title: Near infrared spectrophotometry (cerebral oximetry) in predicting the return of spontaneous circulation in out-of-hospital cardiac arrest.

text: AIM We assessed out-of-hospital cardiac arrest patients' cerebral oxygenation during cardiopulmonary resuscitation (CPR) using near infrared spectrophotometry (NIRS). We evaluated the relation between a rise in patients' cerebral saturation values between the start and end of CPR and return of spontaneous circulation. MATERIALS AND METHODS Twenty-three patients with unwitnessed out-of-hospital cardiac arrest and brought to our emergency department by emergency ambulance were evaluated. Cerebral saturations from time of start of CPR were measured using NIRS. CPR was performed for a maximum of 30 min. The relation between cerebral saturations in patients with or without return of spontaneous circulation was then evaluated. RESULTS Twenty-three patients, 12 (52.2%) female and 11 (47.8%) male, with a mean age of 64.09 ± 13.66 were included. A correlation was determined between a rise in cerebral saturation measured throughout CPR and the return of spontaneous circulation (P < .001). CONCLUSION Patients whose cerebral saturation values measured with NIRS rise during CPR have a higher post-resuscitation survival rate. Monitoring of patients during CPR with this non-invasive technique may be a good method for predicting return of spontaneous circulation.


title: Simulation Training in Neuroangiography-Validation and Effectiveness.

text: PURPOSE Simulators are increasingly used in the training of endovascular procedures; however, for the use of the Mentice vascular interventional system trainer (VIST) simulator in neuroradiology, the validity of the method has not yet been proven. The study was carried out to test the construct validity of such a simulator by demonstrating differences between beginner and expert neurointerventionalists and to evaluate whether a training effect can be demonstrated in repeated cases for different levels of experience. METHODS In this study 4 experts and 6 beginners performed 10 diagnostic angiographies on the VIST simulator (Mentice AB, Gothenburg, Sweden). Of the cases four were non-recurring, whereas three were repeated once and ten subjects performed all tasks. Additionally, another expert performed only five non-recurring cases. The simulator recorded total time, fluoroscopy time, amount of contrast medium and number of material changes. Furthermore, gaze direction and heart rate were recorded, and subjects completed a questionnaire on workload. RESULTS Beginners and experts showed significant differences in total duration time, fluoroscopy time and amount of contrast agent (all p < 0.05). Gaze direction, dwell time and heart rate were similar between both groups. Only beginners improved during training with respect to total duration time, fluoroscopy time and amount of contrast agent. If a case was previously known to them, the total duration and fluoroscopy time were significantly shortened (p < 0.001). CONCLUSION This study demonstrated both the construct validity of a diagnostic neuroangiography simulator as well as a significant training effect for beginners. Therefore, in particular beginner neurointerventionalists should use such simulation tools more extensively in their initial training.


title: Endovascular treatment of tandem occlusions in vertebrobasilar stroke: technical aspects and outcome compared with isolated basilar artery occlusion.

text: BACKGROUND AND PURPOSE Acute basilar artery occlusion (BAO) is a devastating disease with a high rate of mortality and morbidity, and early recanalization is crucial to achieve a good prognosis. The best treatment strategy for BAO combined with a proximal stenosis (tandem occlusion) is not yet clear. Our study aimed to evaluate whether and how vertebrobasilar tandem occlusions can be treated effectively and safely compared with isolated BAO. MATERIALS AND METHODS Fifty-two patients with acute vertebrobasilar occlusive stroke treated with mechanical thrombectomy were identified in a prospective database from March 2010 to September 2016. We retrospectively analysed the clinical, technical, and functional outcomes of the patients. RESULTS Of the 52 patients, 15 presented with a tandem occlusion, 14 with a single intracranial occlusion due to an underlying stenosis, and 23 with a single embolic BAO. Successful recanalization was achieved in all of the patients with tandem occlusions (modified Thrombolysis in Cranial Infarction 2b/3) and in 35 of 37 patients with a single BAO (with and without stenosis). A favourable outcome was achieved (modified Rankin Scale ≤2) in 8 of the 15 patients with a tandem occlusion compared with 4 of the 14 patients with a single BAO with underlying stenosis and 5 of the 23 patients with isolated embolic BAO (p=0.18). CONCLUSIONS We suggest that endovascular treatment of vertebrobasilar tandem occlusions is safe and feasible, with a high rate of good outcome.


title: A novel method for intra-operative colonic decompression without contamination.

text: The need for intra-operative colonic decompression is commonplace within general surgical theatre. However, cases are usually complex, present late and the risk of perforation with subsequent contamination is high. We describe a novel technique for closed decompression using a laparoscopic trocar and standard pool sucker in a 78-year-old gentleman with an obstructing sigmoid tumour.


Socially Distanced Medicine.


title: Gastric access temporary for endoscopy (GATE): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients.

text: BACKGROUND Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is technically challenging. Device-assisted enteroscopy and laparoscopic-assisted methods suffer from high failure rates and/or post-procedural complications. A novel endoscopic technique termed EUS-Directed Transgastric ERCP (EDGE) or Gastric Access Temporary for Endoscopy (GATE) has recently emerged, demonstrating excellent technical and therapeutic success. The technique involves endoscopic ultrasound-guided deployment of a lumen-apposing metal stent (LAMS) to gain access into the remnant stomach to facilitate standard ERCP. In this case series, we describe our center's experience and unique approach with the GATE procedure and discuss several key strategies and differences. METHODS Patients underwent the GATE procedure via a novel algorithmic approach. Key information on procedural details, technical and clinical success, follow-up, and adverse events was prospectively collected and retrospectively reviewed. RESULTS 10 patients underwent the GATE procedure from May 2017 to March 2018. Technical and clinical success were both 100%. Gastric and jejunal access points for LAMS deployment were 30% and 70%, respectively. Total procedure time per patient, including LAMS deployment, ERCP, and all follow-up procedures, averaged 2.37 ± 0.63 h. 2 out of 10 patients (20%) had adverse events that were resolved either intra-procedurally or after repeat endoscopy with no long-term complications and none requiring surgery. For patients with complete follow-up (n = 7), access tract closure rate was 100% with the aid of a temporary plastic double pigtail stent to facilitate closure. CONCLUSIONS GATE appears to be a safe and effective procedure and may be considered the preferred approach to ERCP in patients with RYGB anatomy at centers with LAMS experience. The procedure offers more definitive and higher range of ERCP interventions compared to traditional methods and is associated with fewer adverse events. Improvements in strategies and methods with the GATE technique may reduce risks and improve outcomes.


title: Outcomes after biological mesh reconstruction of the pelvic floor following extra-levator abdominoperineal excision of rectum (APER).

text: BACKGROUND Extra-levator abdominoperineal excision of the rectum (ELAPER) for low rectal cancer is used to avoid the adverse oncological outcomes of inadvertent perforation and a positive circumferential resection margin associated with the conventional APER technique. This wider excision creates a large defect requiring pelvic floor reconstruction, and there is still controversy regarding the best method of closure. The aim of this study is to present outcomes of biological mesh pelvic floor reconstruction following ELAPER. METHODS Prospective data on consecutive patients having ELAPER for low rectal cancer at a single UK institution between October 2008 and March 2013 were collected. The perineum was reconstructed using a biological mesh and the short-term outcomes were evaluated, focusing particularly on perineal wound complications and perineal hernias. RESULTS Thirty-four patients were included [median age 62 years, range 40-72 years, 27 males (79 %)]. The median operative time was 248 min (range 120-340 min). The median length of hospital stay was 9 days (range 4-20 days). There were three perineal complications (9 %) requiring surgical intervention, but no meshes were removed. There were no perineal hernias. The median length of follow-up was 21 months (range 1-54 months). The overall mortality was 9 % from distant metastases. CONCLUSIONS Our series adds to the increasing evidence that good outcomes can be achieved for pelvic floor reconstruction with biological mesh following ELAPER without the additional use of myocutaneous flaps. The low serious complication rate, good outcomes in perineal wound healing and the absence of perineal hernias demonstrates that this is a safe and feasible procedure.


title: T cell-mediated host immune defenses in the lung.

text: Evidence has increasingly shown that the lungs are a major site of immune regulation. A robust and highly regulated immune response in the lung protects the host from pathogen infection, whereas an inefficient or deleterious response can lead to various pulmonary diseases. Many cell types, such as epithelial cells, dendritic cells, macrophages, neutrophils, eosinophils, and B and T lymphocytes, contribute to lung immunity. This review focuses on the recent advances in understanding how T lymphocytes mediate pulmonary host defenses against bacterial, viral, and fungal pathogens.


title: Utility of snout wipe samples for influenza A virus surveillance in exhibition swine populations.

text: BACKGROUND Sporadic influenza A virus (IAV) outbreaks in humans and swine have resulted from commingling of large numbers of people and pigs at agricultural fairs in the United States. Current antemortem IAV surveillance strategies in swine require collecting nasal swabs, which entails restraining pigs with snares. Restraint is labor-intensive for samplers, stressful for pigs, and displeasing to onlookers because pigs often resist and vocalize. OBJECTIVE To evaluate the utility of snout wipes in exhibition swine as a method to make IAV surveillance efforts less intrusive, less labor-intensive, and more widely accepted among pig owners and exhibition officials. METHODS Three materials (rayon/polyester gauze, cotton gauze, and Swiffer(®) Sweeper dry cloths) were inoculated with IAV, and viral recoveries from these materials were quantified using qRT-PCR and TCID50 assays. In a field trial, paired cotton gauze snout wipes and gold standard polyester-tipped nasal swabs were collected from 553 pigs representing 29 agricultural fairs and the qualitative results of rRT-PCR and viral isolation were compared. RESULTS AND CONCLUSIONS Viral recoveries from potential snout wipe materials ranged from 0.26 to 1.59 log10 TCID50 /ml less than that of the positive control in which no substrate was included; rayon/polyester gauze performed significantly worse than the other materials. In the field, snout wipes and nasal swabs had high levels of agreement for both rRT-PCR detection and virus isolation. Although further investigation and refinement of the sampling method is needed, results indicate that snout wipes will facilitate convenient and undisruptive IAV surveillance in pigs at agricultural fairs.


title: RNA interference strategies as therapy for respiratory viral infections.

text: RNA interference (RNAi) is a recently discovered, naturally occurring intracellular process that regulates gene expression through the silencing of specific mRNAs. Methods of harnessing this natural pathway are being developed that allow the catalytic degradation of targeted mRNAs using specifically designed complementary small-interfering RNAs (siRNA). siRNAs are being chemically modified to acquire drug-like properties. Numerous recent high profile publications have provided proofs of concept that RNAi may be of therapeutic use. Much of the design of these siRNAs can be accomplished bioinformatically, thus potentially expediting drug discovery and opening new avenues of therapy for many uncommon, orphan, or emerging diseases. Although endogenous human disease targets can theoretically be affected by RNAi therapeutics, nonendogenous targets (eg, viral targets) are attractive and RNAi therapeutics have been shown to act as antivirals in vivo and in vitro. Respiratory viral infections are particularly attractive targets for RNAi therapeutics because the infected cells exist at the air-lung interface, thereby positioning these cells to be accessible to topical administration of siRNA, for example by aerosol. RNAi therapeutics have been shown to be active against respiratory syncytial virus, parainfluenza and influenza in vitro and in vivo resulting in profound antiviral effects. The first RNAi therapeutic to be designed as an anti-infective medication has now entered proof of concept clinical trials in man. A discussion of the science behind RNAi is followed by a presentation of the potential practical issues in applying this technology to respiratory viral diseases. RNAi may offer new strategies for the treatment of respiratory syncytial virus and other respiratory viruses.


docid: tqboenbd

title: COVID-19 clinical trials: see it big and keep it simple.


docid: totpqgcj

title: COVID outbreak is changing our practices of perinatal psychiatry.


title: Case Report: COVID-19 Presenting as Acute Undifferentiated Febrile Illness-A Tropical World Threat.

text: We report a young Thai man from the Thai-Myanmar border suffering from 2 days of fever and myalgia without respiratory tract signs or symptoms. He reported no history of travel through an area with confirmed COVID-19 cases or contact with sick persons. After excluding malaria and dengue, which are common causative agents of acute undifferentiated febrile illness (AUFI) in Thailand, chest radiography was performed according to the patient triage protocol of our institute for AUFI during the COVID-19 outbreak. Chest radiography revealed findings compatible with pneumonia. Nasopharyngeal, throat, and sputum samples tested positive for SARS-CoV-2 by real-time reverse transcriptase-PCR. The preadmission diagnosis of COVID-19 in this patient enabled appropriate management and isolation to prevent nosocomial transmission. Fever and nonspecific symptoms and laboratory results in early COVID-19 may be difficult to distinguish from tropical infectious diseases, especially when respiratory signs and symptoms are absent. This fact necessitates vigilant awareness in clinical investigation, management, and infection control, especially in tropical resource-limited settings.


Fc Receptors: Introduction.


title: Rationale and design for the detection and neurological impact of cerebrovascular events in non-cardiac surgery patients cohort evaluation (NeuroVISION) study: a prospective international cohort study.

text: OBJECTIVES Covert stroke after non-cardiac surgery may have substantial impact on duration and quality of life. In non-surgical patients, covert stroke is more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac surgery.NeuroVISION is a multicentre, international, prospective cohort study that will characterise the association between perioperative acute covert stroke and postoperative cognitive function. SETTING AND PARTICIPANTS We are recruiting study participants from 12 tertiary care hospitals in 10 countries on 5 continents. PARTICIPANTS We are enrolling patients ≥65 years of age, requiring hospital admission after non-cardiac surgery, who have an anticipated length of hospital stay of at least 2 days after elective non-cardiac surgery that occurs under general or neuraxial anaesthesia. PRIMARY AND SECONDARY OUTCOME MEASURES Patients are recruited before elective non-cardiac surgery, and their cognitive function is measured using the Montreal Cognitive Assessment (MoCA) instrument. After surgery, a brain MRI study is performed between postoperative days 2 and 9 to determine the presence of acute brain infarction. One year after surgery, the MoCA is used to assess postoperative cognitive function. Physicians and patients are blinded to the MRI study results until after the last patient follow-up visit to reduce outcome ascertainment bias.We will undertake a multivariable logistic regression analysis in which the dependent variable is the change in cognitive function 1 year after surgery, and the independent variables are acute perioperative covert stroke as well as other clinical variables that are associated with cognitive dysfunction. CONCLUSIONS The NeuroVISION study will characterise the epidemiology of covert stroke and its clinical consequences. This will be the largest and the most comprehensive study of perioperative stroke after non-cardiac surgery. TRIAL REGISTRATION NUMBER NCT01980511; Pre-results.


title: The role of ultrasound in appropriate endotracheal tube size selection in pediatric patients.

text: BACKGROUND The aim of this prospective study was to investigate the success of ultrasound in pediatric patients in determining the appropriate sized cuffed endotracheal tube and to compare the results with conventional height-based (Broselow) tape and age-based formula tube size. METHODS One hundred and fifty-two children of 1-10 years of age, who received general anesthesia for adenotonsillectomy were enrolled to the study. In all participants, the transverse diameter of the subglottis was measured with ultrasound during apnea. An endotracheal tube was chosen with the outer diameter matched to the measured subglottic airway diameter. An age-based (Motoyama-Khine) and height-based (Broselow) endotracheal tube size was calculated. If there was resistance to passage of the tube into the trachea or an airway pressure >25 cmH2 0 was required to detect an audible leak, the endotracheal tube was replaced with internal diameter of 0.5 mm smaller. If there was an audible leak at airway pressure <10 cmH2 O, or peak pressure >25 cmH2 0 or a cuff pressure > 25 cmH2 O was required to seal, the tube was changed to the 0.5 mm larger internal diameter. Best-fit tube internal diameter was the resultant tube internal diameter that met the previously stated conditions. The need for endotracheal tube replacement and peak airway pressure were recorded. RESULTS The internal diameter of ultrasound determined tube was the same as best-fit tube in 88% of children. Endotracheal tube was replaced in 15 patients with a one size larger, and in three patients with one size smaller tube. Using Bland-Altman analysis, a better agreement was observed with ultrasound measurement rather than height-based estimation and age-based formulas. CONCLUSION Our findings show that subglottic diameter measured by ultrasound appears to be a reliable predictor for the assessment of the subglottic diameter of the airway in estimating appropriate size pediatric endotracheal tube.


Letter: liver disease and COVID-19-not the perfect storm.


docid: tatxvwmk

title: Transcriptomic profiling reveals three molecular phenotypes of adenocarcinoma at the gastroesophageal junction.

text: Cancers occurring at the gastroesophageal junction (GEJ) are classified as predominantly esophageal or gastric, which is often difficult to decipher. We hypothesized that the transcriptomic profile might reveal molecular subgroups which could help to define the tumor origin and behavior beyond anatomical location. The gene expression profiles of 107 treatment-naïve, intestinal type, gastroesophageal adenocarcinomas were assessed by the Illumina-HTv4.0 beadchip. Differential gene expression (limma), unsupervised subgroup assignment (mclust) and pathway analysis (gage) were undertaken in R statistical computing and results were related to demographic and clinical parameters. Unsupervised assignment of the gene expression profiles revealed three distinct molecular subgroups, which were not associated with anatomical location, tumor stage or grade (p > 0.05). Group 1 was enriched for pathways involved in cell turnover, Group 2 was enriched for metabolic processes and Group 3 for immune-response pathways. Patients in group 1 showed the worst overall survival (p = 0.019). Key genes for the three subtypes were confirmed by immunohistochemistry. The newly defined intrinsic subtypes were analyzed in four independent datasets of gastric and esophageal adenocarcinomas with transcriptomic data available (RNAseq data: OCCAMS cohort, n = 158; gene expression arrays: Belfast, n = 63; Singapore, n = 191; Asian Cancer Research Group, n = 300). The subgroups were represented in the independent cohorts and pooled analysis confirmed the prognostic effect of the new subtypes. In conclusion, adenocarcinomas at the GEJ comprise three distinct molecular phenotypes which do not reflect anatomical location but rather inform our understanding of the key pathways expressed.


title: Two decades of experience with thoracoscopic lobectomy in infants and children: standardizing techniques for advanced thoracoscopic surgery.

text: OBJECTIVES This study evaluates the safety and efficacy of thoracoscopic lobectomy in infants and children. MATERIALS AND METHODS From January 1994 to November 2013, 347 patients underwent video-assisted thoracoscopic lobe resection at two institutions. All procedures were performed by or under the direct guidance of a single surgeon. Patients' ages ranged from 1 day to 18 years, and weights ranged from 2.8 to 78 kg. Preoperative diagnosis included sequestration/congenital pulmonary airway malformation (n=306), severe bronchiectasis (n=24), congenital lobar emphysema (n=13), and malignancy (n=4). RESULTS Of the 347 procedures, 342 were completed thoracoscopically. Operative times ranged from 35 minutes to 240 minutes (average, 115 minutes). Average operative time when a trainee was the primary surgeon was 160 minutes. There were 81 upper, 25 middle, and 241 lower lobe resections. There were four intraoperative complications (1.1%) requiring conversion to an open thoracotomy. The postoperative complication rate was 3.3%, and 3 patients required re-exploration for a prolonged air leak. Hospital length of stay (LOS) ranged from 1 to 16 days (average). In patients <5 kg and <3 months of age, the average operative time was 90 minutes, and the LOS was 2.1 days. CONCLUSIONS Thoracoscopic lung resection is a safe and efficacious technique. With proper mentoring it is an exportable technique, which can be performed by pediatric surgical trainees. The procedures are safe and effective even when performed in the first 3 months of life. Early resection avoids the risk of later infection and malignancy.


title: Minimally invasive repair of a pseudomeningocele caused by a sheared intrathecal catheter following implantation of a drug delivery system.

text: Background Shearing of an intrathecal catheter during implantation of a drug delivery system is an underreported complication that can be challenging to manage. Case Description A 53-year-old man with refractory cancer pain had an intrathecal pump system implanted. The procedure was complicated with catheter shear and retention in the intrathecal space. A second catheter was successfully placed but formation of a painful pseudomeningocele and ineffective pain relief complicated the outcome. A minimally invasive approach through a tubular retractor was employed to access the spinal canal via a laminotomy, the sheared catheter was removed and the dural defect repaired. Complete resolution of the pseudomeningocele and efficient pain control were observed at follow-up. Conclusion Minimally invasive approach to the spine is demonstrated as a safe and effective alternative in this case of retained catheter induced cerebrospinal fluid (CSF) leak.


title: Are patients with systemic lupus erythematosus at increased risk of severe COVID-19?

text: We thank So for the interest in our letter and for sharing the results about COVID-19 in patients with systemic lupus erythematosus (SLE) in Hong Kong (1). We agree that the quantification of the risk of infection with severe acute respiratory coronaviruses- 2 (SARS-CoV-2) in SLE patients is a major concern.


title: Current pharmacotherapeutic options for pediatric lower respiratory tract infections with a focus on antimicrobial agents.

text: INTRODUCTION Antibiotics are frequently prescribed to children in the community and in nosocomial settings, mainly because of lower respiratory tract infections(LRTIs), which include influenza, bronchitis, bronchiolitis, pneumonia, and tuberculosis, in addition to bronchiectasis and cystic fibrosis lung disease. It is important to note, however, that more than 50% of these prescriptions are unnecessary or inappropriate. AREAS COVERED The current choice of antimicrobial therapy for etiological agents of LRTIs is examined and discussed considering each type of LRTI. EXPERT OPINION There is a clear need for the appropriate utilization of antibiotics in children. Therefore, accurate drug selection and choice of best dosage and duration of the antibacterial treatment are important to optimize the treatment of LRTIs. It's fundamental to bear in mind that children differ from adults in how LRTIs manifest and evolve not only because of the diversity in the immunological profiles but also the fundamental age-related differences in absorption, distribution, metabolism, and elimination of drugs. Since comprehensive antibiotic guideline recommendations for the treatment of pediatric LRTIs are generally lacking, there is an undeniable need for the introduction of pediatric antimicrobial stewardship programmes in both community and hospital settings.


title: Comparison of contracture, adhesion, tissue ingrowth, and histologic response characteristics of permanent and absorbable barrier meshes in a porcine model of laparoscopic ventral hernia repair.

text: PURPOSE The objective of this study was to determine the mesh contracture, adhesion, tissue ingrowth, and histologic characteristics of a novel absorbable barrier mesh (Ventrio™ ST Hernia Patch) compared to existing permanent (Ventrio™ Hernia Patch) and absorbable barrier meshes (Sepramesh™ IP Composite and PROCEED™ Surgical Mesh). METHODS Standard laparoscopic technique was utilized to bilaterally implant meshes in 20 female Yorkshire pigs (n = 5 pigs/group). Meshes were fixated to the intact peritoneum with SorbaFix™ absorbable fixation devices. Mesh contracture, adhesion coverage, and adhesion tenacity were evaluated after 4 weeks. T-Peel testing and hematoxylin and eosin (H&E) staining were utilized to assess tissue ingrowth and host response. RESULTS A significantly greater percent area contracture was demonstrated for PROCEED™ (26.9%) compared to Ventrio™ ST (8.8%), Ventrio™ (14.5%) and Sepramesh™ (9.2%). Ventrio™ ST demonstrated similar adhesion area, tenacity, and tissue ingrowth compared to all other meshes. Histological scoring revealed a comparable host inflammatory response for all meshes, with a few exceptions. A greater number of giant cells were observed in Ventrio™ ST and Sepramesh™ near the multifilament polyglycolic acid (PGA) fibers; a greater number of macrophages were observed in PROCEED™ compared to Ventrio™; and a greater number of neutrophils were observed in PROCEED™, compared to Sepramesh™ (P < 0.05). Focal areas of hemorrhage were also observed on the visceral surface of PROCEED™. CONCLUSIONS Ventrio™ ST Hernia Patch demonstrated comparable contracture, adhesion, tissue ingrowth, and histologic characteristics compared to existing permanent and absorbable barrier meshes. Host inflammatory and fibrotic responses for all four meshes were minimal and representative of a biocompatible response.


title: Cesarean Section in a Pregnant Woman with COVID-19: First Case in Portugal.

text: We report the first cesarean delivery in a woman with COVID-19 in a level III hospital in Portugal. It refers to a healthy woman with a term pregnancy that tested positive for COVID-19 on the day of labor induction. Given a Bishop score < 4 and the prior history of a cesarean section, the team decided to perform a surgical delivery. Appropriate personal protective equipment and safety circuits were employed, as described in more detail in the case report. Both the mother and the newborn are well. With this report we aimed to share our concerns, clinical management, maternal and neonatal outcomes, and to present our current circuits and adjustments regarding the COVID-19 pandemic in our maternity hospital.


title: Upcycling Single-Use Polyethylene into High-Quality Liquid Products.

text: Our civilization relies on synthetic polymers for all aspects of modern life; yet, inefficient recycling and extremely slow environmental degradation of plastics are causing increasing concern about their widespread use. After a single use, many of these materials are currently treated as waste, underutilizing their inherent chemical and energy value. In this study, energy-rich polyethylene (PE) macromolecules are catalytically transformed into value-added products by hydrogenolysis using well-dispersed Pt nanoparticles (NPs) supported on SrTiO3 perovskite nanocuboids by atomic layer deposition. Pt/SrTiO3 completely converts PE (M n = 8000-158,000 Da) or a single-use plastic bag (M n = 31,000 Da) into high-quality liquid products, such as lubricants and waxes, characterized by a narrow distribution of oligomeric chains, at 170 psi H2 and 300 °C under solvent-free conditions for reaction durations up to 96 h. The binding of PE onto the catalyst surface contributes to the number averaged molecular weight (M n) and the narrow polydispersity (Đ) of the final liquid product. Solid-state nuclear magnetic resonance of 13C-enriched PE adsorption studies and density functional theory computations suggest that PE adsorption is more favorable on Pt sites than that on the SrTiO3 support. Smaller Pt NPs with higher concentrations of undercoordinated Pt sites over-hydrogenolyzed PE to undesired light hydrocarbons.


title: Respiratory Care year in review 2013: airway management, noninvasive monitoring, and invasive mechanical ventilation.

text: Fundamental to respiratory care practice are airway management, noninvasive monitoring, and invasive mechanical ventilation. The purpose of this paper is to review the recent literature related to these topics in a manner that is most likely to have interest to the readers of Respiratory Care.


2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.


title: Establishing a model for predicting the outcome of COVID-19 based on combination of laboratory tests.

text: INTRODUCTION There are currently no satisfactory methods for predicting the outcome of Coronavirus Disease-2019 (COVID-19). The aim of this study is to establish a model for predicting the prognosis of the disease. METHODS The laboratory results were collected from 54 deceased COVID-19 patients on admission and before death. Another 54 recovered COVID-19 patients were enrolled as control cases. RESULTS Many laboratory indicators, such as neutrophils, AST, γ-GT, ALP, LDH, NT-proBNP, Hs-cTnT, PT, APTT, D-dimer, IL-2R, IL-6, IL-8, IL-10, TNF-α, CRP, ferritin and procalcitonin, were all significantly increased in deceased patients compared with recovered patients on admission. In contrast, other indicators such as lymphocytes, platelets, total protein and albumin were significantly decreased in deceased patients on admission. Some indicators such as neutrophils and procalcitonin, others such as lymphocytes and platelets, continuously increased or decreased from admission to death in deceased patients respectively. Using these indicators alone had moderate performance in differentiating between recovered and deceased COVID-19 patients. A model based on combination of four indicators (P = 1/[1 + e-(-2.658+0.587×neutrophils - 2.087×lymphocytes - 0.01×platelets+0.004×IL-2R)]) showed good performance in predicting the death of COVID-19 patients. When cutoff value of 0.572 was used, the sensitivity and specificity of the prediction model were 90.74% and 94.44%, respectively. CONCLUSIONS Using the current indicators alone is of modest value in differentiating between recovered and deceased COVID-19 patients. A prediction model based on combination of neutrophils, lymphocytes, platelets and IL-2R shows good performance in predicting the outcome of COVID-19.


Health promotion ambulances should focus on loneliness in our pandemic age.


title: A global perspective on hantavirus ecology, epidemiology, and disease.

text: Hantaviruses are enzootic viruses that maintain persistent infections in their rodent hosts without apparent disease symptoms. The spillover of these viruses to humans can lead to one of two serious illnesses, hantavirus pulmonary syndrome and hemorrhagic fever with renal syndrome. In recent years, there has been an improved understanding of the epidemiology, pathogenesis, and natural history of these viruses following an increase in the number of outbreaks in the Americas. In this review, current concepts regarding the ecology of and disease associated with these serious human pathogens are presented. Priorities for future research suggest an integration of the ecology and evolution of these and other host-virus ecosystems through modeling and hypothesis-driven research with the risk of emergence, host switching/spillover, and disease transmission to humans.


Evidence does not support vitamin D for reducing respiratory infections, reviews conclude.


Sleep disparities in the era of the COVID-19 pandemic highlight the urgent need to address social determinants of health like the virus of racism.


title: Outcomes of cervical end-to-side triangulating esophagogastric anastomosis with minimally invasive esophagectomy.

text: BACKGROUND Esophagogastric anastomosis after esophagectomy has been performed with a variety of techniques during the past decade. However, anastomotic leakage and stricture are still important clinical problems after esophagogastric anastomosis, causing burdensome symptoms and poor quality of life. Herein, we describe a novel cervical end-to-side triangulating esophagogastric anastomoasis using linear stapler. METHODS A total of 90 patients (85 % male; mean age 63 years) with thoracic esophageal cancer who underwent cervical end-to-side esophagogastric triangular anastomosis using a linear stapler after minimally invasive esophagectomy between November 2006 and April 2013 were retrospectively reviewed. RESULTS The median operation time was 602 min (range 424-936 min). The volume of blood loss during the entire operative procedure was 127 ml (range 0-700 ml). There were no cases of anastomotic leakage in this study, although four patients (4.4 %) developed dysphagia associated with benign anastomotic stricture formation. All patients with a benign anastomotic stricture underwent balloon dilation, which resulted in improvement in their symptoms. CONCLUSIONS Considering the absence of anastomotic leakage and low rate of anastomotic stricture formation in this study, our modified triangular esophagogastric anastomosis technique appears promising and may contribute to reduced morbidity and mortality rates following esophagectomy.


title: Laparoscopic Splenectomy and Azygoportal Disconnection: a Systematic Review.

text: BACKGROUND AND OBJECTIVES Given the technical difficulty of laparoscopic splenectomy and azygoportal disconnection (LSD), data are limited that compare the laparoscopic to the open procedure. As the technique becomes more widespread, questions regarding its safety, feasibility, and reproducibility must be addressed. This review assesses the current status of LSD. METHODS We conducted our literature review with a search of the PubMed database. All published series of 5 or more laparoscopic splenectomy and azygoportal disconnection procedures were examined. The demographic, intraoperative, and postoperative data analyzed included number of ports, conversion rate, operative duration, estimated intraoperative blood loss, postoperative hospital stay, and complications. RESULTS Fifteen articles met the review criteria. Of 412 laparoscopic procedures, traditional laparoscopic splenectomy and azygoportal disconnection (TLSD) was used in 322 patients (78.2%), a modified laparoscopic procedure (MLSD) in 79 (19.2%), and a single-incision laparoscopic procedure (SLSD) in 11 (2.7%). Compared with the traditional and single-incision laparoscopic procedures, the MLSD procedure was associated with shorter operative duration and less blood loss. Furthermore, although the incidence of postoperative portal vein system thrombosis was higher in the laparoscopic than in the open splenectomy with azygoportal disconnection (OSD) procedure, the LSD procedure was associated with less pulmonary infection and pleural effusion and fewer incisional and overall complications than the open procedure. The rate of conversion to an open procedure was 5.4%. CONCLUSIONS LSD is feasible and safe for selected patients when performed by an expert laparoscopic surgeon. It has perioperative advantages over OSD, but studies with longer follow-up periods and larger samples of patients are needed.


title: Development of a radioiodinated apoptosis-inducing ligand, rhTRAIL, and a radiolabelled agonist TRAIL receptor antibody for clinical imaging studies.

text: BACKGROUND AND PURPOSE The TNF-related apoptosis inducing ligand (TRAIL) induces apoptosis through activation of the death receptors, TRAIL-R1 and TRAIL-R2. Recombinant human (rh) TRAIL and the TRAIL-R1 directed monoclonal antibody mapatumumab are currently clinically evaluated as anticancer agents. The objective of this study was to develop radiopharmaceuticals targeting the TRAIL-R1, suitable for clinical use to help understand and predict clinical efficacy in patients. EXPERIMENTAL APPROACH rhTRAIL was radioiodinated with (125) I, and conjugated mapatumumab was radiolabelled with (111) In. The radiopharmaceuticals were characterized, their in vitro stability and death receptor targeting capacities were determined and in vivo biodistribution was studied in nude mice bearing human tumour xenografts with different expression of TRAIL-R1. KEY RESULTS Labelling efficiencies, radiochemical purity, stability and binding properties were optimized for the radioimmunoconjugates. In vivo biodistribution showed rapid renal clearance of [(125) I]rhTRAIL, with highest kidney activity at 15 min and almost no detectable activity after 4 h. Activity rapidly decreased in almost all organs, except for the xenografts. Radiolabelled mapatumumab showed blood clearance between 24 and 168 h and a reduced decrease in radioactivity in the high receptor expression xenograft. CONCLUSIONS AND IMPLICATIONS rhTRAIL and mapatumumab can be efficiently radiolabelled. The new radiopharmaceuticals can be used clinically to study pharmacokinetics, biodistribution and tumour targeting, which could support evaluation of the native targeted agents in phase I/II trials.


title: Interleukin-6 and interleukin-10 as acute kidney injury biomarkers in pediatric cardiac surgery.

text: BACKGROUND Children undergoing cardiac surgery may exhibit a pronounced inflammatory response to cardiopulmonary bypass (CPB). Inflammation is recognized as an important pathophysiologic process leading to acute kidney injury (AKI). The aim of this study was to evaluate the association of the inflammatory cytokines interleukin (IL)-6 and IL-10 with AKI and other adverse outcomes in children after CPB surgery. METHODS This is a sub-study of the Translational Research Investigating Biomarker Endpoints in AKI (TRIBE-AKI) cohort, including 106 children ranging in age from 1 month to 18 years undergoing CPB. Plasma IL-6 and IL-10 concentrations were measured preoperatively and postoperatively [day 1 (within 6 h after surgery) and day 3]. RESULTS Stage 2/3 AKI, defined by at least a doubling of the baseline serum creatinine concentration or dialysis, was diagnosed in 24 (23%) patients. The preoperative IL-6 concentration was significantly higher in patients with stage 2/3 AKI [median 2.6 pg/mL, interquartile range (IQR) 2.6 0.6-4.9 pg/mL] than in those without stage 2/3 AKI (median 0.6 pg/mL, IQR 0.6-2.2 pg/mL) (p = 0.03). After adjustment for clinical and demographic variables, the highest preoperative IL-6 tertile was associated with a sixfold increased risk for stage 2/3 AKI compared with the lowest tertile (adjusted odds ratio 6.41, 95 % confidence interval 1.16-35.35). IL-6 and IL-10 levels increased significantly after surgery, peaking postoperatively on day 1. First postoperative IL-6 and IL-10 measurements did not significantly differ between patients with stage 2/3 AKI and those without stage 2/3 AKI. The elevated IL-6 level on day 3 was associated with longer hospital stay (p = 0.0001). CONCLUSIONS Preoperative plasma IL-6 concentration is associated with the development of stage 2/3 AKI and may be prognostic of resource utilization.


title: Alternative splicing of ACE2 possibly generates variants that may limit the entry of SARS-CoV-2: a potential therapeutic approach using SSOs.

text: Angiotensin-converting enzyme 2 (ACE2) plays an essential role in maintaining the balance of the renin-angiotensin system and also serves as a receptor for the SARS-CoV-2, SARS-CoV, and HCoV-NL63. Following the recent outbreak of SARS-CoV-2 infection, there has been an urgent need to develop therapeutic interventions. ACE2 is a potential target for many treatment approaches for the SARS-CoV-2. With the help of bioinformatics, we have predicted several novel exons of the human ACE2 gene. The inclusion of novel exons located in the 5'UTR/intronic region in the mature transcript may remove the critical ACE2 residues responsible for the interaction with the receptor-binding domain (RBD) of SARS-CoV-2, thus preventing their binding and entry into the cell. Additionally, inclusion of a novel predicted exons located in the 3'UTR by alternative splicing may remove the C-terminal transmembrane domain of ACE2 and generate soluble ACE2 isoforms. Splice-switching antisense oligonucleotides (SSOs) have been employed effectively as a therapeutic strategy in several disease conditions. Alternative splicing of the ACE2 gene could similarly be modulated using SSOs to exclude critical domains required for the entry of SARS-CoV-2. Strategies can also be designed to deliver these SSOs directly to the lungs in order to minimize the damage caused by SARS-CoV-2 pathogenesis.


title: Novel surgical technique for complete traumatic rupture of the pancreas: A case report.

text: INTRODUCTION Complete pancreatic rupture is a rare injury. The typical mechanism by which this occurs is overstretching of the pancreas across the vertebral column during blunt abdominal trauma. The management of this injury depends on the location and extent of the injury. CASE PRESENTATION A 45-year-old Caucasian woman presented with blunt abdominal trauma after she fell onto the end of a handlebar during a bicycle accident. She arrived in the emergency room with stable vital signs and an isolated bruise just above the umbilicus. A computed tomography scan revealed a complete rupture of the pancreas, just ventral to her superior mesenteric vein, and an accompanying hematoma but no additional injuries. An emergency laparotomy was performed; the head of the pancreas was oversewn with interrupted sutures and this was followed by a two-layer pancreaticojejunostomy with the tail of the pancreas. The recovery after surgery was completely uneventful. CONCLUSIONS Isolated complete pancreatic rupture is a rare injury that can be managed with complete organ preservation. The combination of suturing the pancreatic head and two-layer pancreaticojejunostomy with the pancreatic tail is a feasible technique to manage this condition.


How did Occupational and Employee Health Services Strengthen their Health System to meet the challenge presented by the COVID-19 Pandemic?


title: The leader proteinase of foot-and-mouth disease virus negatively regulates the type I interferon pathway by acting as a viral deubiquitinase.

text: The leader proteinase (L(pro)) of foot-and-mouth disease virus (FMDV) is a papain-like proteinase that plays an important role in FMDV pathogenesis. Previously, it has been shown that L(pro) is involved in the inhibition of the type I interferon (IFN) response by FMDV. However, the underlying mechanisms remain unclear. Here we demonstrate that FMDV Lb(pro), a shorter form of L(pro), has deubiquitinating activity. Sequence alignment and structural bioinformatics analyses revealed that the catalytic residues (Cys51 and His148) are highly conserved in FMDV Lb(pro) of all seven serotypes and that the topology of FMDV Lb(pro) is remarkably similar to that of ubiquitin-specific protease 14 (USP14), a cellular deubiquitylation enzyme (DUB), and to that of severe acute respiratory syndrome coronavirus (SARS-CoV) papain-like protease (PLpro), a coronaviral DUB. Both purified Lb(pro) protein and in vivo ectopically expressed Lb(pro) removed ubiquitin (Ub) moieties from cellular substrates, acting on both lysine-48- and lysine-63-linked polyubiquitin chains. Furthermore, Lb(pro) significantly inhibited ubiquitination of retinoic acid-inducible gene I (RIG-I), TANK-binding kinase 1 (TBK1), TNF receptor-associated factor 6 (TRAF6), and TRAF3, key signaling molecules in activation of type I IFN response. Mutations in Lb(pro) that ablate the catalytic activity (C51A or D163N/D164N) or disrupt the SAP (for SAF-A/B, Acinus, and PIAS) domain (I83A/L86A) abrogated the DUB activity of Lb(pro) as well as its ability to block signaling to the IFN-β promoter. Collectively, these results demonstrate that FMDV Lb(pro) possesses DUB activity in addition to serving as a viral proteinase and describe a novel mechanism evolved by FMDV to counteract host innate antiviral responses.


title: Retrospective review of efficacy of radiofrequency ablation for treatment of colorectal cancer liver metastases from a Canadian perspective.

text: PURPOSE A retrospective single-center review of ultrasound-guided radiofrequency ablation (RFA) treatment of colorectal cancer liver metastases was performed. This study reviews the primary and secondary technical effectiveness, overall survival of patients, recurrence-free survival, tumour-free survival, rates of local recurrence, and postprocedural RFA complications. Technical effectiveness and rates of complication with respect to tumour location and size were evaluated. Our results were compared with similar studies from Europe and North America. METHODS A total of 63 patients (109 tumours) treated with RFA between February 2004 and December 2009 were reviewed. Average and median follow-up time was 19.4 and 16.5 months, respectively (range, 1-54 months). Data from patient charts, pathology, and Picture Archiving and Communication System was integrated into an Excel database. Statistical Analysis Software was used for statistical analysis. RESULTS Primary and secondary technical effectiveness of percutaneous and intraoperative RFA were 90.8% and 92.7%, respectively. Average (SE) tumour-free survival was 14.4 ± 1.4 months (range, 1-43 months), and average (SE) recurrence-free survival was 33.5 ± 2.3 months (range, 2-50 months). Local recurrence was seen in 31.2% of treated tumours (range, 2-50 months) (34/109). Overall survival was 89.4% at 1 year, 70.0% at 2 years, and 38.1% at 3 years, with an average (SE) overall survival of 37.0 ± 2.8 months. There were 14 postprocedural complications. There was no statistically significant difference in technical effectiveness for small tumours (1-2 cm) vs intermediate ones (3-5 cm). There was no difference in technical effectiveness for peripheral vs parenchymal tumours. CONCLUSIONS This study demonstrated good-quality outcomes for RFA treatment of colorectal cancer liver metastases from a Canadian perspective and compared favorably with published studies.


title: Is mandatory research ethics reviewing ethical?

text: Review boards responsible for vetting the ethical conduct of research have been criticised for their costliness, unreliability and inappropriate standards when evaluating some non-medical research, but the basic value of mandatory ethical review has not been questioned. When the standards that review boards use to evaluate research proposals are applied to review board practices, it is clear that review boards do not respect researchers or each other, lack merit and integrity, are not just and are not beneficent. The few benefits of mandatory ethical review come at a much greater, but mainly hidden, social cost. It is time that responsibility for the ethical conduct of research is clearly transferred to researchers, except possibly in that small proportion of cases where prospective research participants may be so intrinsically vulnerable that their well-being may need to be overseen.


title: Embolization of the periprostatic venous plexus for erectile dysfunction resulting from venous leakage.

text: PURPOSE To evaluate retrospectively the safety and efficacy of anterograde embolization of the periprostatic venous plexus (AEPV) via percutaneous access of the deep dorsal vein of the penis for erectile dysfunction (ED) resulting from veno-occlusive dysfunction (VOD). MATERIALS AND METHODS From September 2009 through December 2012, 18 patients with moderate to severe ED secondary to insufficiency of physiologic venous occlusion as diagnosed by color Doppler evaluation of the penis after direct pharmacologic stimulation were treated. Preliminary diagnoses were also confirmed with dynamic cavernosography. Selective AEPV was achieved using a combination of N-butyl cyanoacrylate and endovascular coils. Follow-up consisted of collecting International Index of Erectile Function questionnaire (IIEF-6) scores and repeated color Doppler evaluation. RESULTS Immediate technical success was achieved in 16 of 18 patients (88.8%). Follow-up data were obtained at a mean of 13.3 months ± 7.5. In 12 of the patients with technical success, the mean IIEF-6 score improved from 10.5 ± 5.2 to 20.6 ± 8.4 after the procedure (P = .0069). At 3-month short-term follow-up, clinical success defined by an end-diastolic velocity of < 5 cm/s on color Doppler was noted in 81% (13 of 16 patients). Of these 13 patients, 7 patients had continued erectile function at the end of follow-up, and the other 6 patients reported progressive diminishment in the benefit over time. No major complications and two minor complications were encountered. CONCLUSIONS AEPV for ED secondary to VOD is a safe alternative to surgical treatment that demonstrates promising short-term and midterm efficacy.


title: Association of pre-operative estimated GFR on post-operative pulmonary complications in laparoscopic surgeries.

text: Despite a large body of evidence showing the pandemic of chronic kidney disease, the impact of pre-operative kidney function on the risk of post-operative pulmonary complications (PPCs) is not well known. We used multivariable logistic regression analyses with 3-level hierarchical adjustments to identify the association of pre-operative estimated glomerular filtration rate (eGFR) with PPCs in laparoscopic surgeries. Among 452,213 patients between 2005 and 2013 in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database, a total of 3,727 patients (0.9%) experienced PPCs. We found a gradient association between lower eGFR and higher likelihood of PPCs in the unadjusted model. In the case-mix adjusted model, a reverse-J-shaped association was observed; a small albeit significant association with the highest eGFR category emerged. Further adjustment slightly attenuated these associations, but the PPCs risk in the eGFR groups of <30, 30-60, and ≥120 mL/min/1.73 m2 remained significant: odds ratios (95% confidence intervals) of 1.82 (1.54-2.16), 1.38 (1.24-1.54), and 1.28 (1.07-1.53), respectively (reference: 90-120 mL/min/1.73 m2). Our findings propose a need for careful pre-operative evaluation of cardiovascular and pulmonary functions and post-operative fluid management among patients with not only lower but also very high eGFR.


title: Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review.

text: This systematic review provides a comprehensive, up-to-date summary of traumatic brain injury (TBI) epidemiology in Europe, describing incidence, mortality, age, and sex distribution, plus severity, mechanism of injury, and time trends. PubMed, CINAHL, EMBASE, and Web of Science were searched in January 2015 for observational, descriptive, English language studies reporting incidence, mortality, or case fatality of TBI in Europe. There were no limitations according to date, age, or TBI severity. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. Data were presented narratively. Sixty-six studies were included in the review. Country-level data were provided in 22 studies, regional population or treatment center catchment area data were reported by 44 studies. Crude incidence rates varied widely. For all ages and TBI severities, crude incidence rates ranged from 47.3 per 100,000, to 694 per 100,000 population per year (country-level studies) and 83.3 per 100,000, to 849 per 100,000 population per year (regional-level studies). Crude mortality rates ranged from 9 to 28.10 per 100,000 population per year (country-level studies), and 3.3 to 24.4 per 100,000 population per year (regional-level studies.) The most common mechanisms of injury were traffic accidents and falls. Over time, the contribution of traffic accidents to total TBI events may be reducing. Case ascertainment and definitions of TBI are variable. Improved standardization would enable more accurate comparisons.


title: In vitro S. epidermidis and S. aureus adherence to composite and lightweight polypropylene grafts.

text: BACKGROUND Despite the significant risk of infection, prosthetic graft materials have become indispensable for incisional hernia repair. Composite and lightweight grafts have been developed to overcome adhesion and rigidity. The aim of this study was to evaluate in vitro S. epidermidis and S. aureus adherence to these new generation grafts, which have modified composition and textile properties. MATERIALS AND METHODS In this experimental study, sterile samples of multifilament polypropylene, multifilament lightweight composite, monofilament composite, and monofilament polypropylene grafts were incubated with slime positive S. epidermidis and S. aureus strains for 24 h. The grafts were washed and vortexed in saline. The saline was passaged to blood agar and incubated for 24 h. The colonies were counted. Naïve and incubated graft materials were examined by scanning electron microscopy to reveal both textile properties and biofilm formation. Physicochemical properties were evaluated. Wilcoxon signed ranks test and Friedman test were used for statistical analysis. RESULTS S. epidermidis showed a significantly decreased adherence to monofilament polypropylene graft, and increased adherence to multifilament polypropylene graft (P<0.05). S. aureus showed a significant affinity for monofilament composite graft (P<0.05). SEM studies showed that biofilm formation was present on multifilament polypropylene graft. CONCLUSIONS Both S. epidermidis and S. aureus had significantly less adherence to multifilament lightweight composite than multifilament polypropylene graft. S. epidermidis showed a greater affinity to monofilament composite graft compared with monofilament polypropylene graft. Overall S. epidermidis adherence for multifilament lightweight composite and monofilament composite was less than multifilament polypropylene and higher than monofilament polypropylene. S. epidermidis and S. aureus showed different adherence for each graft. Changes in material composition and textile properties may well influence bacterial adherence.


Minding the epistemic gap in covid-19 and beyond.


European Society of Minimally Invasive Neurological Therapy (ESMINT) recommendations for optimal interventional neurovascular management in the covid-19 era.


title: The utility of common surgical instruments for pediatric adenotonsillectomy.

text: OBJECTIVES/HYPOTHESIS To evaluate the correlation between surgical instrumentation and intraoperative surgical time, postoperative hemorrhage, and associated healthcare cost for pediatric adenotonsillectomy. STUDY DESIGN Retrospective chart analysis. METHODS Chart data were collected from pediatric patients who underwent adenotonsillectomy from 2011 to 2013. Monopolar electrocautery, radiofrequency ablation, and PlasmaBlade instruments were compared for intraoperative surgical time and postoperative hemorrhage rate. Univariate analysis of variance (ANOVA) and χ(2) analysis was utilized to evaluate differences between instrumentation and variables. Cost analysis examining instrumentation and intraoperative anesthesia was also reviewed. RESULTS A total of 1,280 patients who underwent adenotonsillectomy were evaluated. There was no significant overall difference in age, sex, or preoperative diagnosis identified between the three instrumentation groups. When examining the various instruments' effect on procedure time in minutes, univariate ANOVA demonstrated a significant difference overall among the three groups (F = 8.79; P < .001). Post-hoc pairwise comparisons identified significantly faster surgical times for monopolar cautery than either PlasmaBlade (P = .03) or radiofrequency ablation (P < .001). The difference in the number of patients who experienced a postoperative bleed by instrument was not statistically significant (χ(2) = 2.36; P = .31). After instrumentation expenses were added to anesthesia cost, the overall average costs by instrument and surgical time were estimated to be $30.04 for monopolar cautery, $246.95 for PlasmaBlade, and $244.32 for radiofrequency ablation. CONCLUSIONS The ideal surgical instrumentation should be cost and time efficient with a low complication rate. Monopolar cautery was associated with a statistically significant lower intraoperative surgical time, similar postoperative hemorrhage rates, and lower operative costs when compared to radiofrequency ablation and PlasmaBlade. LEVEL OF EVIDENCE 4.


title: Evaluation of endoscopy in localizing transgastric access for natural orifice transluminal endoscopic surgery in humans.

text: BACKGROUND To date, transgastric access in humans for natural orifice transluminal endoscopic surgery (NOTES) has been poorly evaluated. OBJECTIVE To compare endoscopic visualization of the transgastric access point with the laparoscopically defined ideal entrance to the peritoneal cavity. DESIGN Prospective pilot study in humans. SETTING Single tertiary-care center. PATIENTS This study involved 31 patients referred for laparoscopic cholecystectomy. INTERVENTION Access points were marked by endoscopy alone, endoscopy combined with diaphanoscopy, and endoscopy after pneumoperitoneum. Points were correlated with a laparoscopically visualized, previously defined ideal access area. MAIN OUTCOME MEASUREMENTS To choose the appropriate access point within the laparoscopically defined ideal access area to the peritoneal cavity away from major vessels and adjacent organs, by using endoscopy and to establish landmarks for the endoscopist, look for a learning curve, and identify potential problems. RESULTS The percentage of access points within the laparoscopically defined ideal area was 35.5% with endoscopy alone, 13.8% using the diaphanoscopy method, and 45.2% after transcutaneous pneumoperitoneum. A safe access point (> or = 3 cm from major gastric vessels) could be achieved with the 3 techniques in 83.9%, 65.5%, and 87.1% of patients, respectively. A positive learning curve for endoscopic localization was identified before (P = .008) and after (P = .014) pneumoperitoneum. Virtual complications were greater in obese patients. LIMITATIONS This was a small pilot study with hypothetical complications and problems, because actual transgastric access was not performed. The criteria for an ideal access area were very strict. CONCLUSION Endoscopy, especially with the use of pneumoperitoneum, can reliably locate a safe transgastric entrance point. However, the endoscopically chosen site correlates poorly with the ideal laparoscopically determined site for transgastric access.


title: [Clinical characteristics and CT imaging features of patients with different clinical types of coronavirus disease 2019].

text: OBJECTIVE To investigate the clinical characteristics and CT imaging features of patients with different clinical types of coronavirus disease 2019 (COVID-19), so as to provide a reference for the treatment and evaluation of COVID-19. METHODS The clinical data of 278 patients with COVID-19 admitted to Guangzhou Eighth People's Hospital from January 20th to February 10th in 2020 were collected. The patients were divided into mild, ordinary, severe and critical types. The differences of clinical symptoms and signs, laboratory examination indexes and CT image features of lung in different clinical types were analyzed and compared, and the relationship between clinical and imaging features and clinical types of diseases were analyzed. RESULTS Among the 278 patients with COVID-19, 130 were male (46.8%) and 148 were female (53.2%), of whom 88.8% (247/278) were 20 to 69 years old. 238 (85.6%) patients combined one or more basic diseases. The source of cases was mainly imported cases (n = 201, 72.3%), of whom 89 cases were imported from Wuhan, accounting for 44.3% of all imported cases. With the aggravation of the disease, the male composition ratio, age and the number of basic diseases of patients gradually increased, and the incidences of fever, dry cough, chilly or chills, and fatigue in severe and critical patients were significantly higher than those in the mild and ordinary ones. The white blood cell count (WBC), neutrophil counts (NEU) and proportions (NEU%) of the severe and critical patients were higher than those of the mild and ordinary patients [WBC (×109/L): 5.7±3.1, 6.5±2.4 vs. 5.4±1.7, 4.9±1.6; NEU (×109/L): 4.4±3.1, 4.9±2.5 vs. 2.8±1.2, 2.9±1.3; NEU%: 0.72±0.13, 0.73±0.14 vs. 0.51±0.12, 0.59±0.11; all P < 0.01], while the lymphocyte count (LYM) and ratio (LYM%), platelet count (PLT) were lower than those in the mild and ordinary patients [LYM (×109/L): 1.0±0.4, 1.2±0.8 vs. 2.1±0.9, 1.5±0.6; LYM%: 0.21±0.11, 0.20±0.12 vs. 0.40±0.11, 0.32±0.11; PLT (×109/L): 177.1±47.8, 157.7±51.6 vs. 215.3±59.7, 191.8±64.3; all P < 0.05]. The level of albumin (Alb) was the lowest in the critical patients and the level of total bilirubin (TBil) was the highest, which was statistically significant as compared with the mild, ordinary and severe patients [Alb (g/L): 33.0±5.8 vs. 42.8±4.4, 39.6±5.1, 34.4±4.2; TBil (μmol/L): 20.1±12.8 vs. 12.0±8.7, 10.9±6.3, 12.2±8.3; both P < 0.01]. Lactate dehydration (LDH) and cardiac troponin I (cTnI) in the severe and critical patients were significantly higher than those in the mild and ordinary patients [LDH (μmol×s-1×L-1): 5.6±2.2, 5.0±2.9 vs. 2.8±0.9, 3.3±1.2; cTnI (μg/L): 0.010 (0.006, 0.012), 0.010 (0.006, 0.012) vs. 0.005 (0.003, 0.006), 0.005 (0.001, 0.008); both P < 0.05]. C-reactive protein (CRP) level of severe patients were higher than that in the mild, ordinary and critical patients [mg/L: 43.3 (33.2, 72.1) vs. 22.1 (16.2, 25.7), 29.7 (19.8, 43.1), 25.8 (23.0, 36.7), P < 0.01]. The level of procalcitonin (PCT) in the severe and critical patients was higher than that in the mild and ordinary patients [μg/L: 0.17 (0.12, 0.26), 0.13 (0.09, 0.24) vs. 0.06 (0.05, 0.08), 0.05 (0.04, 0.09), P < 0.01]. The typical CT imaging features were as follows: the ordinary type mainly showed the single or multiple ground glass shadows on the chest image; the severe type mainly showed the multiple ground glass shadows, infiltration shadows or solid transformation shadows. Compared with the ordinary patients, the lesions increase, and the scope of the lesion expanded to show double lungs. Critical type was mainly manifested as diffuse consolidation of both lungs with multiple patchy density increase shadows, multiple leafy patchy density increase shadows were seen on each leaf, most of them were ground glass-like density, and some were shown separately lung consolidation. CONCLUSIONS Men, advanced aged, and combining multiple underlying diseases are high-risk populations of COVID-19, and they should pay close attention to the risk of progressing to severe or critical type. CT imaging features could be used as an important supplement when diagnosing severe and critical COVID-19.


Letter: ACE2, Rho kinase inhibition and the potential role of vitamin D against COVID-19.


title: Update on use of chloroquine/hydroxychloroquine to treat coronavirus disease 2019 (COVID-19).

text: Drugs that are specifically efficacious against SARS-CoV-2 have yet to be established. Chloroquine and hydroxychloroquine have garnered considerable attention for their potential to treat coronavirus disease 2019 (COVID-19). Increasing evidence obtained from completed clinical studies indicates the prospects for chloroquine/hydroxychloroquine to treat COVID-19. More randomized control clinical studies are warranted to determine the feasibility of these two drugs in treating COVID-19.


title: Tranexamic acid to improve functional status in adults with spontaneous intracerebral haemorrhage: the TICH-2 RCT.

text: BACKGROUND Tranexamic acid reduces death due to bleeding after trauma and postpartum haemorrhage. OBJECTIVE The aim of the study was to assess if tranexamic acid is safe, reduces haematoma expansion and improves outcomes in adults with spontaneous intracerebral haemorrhage (ICH). DESIGN The TICH-2 (Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage) study was a pragmatic, Phase III, prospective, double-blind, randomised placebo-controlled trial. SETTING Acute stroke services at 124 hospitals in 12 countries (Denmark, Georgia, Hungary, Ireland, Italy, Malaysia, Poland, Spain, Sweden, Switzerland, Turkey and the UK). PARTICIPANTS Adult patients (aged ≥ 18 years) with ICH within 8 hours of onset. EXCLUSION CRITERIA Exclusion criteria were ICH secondary to anticoagulation, thrombolysis, trauma or a known underlying structural abnormality; patients for whom tranexamic acid was thought to be contraindicated; prestroke dependence (i.e. patients with a modified Rankin Scale [mRS] score > 4); life expectancy < 3 months; and a Glasgow Coma Scale score of < 5. INTERVENTIONS Participants, allocated by randomisation, received 1 g of an intravenous tranexamic acid bolus followed by an 8-hour 1-g infusion or matching placebo (i.e. 0.9% saline). MAIN OUTCOME MEASURE The primary outcome was functional status (death or dependency) at day 90, which was measured by the shift in the mRS score, using ordinal logistic regression, with adjustment for stratification and minimisation criteria. RESULTS A total of 2325 participants (tranexamic acid, n = 1161; placebo, n = 1164) were recruited from 124 hospitals in 12 countries between 2013 and 2017. Treatment groups were well balanced at baseline. The primary outcome was determined for 2307 participants (tranexamic acid, n = 1152; placebo, n = 1155). There was no statistically significant difference between the treatment groups for the primary outcome of functional status at day 90 [adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.76 to 1.03; p = 0.11]. Although there were fewer deaths by day 7 in the tranexamic acid group (aOR 0.73, 95% CI 0.53 to 0.99; p = 0.041), there was no difference in case fatality at 90 days (adjusted hazard ratio 0.92, 95% CI 0.77 to 1.10; p = 0.37). Fewer patients experienced serious adverse events (SAEs) after treatment with tranexamic acid than with placebo by days 2 (p = 0.027), 7 (p = 0.020) and 90 (p = 0.039). There was no increase in thromboembolic events or seizures. LIMITATIONS Despite attempts to enrol patients rapidly, the majority of participants were enrolled and treated > 4.5 hours after stroke onset. Pragmatic inclusion criteria led to a heterogeneous population of participants, some of whom had very large strokes. Although 12 countries enrolled participants, the majority (82.1%) were from the UK. CONCLUSIONS Tranexamic acid did not affect a patient's functional status at 90 days after ICH, despite there being significant modest reductions in early death (by 7 days), haematoma expansion and SAEs, which is consistent with an antifibrinolytic effect. Tranexamic acid was safe, with no increase in thromboembolic events. FUTURE WORK Future work should focus on enrolling and treating patients early after stroke and identify which participants are most likely to benefit from haemostatic therapy. Large randomised trials are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN93732214. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 35. See the NIHR Journals Library website for further project information. The project was also funded by the Pragmatic Trials, UK, funding call and the Swiss Heart Foundation in Switzerland.


title: Predicting Intracerebral Hemorrhage Growth With the Spot Sign: The Effect of Onset-to-Scan Time.

text: BACKGROUND AND PURPOSE Hematoma expansion after acute intracerebral hemorrhage is common and is associated with early deterioration and poor clinical outcome. The computed tomographic angiography (CTA) spot sign is a promising predictor of expansion; however, frequency and predictive values are variable across studies, possibly because of differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign. METHODS We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to 5 predefined categorized onset-to-CTA times. We calculated spot-sign frequency both as raw and frequency-adjusted rates. RESULTS Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot-sign status, and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up computed tomographies for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within 2 hours of onset to 13% beyond 8 hours (P<0.001). There was a significant decrease in hematoma expansion in spot-positive patients as onset-to-CTA time increased (P=0.004), with positive predictive values decreasing from 53% to 33%. CONCLUSIONS The frequency of the CTA spot sign is inversely related to intracerebral hemorrhage onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk stratification for patients with acute intracerebral hemorrhage and will help refine clinical prediction rules for intracerebral hemorrhage expansion.


COVID-19 and the Death of Italy's Physicians.


title: Proning in Non-Intubated (PINI) in Times of COVID-19: Case Series and a Review.

text: It has been well known for decades that prone positioning (PP) improves oxygenation. However, it has gained widespread acceptance only in the last few years since studies have shown significant survival benefit. Many centers have established prone ventilation in their treatment algorithm for mechanically ventilated patients with severe acute respiratory distress syndrome (ARDS). Physiologically, PP should also benefit awake, non-intubated patients with acute hypoxemic respiratory failure. However, proning in non-intubated (PINI) patients did not gain any momentum until a few months ago when the Coronavirus disease 2019 (COVID-19) pandemic surged. A large number of sick patients overwhelmed the health care system, and many centers faced a dearth of ventilators. In addition, outcomes of patients placed on mechanical ventilation because of COVID-19 infection have been highly variable and often dismal. Hence, increased focus has shifted to using various strategies to prevent intubation, such as PINI. There is accumulating evidence that PINI is a low-risk intervention that can be performed even outside intensive care unit with minimal assistance and may prevent intubation in certain patients with ARDS. It can also be performed safely at smaller centers and, therefore, may reduce the patient transfer to larger institutions that are overwhelmed in the current crisis. We present a case series of 2 patients with acute hypoxemic respiratory failure who experienced significant improvements in oxygenation with PP. In addition, the physiology of PP is described, and concerns such as proning in obese and patient's anxiety are addressed; an educational pamphlet that may be useful for both patients and health care providers is provided.


Rapid response activatable molecular probes for intraoperative optical image-guided tumor resection.


title: Discovery and Sequence Analysis of Four Deltacoronaviruses from Birds in the Middle East Reveal Interspecies Jumping with Recombination as a Potential Mechanism for Avian-to-Avian and Avian-to-Mammalian Transmission.

text: The emergence of Middle East respiratory syndrome showed once again that coronaviruses (CoVs) in animals are potential source for epidemics in humans. To explore the diversity of deltacoronaviruses in animals in the Middle East, we tested fecal samples from 1,356 mammals and birds in Dubai, The United Arab Emirates. Four novel deltacoronaviruses were detected from eight birds of four species by reverse transcription-PCR (RT-PCR): FalCoV UAE-HKU27 from a falcon, HouCoV UAE-HKU28 from a houbara bustard, PiCoV UAE-HKU29 from a pigeon, and QuaCoV UAE-HKU30 from five quails. Complete genome sequencing showed that FalCoV UAE-HKU27, HouCoV UAE-HKU28, and PiCoV UAE-HKU29 belong to the same CoV species, suggesting recent interspecies transmission between falcons and their prey, houbara bustards and pigeons, possibly along the food chain. Western blotting detected specific anti-FalCoV UAE-HKU27 antibodies in 33 (75%) of 44 falcon serum samples, supporting genuine infection in falcons after virus acquisition. QuaCoV UAE-HKU30 belongs to the same CoV species as porcine coronavirus HKU15 (PorCoV HKU15) and sparrow coronavirus HKU17 (SpCoV HKU17), discovered previously from swine and tree sparrows, respectively, supporting avian-to-swine transmission. Recombination involving the spike protein is common among deltacoronaviruses, which may facilitate cross-species transmission. FalCoV UAE-HKU27, HouCoV UAE-HKU28, and PiCoV UAE-HKU29 originated from recombination between white-eye coronavirus HKU16 (WECoV HKU16) and magpie robin coronavirus HKU18 (MRCoV HKU18), QuaCoV UAE-HKU30 from recombination between PorCoV HKU15/SpCoV HKU17 and munia coronavirus HKU13 (MunCoV HKU13), and PorCoV HKU15 from recombination between SpCoV HKU17 and bulbul coronavirus HKU11 (BuCoV HKU11). Birds in the Middle East are hosts for diverse deltacoronaviruses with potential for interspecies transmission.IMPORTANCE During an attempt to explore the diversity of deltacoronaviruses among mammals and birds in Dubai, four novel deltacoronaviruses were detected in fecal samples from eight birds of four different species: FalCoV UAE-HKU27 from a falcon, HouCoV UAE-HKU28 from a houbara bustard, PiCoV UAE-HKU29 from a pigeon, and QuaCoV UAE-HKU30 from five quails. Genome analysis revealed evidence of recent interspecies transmission between falcons and their prey, houbara bustards and pigeons, possibly along the food chain, as well as avian-to-swine transmission. Recombination, which is known to occur frequently in some coronaviruses, was also common among these deltacoronaviruses and occurred predominantly at the spike region. Such recombination, involving the receptor binding protein, may contribute to the emergence of new viruses capable of infecting new hosts. Birds in the Middle East are hosts for diverse deltacoronaviruses with potential for interspecies transmission.


title: Medical and Surgical Education Challenges and Innovations in the COVID-19 Era: A Systematic Review.

text: The aim of this systematic review was to identify the challenges imposed on medical and surgical education by the COVID-19 pandemic, and the proposed innovations enabling the continuation of medical student and resident training. A systematic review on the MEDLINE and EMBASE databases was performed on April 18th, 2020, and yielded 1288 articles. Sixty-one of the included manuscripts were synthesized in a qualitative description focused on two major axes, "challenges" and "innovative solutions", and two minor axes, "mental health" and "medical students in the frontlines". Shortage of personal protective equipment, suspension of clinical clerkships and observerships and reduction in elective surgical cases unavoidably affect medical and surgical education. Interesting solutions involving the use of virtual learning, videoconferencing, social media and telemedicine could effectively tackle the sudden cease in medical education. Furthermore, trainee's mental health should be safeguarded, and medical students can be involved in the COVID-19 clinical treatment if needed.


title: Intensive medical student involvement in short-term surgical trips provides safe and effective patient care: a case review.

text: BACKGROUND The hierarchical nature of medical education has been thought necessary for the safe care of patients. In this setting, medical students in particular have limited opportunities for experiential learning. We report on a student-faculty collaboration that has successfully operated an annual, short-term surgical intervention in Haiti for the last three years. Medical students were responsible for logistics and were overseen by faculty members for patient care. Substantial planning with local partners ensured that trip activities supplemented existing surgical services. A case review was performed hypothesizing that such trips could provide effective surgical care while also providing a suitable educational experience. FINDINGS Over three week-long trips, 64 cases were performed without any reported complications, and no immediate perioperative morbidity or mortality. A plurality of cases were complex urological procedures that required surgical skills that were locally unavailable (43%). Surgical productivity was twice that of comparable peer institutions in the region. Student roles in patient care were greatly expanded in comparison to those at U.S. academic medical centers and appropriate supervision was maintained. DISCUSSION This demonstration project suggests that a properly designed surgical trip model can effectively balance the surgical needs of the community with an opportunity to expose young trainees to a clinical and cross-cultural experience rarely provided at this early stage of medical education. Few formalized programs currently exist although the experience above suggests the rewarding potential for broad-based adoption.


title: Effectiveness of budesonide MMX (Cortiment) for the treatment of mild-to-moderate active ulcerative colitis: study protocol for a prospective multicentre observational cohort study.

text: INTRODUCTION A study has been developed to assess the use and effectiveness of budesonide MMX for mild-to-moderate active ulcerative colitis (UC) in routine clinical practice. METHODS AND ANALYSIS A prospective, multicentre, observational, cohort study of 300 patients prescribed budesonide MMX for the treatment of mild-to-moderate active UC will be conducted in Europe, Israel and Canada. Patients will be treated with budesonide MMX9 mg daily for induction of remission for ≤8 weeks. Data on effectiveness, including patient-reported outcomes, tolerability and use will be recorded at the end of treatment and at ≥2 weeks after. The primary outcome (improvement ≥3 point in the clinical subscores of the UC Disease Activity Index score at the end of treatment) will be compared in: patients who receive budesonide MMX added to mesalazine >2 weeks after increased/optimised mesalazine dose for the treatment of flare (late add-on); patients who receive budesonide MMX added to mesalazine ≤2 weeks since mesalazine increased/optimised for the treatment of flare, or without mesalazine dose modification (early add-on); and patients who receive budesonide MMX as monotherapy for the treatment of flare (mono). Propensity scoring will be used to minimise bias and confounding inherent in observational studies. ETHICS AND DISSEMINATION First ethical approval: Ethikkommission der Ärztekammer Hamburg (12/22/2015). The results will be published in full. DISCUSSION Completion of primary data collection is expected in December 2017. Our results will provide further evidence on the effectiveness of budesonide MMX to support clinicians in their daily practice and inform therapeutic guidelines. TRIAL REGISTRATION NUMBER NCT02586259.


title: From the frontlines of COVID-19 - How prepared are we as obstetricians: a commentary.

text: The World Health Organization (WHO) has declared the outbreak of novel coronavirus (2019-nCoV) - now known as Coronavirus Disease (COVID-19)1 - as a global health emergency. Singapore currently stands as the country with the highest number of reported cases of COVID-19 outside of China2 , excluding patients on a cruise ship offshore of Japan.


title: A novel class of antimicrobial peptides from the scorpion Heterometrus spinifer.

text: The venom peptides from the scorpion Heterometrus spinifer have been poorly characterized so far. Here, we identified a novel class of antimicrobial peptides from the venom gland of H. spinifer, which were referred to as HsAp, HsAp2, HsAp3 and HsAp4, respectively. Each of the four peptides consists of 29 amino acid residues, and is cationic and weakly amphipathic. They display no significant homology to any other known peptides, and thus represent a new family of venom peptides from scorpions. Antimicrobial assay showed that HsAp is able to inhibit the growth of both Gram-negative and Gram-positive bacteria with the MIC values of 11.8-51.2 μM. HsAp is also able to inhibit the growth of the tested fungus. Genomic analysis indicated that the genes of all the four peptides are intronless. Our studies expand the families of antimicrobial peptides from scorpions.


title: Comparison of the Effects of Minimal and High-Flow Anaesthesia on Cerebral Perfusion During Septorhinoplasty.

text: Objective The aim of this study was to analyse the effects of minimal-and high-flow anaesthesia on cerebral oxygenation during septorhinoplasty with controlled hypotension using near-infrared spectroscopy. Methods Eighty patients scheduled for septorhinoplasty under general anaesthesia with controlled hypotension were randomised into two groups: minimal-flow (MF) or high-flow (HF). Both groups received desflurane anaesthesia to maintain bispectral index values at 40%-50% and 0.25-0.5 μg kg-1 min-1 i.v. remifentanyl infusion to maintain mean arterial blood pressure between 55 and 65 mmHg. The MF group received 5 L min-1 of fresh gas flow for the first 10 mins then the gas flow was reduced 0.4 L min-1. The HF group received 2 L min-1 of fresh gas flow throughout. Haemodynamic parameters and cerebral oxygen saturation were measured. Results There were no statistical differences in demographic variables, duration of anaesthesia and surgery, time to extubation and proceeding to an Aldrete score of 9. There were no statistical differences in haemodynamic parameters, end-tidal CO2 and cerebral oxygen saturation. The amount of desflurane used in the MF group was significantly lower than that used in the HF group (30.5±9.8 mL vs. 48.5±12.1 mL; p<0.05). Conclusion MF and HF anaesthesia did not lead to any difference in cerebral oxygen saturation in patients undergoing septorhinoplasty with controlled hypotension. MF anaesthesia may thus be used as safely as HF anaesthesia is.


title: History of colorectal surgery: A comprehensive historical review from the ancient Egyptians to the surgical robot.

text: BACKGROUND Colorectal surgery has its roots in the early civilisations and its development followed a complex pathway never disjoined from the social and cultural environment where it took place. METHOD The most relevant historical sources have been evaluated. RESULTS A comprehensive review of the history of colorectal surgery is presented, from the ancient Egyptian culture to the modern achievements. The development of surgery of colon, rectum and anus is reported with particular reference to the social environment and history; as the development of colorectal surgery parallels the occurrence of human historical events, the study of the former cannot be disjoined from the latter. CONCLUSION Study and knowledge of the history of medicine--and, in particular, of colorectal surgery for those interested in this particular subject--is a privileged way to understand who we are nowadays and where we come from.


title: Practice does not always make perfect: need for selection curricula in modern surgical training.

text: BACKGROUND It is hypothesized that not all surgical trainees are able to reach technical competence despite ongoing practice. The objectives of the study were to assess a trainees' ability to reach technical competence by assessing learning patterns of the acquisition of surgical skills. Furthermore, it aims to determine whether individuals' learning patterns were consistent across a range of open and laparoscopic tasks of variable difficulty. METHODS Sixty-five preclinical medical students participated in a training curriculum with standardized feedback over forty repetitions of the following laparoscopic and open technical tasks: peg transfer (PT), circle cutting (CC), intracorporeal knot tie (IKT), one-handed tie, and simulated laparotomy closure. Data mining techniques were used to analyze the prospectively collected data and stratify the students into four learning clusters. Performance was compared between groups, and learning curve characteristics unique to trainees who have difficulty reaching technical competence were quantified. RESULTS Top performers (22-35%) and high performers (32-42%) reached proficiency in all tasks. Moderate performers (25-37%) reached proficiency for all open tasks but not all laparoscopic tasks. Low performers (8-15%) failed to reach proficiency in four of five tasks including all laparoscopic tasks (PT 7.8%; CC 9.4%; IKT 15.6%). Participants in lower performance clusters demonstrated sustained performance disadvantage across tasks, with widely variable learning curves and no evidence of progression towards a plateau phase. CONCLUSIONS Most students reached proficiency across a range of surgical tasks, but low-performing trainees failed to reach competence in laparoscopic tasks. With increasing use of laparoscopy in surgical practice, screening potential candidates to identify the lowest performers may be beneficial.


title: Nonviral pulmonary delivery of siRNA.

text: RNA interference (RNAi) is an important part of the cell's defenses against viruses and other foreign genes. Moreover, the biotechnological exploitation of RNAi offers therapeutic potential for a range of diseases for which drugs are currently unavailable. Unfortunately, the small interfering RNAs (siRNAs) that are central to RNAi in the cytoplasm are readily degradable by ubiquitous nucleases, are inefficiently targeted to desired organs and cell types, and are excreted quickly upon systemic injection. As a result, local administration techniques have been favored over the past few years, resulting in great success in the treatment of viral infections and other respiratory disorders. Because there are several advantages of pulmonary delivery over systemic administration, two of the four siRNA drugs currently in phase II clinical trials are delivered intranasally or by inhalation. The air-blood barrier, however, has only limited permeability toward large, hydrophilic biopharmaceuticals such as nucleic acids; in addition, the lung imposes intrinsic hurdles to efficient siRNA delivery. Thus, appropriate formulations and delivery devices are very much needed. Although many different formulations have been optimized for in vitro siRNA delivery to lung cells, only a few have been reported successful in vivo. In this Account, we discuss both obstacles to pulmonary siRNA delivery and the success stories that have been achieved thus far. The optimal pulmonary delivery vehicle should be neither cytotoxic nor immunogenic, should protect the payload from degradation by nucleases during the delivery process, and should mediate the intracellular uptake of siRNA. Further requirements include the improvement of the pharmacokinetics and lung distribution profiles of siRNA, the extension of lung retention times (through reduced recognition by macrophages), and the incorporation of reversible or stimuli-responsive binding of siRNA to allow for efficient release of the siRNAs at the target site. In addition, the ideal carrier would be biodegradable (to address difficulties with repeated administration for the treatment of chronic diseases) and would contain targeting moieties to enhance uptake by specific cell types. None of the currently available polymer- and lipid-based formulations meet every one of these requirements, but we introduce here several promising new approaches, including a biodegradable, nonimmunogenic polyester. We also discuss imaging techniques for following the biodistribution according to the administration route. This tracking is crucial for better understanding the translocation and clearance of nanoformulated siRNA subsequent to pulmonary delivery. In the literature, the success of pulmonary siRNA delivery is evaluated solely by relief from or prophylaxis against a disease; side effects are not studied in detail. It also remains unclear which cell types in the lung eventually take up siRNA. These are critical issues for the translational use of pulmonary siRNA formulations; accordingly, we present a flow cytometry technique that can be utilized to differentiate transfected cell populations in a mouse model that expresses transgenic enhanced green fluorescence protein (EGFP). This technique, in which different cell types are identified on the basis of their surface antigen expression, may eventually help in the development of safer carriers with minimized side effects in nontargeted tissues.


title: Survey study of the knowledge, attitudes, and expected behaviors of critical care clinicians regarding an influenza pandemic.

text: OBJECTIVE Intensive care units (ICUs) are potential high-risk areas for the transmission of respiratory viruses such as influenza. An influenza pandemic is expected to result in a dramatic surge of critically ill patients, and ICU healthcare workers (HCW) are likely to be at high risk of infection. OBJECTIVE To characterize the knowledge, attitudes, and expected behaviors of ICU HCWs concerning the risk of and response to an influenza pandemic. DESIGN, PARTICIPANTS, AND SETTING A survey was distributed to 292 HCWs (ie, internal medicine house staff, pulmonary and critical care fellows and faculty members, nurses, and respiratory care professionals) at 2 hospitals in Baltimore, Maryland. RESULTS Of the 292 HCWs, 256 (88%) completed the survey. Just over one-half of the respondents believed there is at least a 45% chance of an influenza pandemic within the next 5 years. However, only 41% reported knowing how to protect themselves during an outbreak. Despite this common belief that a pandemic is likely in the near future, 59% of those surveyed reported only minimal knowledge of the risks of and protective strategies for an influenza pandemic, and 20% reported being unlikely to report to work during a pandemic or being unsure about whether they would do so. The odds of reporting to work varied on the basis of race and responsibility for child care. CONCLUSIONS ICU HCWs reported having minimal knowledge concerning the risk of and response to an influenza pandemic, even though more that one-half of HCWs expect that a pandemic will occur in the near future. This finding in a high-risk setting is of concern, given that lack of knowledge among HCWs may result in increased nosocomial transmission to HCWs and patients. Interventions to improve knowledge of pandemics and understanding of risks among ICU HCWs are essential.


title: Transgastric jejunal snare technique facilitates primary jejunostomy placement.

text: Placement of percutaneous jejunostomy tubes using fluoroscopy may be technically challenging because of the peristaltic motion of small bowel loops within the peritoneum. Furthermore, fluoroscopic jejunostomy placement has an inherent risk of complications, including peritonitis and death. A transnasal snare technique to facilitate direct jejunostomy in patients with a surgically altered gastric anatomy has been previously reported. This report describes a patient with gastroparesis and a chronic nasojejunal tube who underwent a percutaneous transgastric snare technique to facilitate the placement of a direct jejunostomy.


Climate vs coronavirus: Why massive stimulus plans could represent missed opportunities.


Influence of the life style parameters including dietary habit, chronic stress and environmental factors and jobs on the human health in relation to COVID-19 pandemic.


title: Henipavirus pathogenesis and antiviral approaches.

text: Hendra virus and Nipah virus are closely related, recently emerged zoonotic paramyxoviruses, belonging to the Henipavirus genus. Both viruses induce generalized vasculitis affecting particularly the respiratory tract and CNS. The exceptionally broad species tropism of Henipavirus, the high case fatality rate and person-to-person transmission associated with Nipah virus outbreaks emphasize the necessity of effective antiviral strategies for these intriguing threatening pathogens. Current therapeutic approaches, validated in animal models, target early steps in viral infection; they include the use of neutralizing virus-specific antibodies and blocking membrane fusion with peptides that bind the viral fusion protein. A better understanding of Henipavirus pathogenesis is critical for the further advancement of antiviral treatment, and we summarize here the recent progress in the field.


title: An inguinal hernia of a third kind?

text: Inguinal hernias are classified anatomically into indirect and direct types. We illustrate two cases of an inguinal hernia where the defect was demonstrated to lie between the deep ring and the inferior epigastric vessels, therefore, not fitting the standard criteria for either direct or indirect inguinal hernias. Taking this into account, we propose that the hernia which we describe should either be considered as a completely new type of inguinal hernia or, alternatively, all of the currently accepted classifications should be changed or adapted to incorporate it.


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title: Radiation dose from volumetric helical perfusion CT of the thorax, abdomen or pelvis.

text: PURPOSE To evaluate the radiation doses delivered during volumetric helical perfusion CT of the thorax, abdomen or pelvis. MATERIALS AND METHODS The dose-length product (DLP) and CT dose index (CTDIvol) were recorded and effective dose (E) determined for patients undergoing CT (4D adaptive spiral) for tumour evaluation. Image noise and contrast to noise (CNR) at peak enhancement were also assessed for quality. RESULTS Forty two consecutive examinations were included: thorax (16), abdomen (10), pelvis (16). Z-axis coverage ranged from 11.4 to 15.7 cm. Mean DLP was 1288.8 mGy.cm (range: 648 to 2456 mGy.cm). Mean CTDIvol was 96.2 mGy (range: 32.3 to 169.4 mGy). Mean effective dose was 19.6 mSv (range: 12.3 mSv to 36.7 mSv). In comparison mean DLP and effective dose was 885.2 mGy.cm (range: 504 to 1633 mGy.cm) and 13.3 mSV (range: 7.8 to 24.5 mSv) respectively for the standard staging CT thorax, abdomen and pelvis. Mean tumour CNR at peak enhancement was 1.87. CONCLUSION The radiation dose imposed by perfusion CT was on average 1.5 times that of a CT thorax, abdomen and pelvis. The dose is not insubstantial, and must be balanced by the potential clinical utility of additional physiologic data. Further efforts towards dose reduction should be encouraged.


Developing an early warning system for bovine respiratory disease.