheless, this approach is not as popular as the transperitoneal approach, likely because of the steeper learning curve. We believe that hand-assistance reduces the learning curve because of the tactile feedback and similarity to open surgery. METHODS Over a 4-year period, 133 HARP nephrectomies were performed, including 92 radical nephrectomies, 19 radical nephroureterectomies, 12 total nephrectomies, and 10 live donor nephrectomies. Mean patient age was 62 years and mean body mass index was 30; 42% of patients had abdominal scars. Our technique uses a 7-cm muscle-sparing Gibson incision for the hand-port with 2 endoscopic ports. RESULTS Mean operative time, including ureterectomy, was 109 minutes, with a mean operative blood loss of 167 mL. Average hospitalization was 3.8 days. Two cases (1.5%) required open conversion. The complication rate was limited to 3.8% for blood transfusion, 3.8% for cardiac issues, 1.5% for pulmonary embolism, 2.3% for wound infection, and 1.5% for urinary retention. CONCLUSIONS Based on our results, we conclude that HARP nephrectomy is safe and effective and can be expeditiously performed. It is a versatile approach that is applicable for both neoplastic and non-neoplastic indications. In addition, HARP provides a minimally invasive alternative to open conversion in difficult cases of simple nephrectomy.


title: Clinical screening of oropharyngeal dysphagia in patients with ALS.

text: OBJECTIVE It is a major issue to diagnose and detect oropharyngeal dysphagia in the early stage of ALS in order to avoid pulmonary and nutritional complications. The aim of this study was to validate a simple clinical test, the Volume-Viscosity Swallow Test (V-VST), to detect oropharyngeal dysphagia in this population. PATIENTS AND METHODS Twenty patients were included in this study (mean age: 66.1 ± 8.13, six women). All patients had their swallowing function assessed by videofluoroscopy and V-VST. RESULTS Among these 20 patients, 15 presented oropharyngeal dysphagia, diagnosed by videofluoroscopy, and five had normal swallowing. Norris score was lower in patients with oropharyngeal dysphagia compared to the patients with normal swallowing (27 ± 6 versus 36 ± 2; P=0.003). Among the 15 patients with oropharyngeal dysphagia, 14 had abnormal V-VST, and only one had normal V-VST. The sensibility of V-VST to detect oropharyngeal dysphagia in these patients with ALS was of 93%, and the specificity was of 80% (P=0.007). There was no significant difference between the two populations for ALSFRS score (22 ± 6 versus 20 ± 6) and body mass index (BMI) (26 ± 6 versus 26 ± 6 kg/m(2)). CONCLUSION The V-VST presented good sensibility and specificity. It may be interesting to use it systematically for the detection of oropharyngeal dysphagia in ALS, after confirming these results on a wider patient sample.


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title: Mortality rates of severe traumatic brain injury patients: impact of direct versus nondirect transfers.

text: BACKGROUND Direct transport of patients with severe traumatic brain injury (sTBI) to trauma centers (TCs) that can provide definitive care results in lower mortality rates. This study investigated the impact of direct versus nondirect transfers on the mortality rates of patients with sTBI. METHODS Data on patients with TBI admitted between January 1, 2012, and December 31, 2013, to our Level I TC were obtained from the trauma registry. Data included patient age, sex, mechanism, and type of injury, comorbidities, Glasgow Coma Scale, Injury Severity scores, prehospital time, time to request and to transfer, time to initiation of multimodality monitoring and goal-directed therapy protocol, dwell time in the emergency department (EDT), and mortality. Data, reported in means ± standard deviation, were analyzed with the Student t-test and chi-square. Statistical significance was accepted at a P value < 0.05. RESULTS sTBI direct transfer to TC versus transfer from non-TCs (NTC): Of the 1187 patients with TBI admitted to our TC, 768 (64.7%) were admitted directly from the scene, whereas 419 (35.3%) were admitted after secondary transfer. One hundred seventy-one (22.2%) of the direct transfers had Glasgow Coma Scale < 8 (sTBI) and 92 (21.9%) of the secondary transfers had sTBI. The transfer time: Time from scene to arrival to the EDT was significantly shorter for TC versus NTCs 43 ± 14 versus 77 ± 26 min, respectively (P < 0.05). EDT dwell time before transfer and time from injury to arrival to TC were 4.2 ± 2.1 and 6.2 ± 8.3 h, respectively. Mortality: There was a statistically significant lower mortality for patients with sTBI transferred directly from the scene to TCs as opposed to patients secondarily transferred, 33/171 (19.3%) versus 33/92 (35.8%), respectively (P < 0.05). CONCLUSIONS To decrease TBI-related mortality, patients with suspected sTBI should be taken directly to a Level I or II TC unless they require life-saving stabilization at NTCs.


title: Biological and social aspects of Coronavirus Disease 2019 (COVID-19) related to oral health.

text: The expansion of coronavirus disease 2019 (COVID-19) throughout the world has alarmed all health professionals. Especially in dentistry, there is a growing concern due to it's high virulence and routes of transmission through saliva aerosols. The virus keeps viable on air for at least 3 hours and on plastic and stainless-steel surfaces up to 72 hours. In this sense, dental offices, both in the public and private sectors, are high-risk settings of cross infection among patients, dentists and health professionals in the clinical environment (including hospital's intensive dental care facilities). This manuscript aims to compile current available evidence on prevention strategies for dental professionals. Besides, we briefly describe promising treatment strategies recognized until this moment. The purpose is to clarify dental practitioners about the virus history and microbiology, besides guiding on how to proceed during emergency consultations based on international documents. Dentists should consider that a substantial number of individuals (including children) who do not show any signs and symptoms of COVID-19 may be infected and can disseminate the virus. Currently, there is no effective treatment and fast diagnosis is still a challenge. All elective dental treatments and non-essential procedures should be postponed, keeping only urgent and emergency visits to the dental office. The use of teledentistry (phone calls, text messages) is a very promising tool to keep contact with the patient without being at risk of infection.


title: Digital pathology and artificial intelligence will be key to supporting clinical and academic cellular pathology through COVID-19 and future crises: the PathLAKE consortium perspective.

text: The measures to control the COVID-19 outbreak will likely remain a feature of our working lives until a suitable vaccine or treatment is found. The pandemic has had a substantial impact on clinical services, including cancer pathways. Pathologists are working remotely in many circumstances to protect themselves, colleagues, family members and the delivery of clinical services. The effects of COVID-19 on research and clinical trials have also been significant with changes to protocols, suspensions of studies and redeployment of resources to COVID-19. In this article, we explore the specific impact of COVID-19 on clinical and academic pathology and explore how digital pathology and artificial intelligence can play a key role to safeguarding clinical services and pathology-based research in the current climate and in the future.


title: Outcomes associated with ablation compared to combined ablation and transilluminated powered phlebectomy in the treatment of venous varicosities.

text: BACKGROUND Patients with painful varicose veins and venous insufficiency can be treated by eliminating axial reflux only or by eliminating axial reflux plus phlebectomy with transilluminated powered phlebectomy. This study was undertaken with the aim of determining and improving signs and symptoms of venous disease (measured by venous clinical severity score) and complications (by routine surveillance ultrasound and long-term post-operative follow up) for each treatment strategy. METHODS We performed a retrospective evaluation of prospectively collected data from 979 limbs undergoing procedures for significant varicose veins and venous insufficiency from March 2008 until June 2014 performed at a single tertiary referral hospital. Patient demographics, Clinical Etiology Anatomy and Pathophysiology classification, venous clinical severity scores pre- and post-procedure, treatment chosen, and peri-operative complications were collected; descriptive statistics were calculated and unadjusted surgical outcomes for patients stratified by the procedure performed. Multivariable logistic regression was used to evaluate the relationship between procedure type and thrombotic complications after adjusting for patient characteristics, severity of disease, pre-operative anticoagulation, and post-operative compression. RESULT Venous clinical severity scores improved more with radiofrequency ablation + transilluminated powered phlebectomy as compared to radiofrequency ablation alone (3.8 ± 3.4 vs. 3.2 ± 3.1, p = 0.018). Regarding deep venous thrombosis, there was no significant difference between radiofrequency ablation + transilluminated powered phlebectomy vs. radiofrequency ablation alone. There was no statistical difference in asymptomatic endovenous heat-induced thrombosis or infection, although there were slightly more hematomas and cases of asymptomatic superficial thrombophlebitis with combined therapy. On multivariable analysis, only procedure type predicted thrombotic complications. CONCLUSION Ablation of axial reflux plus transilluminated powered phlebectomy produces improved outcomes as measured by venous clinical severity score, with slight increases in minor post-operative complications and should be strongly considered as initial therapy when patients present with significant symptomatic varicose veins and superficial venous insufficiency. Implementation of a standardized thromboprophylaxis protocol with individual risk assessment results in few significant thrombotic complications amongst high-risk patients, thus potentially obviating the need for routine post-operative duplex.


title: Exploring the conformational space of Vpu from HIV-1: a versatile adaptable protein.

text: The dynamic behavior of monomeric Vpu(1-32) from HIV-1 in different lipid environments has been studied. The peptide shows highly flexible behavior during the simulations and easily adapts to changing lipid environments as it experiences when travelling through the Golgi apparatus. Protein-lipid interactions do not show any significant correlation towards lipid type or thickness based on multiple 10 ns simulations. The averaged structure of a series of 16 independent simulations suggest kink around Ser-24, which compensates the polarity of its side chain by forming hydrogen bonds with the carbonyl backbone of adjacent amino acids towards the N-terminus.


title: COVID-19 Pandemic: Perspective from Italian Pediatric Emergency Physicians.

text: OBJECTIVE To document the lived experience of Italian pediatric emergency physicians during the COVID-19 pandemic. METHODS We developed a structured interview to collect the lived experience of the staff of the Pediatric emergency department (PED) of a tertiary referral university hospital in Northern Italy. The open-ended questions were draft according to the suggestions of Canadian colleagues and administered by one interviewer, who was part of the PED staff, at the end of March 2020. All the PED staff was interviewed, on a voluntary basis, using purposive sampling. RESULTS Most respondents declared to be afraid of becoming infected and of infecting their families. The number of patients seen in the PED has decreased, and the cases tend to be more severe. A shift in the clinical approach to the ill child has occurred, the physical examination is problem-oriented, aiming to avoid un-necessary maneuvers and to minimize the number of practitioners involved. The most challenging aspects reported are: (1) performing a physical examination in personal protective equipment (PPE); (2) being updated with rapidly evolving guidelines; (3) staying focused on the possible COVID-19 clinical presentation without failing in differential diagnosis. CONCLUSIONS During the COVID-19 pandemic, it seems that pediatric emergency physicians are radically changing their clinical practice, aiming at prioritizing essential interventions and maneuvers and self-protection.


title: Canine Bocavirus Type 2 Infection Associated With Intestinal Lesions.

text: Bocaviruses are small nonenveloped DNA viruses belonging to the Bocaparvovirus genus of the Parvoviridae family and have been linked to both respiratory and enteric disease in humans and animals. To date, 3 bocaviruses, canine bocaviruses 1 to 3 (CBoV-1-3), have been shown to affect dogs with different disease manifestations reported for infected animals. We used next-generation sequencing to identify a novel strain of canine CBoV-2 (CBoV TH-2016) in a litter of puppies that died in Thailand from acute dyspnea and hemoptysis, for which no causal pathogen could be identified in routine assays. Analysis of the complete coding sequences of CBoV TH-2016 showed that this virus was most closely related to a strain previously identified in South Korea (isolate 14D193), with evidence of genetic recombination in the VP2 gene with related strains from South Korea and Hong Kong. Use of quantitative polymerase chain reaction showed the presence of CBoV TH-2016 in several tissues, suggesting hematogenous virus spread, while only intestinal tissue was found to be positive by in situ hybridization and electron microscopy. Histologic small intestinal lesions associated with CBoV TH-2016 infection were eosinophilic intranuclear inclusion bodies within villous enterocytes without villous atrophy or fusion, similar to those previously considered pathognomonic for CBoV-1 infection. Therefore, this study provides novel insights in the pathogenicity of canine bocavirus infections and suggests that a novel recombinant CBoV-2 may result in atypical findings of CBoV infection. Although the specific cause of death of these puppies remained undetermined, a contributory role of enteric CBoV TH-2016 infection is possible.


title: Single-incision pediatric endosurgery: a systematic review.

text: BACKGROUND Single-incision pediatric endosurgery (SIPES) is defined as minimally invasive surgery performed through a unique incision in the abdomen, chest, or retroperitoneum. Several publications exist, but no previous systematic review has been made to evaluate the real benefits of this approach in terms of feasibility and clinical outcomes. MATERIALS AND METHODS We performed an electronic search in PubMed up to March 2012 with the terms "single AND incision OR site OR port OR trocar AND children" including related articles and obtained 197 articles. After applying our inclusion criteria, 78 articles were reviewed. RESULTS We identified prospective controlled trials (n=1), case-control studies (n=12), case series (n=49), and case reports (n=16). In total, 4212 patients had been operated on by SIPES and were separated by systems: gastrointestinal (n=2888), urologic (n=390), gynecologic (n=27), other abdominal (n=874), and thoracic (n=33) procedures. The most common procedure was SIPES appendectomy, and a unique prospective controlled trial supports its safety and effectiveness. Technically demanding surgeries such as hepatojejunostomy and colonic surgeries were described. Multichannel ports and multiple ports, standard and articulated instruments, transparietal instruments, retraction sutures, and magnets were used. Operative times, length of stay, and complications similar to standard laparoscopic surgery were described. A low conversion rate (to a reduced port, standard laparoscopy and open procedures) was also mentioned. No comparable measure for pain and cosmesis assessment was used. CONCLUSIONS A wide experience in SIPES and feasibility has already been described with good clinical outcomes and low rate of conversion. Appendectomy is the unique procedure in which SIPES has been demonstrated to be safe and effective. It is pending the execution of prospective controlled trials for other operations to demonstrate, with objective evidence, the real benefits of this less invasive approach.


title: Malaria exacerbates inflammation-associated elevation in ferritin and soluble transferrin receptor with only modest effects on iron deficiency and iron deficiency anaemia among rural Zambian children.

text: OBJECTIVE In 4- to 8-year-old Zambian children (n = 744), we evaluated the effects of adjusting for inflammation (α1-acid glycoprotein >1 g/l), with or without additional adjustment for malaria, on prevalence estimates of iron deficiency (ID) and iron deficiency anaemia (IDA) during low malaria (LowM) and high malaria (HighM) transmission seasons. METHODS To estimate adjustment factors, children were classified as: (i) reference (malaria negative without inflammation), (ii) inflammation without malaria (I), (iii) malaria without inflammation (M) and (iv) inflammation with malaria (IM). We estimated the unadjusted ID or IDA prevalence, and then adjusted for inflammation alone (IDI or IDAI ) or inflammation and malaria (IDIM or IDAIM ). RESULTS Mean ferritin was 38 (reference), 45 (I), 43 (M) and 54 μg/l (IM) in LowM, increasing to 44, 56, 96 and 167 μg/l, respectively, in HighM. Corresponding mean sTfR was 6.4, 6.9, 7.9 and 8.4 mg/l in LowM, increasing to 8.2, 9.2. 8.7 and 9.7 mg/l in HighM. Ferritin-based ID, IDI and IDIM were 7.8%, 8.7% or 9.1%, respectively, in LowM and 4.6%, 10.0% or 11.7%, respectively, in HighM. Corresponding soluble transferrin receptor (sTfR)-based estimates were 27.0%, 24.1% and 19.1%, respectively, in LowM, increasing to 53.6%, 46.5% and 45.3%, respectively, in HighM. Additional adjustment for malaria resulted in a ~1- to 2-percentage point change in IDA, depending on biomarker and season. CONCLUSIONS In this population, malaria substantially increased ferritin and sTfR concentrations, with modest effects on ID and IDA prevalence estimates.


title: Objective assessment of changes in physical activity and sedentary behavior: Pre- through 3 years post-bariatric surgery.

text: OBJECTIVE To evaluate change in sedentary behavior (SB) and physical activity (PA) over 3 years following bariatric surgery. METHODS A subset of participants in an observational study (n = 473 of 2,458; 79% female, median body mass index 45 kg m(-2) ) wore an activity monitor presurgery and at 1-3 annual postsurgery assessments. RESULTS Over the first year, on average, sedentary time decreased from 573 (95% CI: 563-582) to 545 (95% CI: 534-555) min days(-1) and moderate- to vigorous-intensity PA (MVPA) increased from 77 (95% CI: 71-84) to 106 (95% CI: 98-116) min week(-1) , or 7 (95% CI: 5-10) to 24 (95% CI: 18-29) min week(-1) in MVPA bouts ≥10 min. There were no changes in these parameters from years 1 to 3 (P for all > 0.05). The percentage of participants achieving ≥150 min week(-1) of bout-related MVPA was not different at year 3 [6.5% (95% CI: 3.1-12.7)] vs. presurgery [3.4% (95% CI: 1.8-5.0); P = 0.45]. Most participants followed SB and PA trajectories that paralleled mean change and were consistent with their presurgery position in relation to the group. CONCLUSIONS On average, bariatric surgical patients make small reductions in SB and increases in PA during the first postsurgery year, which are maintained through 3 years. Still, postsurgery PA levels fall short of PA guidelines for general health or weight control.


title: COVID-19 - what should anaethesiologists and intensivists know about it?

text: Over the past three months, the world has faced an unprecedented health hazard. The World Health Organization has announced a pandemic infection with an unknown species of coronavirus called SARS-CoV-2. Spreading mainly through the droplet route, the virus causes mild symptoms in the majority of cases, the most common being: fever (80%), dry cough (56%), fatigue (22%) and muscle pain (7%); less common symptoms include a sore throat, a runny nose, diarrhea, hemoptysis and chills. A life-threatening complication of SARS-CoV-2 infection is an acute respiratory distress syndrome (ARDS), which occurs more often in older adults, those with immune disorders and co-morbidities. Severe forms of the infection, being an indication for treatment in the intensive care unit, comprise acute lung inflammation, ARDS, sepsis and septic shock. The article presents basic information about etiology, pathogenesis and diagnostics (with particular emphasis on the importance of tomocomputer imaging), clinical picture, treatment and prevention of the infection. It goes on to emphasize the specific risks of providing anesthesiology and intensive care services. Due to the fact that effective causal treatment is not yet available and the number of infections and deaths increases day by day, infection prevention and strict adherence to recommendations of infection control organizations remain the basis for fighting the virus.


title: Effect of candesartan on prevention (DIRECT-Prevent 1) and progression (DIRECT-Protect 1) of retinopathy in type 1 diabetes: randomised, placebo-controlled trials.

text: BACKGROUND Results of previous studies suggest that renin-angiotensin system blockers might reduce the burden of diabetic retinopathy. We therefore designed the DIabetic REtinopathy Candesartan Trials (DIRECT) Programme to assess whether candesartan could reduce the incidence and progression of retinopathy in type 1 diabetes. METHODS Two randomised, double-blind, parallel-design, placebo-controlled trials were done in 309 centres worldwide. Participants with normotensive, normoalbuminuric type 1 diabetes without retinopathy were recruited to the DIRECT-Prevent 1 trial and those with existing retinopathy were recruited to DIRECT-Protect 1, and were assigned to candesartan 16 mg once a day or matching placebo. After 1 month, the dose was doubled to 32 mg. Investigators and participants were unaware of the treatment allocation status. The primary endpoints were incidence and progression of retinopathy and were defined as at least a two-step and at least a three-step increase on the Early Treatment Diabetic Retinopathy Study (ETDRS) scale, respectively. These trials are registered with ClinicalTrials.gov, numbers NCT00252733 for DIRECT-Prevent 1 and NCT00252720 for DIRECT-Protect 1. FINDINGS 1421 participants (aged 18-50 years) were randomly assigned to candesartan (n=711) or to placebo (n=710) in DIRECT-Prevent 1, and 1905 (aged 18-55 years) to candesartan (n=951) or to placebo (n=954) in DIRECT-Protect 1. Incidence of retinopathy was seen in 178 (25%) participants in the candesartan group versus 217 (31%) in the placebo group. Progression of retinopathy occurred in 127 (13%) participants in the candesartan group versus 124 (13%) in the placebo group. Hazard ratio (HR for candesartan vs placebo) was 0.82 (95% CI 0.67-1.00, p=0.0508) for incidence of retinopathy and 1.02 (0.80-1.31, p=0.85) for progression of retinopathy. The post-hoc outcome of at least a three-step increase for incidence yielded an HR of 0.65 (0.48-0.87, p=0.0034), which was attenuated but still significant after adjustment for baseline characteristics (0.71, 0.53-0.95, p=0.046). Final ETDRS level was more likely to have improved with candesartan treatment in both DIRECT-Prevent 1 (odds 1.16, 95% CI 1.05-1.30, p=0.0048) and DIRECT-Protect 1 (1.12, 95% CI 1.01-1.25, p=0.0264). Adverse events did not differ between the treatment groups. INTERPRETATION Although candesartan reduces the incidence of retinopathy, we did not see a beneficial effect on retinopathy progression.


title: A Prospective Multicenter Trial of the TransForm Occlusion Balloon Catheter: Trial Design and Results.

text: Background and Purpose Adjunctive treatments like balloon-assisted coil embolization (BACE) and stent-assisted coil embolization play a major role in the treatment of wide-neck and large intracranial aneurysms. The TransForm™ Occlusion Balloon Catheter (TOBC) registry is intended to evaluate the safety, efficacy, and efficiency of BACE using the TOBC. Method and Study Design The TOBC registry is a prospective multicenter registry trial. Seven sites in the USA and 1 site in Spain participated and enrolled 81 patients. Results The performance and safety of the TOBC was evaluated based on scoring for different variables. Scores were measured using a semiquantitative rating scale (1 = excellent, 5 = poor). The mean scores for these variables were as follows: visibility under fluoroscopy, 1.8; ability to reach the intended site, 1.6; stability during first positioning, 1.5; stability during inflation, 1.6; stability during deflation, 1.6; ability to temporarily stop flow, 1.6; and ability to assist in coil embolization, 1.7. The mean inflation and deflation times were 4.9 and 5.6 s, respectively. Complete obliteration of the aneurysm (Raymond class I) was achieved in 69.4% of the BACE cases. Thrombus formation occurred in 4/81 (4.8%) of the cases. In all cases, the thrombus resolved with medications, no patient suffered an infarction, and an underlying hypercoagulable state from subarachnoid hemorrhage was considered a contributing factor. Vessel rupture occurred in 1/81 (1.2%) of the cases, but was unrelated to TOBC use. Conclusion BACE using the TOBC is safe and effective. All variables assessed for performance showed good-to-excellent results.


title: Crystal structure of Junin virus nucleoprotein.

text: Junin virus (JUNV) has been identified as the aetiological agent of Argentine haemorrhagic fever (AHF), which is a serious public health problem with approximately 5 million people at risk. It is treated as a potential bioterrorism agent because of its rapid transmission by aerosols. JUNV is a negative-sense ssRNA virus that belongs to the genus Arenavirus within the family Arenaviridae, and its genomic RNA contains two segments encoding four proteins. Among these, the nucleoprotein (NP) has essential roles in viral RNA synthesis and immune suppression, but the molecular mechanisms of its actions are only partially understood. Here, we determined a 2.2 Å crystal structure of the C-terminal domain of JUNV NP. This structure showed high similarity to the Lassa fever virus (LASV) NP C-terminal domain. However, both the structure and function of JUNV NP showed differences compared with LASV NP. This study extends our structural insight into the negative-sense ssRNA virus NPs.


title: Remote assessment in sport and exercise medicine (SEM): a narrative review and teleSEM solutions for and beyond the COVID-19 pandemic.

text: BACKGROUND The COVID-19 pandemic forces sport and exercise medicine (SEM) physicians to think differently about the clinical care of patients. Many rapidly implement eHealth and telemedicine solutions specific to SEM without guidance on how best to provide these services. AIM The aim of this paper is to present some guiding principles on how to plan for and perform an SEM consultation remotely (teleSEM) based on a narrative review of the literature. A secondary aim is to develop a generic teleSEM injury template. RESULTS eHealth and telemedicine are essential solutions to effective remote patient care, also in SEM. This paper provides guidance for wise planning and delivery of teleSEM. It is crucial for SEM physicians, technology providers and organisations to codesign teleSEM services, ideally involving athletes, coaches and other clinicians involved in the clinical care of athletes, and to gradually implement these services with appropriate support and education. CONCLUSION teleSEM provides solutions for remote athlete clinical care during and after the COVID-19 pandemic. We define two new terms-eSEM and teleSEM and discuss guiding principles on how to plan for and perform SEM consultations remotely (teleSEM). We provide an example of a generic teleSEM injury assessment guide.


Covid-19: US health department staff sent to meet citizens returning from China weren't protected, claims whistleblower.


title: Tuberculous meningitis in an immunocompetent male complicated by hydrocephalus.

text: A 39-year-old man, born in India but resident in the UK for 10 years, was travelling in America when he became feverish with an altered mentation. He reported a 10-day history of fever, photophobia, headache and fatigue. His medical history included hypothyroidism and migraine. He was a non-smoker, did not consume alcohol and denied a history of drug use. He was transferred to the emergency department. Laboratory investigations confirmed hyponatraemia (sodium 128 mmol/L). A chest radiograph confirmed no focal consolidation. Further investigation with a CT brain was unremarkable. A lumbar puncture was suggestive of viral meningitis, with a raised white cell count, lymphocytosis, high protein and low glucose. His PCR was negative for enterovirus and herpes simplex virus. Further investigation with a CT thorax, abdomen and pelvis demonstrated bilateral upper-lobe infiltrations. A bronchoalveolar lavage was negative for acid alcohol fast bacilli (AAFB). A diagnosis of tuberculous meningitis was rendered following a repeat lumbar puncture. Gram stain revealed AAFB and PCR was also positive. He started antitubercular treatment and corticosteroids. A repeat CT brain demonstrated ventriculomegaly, suggestive of hydrocephalus and an MRI head revealed likely communicating hydrocephalus with basilar enhancement. He was repatriated to the UK. Eleven days post transfer, he became acutely confused and required external ventricular drain insertion. After surgical management of his hydrocephalus, there was no further neurological deterioration. He remains committed to his neurorehabilitation.


title: The Future of Maternal and Child Health.

text: INTRODUCTION The purpose of this commentary is to start a national conversation about the future of maternal and child health (MCH). In the coming decades, we will have unprecedented opportunities to improve MCH, but will also face unprecedented threats. METHODS This paper examines emerging opportunities and threats to MCH, and discusses strategies for leading the future of MCH. RESULTS Scientific advancements will continue to drive improvements in MCH, but to unleash its full potential for improving population health future MCH research must become more transdisciplinary, translational, and precise. Technological innovations could dramatically transform our work in MCH while big data could enhance predictive analytics and precision health; our challenge will be to assure equitable access. The greatest gains in MCH will continue to come from improving social conditions, which will require advancing MCH in all policies. Climate change, infectious outbreaks and antimicrobial resistance pose increasing threats to MCH, which can be averted by reducing global warming, implementing global early warning systems, and instituting responsible antimicrobial stewardship. The growing burden of chronic diseases in children and adults need to be addressed from an ecological and life course perspective. The water crisis in Flint shined a spotlight on the growing health threats from America's decaying infrastructure. DISCUSSION We can lead the future of MCH by starting a national conversation, improving MCH research, and preparing future MCH workforce, but the future of MCH will depend on our effectiveness in bringing about social and political change in the coming decades.


title: Nomogram to Predict Mortality of Endovascular Thrombectomy for Ischemic Stroke Despite Successful Recanalization.

text: Background The trajectory of ischemic stroke patients attributable to large vessel occlusion is fundamentally altered by endovascular thrombectomy. This study aimed to develop a nomogram for predicting 3-month mortality risk in patients with ischemic stroke attributed to artery occlusion in anterior circulation who received successful endovascular thrombectomy treatment. Methods and Results Patients with successful endovascular thrombectomy (modified Thrombolysis in Cerebral Infarction IIb or III) were enrolled from a multicenter registry as the training cohort. Step-wise logistic regression with Akaike information criterion was utilized to establish the best-fit nomogram. The discriminative value of the nomogram was tested by concordance index. An additional 224 patients from 2 comprehensive stroke centers were prospectively recruited as the test cohort for validating the new nomogram. Altogether, 417 patients were enrolled in the training cohort. Age (odds ratio [OR], 1.07; 95% CI, 1.03-1.10), poor pretreatment collateral status (OR, 2.13; 95% CI, 1.18-3.85), baseline blood glucose level (OR, 1.12; 95% CI, 1.04-1.21), symptomatic intracranial hemorrhage (OR, 9.51; 95% CI, 4.54-19.92), and baseline National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.03-1.12) were associated with mortality and were incorporated in the nomogram. The c-index of the nomogram was 0.835 (95% CI, 0.785-0.885) in the training cohort and 0.758 (95% CI, 0.667-0.849) in the test cohort. Conclusions The nomogram, composed of age, pretreatment collateral status, baseline blood glucose level, symptomatic intracranial hemorrhage, and baseline National Institutes of Health Stroke Scale score, may predict risk of mortality in patients with ischemic stroke and treated successfully with endovascular thrombectomy.


title: Anti-CD52 blocks EAE independent of PD-1 signals and promotes repopulation dominated by double negative T cells and newly generated T and B cells.

text: Lymphocyte depletion using anti-CD52 antibody effectively reduces relapses of multiple sclerosis (MS). To begin to understand what mechanisms might control this outcome, we examined the effect of a murine-CD52 specific monoclonal antibody on the depletion and repopulation of immune cells in mice with experimental autoimmune encephalomyelitis (EAE), a model of MS. We tested whether the tolerance-promoting receptor PD-1 is required for disease remission post anti-CD52; and found that PD-1 deficient mice with a more severe EAE were nevertheless effectively treated with anti-CD52. Anti-CD52 increased the proportions of newly generated T cells and DN T cells, while reducing newly generated B cells; the latter effect being associated with a higher expression of CD52 by these cells. In the longer-term, anti-CD52 caused substantial increases in the proportion of newly generated lymphocytes and DN T cells, in mice with EAE. Thus, the rapid repopulation of lymphocytes from central lymphoid organs post anti-CD52 may limit further disease. Furthermore, these data identify DN T cells, a subset with immunoregulatory potential, as a significant hyper-repopulating subset following CD52 mediated depletion. This article is protected by copyright. All rights reserved.


title: Occurrence of acute otitis media during colds in children younger than four years.

text: To determine how frequently acute otitis media (AOM) occurs, we enrolled children between 6 months and 3 years of age who returned several weeks before and 6 to 10 times during a cold for tympanometry and photography of the tympanic membrane. American Academy of Pediatrics (AAP) criteria were used to diagnose AOM. Children visited their physicians at their discretion. AOM occurred in 17 (55%) of 31 colds; in 12 (100%) colds with pre-existing middle ear effusion (MEE); and in 5 (26%) of 19 colds with no pre-existing MEE (P < 0.0001). Four patients received antibiotics from their physicians. Of 17 children with AOM, 12 did not seek care. AOM is common during colds, particularly with pre-existing MEE.


title: Assessing health systems' responsiveness in tackling COVID-19 pandemic.

text: Health systems' responsiveness is the key to addressing infectious disease threats such as pandemics. The article outlines an assessment of health systems based on World Health Organization's building blocks for select countries. It also compares these with the findings from a more comprehensive analysis of Global Health Security (GHS) Index, which assesses the preparedness of the health system for such pandemics. The GHS report (2019) spelt out very objectively that none of the countries of the world was prepared to effectively handle such emergencies, should they arise. Observations emerging from different countries highlight these findings although some of them seem to be discordant. Overall, it appears that Asian countries could fight the battle better than most developed nations in the Europe and America during the current pandemic, despite having poor GHS scores. Experiences of these countries in facing similar crisis in the past probably sensitized their strained health systems for a greater good. There are several lessons to be learned from such countries.


title: Successful laparoscopic management of an incarcerated obturator hernia.

text: Obturator hernia is a rare pelvic hernia that occurs primarily in multiparous, elderly (>70 years of age), thin females. This case highlights the successful laparoscopic mesh repair of an incarcerated obturator hernia in an octogenarian. The authors report a case of an incarcerated obturator hernia in an elderly female with subsequent high-grade small bowel and its successful laparoscopic operative management. A review of the relevant literature was also performed following a search on the online literature databases such as PUBMED and EMBASE. Laparoscopic mesh repair of the incarcerated obturator hernia and an ipsilateral femoral hernia found incidentally was successfully performed. A review of the literature showed a significant burden of morbidity and mortality associated with obturator hernias. Laparoscopic mesh repair has been previously shown to be a safe therapeutic modality. Small bowel obstruction and leg pain in a thin elderly lady should arouse suspicion for an incarcerated obturator hernia. Laparoscopic management of an incarcerated obturator hernia is a feasible and safe therapeutic option.


title: Poor preoperative sleep quality is a risk factor for severe postoperative pain after breast cancer surgery: A prospective cohort study.

text: The aim of this study was to assess the effect of preoperative sleep quality on acute postoperative pain in breast cancer patients.The Pittsburgh Sleep Quality Index questionnaire (PSQI) was used to assess the overall sleep status of women scheduled for unilateral modified radical mastectomy in the past month. Based on the responses, patients were allocated to good sleep group or poor sleep group. Postoperatively, acute pain was assessed using the numerical rating score in the first 24 hours; in addition, the requirement of analgesics and the incidence of postoperative complications were recorded.A total of 108 breast surgery patients were enrolled. Based on the PSQI results, 55 (51%) patients were allocated to poor sleep group and 53 (49%) to good sleep group. Pain scores were similar in the 2 groups at the end of surgery (P = .589); however, poor sleep group reported higher postoperative pain scores than the good sleep group at 2 (P = .002), 6 (P < .001), 12 (P < .001), and 24 (P = .002) hours after surgery. The incidence of severe pain in the poor sleep group was higher than that in the good sleep group (27% vs 8%, P = .018), and the ratio of participants who required rescued analgesics was greater in the poor sleep group (52% vs 22%, P = .002). In addition, patients with poor sleep quality had more postoperative complications and longer hospital stay.In this study, breast cancer patients with poor preoperative sleep quality reported more severe postoperative pain, required more analgesics, experienced more complications, and had longer hospital stay.


docid: hrhnogmm

title: Misguided drug advice for COVID-19.


title: Porcine Reproductive and Respiratory Syndrome Virus nsp1α Inhibits NF-κB Activation by Targeting the Linear Ubiquitin Chain Assembly Complex.

text: Linear ubiquitination, a newly discovered posttranslational modification, is catalyzed by the linear ubiquitin chain assembly complex (LUBAC), which is composed of three subunits: one catalytic subunit HOIP and two accessory molecules, HOIL-1L and SHARPIN. Accumulating evidence suggests that linear ubiquitination plays a crucial role in innate immune signaling and especially in the activation of the NF-κB pathway by conjugating linear polyubiquitin chains to NF-κB essential modulator (NEMO, also called IKKγ), the regulatory subunit of the IKK complex. Porcine reproductive and respiratory syndrome virus (PRRSV), an Arterivirus that has devastated the swine industry worldwide, is an ideal model to study the host's disordered inflammatory responses after viral infection. Here, we found that LUBAC-induced NF-κB and proinflammatory cytokine expression can be inhibited in the early phase of PRRSV infection. Screening the PRRSV-encoded proteins showed that nonstructural protein 1α (nsp1α) suppresses LUBAC-mediated NF-κB activation and its CTE domain is required for the inhibition. Mechanistically, nsp1α binds to HOIP/HOIL-1L and impairs the interaction between HOIP and SHARPIN, thus reducing the LUBAC-dependent linear ubiquitination of NEMO. Moreover, PRRSV infection also blocks LUBAC complex formation and NEMO linear-ubiquitination, the important step for transducing NF-κB signaling. This unexpected finding demonstrates a previously unrecognized role of PRRSV nsp1α in modulating LUBAC signaling and explains an additional mechanism of immune modulation by PRRSV. IMPORTANCE Porcine reproductive and respiratory syndrome (PRRS) is one of the most important veterinary infectious diseases in countries with intensive swine industries. PRRS virus (PRRSV) infection usually suppresses proinflammatory cytokine expression in the early stage of infection, whereas it induces an inflammatory storm in the late stage. However, precisely how the virus is capable of doing so remains obscure. In this study, we found that by blocking the interaction of its catalytic subunit HOIP and accessory molecule SHARPIN, PRRSV can suppress NF-κB signal transduction in the early stage of infection. Our findings not only reveal a novel mechanism evolved by PRRSV to regulate inflammatory responses but also highlight the important role of linear ubiquitination modification during virus infection.


docid: ngznwgvw

title: Impact of isoproterenol infusion on BIS and metabolic values in pediatric patients undergoing electrophysiology studies.

text: STUDY OBJECTIVE To study changes in BIS values and metabolic parameters during an infusion of isoproterenol in pediatric patients. DESIGN Retrospective study approved By Committee For The Protection Of Human Subjects at University Of Texas Medical School at Houston. SETTING University-affiliated children's hospital. MEASUREMENTS The records of pediatric patients undergoing general anesthesia for electrophysiology procedures were analyzed. Electronic data collected included Bispectral Index (BIS) values, anesthetics (eg, opioids, expired concentration of inhaled anesthetics, muscle relaxants), hemodynamic values (ie, heart rate, invasive blood pressure), respiratory parameters [ie, tidal volume, respiratory rate, end-tidal CO2 (ETCO2)], and routine arterial blood gases. These parameters were analyzed 10 minutes prior to the start of the isoproterenol infusion (T-pre) and 10 minutes after isoproterenol had reduced the cardiac cycle length by 20% (T-infusion). MAIN RESULTS Of the 29 records that were screened, 22 met the above criteria (mean age 13 ± 5 yrs). BIS values increased by an average of 8 (33 ± 8 to 41 ± 10; P < 0.001) during the isoproterenol infusion. Statistically significant increases in ETCO2 (median 33 - 36 mmHg; P = 0.01), PaCO2 (35 - 38 mmHg; P = 0.002), and lactate (1.1 -1.5 mg/dL; P < 0.001) occurred with infusion of isoproterenol. Patients undergoing controlled mechanical ventilation showed an increase in ETCO2 (mean 34 ± 6 mmHg to 37 ± 5 mmHg; P = 0.001) whereas those breathing spontaneously had an increase in minute ventilation (average increase 111 ± 30 mL/kg). CONCLUSIONS Isoproterenol increases metabolic, respiratory, and BIS values in pediatric patients during general anesthesia. We recommend the use of BIS, close monitoring of ETCO2, and careful titration of anesthetics during isoproterenol infusion, especially when lighter planes of general anesthesia are requested for pediatric electrophysiologic procedures.


title: Anaerobic co-digestion of recalcitrant agricultural wastes: Characterizing of biochemical parameters of digestate and its impacts on soil ecosystem.

text: Anaerobic digestion (AD) of organic wastes is a promising alternative to landfilling for reducing Greenhouse Gas Emission (GHG) and it is encouraged by current regulation in Europe. Biogas-AD produced, represents a useful source of green energy, while its by-product (digestate) is a waste, that needs to be safely disposal. The sustainability of anaerobic digestion plants partly depends on the management of their digestion residues. This study has been focused on the environmental and economic benefits of co-digest recalcitrant agricultural wastes such olive wastes and citrus pulp, in combination with livestock wastes, straw and cheese whey for biogas production. The aim of this work was to investigate the effects of two different bioenergy by-products on soil carbon stock, enzymes involved in nutrient cycling and microbial content. The two digestates were obtained from two plants differently fed: the first plant (Uliva) was powered with 60% of recalcitrant agricultural wastes, and 40% of livestock manure milk serum and maize silage. The second one (Fattoria) was fed with 40% of recalcitrant agricultural wastes and 60% of livestock manure, milk serum and maize silage. Each digestate, separated in liquid and solid fractions, was added to the soil at different concentrations. Our results evidenced that mixing and type of input feedstock affected the composition of digestates. Three months after treatments, our results showed that changes in soil chemical and biochemical characteristics depended on the source of digestate, the type of fraction and the concentration used. The mainly affected soil parameters were: Soil Organic Matter (SOM), Microbial Biomass Carbon (MBC), Fluorescein Diacetate Hydrolysis (FDA), Water Soluble Phenol (WSP) and Catalase (CAT) that can be used to assess the digestate agronomical feasibility. These results show that the agronomic quality of a digestate is strictly dependent on percentage and type of feedstocks that will be used to power the digester.


docid: baiggzyo

title: Human pathogens and the host cell SUMOylation system.

text: Since posttranslational modification (PTM) by the small ubiquitin-related modifiers (SUMOs) was discovered over a decade ago, a huge number of cellular proteins have been found to be reversibly modified, resulting in alteration of differential cellular pathways. Although the molecular consequences of SUMO attachment are difficult to predict, the underlying principle of SUMOylation is altering inter- and/or intramolecular interactions of the modified substrate, changing localization, stability, and/or activity. Unsurprisingly, many different pathogens have evolved to exploit the cellular SUMO modification system due to its functional flexibility and far-reaching functional downstream consequences. Although the extensive knowledge gained so far is impressive, a definitive conclusion about the role of SUMO modification during virus infection in general remains elusive and is still restricted to a few, yet promising concepts. Based on the available data, this review aims, first, to provide a detailed overview of the current state of knowledge and, second, to evaluate the currently known common principles/molecular mechanisms of how human pathogenic microbes, especially viruses and their regulatory proteins, exploit the host cell SUMO modification system.


A Role for Telemedicine in Medical Education During the COVID-19 Pandemic.


title: Resilience is spreading: Mental health within the COVID-19 pandemic.

text: The COVID-19 global pandemic is in many ways unchartered mental health territory, but history would suggest that long-term resilience will be the most common outcome, even for those most directly impacted by the outbreak. We address 4 common myths about resilience and discuss ways to systematically build individual and community resiliency. Actively cultivating social support, adaptive meaning, and direct prosocial behaviors to reach the most vulnerable can have powerful resilience promoting effects. (PsycInfo Database Record (c) 2020 APA, all rights reserved).