title: Long-term outcomes of patients with necrotizing fasciitis.

text: CONTEXT Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. OBJECTIVE To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. DESIGN Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. SETTINGS A university-based Burn and Trauma Center. PATIENTS A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. INTERVENTION None. MAIN OUTCOME MEASURES Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last driver's license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalen's additive hazard model. RESULTS Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1-86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0-15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25-13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. CONCLUSIONS Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.


title: Outcomes After Hip Fracture Surgery Compared With Elective Total Hip Replacement.

text: IMPORTANCE Patients undergoing surgery for a hip fracture have a higher risk of mortality and major complications compared with patients undergoing an elective total hip replacement (THR) operation. The effect of older age and comorbidities associated with hip fracture on this increased perioperative risk is unknown. OBJECTIVE To determine if there was a difference in hospital mortality among patients who underwent hip fracture surgery relative to an elective THR, after adjustment for age, sex, and preoperative comorbidities. DESIGN, SETTING, AND PARTICIPANTS Using the French National Hospital Discharge Database from January 2010 to December 2013, patients older than 45 years undergoing hip surgery at French hospitals were included. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), codes were used to determine patients' comorbidities and complications after surgery. A population matched for age, sex, and preoperative comorbidities of patients who underwent elective THR or hip fracture surgery was created using a multivariable logistic model and a greedy matching algorithm with a 1:1 ratio. EXPOSURE Hip fracture. MAIN OUTCOMES AND MEASURES Postoperative in-hospital mortality. RESULTS A total of 690,995 eligible patients were included from 864 centers in France. Patients undergoing elective THR surgery (n = 371,191) were younger, more commonly men, and had less comorbidity compared with patients undergoing hip fracture surgery. Following hip fracture surgery (n = 319,804), 10,931 patients (3.42%) died before hospital discharge and 669 patients (0.18%) died after elective THR. Multivariable analysis of the matched populations (n = 234,314) demonstrated a higher risk of mortality (1.82% for hip fracture surgery vs 0.31% for elective THR; absolute risk increase, 1.51% [95% CI, 1.46%-1.55%]; relative risk [RR], 5.88 [95% CI, 5.26-6.58]; P < .001) and of major postoperative complications (5.88% for hip fracture surgery vs 2.34% for elective THR; absolute risk increase, 3.54% [95% CI, 3.50%-3.59%]; RR, 2.50 [95% CI, 2.40-2.62]; P < .001) among patients undergoing hip fracture surgery. CONCLUSIONS AND RELEVANCE In a large cohort of French patients, hip fracture surgery compared with elective THR was associated with a higher risk of in-hospital mortality after adjustment for age, sex, and measured comorbidities. Further studies are needed to define the causes for these differences.


title: Protective distal side-to-side neurorrhaphy in proximal nerve injury-an experimental study with rats.

text: BACKGROUND Side-to-side neurorrhaphy may protect the denervated end organ and preserve the initial connection with proximal stump. We examined the effect of protective side-to-side anastomosis on nerve and end organ regeneration in proximal nerve injury model. METHODS The left common peroneal nerve of 24 Sprague Dawley rats was proximally transected. In groups B and C, side-to-side neurorrhaphy was performed distally between the peroneal and tibial nerves without (group B) and with (group C) partial donor nerve axotomy inside the epineural window. Group A served as an unprotected control. After 26 weeks, the proximal transection was repaired with end-to-end neurorrhaphy on all animals. Regeneration was followed during 12 weeks with the walk track analysis. Morphometric studies and wet muscle mass calculations were conducted at the end of the follow-up period. RESULTS The results of the walk track analysis were significantly better in groups B and C compared to group A. Groups B and C showed significantly higher wet mass ratios of the tibialis anterior and extensor digitorum longus muscle compared to group A. Group C showed significantly higher morphometric values compared to group A. Group B reached higher values of the fibre count, fibre density, and percentage of the fibre area compared to group A. CONCLUSIONS Protective distal side-to-side neurorrhaphy reduced muscle atrophy and had an improving effect on the morphometric studies and walk track analysis. Distal side-to-side neurorrhaphy does not prevent the regenerating axons to grow from the proximal stump to achieve distal nerve stump.


title: Gastrointestinal quality of life after laparoscopic-assisted sigmoidectomy for diverticular disease.

text: PURPOSE Laparoscopic-assisted sigmoidectomy is a widely applied technique in the operative treatment of diverticular disease. Treatment guidelines recommend operation of complicated diverticulitis and after recurrent attacks of uncomplicated diverticulitis. These guidelines have become subject to controversy. The objective of this study was to assess disease-related quality of life after laparoscopic sigmoidectomy. METHODS Data were collected retrospectively. Patients filled in a form describing their quality of life. All patients undergoing elective operation for diverticular disease between 1999 and 2006 at the Department of Surgery of the Uster Hospital, a regional medical center in Switzerland were included. The measurement tool we used is the Gastrointestinal Quality of Life Index (GIQLI). Wilcoxon-Mann-Whitney test or unpaired t-tests were applied to determine statistical significance of differences observed. RESULTS A total of 130 patients were included and 120 questionnaires were available for analysis. Mean follow-up was 40 months. Of the total, 48% reported a GIQLI >100 before the operation, which rose to 83% after the operation (p < 0.0001). Mean GIQLI was 95 before and 114 after the operation (p < 0.0001). Female patients reported lower GIQLI rates. Overall, 96% were satisfied with the operation. CONCLUSIONS The results in this study population show that in a majority of patients who underwent elective laparoscopic-assisted sigmoidectomy for recurrent diverticulitis gastrointestinal quality of life improved with the operation.


title: Effectiveness of person- and family-centered care transition interventions: a systematic review protocol.

text: BACKGROUND Care transitions from the hospital to home are critical to the sustainability of our health care system. Ineffective care transitions can be caused by high incidences of post-discharge adverse events, by poor communication with patients, and/or by inadequate information transfer between providers from the hospital to home. Any one of these can lead to fragmented care, high readmission rates, increased visits to the emergency department, and ultimately poor patient outcomes. Despite the ongoing improvement efforts of health care organizations, the efficacy of person- and family-centered care transition interventions on the quality of care and on the patient experience are not known. The aim of this systematic review is to critically analyze the body of evidence regarding the effectiveness of person- and family-centered care transition interventions on the quality of care, and the experience of patients. METHODS We will conduct a systematic review using the Cochrane Handbook's guidelines and will adhere to a standardized reporting format: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search strategy will be conducted in the following databases: MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and the Cochrane Consumers and Communication Group. Following a two-step screening process, data including the full reference, objectives, target population, description of the intervention and control intervention, outcome measures, design, length of post-intervention follow-up period, and the study results will be extracted, synthesized, and reported. Risk of bias and quality of the studies will also be assessed. DISCUSSION This systematic review will summarize and present the evidence base for person- and family-centered care transition interventions. This review will also inform further research and will lay the groundwork for more empirical studies on person- and family-centered care transitions. Specifically, the results of this systematic review may inform the development of measures to monitor safe and effective person- and family-centered transitions from the hospital to home. These results may also be important for policy makers, decision-makers, clinicians, and patients/families who are involved in navigating the health care system. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017067990.


title: Two-photon imaging of remyelination of spinal cord axons by engrafted neural precursor cells in a viral model of multiple sclerosis.

text: Neural precursor cells (NPCs) offer a promising approach for treating demyelinating diseases. However, the cellular dynamics that underlie transplanted NPC-mediated remyelination have not been described. Using two-photon imaging of a newly developed ventral spinal cord preparation and a viral model of demyelination, we describe the motility and intercellular interactions of transplanted mouse NPCs expressing green fluorescent protein (GFP) with damaged axons expressing yellow fluorescent protein (YFP). Our findings reveal focal axonal degeneration that occurs in the ventral side of the spinal cord within 1 wk following intracranial instillation with the neurotropic JHM strain of mouse hepatitis virus (JHMV). Axonal damage precedes extensive demyelination and is characterized by swelling along the length of the axon, loss of YFP signal, and transected appearance. NPCs engrafted into spinal cords of JHMV-infected mice exhibited diminished migration velocities and increased proliferation compared with transplanted cells in noninfected mice. NPCs preferentially accumulated within areas of axonal damage, initiated direct contact with axons, and subsequently expressed the myelin proteolipid protein gene, initiating remyelination. These findings indicate that NPCs transplanted into an inflammatory demyelinating microenvironment participate directly in therapeutic outcome through the wrapping of myelin around damaged neurons.


title: An introduction and overview of machine learning in neurosurgical care.

text: BACKGROUND Machine learning (ML) is a branch of artificial intelligence that allows computers to learn from large complex datasets without being explicitly programmed. Although ML is already widely manifest in our daily lives in various forms, the considerable potential of ML has yet to find its way into mainstream medical research and day-to-day clinical care. The complex diagnostic and therapeutic modalities used in neurosurgery provide a vast amount of data that is ideally suited for ML models. This systematic review explores ML's potential to assist and improve neurosurgical care. METHOD A systematic literature search was performed in the PubMed and Embase databases to identify all potentially relevant studies up to January 1, 2017. All studies were included that evaluated ML models assisting neurosurgical treatment. RESULTS Of the 6,402 citations identified, 221 studies were selected after subsequent title/abstract and full-text screening. In these studies, ML was used to assist surgical treatment of patients with epilepsy, brain tumors, spinal lesions, neurovascular pathology, Parkinson's disease, traumatic brain injury, and hydrocephalus. Across multiple paradigms, ML was found to be a valuable tool for presurgical planning, intraoperative guidance, neurophysiological monitoring, and neurosurgical outcome prediction. CONCLUSIONS ML has started to find applications aimed at improving neurosurgical care by increasing the efficiency and precision of perioperative decision-making. A thorough validation of specific ML models is essential before implementation in clinical neurosurgical care. To bridge the gap between research and clinical care, practical and ethical issues should be considered parallel to the development of these techniques.


title: Use of the Pipeline embolization device for recurrent and residual cerebral aneurysms: a safety and efficacy analysis with short-term follow-up.

text: OBJECTIVE Evaluation of the safety and efficacy of the Pipeline embolization device (PED) when used as second-line treatment for recurrent or residual, pretreated ruptured and unruptured intracranial aneurysms (IAs). METHODS Retrospective review of our database to include all patients who were treated with a PED for recurrent or residual IAs following surgical clipping or coiling. We evaluated neurological outcome and angiograms at discharge, 6- and 12-months' follow-up and assessed intimal hyperplasia at follow-up. RESULTS Twenty-four patients met our inclusion criteria. Most IAs were located in the anterior circulation (n=21). No change of preprocedure modified Rankin Scale score was seen at discharge or at any scheduled follow-up. Complete or near-complete aneurysm occlusion on 6- and 12-month angiograms was seen in 94.4% (17/18 cases) and 93.3% (14/15 cases), respectively. Complete or near-complete occlusion was seen in 100% of previously ruptured and 85.7% (6/7 cases) and 83.3% (5/6 cases) of previously unruptured cases at the 6- and 12-months' follow-up, respectively. One case of moderate intimal hyperplasia was observed at 6 months and decreased to mild at the 12-months' follow-up. No difference in device performance was observed among pretreated unruptured or ruptured IAs. CONCLUSIONS Treatment of recurrent or residual IAs with a PED after previous coiling or clipping is feasible and safe. There is no difference in device performance between ruptured or unruptured IAs.


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title: Laparoscopic lateral pancreaticojejunostomy and laparoscopic Berne modification of Beger procedure for the treatment of chronic pancreatitis: the first UK experience.

text: BACKGROUND Pancreatic resection and/or ductal drainage are common surgical options in the management of unremitting abdominal pain of chronic pancreatitis (CP). We describe the results of the largest UK series of laparoscopic approach to pancreatic duct drainage and head resection for CP. METHODS Patients with CP and intractable abdominal pain requiring duodenum-preserving pancreatic head resection (Berne modification of Beger procedure) or Puestow procedure were offered laparoscopic surgery by a single surgeon. The results shown represent median (range). RESULTS Six patients (3 males) with CP (alcohol induced, n=4; idiopathic, n=2) underwent surgery between 2009 and 2012. The pancreatic duct diameter was 8.75 (6 to 11) mm. Five patients have had lateral pancreaticojejunostomy and 1 patient underwent Berne modification of Beger procedure, all of which were completed laparoscopically. The operating time was 277.5 (250 to 360) minutes. There were no deaths and 1 patient was readmitted 10 days postoperatively and had laparotomy for pancreatic bleeding after pancreaticojejunostomy (morbidity, 17%). The hospital stay was 5 (5 to 8) days. At a follow-up of 14.2 (10 to 35) months, 4 of the patients were pain free, whereas 2 patients required one third and half of the preoperative oral opioid dose for pain control. CONCLUSIONS The laparoscopic approach to pancreatic duct drainage and duodenum-preserving head resection in carefully selected patients and in experienced hands is feasible and safe with good short-term results and potential advantages. Further expansion of experience and longer follow-up is required.


title: Single-port laparoscopic left adrenalectomy (SILS): 3 years' experience of a single institution.

text: BACKGROUND Laparoscopic adrenalectomy by 3 or 4 trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. METHODS Between April 2010 and January 2013, all consecutive patients with adrenal masses who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5 cm subcostal incision was the sole point of entry. Data of patients undergoing SILS adrenalectomy were compared with those from an uncontrolled group of patients undergoing conventional laparoscopic adrenalectomy during the same study period. RESULTS There were 40 patients in each study group. SILS was successfully performed and none of the patients required conversion to an open procedure. In 1 case of SILS procedure, an additional lateral 5 mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 80 (20) minutes in the SILS group and 75 (8) minutes in the conventional laparoscopic adrenalectomy group (P=0.150). No intraoperative or postoperative complications occurred. Differences between the 2 study groups in postoperative pain, number of patients resuming oral intake within the first 24 hours, final pathologic diagnosis (Conn syndrome, Cushing adenomas, nonfunctioning adrenal tumors), and length of hospital stay were not observed. CONCLUSIONS SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients and seems to have results similar to a conventional approach in our initial comparison.


The semiotics of distal thrombectomy: towards a TICI score for the target vessel.


Bioprosthetics: changing the landscape for breast reconstruction?


title: Inhibition of the ubiquitin-proteasome system affects influenza A virus infection at a postfusion step.

text: We have demonstrated that influenza A virus (IAV) RNA synthesis depends on the ubiquitin-proteasome system. IAV replication was reduced both by proteasome inhibitors and in E36ts20 cells, which contain the thermolabile ubiquitin-activating enzyme E1. While virus entry was not affected in E36ts20 cells, the proteasome inhibitor MG132 retained viral particles in the cytoplasm. Addition-removal experiments of MG132 in combination with bafilomycin A1, a well-established inhibitor of IAV entry and fusion, showed that MG132 affected IAV infection at a postfusion step. This was confirmed by the lack of inhibition of IAV entry by proteasome inhibitors in a virus-like particle fusion assay.


title: Human bocavirus: passenger or pathogen in acute respiratory tract infections?

text: Human bocavirus (HBoV) is a newly identified virus tentatively assigned to the family Parvoviridae, subfamily Parvovirinae, genus Bocavirus. HBoV was first described in 2005 and has since been detected in respiratory tract secretions worldwide. Herein we review the literature on HBoV and discuss the biology and potential clinical impact of this virus. Most studies have been PCR based and performed on patients with acute respiratory symptoms, from whom HBoV was detected in 2 to 19% of the samples. HBoV-positive samples have been derived mainly from infants and young children. HBoV DNA has also been detected in the blood of patients with respiratory tract infection and in fecal samples of patients with diarrhea with or without concomitant respiratory symptoms. A characteristic feature of HBoV studies is the high frequency of coinciding detections, or codetections, with other viruses. Available data nevertheless indicate a statistical association between HBoV and acute respiratory tract disease. We present a model incorporating these somewhat contradictory findings and suggest that primary HBoV infection causes respiratory tract symptoms which can be followed by prolonged low-level virus shedding in the respiratory tract. Detection of the virus in this phase will be facilitated by other infections, either simply via increased sample cell count or via reactivation of HBoV, leading to an increased detection frequency of HBoV during other virus infections. We conclude that the majority of available HBoV studies are limited by the sole use of PCR diagnostics on respiratory tract secretions, addressing virus prevalence but not disease association. The ability to detect primary infection through the development of improved diagnostic methods will be of great importance for future studies seeking to assign a role for HBoV in causing respiratory illnesses.


title: What makes mental health and substance use services youth friendly? A scoping review of literature.

text: BACKGROUND There are increasing calls to make mental health and substance use services youth friendly, with hopes of improving service uptake, engagement and satisfaction. However, youth-friendliness in this area has not been clearly defined and there is a lack of information about the characteristics that make such services youth friendly. The purpose of this scoping review was to examine the literature available on youth-friendly mental health and substance use services in order to identify the characteristics, outline the expected impacts, and establish a definition. METHODS A scoping review of seven databases and grey literature sources was conducted. Twenty-eight documents were retained as relevant to the research questions. Relevant data from these documents was extracted, analyzed and presented to stakeholders, including youth, caregivers and service providers to validate and refine the results. RESULTS Youth-friendly mental health and substance use services include integrated, inclusive, confidential and safe organization and policy characteristics; bright, comfortable, environment with informational materials; welcoming and genuine service providers with appropriate communication and counselling skills; an accessible location; minimal wait times; and individualized and innovative approaches. All areas in which youth friendliness should be implemented in a mental health and substance use service organization had a core value of youth voice. CONCLUSION Improving the youth friendliness of mental health and substance use services includes incorporating youth voice in organization, policy, environment, service providers, and treatment services, and has implications for treatment uptake, engagement and satisfaction. Further research is required to determine the impact of youth friendliness in such services.


title: A Microbiological and Ultrastructural Comparison of Aseptic versus Sterile Acellular Dermal Matrix as a Reconstructive Material and a Scaffold for Stem Cell Ingrowth.

text: BACKGROUND Recent data suggest an increased risk for infection when acellular dermal matrix is used in breast reconstruction. This may be because some acellular dermal matrices are actually not terminally sterilized but are instead "aseptically processed." This study evaluates aseptic and sterile matrices for evidence of bacterial contamination and whether or not terminal sterilization affects matrix collagen architecture and stem cell ingrowth. METHODS Five separate samples of 14 different matrices were analyzed by fluorescent in situ hybridization using a bacterial DNA probe to detect bacterial DNA on the matrices. Separate samples were incubated for bacteria, acid-fast bacilli, and fungi for 2 to 6 weeks to detect living organisms. The impact of terminal sterilization on the collagen network and stem cell ingrowth on the matrices was then assessed. RESULTS Traces of bacterial DNA were encountered on all matrices, with more bacteria in the aseptic group compared with the sterile group (3.4 versus 1.6; p = 0.003). The number of positive cultures was the same between groups (3.8 percent). Electron microscopy demonstrated decreased collagen organization in the sterile group. Stem cell seeding on the matrices displayed a wide variation of cellular ingrowth between matrices, with no difference between aseptic and sterile groups (p = 0.2). CONCLUSIONS Although there was more evidence of prior bacterial contamination on aseptically processed matrices compared with sterile matrices; clinical cultures did not differ between groups. Terminal sterilization does not appear to affect stem cell ingrowth but may come at the cost of damaging the collagen network. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.


Pulmonary Embolism in Covid-19. Coagulation Parameters, Close Monitoring to Prevent?


title: Genetic variation and recombination in Aichi virus.

text: Aichi virus (AiV), a member of the genus Kobuvirus in the family Picornaviridae, causes gastroenteritis in humans. It was noted that AiV differs from other picornaviruses in its unusually high C content and a very high degree of genome-ordered RNA secondary structures. However, the genetic variability and mutational restrictions on a full-genome scale have not been studied. In addition to the available five complete AiV genomes, we determined here another five complete coding sequences of AiV sampled in Germany, 2004. Distinctive AiV genetic features included a low incidence of recombination along the genome without obvious hotspots or spared regions and very low rates of synonymous and non-synonymous variation, supporting an absence of AiV serotypes. In addition, the absence of recombination between AiV genotypes A and B suggested the existence of reproductive isolation between taxonomic units below the species level. In contrast to most other picornaviruses, AiV genomes strongly avoided the UpA dinucleotide, while there was no obvious selection against the CpG dinucleotide. AiV genomes also appeared to contain a codon usage bias (CUB) apparent as an effective number of codons of 39.5, which was amongst the most extreme among RNA viruses. A set of sequence scrambling algorithms was developed to determine the origin of CUB in AiV. While in most picornaviruses the genomic dinucleotide content contributed significantly to CUB, in AiV its extreme nucleotide content, i.e. 57 % third codon position C, was the main driving force behind the apparent CUB.


Endolymphatic Optical Coherence Tomography Facilitates Evaluation of the Thoracic Duct Prior to Embolization.


title: Comparison of cerebral tissue oxygenation values in full term and preterm newborns by the simultaneous use of two near-infrared spectroscopy devices: an absolute and a relative trending oximeter.

text: The aim of this study is to compare a two-wavelength light emitting diode-based tissue oximeter (INVOS), which is designed to show trends in tissue oxygenation, with a four-wavelength laser-based oximeter (FORE-SIGHT), designed to deliver absolute values of tissue oxygenation. Simultaneous values of cerebral tissue oxygenation (StO2) are measured using both devices in 15 term and 15 preterm clinically stable newborns on the first and third day of life. Values are recorded simultaneously in two periods between which oximeter sensor positions are switched to the contralateral side. Agreement between StO2 values before and after the change of sensor position is analyzed. We find that mean cerebral StO2 values are similar between devices for term and preterm babies, but INVOS shows StO2 values spread over a wider range, with wider standard deviations than shown by the FORE-SIGHT. There is relatively good agreement with a bias up to 3.5% and limits of agreement up to 11.8%. Measurements from each side of the forehead show better repeatability for the FORE-SIGHT monitor. We conclude that performance of the two devices is probably acceptable for clinical purposes. Both performed sufficiently well, but the use of FORE-SIGHT may be associated with tighter range and better repeatability of data.


title: Membrane fission by protein crowding.

text: Membrane fission, which facilitates compartmentalization of biological processes into discrete, membrane-bound volumes, is essential for cellular life. Proteins with specific structural features including constricting rings, helical scaffolds, and hydrophobic membrane insertions are thought to be the primary drivers of fission. In contrast, here we report a mechanism of fission that is independent of protein structure-steric pressure among membrane-bound proteins. In particular, random collisions among crowded proteins generate substantial pressure, which if unbalanced on the opposite membrane surface can dramatically increase membrane curvature, leading to fission. Using the endocytic protein epsin1 N-terminal homology domain (ENTH), previously thought to drive fission by hydrophobic insertion, our results show that membrane coverage correlates equally with fission regardless of the hydrophobicity of insertions. Specifically, combining FRET-based measurements of membrane coverage with multiple, independent measurements of membrane vesiculation revealed that fission became spontaneous as steric pressure increased. Further, fission efficiency remained equally potent when helices were replaced by synthetic membrane-binding motifs. These data challenge the view that hydrophobic insertions drive membrane fission, suggesting instead that the role of insertions is to anchor proteins strongly to membrane surfaces, amplifying steric pressure. In line with these conclusions, even green fluorescent protein (GFP) was able to drive fission efficiently when bound to the membrane at high coverage. Our conclusions are further strengthened by the finding that intrinsically disordered proteins, which have large hydrodynamic radii yet lack a defined structure, drove fission with substantially greater potency than smaller, structured proteins.


title: Effects of human anti-spike protein receptor binding domain antibodies on severe acute respiratory syndrome coronavirus neutralization escape and fitness.

text: UNLABELLED The receptor binding domain (RBD) of the spike (S) glycoprotein of severe acute respiratory syndrome coronavirus (SARS-CoV) is a major target of protective immunity in vivo. Although a large number of neutralizing antibodies (nAbs) have been developed, it remains unclear if a single RBD-targeting nAb or two in combination can prevent neutralization escape and, if not, attenuate viral virulence in vivo. In this study, we used a large panel of human nAbs against an epitope that overlaps the interface between the RBD and its receptor, angiotensin-converting enzyme 2 (ACE2), to assess their cross-neutralization activities against a panel of human and zoonotic SARS-CoVs and neutralization escape mutants. We also investigated the neutralization escape profiles of these nAbs and evaluated their effects on receptor binding and virus fitness in vitro and in mice. We found that some nAbs had great potency and breadth in neutralizing multiple viral strains, including neutralization escape viruses derived from other nAbs; however, no single nAb or combination of two blocked neutralization escape. Interestingly, in mice the neutralization escape mutant viruses showed either attenuation (Urbani background) or increased virulence (GD03 background) consistent with the different binding affinities between their RBDs and the mouse ACE2. We conclude that using either single nAbs or dual nAb combinations to target a SARS-CoV RBD epitope that shows plasticity may have limitations for preventing neutralization escape during in vivo immunotherapy. However, RBD-directed nAbs may be useful for providing broad neutralization and prevention of escape variants when combined with other nAbs that target a second conserved epitope with less plasticity and more structural constraint. IMPORTANCE The emergence of severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 has resulted in severe human respiratory disease with high death rates. Their zoonotic origins highlight the likelihood of reemergence or further evolution into novel human coronavirus pathogens. Broadly neutralizing antibodies (nAbs) that prevent infection of related viruses represent an important immunostrategy for combating coronavirus infections; however, for this strategy to succeed, it is essential to uncover nAb-mediated escape pathways and to pioneer strategies that prevent escape. Here, we used SARS-CoV as a research model and examined the escape pathways of broad nAbs that target the receptor binding domain (RBD) of the virus. We found that neither single nAbs nor two nAbs in combination blocked escape. Our results suggest that targeting conserved regions with less plasticity and more structural constraint rather than the SARS-CoV RBD-like region(s) should have broader utility for antibody-based immunotherapy.


title: Vaccination mitigates the impact of PRRSv infection on the pharmacokinetics of ceftiofur crystalline-free acid in pigs.

text: The pharmacokinetics of intramuscularly administered ceftiofur crystalline-free acid (CCFA) were determined in pigs that were clinically healthy (n = 8), vaccinated with a Porcine reproductive and respiratory syndrome modified live virus (PRRS MLV) (n = 10), challenged with wild-type porcine reproductive and respiratory syndrome virus (PRRSv) VR-2385 (n = 10), or vaccinated with PRRS MLV and later challenged with wild-type PRRSv VR-2385 (n = 10). Animals were given a single dose of CCFA intramuscularly at 5 mg/kg body weight. Blood was collected at 0 (pretreatment), 0.25, 0.5, 1, 6, 12, 24, 48, 96, 144, 192, and 240 h postinjection. Plasma was analyzed using liquid chromatography-mass spectrometry. Plasma concentration-time curves for each group were evaluated with noncompartmental modeling. When compared to control animals, those receiving the PRRSv wild-type challenge only had a lower AUC0-last , higher Cl/F, and higher Vz/F. The PRRSv wild-type challenge only group had the longest T1/2λ . The Cmax did not differ among all four treatments. Control animals had no statistically significant differences from animals vaccinated with PRRS MLV alone or animals vaccinated with PRRS MLV and later challenged with wild-type PRRSv. Our results suggest that PRRSv wild-type infection has the potential to alter CCFA pharmacokinetics and PRRS MLV vaccination may attenuate those changes.


What will we learn from covid-19? That we live in an uncertain world.


Mental health delivery and neurogenetics discovery in Africa.


title: The role of embolic protection in peripheral arterial atherectomy.

text: Embolic protection devices were initially developed for use in the treatment of saphenous vein aortocoronary bypass graft stenosis as well as in carotid artery stenting because of the significant risk of atheroembolism and their use is well accepted. The use of these devices for lower-extremity arterial interventions is becoming well accepted because of the significant consequences of embolization in patients with limited circulatory runoff. This is especially true in the use of mechanical atherectomy devices for femoropopliteal arterial lesions.


title: Simplified versus standard regimen for focal radiofrequency ablation of dysplastic Barrett's oesophagus: a multicentre randomised controlled trial.

text: BACKGROUND For focal radiofrequency ablation of Barrett's oesophagus, a simplified regimen (3 × 15 J/cm2, without cleaning) has proven to be as effective as the standard regimen (2 × 15 J/cm2, followed by cleaning, followed by 2 × 15 J/cm2). However, this simplified regimen seemed to be associated with a higher stenosis rate. Therefore, we lowered the radiofrequency energy and hypothesised that this new simplified regimen would be as effective and safe as the standard regimen. METHODS This randomised non-inferiority trial included patients with dysplastic Barrett's oesophagus or residual Barrett's oesophagus after endoscopic resection or circumferential radiofrequency ablation, in five European tertiary referral centres. Patients were randomly assigned (1:1) to the new simplified regimen (3 × 12 J/cm2, without cleaning) or the standard regimen, with variable block sizes of four, six, and eight patients, stratified by participating hospital. Focal radiofrequency ablation was done every 3 months, up to a maximum of three treatments, until all Barrett's oesophagus was eradicated. The primary outcome was complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments, assessed in the intention-to-treat population. Non-inferiority was assessed on the basis of the difference between groups in the median percentage of Barrett's oesophagus surface regression, with a non-inferiority margin of -15%. This study is registered with www.trialregister.nl, number NTR4994, and is completed. FINDINGS Between March 25, 2015, and July 25, 2016, 84 patients were randomly assigned to treatment: 44 to receive the simplified regimen and 40 to receive the standard regimen. One patient assigned to the simplified regimen and four assigned to the standard regimen were excluded because they weree found not to be eligible; therefore the final intention-to-treat population consisted of 43 patients in the simplified ablation group and 36 in the standard ablation group. Complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments was achieved in 32 (74%, 95% CI 59-87) patients treated with the simplified protocol, versus 30 (83%, 95% CI 67-94) patients treated with the standard protocol (p=0·34). Median Barrett's oesophagus surface regression after two focal radiofrequency ablation sessions was 98% (IQR 95-100) in the simplified regimen group and 100% (97-100) in the standard regimen group. The difference between medians was 2% (95% CI -0·562 to 3·162); thus the simplified regimen was deemed non-inferior to the standard regimen. Stenoses requiring dilatation were observed in four (9%) of 43 patients in the simplified regimen group and four (11%) of 36 in the standard regimen group. Post-procedural bleeding requiring repeat endoscopy occurred in one (2%) patient in the simplified ablation group and three (8%) patients in the standard ablation group. One patient (2%) in the simplified treatment group died 36 days after the second radiofrequency ablation procedure, due to an unknown cause. INTERPRETATION Based on the results of this study, we conclude that the simplified regimen is the preferred regimen for focal radiofrequency ablation of Barrett's oesophagus. FUNDING None.


title: Development of SPR biosensor for simultaneous detection of multiplex respiratory viruses.

text: A surface plasmon resonance (SPR)-based biosensor was developed for specific detection of nine common respiratory virus, including influenza A and influenza B, H1N1, respiratory syncytial virus (RSV), parainfluenza virus 1-3 (PIV1, 2, 3), adenovirus, and severe acute respiratory syndrome coronavirus (SARS). The SPR biosensor was developed by immobilizing nine respiratory virus-specific oligonucleotides in an SPR chip. To increase the biosensor sensitivity, biotin was used to label the PCR primer and further amplify the signal by introducing streptavidin after hybridization. Throat swab specimens representing nine common respiratory viruses were tested by the innovative SPR-based biosensor to evaluate the sensitivity, specificity and reproducibility of this method. Results suggest that this biosensor has the potential to simultaneously identify common respiratory viruses.


title: Genomic Profiling of Stage II Colorectal Cancer Identifies Candidate Genes Associated with Recurrence-Free Survival, Tumor Location, and Differentiation Grade.

text: BACKGROUND Identification of high-risk stage II colorectal cancer (CRC) patients, potential candidates for adjuvant chemotherapy, is challenging. Current clinical guidelines rely mainly on histopathological markers with relatively weak prognostic value. This motivates further search for prognostic markers. METHODS This explorative study aimed to identify potential candidate gene mutations to facilitate differentiation between subgroups of patients with CRC stage II. Panel-based massive parallel sequencing was used to genetically characterize tumor tissues from 85 patients radically operated for CRC stage II, of which 12 developed recurrent cancer during follow-up. Genetic data was compared between patients with or without cancer recurrence, between tumors located in colon and in rectum, and for association with tumor differentiation grade. RESULTS Genetic variation in ATM, C11ORF65 was associated with recurrence-free survival. Previous reports regarding the association between BRAF mutation and a higher age at diagnosis, and tumor location in colon were confirmed. APC, BRAF, or KRAS mutation was associated with tumor differentiation grade. Multiple correspondence analyses revealed no obvious clustering of patients with the studied clinical characteristics, indicating that the genetic signatures observed here were unique for each individual. CONCLUSIONS Taken together, we have demonstrated the utility of panel-based massive parallel sequencing to explore the pathogenesis of CRC stage II. We have identified promising candidate gene mutations associated with cancer recurrence, tumor location, and differentiation grade in patients with CRC stage II, which merit further investigation.


title: Single trocar skin puncture laparoscopic orchidopexy.

text: OBJECTIVE To assess the outcomes of a modified technique for pediatric laparoscopic orchidopexy performed without instrument trocars. METHODS A retrospective cohort study, for all laparoscopic orchidopexy performed without instrument trocars, was performed. Patient demographics, surgical technique, complications, and clinical outcomes were reviewed. All patients undergoing this procedure had a single trocar placed to insufflate and introduce the laparoscope. Skin punctures were used without trocars to introduce 3-mm instrumentation for laparoscopic orchidopexy. Initial follow-up visits were performed 2 to 4 weeks after surgery. Subsequent follow-up visits were performed at 6 to 12 months after surgery to reassess position and size of the testes. RESULTS A total of 22 patients with 27 undescended testes (20 right, 7 left) were identified. Median age was 1.3 years old (range, 5 months-7 years). Median operative time was 61 minutes (range, 42-81 minutes) for primary unilateral procedures (18 patients). Median operative time was 84 minutes (range, 75-90 minutes) for bilateral procedures (3 patients). All procedures were performed without additional trocars. There were no intraoperative complications. Patients were followed for 1 year and discharged. No patients were lost in follow-up. Postoperatively, 26 of 27 (96%) laparoscopic orchidopexy were successful. One patient developed atrophy with subsequent orchiectomy 6 months after the initial procedure. CONCLUSION Using skin punctures without trocars for laparoscopic orchidopexy is a safe and effective modification of standard laparoscopic orchidopexy. Further studies are warranted to compare the morbidity, ergonomics, cosmesis, costs, and reproducibility of outcomes for various options of pediatric minimally invasive surgery for intra-abdominal testes.


title: Meta-analysis of diagnostic performance of serological tests for SARS-CoV-2 antibodies up to 25 April 2020 and public health implications.

text: We reviewed the diagnostic accuracy of SARS-CoV-2 serological tests. Random-effects models yielded a summary sensitivity of 82% for IgM, and 85% for IgG and total antibodies. For specificity, the pooled estimate were 98% for IgM and 99% for IgG and total antibodies. In populations with ≤ 5% of seroconverted individuals, unless the assays have perfect (i.e. 100%) specificity, the positive predictive value would be ≤ 88%. Serological tests should be used for prevalence surveys only in hard-hit areas.


title: Natural brominated phenoxyphenols kill persistent and biofilm-incorporated cells of MRSA and other pathogenic bacteria.

text: Due to a high unresponsiveness to chemotherapy, biofilm formation is an important medical problem that frequently occurs during infection with many bacterial pathogens. In this study, the marine sponge-derived natural compounds 4,6-dibromo-2-(2',4'-dibromophenoxy)phenol and 3,4,6-tribromo-2-(2',4'-dibromophenoxy)phenol were found to exhibit broad antibacterial activity against medically relevant gram-positive and gram-negative pathogens. The compounds were not only bactericidal against both replicating and stationary phase-persistent planktonic cells of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa; they also killed biofilm-incorporated cells of both species while not affecting biofilm structural integrity. Moreover, these compounds were active against carbapenemase-producing Enterobacter sp. This simultaneous activity of compounds against different growth forms of both gram-positive and gram-negative bacteria is rare. Genome sequencing of spontaneous resistant mutants and proteome analysis suggest that resistance is mediated by downregulation of the bacterial EIIBC phosphotransferase components scrA and mtlA in MRSA likely leading to a lower uptake of the molecules. Due to their only moderate cytotoxicity against human cell lines, phenoxyphenols provide an interesting new scaffold for development of antimicrobial agents with activity against planktonic cells, persisters and biofilm-incoporated cells of ESKAPE pathogens. KEY POINTS: • Brominated phenoxyphenols kill actively replicating and biofilm-incorporated bacteria. • Phosphotransferase systems mediate uptake of brominated phenoxyphenols. • Downregulation of phosphotransferase systems mediate resistance.


Flow-mediated dilation, nitroglycerin-mediated dilation and their ratio predict successful renal denervation in mild resistant hypertension.


title: Staples equal sutures for skin closure after soft tissue tumor resection.

text: BACKGROUND Wound closure accounts for a relatively constant portion of the time required to complete a surgical case. Both longer closure times and wound infections contribute to higher medical costs and patient morbidity. QUESTIONS/PURPOSES We therefore determined whether (1) biologic and treatment factors greater influenced wound healing than the choice of sutures or staples; and (2) different times to closure affected cost when sutures or staples are used in patients with musculoskeletal tumors. METHODS We retrospectively reviewed 511 patients who had sarcoma resections of the buttock, thigh, and femur from 2003 to 2010; 376 had closure with sutures and 135 with staples. Data were abstracted on patient demographics, comorbidities, select procedural data, and wound complications. Wound complications were defined by hospitalization within 6 months postoperatively for a wound problem, irrigation and débridement, or infection treated with antibiotics. We determined the association between staples versus sutures and wound complications after controlling for confounding factors. The minimum followup was 2 weeks. A prospective, timed analysis of wounds closed with either sutures or staples was also performed. RESULTS We found an association between obesity and radiation and wound complications. Wounds were closed an average of 5.3 minutes faster with staples than with suture (0.29 minutes versus 5.6 minutes, respectively), saving a mean 2.1% of the total operating time although the total operating time was similar in the two groups. CONCLUSIONS We found no difference in wound complications after closure with sutures or staples, although obesity and radiation treatment appear to affect wound outcomes. Data suggest that time saved in the operating room by closing with staples compensates for added material costs and does not compromise wound care in patients with lower extremity sarcomas. LEVEL OF EVIDENCE Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.


title: Seven-point Checklist: Have You Prepared Sufficiently for the COVID-19 Crisis in Your Neurosurgery Department?

text: Coronavirus disease 2019 (COVID-19) is a novel infectious disease caused by severe acute respiratory syndrome coronavirus 2. COVID-19 was initially detected in Wuhan, China, in late 2019, and has now rapidly spread worldwide. Departments of Neurosurgery are required to employ an acute response against this pandemic. In this article, we discuss the important factors that neurosurgeons need to consider when managing their departments during the COVID-19 pandemic. We have summarized perspectives of the articles published on COVID-19, as well as the suggestions from neurosurgical societies in highly infected regions. We have proposed a seven-point checklist for neurosurgery departments: (1) networking among medical institutions; (2) coordinating teams within each institution; (3) prevention of infection within the department; (4) perioperative management; (5) triage; (6) changing subspecialty management protocols; and (7) psychological support for medical staff and patients.


title: Time of day and short-duration high-intensity exercise influences on coagulation and fibrinolysis.

text: Exercise has been demonstrated to have considerable effects upon haemostasis, with activation dependent upon the duration and intensity of the exercise bout. In addition, markers of coagulation and fibrinolysis have been shown to possess circadian rhythms, peaking within the morning (0600-1200 h). Therefore, the time of day in which exercise is performed may influence the activation of the coagulation and fibrinolytic systems. This study aimed to examine coagulation and fibrinolytic responses to short-duration high-intensity exercise when completed at different times of the day. Fifteen male cyclists (VO2max: 60.3 ± 8.1 ml kg-1 min-1) completed a 4-km cycling time trial (TT) on five separate occasions at 0830, 1130, 1430, 1730 and 2030. Venous blood samples were obtained pre- and immediately post-exercise, and analysed for tissue factor (TF), tissue factor pathway inhibitor (TFPI), thrombin-anti-thrombin complexes (TAT) and D-Dimer. Exercise significantly increased plasma concentrations of TF (p < .0005), TFPI (p < .0006), TAT complexes (p < .0012) and D-Dimer (p < .0003). There was a time-of-day effect in pre-exercise TF (p = .004) and TFPI (p = .031), with 0830 greater than 1730 (p .001), while 1730 was less than 2030 h (p = .008), respectively. There was no significant effect of time of day for TAT (p = .364) and D-Dimer (p = .228). Power output, TT time and heart rate were not significantly different between TTs (p > .05); however, percentage VO2max was greater at 1730 when compared to 2030 (p = .04). Due to a time-of-day effect present within TF, peaking at 0830, caution should be applied when prescribing short-duration high-intensity exercise bout within the morning in populations predisposed to hypercoagulability.


title: Simultaneous bilateral single-port radical nephrectomies.

text: The management of bilateral enhancing renal masses can be technically challenging. Simultaneous bilateral laparoscopic nephrectomies in postrenal transplant patients have been previously described, but these typically require multiple port placements in addition to a hand port. Herein, we describe simultaneous bilateral single-port laparoscopic radical nephrectomies in a postrenal transplant patient.


title: Diagnostic tests for influenza infection.

text: PURPOSE OF REVIEW The 2009 H1N1 pandemic focused attention on the speed and accuracy of influenza diagnostic methods. This review provides an update on current tests and new developments. RECENT FINDINGS Widely used rapid antigen tests and immunofluorescence tests were generally less sensitive for 2009 H1N1 influenza than for seasonal influenza. In addition, marked variability was reported for the same tests in different settings and patient groups. The advantages of molecular testing gained wide recognition, namely high sensitivity, speed compared with culture, ability to assess viral load and to identify subtype. Although adoption of influenza molecular testing can be expected to accelerate, immunoassays and rapid cultures performed on site retain advantages for many facilities. Falsely negative results were seen with all methods, especially for samples collected very early or late. SUMMARY Influenza diagnostic test performance can be adversely affected by viral genetic and antigenic changes and should be re-assessed annually. Variability in sensitivity and specificity of the same test in different settings highlights the need for each laboratory to ensure optimal procedures and work with clinicians to improve sample quality. Manufacturers have been motivated to improve immunoassays and develop simpler and faster multiplex molecular tests, hopefully in advance of the next pandemic.


title: Pre-gestational diabetes during the COVID-19 pandemic in Bergamo, Italy.

text: The COVID-19 pandemic has caused the proliferation of a highly contagious and frequently fatal pneumonia around the world.[1] COVID-19 has severely affected Italy, and at the onset of this crisis, Bergamo, a city in northern Italy, regularly reported the highest number of cases in the country for many weeks. During outbreaks of infectious disease, pregnant women represent a high-risk population due to their increased susceptibility to infections, particularly when comorbidities such as pre-gestational diabetes (present in 0.5% of pregnant populations) are present.[2,3] Few data are available on pregnant women with pre-gestational diabetes during the COVID-19 pandemic.


title: Bariatric surgery vs. advanced practice medical management in the treatment of type 2 diabetes mellitus: rationale and design of the Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently trial (STAMPEDE).

text: Obesity and Type 2 diabetes mellitus (T2DM) are closely interrelated, and are two of the most common chronic, debilitating diseases worldwide. Surgical approaches to weight loss (bariatric surgery) result in marked improvement of T2DM, however randomized trials directly comparing the efficacy of surgical and medical approaches are lacking. The Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial was designed to evaluate the efficacy of two bariatric surgery procedures involving gastric restriction only (laparascopic sleeve gastrectomy) and gastric bypass (Roux-en-Y) to advanced medical therapy in patients with T2DM with modest obesity with BMI of 27-42 kg/m2. This single site, prospective, randomized controlled trial will enroll 150 subjects who will be followed. The primary end point will be the rate of biochemical resolution of T2DM at 1 year as measured by HbA1c < 6%. The safety and adverse event rates will also be compared between the three arms of the study.


title: Anaesthesia in medetomidine premedicated New Zealand White rabbits: a comparison between intravenous sufentanil-midazolam and isoflurane anaesthesia for orthopaedic surgery.

text: Eighteen female New Zealand White rabbits (3.9 ± 0.4 kg) were anaesthetized with sufentanil-midazolam by intravenous infusion (SUF-MID, n = 9) or isoflurane (ISO, n = 9) for bilateral creation of an osteochondral defect in the medial femur condyle. Subcutaneous premedication with 0.1 mg/kg medetomidine and anaesthesia induction by intravenous infusion of 1.1 µg/kg sufentanil and 0.2 mg/kg midazolam were identical in both groups. During surgery (60 min), the effects on respiratory and circulatory variables serum lactate, total protein and blood glucose were examined. Intermittent positive pressure ventilation (IPPV) was initiated if apnoea lasted>30 s or if end-tidal CO2 ≥8 kPa. The righting reflex was lost in 3 min. IPPV was necessary during most of the anaesthesia for most of the rabbits. Maintenance doses during surgery were 2.0 µg/kg/h sufentanil and 0.4 mg/kg/h midazolam, and 1.4% isoflurane, respectively. Mean arterial blood pressure (MAP) was higher in group SUF-MID than group ISO during surgery (63 ± 12 vs 50 ± 8 mmHg). In group ISO the heart rate was higher during surgery than before anaesthesia (197 ± 26 vs 158 ± 40 bpm) as was blood glucose (9 ± 2 vs 12 ± 3 mmol/L). Serum lactate levels remained unchanged whereas total protein decreased in both groups. Time to recover from anaesthesia did not differ between groups (20 min). Intravenous sufentanil-midazolam infusion provided surgical anaesthesia with a higher MAP than isoflurane anaesthesia. The protocol can be useful in situations in which gas anaesthesia cannot be used or in animals with limited cardiovascular reserves. However, IPPV is necessary.


ISV Congress back to Europe.


title: Is There an Advantage to Knotless Barbed Suture in TKA Wound Closure? A Randomized Trial in Simultaneous Bilateral TKAs.

text: BACKGROUND Effective wound closure is critical to minimizing wound complications and withstanding the forces associated with early knee motion after TKA. Barbed sutures allow for knotless fixation, have been used successfully in other specialties, and may provide for more even distribution of tension along the length of the incision; however, data regarding unidirectional barbed sutures from randomized trials have raised important concerns about their use. Bidirectional barbed sutures offer a potential alternative, but have not been studied extensively in orthopaedic surgery. QUESTIONS/PURPOSES Using a prospective, randomized, within-patient controlled study design I compared wound closure performed with bidirectional barbed sutures in one knee of bilateral TKAs performed under the same anesthetic with those performed with standard sutures in the other knee to determine whether the barbed suture was associated with (1) faster closure times; (2) fewer intraoperative suture issues, such as needle sticks or suture breakage, and fewer postoperative wound complications; (3) no detrimental effect on clinical outcomes, including knee ROM and Knee Society scores; and (4) lower total operative cost, considering suture material cost and operating room time savings. METHODS Between 2011 and 2012, 50 consecutive patients meeting prespecified inclusion criteria with simultaneous bilateral TKAs had deep and superficial closures performed using interrupted and running standard sutures in one randomly assigned knee, and running knotless bidirectional barbed sutures in the other knee. The barbed suture is US FDA-approved for soft tissue approximation wherever absorbable sutures are appropriate. Intraoperative suture issues and the number of sutures used were recorded at the time of wound closure. Suture cost was compared between the standard and barbed sutures and measured against the operative time cost, as estimated per minute saved. Patients were followed postoperatively at 2, 6, and 12 weeks, and 1 year. Outcomes assessed included detailed operative and tourniquet time, knee ROM, Knee Society scores, postoperative complications, use of antibiotics, and any subsequent surgical interventions. These outcomes were assessed at each visit except for Knee Society scores which were collected at the 12-week and 1-year evaluations. All patients completed followups up to the final evaluation at 1 year. RESULTS Mean wound closure time was 4.7 minutes less using barbed sutures (SD, ± 2.8; 95% CI, -5.5 to -3.7; p < 0.001), average 16.1 (SD, ± 2.2) versus 11.4 (SD, ± 2.2) minutes for the standard versus barbed suture types, respectively. Overall tourniquet time was not different at 78.7 minutes (SD, ± 11.1 minutes) versus 74.9 minutes (SD, ± 10.1 minutes), respectively (p > 0.1). There were no intraoperative clinical issues, such as provider or patient injury, using either suture. There were no needle disengagements or suture breakages with barbed-suture closure; five episodes of premature disengagement of the suture from the needle and three suture breakages were observed with standard closures (p < 0.005). There were no postoperative wound dehiscences or disruptions of the arthrotomy closure with either closure technique. Final ROM was not different with the numbers available (barbed-suture group mean, 126.7° ± 6.9° SD vs standard-suture group mean, 125.6° ± 7.0° SD; p = 0.4, 95% CI, -3.77 to 1.73) between patient groups at 1 year. There were no differences with the numbers available in 1-year Knee Society knee scores (barbed mean, 92.8 ± 6.69 SD vs standard mean, 93.3 ± 6.2 SD; p = 0.6, 95% CI, -1.97 to 3.36). Considering suture material cost against time savings in operating room time, there was a cost savings of mean USD 175 per case when using barbed suture. CONCLUSIONS In this randomized controlled trial, I found knotless bidirectional barbed suture to be more efficient in terms of closure time and lower in direct operative cost than conventional suture material, while showing no difference in terms of Knee Society knee scores, ROM, or wound appearance with the numbers available. Future studies with larger numbers will be needed to compare overall costs of care and to detect uncommon complications that might arise, although none were observed in this small series. LEVEL OF EVIDENCE Level I, therapeutic study.


title: Percutaneous ablation of hepatocellular carcinoma: current status.

text: Hepatocellular carcinoma (HCC) is an increasingly common disease with dismal long-term survival. Percutaneous ablation has gained popularity as a minimally invasive, potentially curative therapy for HCC in nonoperative candidates. The seminal technique of percutaneous ethanol injection has been largely supplanted by newer modalities, including radiofrequency ablation, microwave ablation, cryoablation, and high-intensity focused ultrasound ablation. A review of these modalities, including technical success, survival rates, and complications, will be presented, as well as considerations for treatment planning and follow-up.


title: Understanding the role that 'COVID toe' has in recognizing the potential extent of COVID-19 infections: a case study.

text: Dermatological manifestations have shown to be associated with COVID-19 infections. The numbers of papers have quadrupled within May 2020 alone. One particular cutaneous manifestation named pseudo chilblains (COVID toe), expressed mostly in otherwise asymptomatic younger patients, has had particular media attention. Public health bodies, on the other hand, have been slow to recognize it as a symptom. This article will be discussing two case studies to demonstrate the lack of public knowledge and of public health guidance associated with this symptom. We will further explore the use of COVID toe in the epidemiology of COVID-19 and its utility as a sign for total cases and contact tracing.


title: Improved Outcomes Utilizing a Valveless-Trocar System during Robot-assisted Radical Prostatectomy (RARP).

text: Introduction To evaluate the effect of valveless trocar system (VTS) on intra-operative parameters, peri-operative outcomes, and 30-day postoperative complications in patients undergoing robotic-assisted laparoscopic prostatectomy. Methods A total of 200 consecutive patients undergoing Robot-assisted radical prostatectomy by a single surgeon were prospectively evaluated using either the valveless trocar (n = 100) or standard trocars (n = 100). Patient demographics, intra-operative parameters, length of stay, presence or absence of postoperative nausea and vomiting, analog pain score at 0-6 hours, 6-12 hours, 12-18 hours, and >24 hours, and 30-day postoperative complications were analyzed. Results There were no significant differences in estimated blood loss, intra-operative urine output, length of stay, or 30-day complication rates between the two groups. While the VTS group had higher Body Mass Index (BMI) (28.45 vs. 27.23; P = 0.049), the operative time was significantly shorter in the VTS group (146 minutes vs. 167 minutes; P < .005). The VTS group experienced fewer episodes of nausea (2% vs. 10%; P = 0.0172). The VTS group had less pain intensity compared to the control in the first 18 hours: 0-6 hours (1.9 vs. 2.5; P = 0.034), 6-12 hours (2.8 vs. 3.6; P = 0.044), and 12-18 hours (2.2 vs. 3.1; P = 0.049), respectively. Conclusion The use of a valveless trocar system during robot-assisted robotic prostatectomy may shorten operative times, and reduce postoperative pain scores and nausea episodes without increasing the 30-day complication rate. Further prospective randomized trials should be performed to validate these findings.


title: Successful total shift from multiport to single-port laparoscopic surgery in low anterior resection of colorectal cancer.

text: OBJECTIVE To assess the possibility of using single-port low anterior resection (LAR) in place of conventional laparoscopic LAR. BACKGROUND Though single-port LS is gradually evolving, the application of single-port LS techniques in LAR have been viewed with skepticism due to technical difficulties. METHODS Data from patients who had undergone either conventional laparoscopic LAR (n = 49) or single-port LAR (n = 67) for colorectal cancers between March 2006 and March 2013 were analyzed retrospectively. RESULTS In single-port LAR group, oncologic outcomes were satisfactory with respect to attainment of lymph nodes (23.4 ± 15.3) and surgical margins (proximal cut margin: 7.1 ± 4.6 cm, distal cut margin: 7.7 ± 5.7 cm). Single-port LAR showed acceptable clinical outcomes manifested by comparable outcomes of post-operative analgesics requirement and length of hospital stay, and by low incidence of post-operative complications (conventional laparoscopic LAR group: 30.6% vs. single-port LAR group: 14.9%; P < 0.01). Operative time was comparable between groups (conventional laparoscopic LAR group: 309 ± 93 min vs. single-port LAR group: 277 ± 106 min; P = 0.097). Throughout a series of 67 consecutive single-port LARs, no conversion to multiport or open surgery was occurred. CONCLUSION This study shows that single-port LAR is both safe and feasible for use in resection of colorectal cancer when performed by surgeons who are trained in conventional laparoscopic technique. If further and more extensive studies support our results, then single-port LAR can be an acceptable alternative to conventional laparoscopic LAR for treatment of colorectal cancer.


Keep older healthcare workers off the covid-19 front line.


title: Laparoscopic vaginal vault closure with conventional straight instruments in single-port access total laparoscopic hysterectomy.

text: OBJECTIVE Laparoscopic vaginal vault closure with conventional straight instruments is the final barrier to single-port access total laparoscopic hysterectomy (SPA-TLH). The aim of this study is to find out the safer, easier, simpler, faster, and even cheaper way to overcome it. METHODS Vaginal vault suturing techniques of 152 consecutive single-port access total laparoscopic hysterectomy cases performed by the author in Gangnam CHA Hospital, CHA University from October 1, 2003 to June 30, 2012, were retrospectively analysed with medical records and DVDs. RESULTS Of 152 patients who were attempted SPA-TLH, 119 patients (78%) were finished their operations without conversion to multi-port laparoscopy or laparotomy. Of women with successful SPA-TLH, 8 cases (7%) were closed their vaginal vaults vaginally (median, 20 minutes; range, 15-44 minutes), and 111 cases (93%) laparoscopically (median, 44 minutes; range, 13-56 minutes). Laparoscopic vault closure techniques were continuous suture (4 cases, 3%; median, 36 minutes; range, 30-45 minutes), interrupted sutures using knot-pusher (7 cases, 6%; median, 52 minutes; range, 48-56 minutes) Endo Stitch suture (2 cases, 2%; median, 32 minutes; range, 13-50 minutes), continuous vault closure using percutaneous sling sutures (PCSS) (92 cases, 77%; median, 40 minutes; range, 19-56 minutes), and continuous vault closure without PCSS (6 cases, 5%; median, 23 minutes; range, 16-31 minutes). CONCLUSION Laparoscopic vault closure using PCSS in SPA-TLH only with conventional straight instruments is the best way to overcome the barrier and the short-cut to shorten the learning curve to date.


Monitoring for post-injection delirium/sedation syndrome with long-acting olanzapine during the COVID-19 pandemic.


title: Acute Myopericarditis with Pericardial Effusion and Cardiac Tamponade in a Patient with COVID-19.

text: BACKGROUND Coronavirus disease 2019 (COVID-19) is primarily a respiratory illness. However, with rising numbers of cases, multiple reports of cardiovascular manifestations have emerged. We present a case of COVID-19 infection complicated by myopericarditis and tamponade requiring drainage. CASE REPORT An 82-year-old woman with multiple comorbidities presented with five days of productive cough, fever with chills, and intermittent diarrhea. She tested positive for COVID-19. Index EKG revealed new diffuse T-wave inversions and a prolonged QT interval (>500 ms). Troponin was mildly elevated without any anginal symptoms. Hydroxychloroquine and azithromycin were not initiated due to concerns about QT prolongation. The echocardiogram revealed preserved left ventricular (LV) function, a small global pericardial effusion, and apical hypokinesis. Serial echocardiograms revealed an enlarging circumferential pericardial effusion with pacemaker wire reported as 'piercing' the right ventricular (RV) apex alongside early diastolic collapse of the right ventricle, suggesting echocardiographic tamponade. Chest CT revealed extension of the RV pacemaker lead into the pericardial fat. Interestingly, on comparison with a previous chest CT from 2019, similar lead positions were confirmed. Pericardiocentesis was performed with removal of 400 cc exudate. CONCLUSIONS Acute myopericarditis and pericardial effusion can occur in COVID-19 infection, even in the absence of severe pulmonary disease. This case highlights the importance of awareness of rare cardiac manifestations of COVID-19 in the form of acute myopericarditis and cardiac tamponade and their early diagnosis and management.


title: Oncological feasibility of laparoscopic subtotal gastrectomy compared with laparoscopic proximal or total gastrectomy for cT1N0M0 gastric cancer in the upper gastric body.

text: BACKGROUND The upper gastric body is of particular interest in relation to gastrectomy because this area includes a border; that is, both distal and proximal gastrectomy for early gastric cancer can involve this area. Laparoscopic subtotal gastrectomy (LsTG) is reported to be suitable procedure compared with laparoscopic proximal and total gastrectomy (LPG, LTG), regarding postoperative nutritional status and surgical safety. However, whether LsTG is an oncologically acceptable procedure for early gastric cancer in the upper gastric body is unclear. METHODS We analyzed 215 patients with cT1N0M0 gastric cancer limitedly located in the upper gastric body. The frequency of conversion from each intended procedure to an alternative procedure, the width of the pathological margin, the incidence of lymph node metastasis at each station and the 3-year overall survival (OS) and relapse-free survival (RFS) were evaluated. RESULTS LsTG was planned for 65 patients, and LPG for 72 and LTG for 78, respectively. Conversion to other procedures was required in about 10% of patients for whom LsTG or LPG was planned. The width of the pathological margin in patients who underwent LsTG was significantly shorter than patients who underwent the others. No patients who underwent LsTG, LPG or LTG had metastases in station no. 2 or 4sa lymph node. The 3-year OS and RFS rates of patients for whom each procedure was planned were not different. CONCLUSIONS LsTG could be an oncologically acceptable procedure for cT1N0M0 gastric cancer in the upper gastric body. LsTG could be one option for such disease.


title: Mass budget in two high altitude lakes reveals their role as atmospheric PCB sinks.

text: A mass budget of polychlorinated biphenyls (PCBs) was constructed for two altitude lakes located in the French Alps to (i) quantify inward and outward PCB flux over the entire year of 2012, (ii) hierarchize the dominant pathways of PCB transfers, and (iii) evaluate to what extent these pathways vary between both lakes. The annual PCB inputs were similar, and the glacial runoff and sediment-to-water exchange were negligible sources of PCBs to the water column relative to atmospheric deposition. The annual inputs were primarily introduced by snow deposition and transferred into the lakes during the few weeks of spring thaw. While the dominant deposition pathways were similar, the main processes by which the water column lost pollutants differed between the two lakes. Despite these differences, the mass budget revealed that PCB inputs exceeded outputs for both studied lakes and that the lakes acted as atmospheric PCB sinks for the surrounding mountain environment. The differences in the PCB distribution between the key compartments (sediment and water column) are most likely due to differences in the lacustrine internal processes.


Perioperative goal-directed therapy.


title: Evaluation of recombinant P23 protein as a vaccine for passive immunization of newborn calves against Cryptosporidium parvum.

text: Cryptosporidiosis is a zoonotic protozoan disease that affects the gastrointestinal tract of animals and humans. Diarrhoea as the most important indication of the infection leads to high economic losses in livestock industries and is a life threatening infection in immunocompromised individuals. In the absence of the effective drugs, vaccine has an effective role in the prevention of infection. For this purpose we developed a vaccine utilizing recombinant P23 protein and immunized pregnant cows four times from 70 days to parturition every 2 weeks. After parturition, each calf received his dam colostrum and challenged with 1 × 10(7) Cryptosporidium parvum oocysts at 12 h of age. Results showed that in contrast with the control group, the antibody titre in the sera and first milking colostra of the immunized cows significantly increased and calves fed hyperimmune colostrum did not show cryptosporidiosis signs. Moreover, enriched colostrum not only reduced significantly the amount of oocyst excretion but also delayed its onset. Our study showed that recombinant P23 protein could be used for passive immunization of newborn calves against Cryptosporidium parvum.


title: Initial experience with extraperitoneal robotic-assisted simple prostatectomy using the da Vinci SP surgical system.

text: Robotic-assisted simple prostatectomy (RASP) has emerged as a safe and effective treatment option for symptomatic patients with lower urinary tract symptoms related to significant benign prostatic enlargement (BPE) above 80 g. The recent release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA, USA) continues to advance the minimally invasive nature of robotic surgical technology. We now report our institution's initial experience performing RASP using the da Vinci SP robotic system. An IRB-approved, retrospective chart review was performed of all patients undergoing robotic-assisted simple prostatectomy using the da Vinci SP surgical system in the treatment of benign prostatic enlargement by a single surgeon from March to June 2019. Pre-operative, intraoperative, and post-operative data were collected for descriptive analysis. A total of 10 men, mean age of 69 ± 4 years, with mean prostate volume of 104 ± 11 g underwent surgery. The robotic cannula and a single assistant port were utilized in all cases. No cases required conversion to a multi-port robotic platform or open approach, nor required the placement of additional assistant ports. No intraoperative or immediate post-operative complications were noted. Mean estimated blood loss was 141 ± 98 mL and operative time was 172 ± 19 min. Mean catheter time was 1.9 ± 1.8 days. One patient reported transient de novo stress urinary incontinence. Single-port RASP is a safe and effective intervention for BPE. The smaller surgical footprint from the device appears to make earlier catheter removal possible. Comparative evaluation with multi-port RASP and other modalities is warranted.


title: Selective exposure of the fetal lung and skin/amnion (but not gastro-intestinal tract) to LPS elicits acute systemic inflammation in fetal sheep.

text: Inflammation of the uterine environment (commonly as a result of microbial colonisation of the fetal membranes, amniotic fluid and fetus) is strongly associated with preterm labour and birth. Both preterm birth and fetal inflammation are independently associated with elevated risks of subsequent short- and long-term respiratory, gastro-intestinal and neurological complications. Despite numerous clinical and experimental studies to investigate localised and systemic fetal inflammation following exposure to microbial agonists, there is minimal data to describe which fetal organ(s) drive systemic fetal inflammation. We used lipopolysaccharide (LPS) from E.coli in an instrumented ovine model of fetal inflammation and conducted a series of experiments to assess the systemic pro-inflammatory capacity of the three major fetal surfaces exposed to inflammatory mediators in pregnancy (the lung, gastro-intestinal tract and skin/amnion). Exposure of the fetal lung and fetal skin/amnion (but not gastro-intestinal tract) caused a significant acute systemic inflammatory response characterised by altered leucocytosis, neutrophilia, elevated plasma MCP-1 levels and inflammation of the fetal liver and spleen. These novel findings reveal differential fetal organ responses to pro-inflammatory stimulation and shed light on the pathogenesis of fetal systemic inflammation after exposure to chorioamnionitis.


The presence and distribution of novel coronavirus in medical environment.


High-flow oxygen therapy for the management of patients with acute exacerbation of cystic fibrosis.


title: Sinonasal Quality of Life in Children After Outfracture of Inferior Turbinates and Submucous Inferior Turbinoplasty for Chronic Nasal Congestion.

text: Importance Chronic nasal congestion often persists in children despite empirical treatment using intranasal corticosteroids, systemic antihistamines, and/or leukotriene receptor antagonists. Symptoms are often reported even with negative results of skin or blood allergy testing. Inferior turbinoplasty has been effective in adults and children, but outfracture of inferior turbinates in children is rarely reported, as is use of validated quality-of-life measures to quantify improvements after intervention. Effective use of these 2 procedures for treating chronic nasal congestion may reduce the need for medication and improve sinonasal quality of life. Objective To quantify changes in sinonasal quality of life for children after outfracture of inferior turbinates and concomitant submucous microdebrider inferior turbinoplasty for chronic nasal congestion. Design, Setting, and Participants A case series with planned data collection was conducted in an ambulatory pediatric otolaryngology clinic among 43 patients with chronic nasal congestion who underwent surgical intervention between January 1, 2014, and May 31, 2015. Exposures Microdebrider submucous inferior turbinoplasty (without bony resection) and outfracture of inferior turbinates. Main Outcomes and Measures Demographics and medication use before and after the procedure were reviewed. Scores on the Sinus and Nasal Quality of Life Survey (SN-5) and quality-of-life scores were collected at baseline, 4 to 6 weeks after the procedure, and more than 6 months after the procedure. Results Among the 43 patients (14 girls and 29 boys; mean age, 11.2 years [range, 4.8-17.6 years]), every domain showed significant improvements in scores on the Sinus and Nasal Quality of Life Survey and quality-of-life scores 1 to 2 months after the proecdure: sinus infection (-2.55; 95% CI, 1.85-3.26), nasal obstruction (-3.51; 95% CI, 2.88-4.14), allergy symptoms (-2.14; 95% CI, 1.43-2.86), emotional distress (-2.37; 95% CI, 1.68-3.06), activity limitation (-1.70; 95% CI, 1.14-2.25), and overall quality of life (3.72; 95% CI, 2.95-4.48). At long-term follow-up, improvement was maintained in all categories. Significant improvements in SN-5 and quality-of-life scores correlated with proportional decreased reporting of snoring after the procedure (33 [77%] vs 1 [2%]; absolute reduction, 75%; 95% CI, 62%-88%), as well as nasal congestion (41 [95%] vs 1 [2%]; absolute reduction, 93% ; 95% CI, 85%-100%), and rhinorrhea (44 [41%] vs 1 [2%]; absolute reduction, 42%; 95% CI, 27%-57%). The proportion reporting use of intranasal corticosteroids (25 [58%] vs 2 [5%]; absolute reduction, 50%; 95% CI, 39%-71%), antihistamines (27 [63%] vs 1 [2%]; absolute reduction, 61%; 95% CI, 46%-75%), and leukotriene receptor antagonists (13 [30%] vs 0; absolute reduction, 30%; 95% CI, 16%-44%) also decreased. Conclusions and Relevance Concomitant outfracture and submucous microdebrider inferior turbinoplasty improves quality of life in children with chronic nasal congestion and can reduce use of daily medication.


title: Developing an algorithm for pulse oximetry derived respiratory rate (RR(oxi)): a healthy volunteer study.

text: OBJECTIVE The presence of respiratory information within the pulse oximeter signal (PPG) is a well-documented phenomenon. However, extracting this information for the purpose of continuously monitoring respiratory rate requires: (1) the recognition of the multi-faceted manifestations of respiratory modulation components within the PPG and the complex interactions among them; (2) the implementation of appropriate advanced signal processing techniques to take full advantage of this information; and (3) the post-processing infrastructure to deliver a clinically useful reported respiratory rate to the end user. A holistic algorithmic approach to the problem is therefore required. We have developed the RR(OXI) algorithm based on this principle and its performance on healthy subject trial data is described herein. METHODS Finger PPGs were collected from a cohort of 139 healthy adult volunteers monitored during free breathing over an 8-min period. These were subsequently processed using a novel in-house algorithm based on continuous wavelet transform technology within an infrastructure incorporating weighted averaging and logical decision making processes. The computed oximeter respiratory rates (RR(oxi)) were then compared to an end-tidal CO2 reference rate RR(ETCO2). RESULTS RR(ETCO2) ranged from a lowest recorded value of 2.97 breaths per min (br/min) to a highest value of 28.02 br/min. The mean rate was 14.49 br/min with standard deviation of 4.36 br/min. Excellent agreement was found between RR(oxi) and RR(ETCO2), with a mean difference of -0.23 br/min and standard deviation of 1.14 br/min. The two measures are tightly spread around the line of agreement with a strong correlation observable between them (R2 = 0.93). CONCLUSIONS These data indicate that RR(oxi) represents a viable technology for the measurement of respiratory rate of healthy individuals.


The Impact of the COVID-19 Pandemic on the Biotech Industry.


title: Does Gleason score of positive surgical margin after radical prostatectomy affect biochemical recurrence and oncological outcomes? Protocol for systematic review.

text: INTRODUCTION Positive surgical margins (PSM) in cancer patients are commonly associated with worse prognosis and a higher risk of secondary treatment. However, the relevance of this parameter in prostate cancer patients undergoing radical prostatectomy (RP) remains controversial, given the inconsistencies in its ability to predict biochemical recurrence (BCR) and oncological outcomes. Hence, further assessment of the utility of surgical margins for prostate cancer prognosis is required to predict these outcomes more accurately. Over the last decade, studies have used the Gleason score (GS) of positive margins to predict outcomes. Herein, the authors aim to conduct a systematic review investigating the role of GS of PSM after radical prostatectomy in predicting BCR and oncological outcomes. METHODS AND ANALYSIS We will perform a search using MEDLINE, EMBASE, SCOPUS and COCHRANE databases. The review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will screen titles and abstracts to select articles appropriate for full-text review. Studies discussing GS of PSM after RP will be included. Given the change in reporting of GS, only articles from 2005 to 2019 will be included. The quality of the studies chosen will be assessed using the Newcastle Ottawa tool for non-randomised and Cochrane risk of bias for randomised control studies. We will adopt the grading of recommendations, assessment, development and evaluation framework to comment on quality of cumulative evidence. The primary outcome measure will be time to BCR. Secondary outcome measures include secondary treatment, disease-specific survival, disease progression-free and overall mortality at follow-up period. We aim to perform a meta-analysis if the level of heterogeneity is acceptable (I2 <50%). ETHICS AND DISSEMINATION The review does not require ethics approval as it is a review of published literature. The findings of the review will be submitted for peer-reviewed publications and presented at scientific meetings. PROSPERO REGISTRATION NUMBER CRD42019131800.


title: Robotic-assisted paraesophageal hernia repair--a case-control study.

text: AIMS The da Vinci® telemanipulation system offers a wide range of precise movements and 3D visualization with depth perception and magnification effect. Such a system could be useful for improving minimally invasive procedures-as in the case of large hiatal hernia with paraesophageal involvement (PEH) repair. Studies reporting on the robotic-assisted PEH repair are scarce, and a comparison to the standard operation techniques is lacking. Therefore, we decided to investigate the feasibility and safety of robotic-assisted surgery (RAS) compared to conventional laparoscopic (CLS) and open surgery (OS) for the first time. METHODS We investigated 42 patients for the perioperative outcome after PEH repair. Twelve patients were operated on with RAS, 17 with CLS, and 13 with OS. Operating time, intraoperative blood loss, intra- and postoperative complications, mortality, and duration of hospital stay were analyzed in each method. RESULTS On average, operating time in the RAS group was 38 min longer, and the intraoperative blood was loss 217 ml lower compared to OS. Both results were similar to the CLS group. The intraoperative complication rate was similar in all groups. The postoperative complication rate in the RAS group was significantly lower than the OS group, though again similar to the CLS group. The hospital stay was 5 days shorter in the RAS group than the OS group and once again similar to the CLS group. CONCLUSION The results show that RAS is feasible and safe. It appears to be an alternative to OS due to lower intraoperative blood loss and potentially fewer postoperative complications, as well as shorter hospital stay. Though, RAS is not superior to CLS.


title: COVID-19 Case-initiated contact tracing using anonymous notification techniques.

text: UNSTRUCTURED We propose a concept of contact notification tool for assisting tracing contacts who are exposure to confirmed COVID-19 cases, which is simple and affordable for countries with limited health manpower and high-tech means.


Chloroquine and hydroxychloroquine to treat COVID-19: between hope and caution.


Critical Illness in Patients With COVID-19: Mounting an Effective Clinical and Research Response.


title: Fitting Community-Centered Population Health (CCPH) Into the Existing Health Care Delivery Patchwork: The Politics of CCPH.

text: The COVID-19 crisis has nakedly exposed the problems and huge holes in the health care system of the United States. For today, we need to address the current pandemic from the point of view of both control and suppression. But such efforts could also provide insights into a post-pandemic restructuring of health care. If one or several states succeed in addressing the COVID pandemic together with an associated modest economic resurgence, citizens could develop the trust in state leadership necessary to finally make fundamental changes in our health care system. Such change is a once in a century opportunity.


title: Vascular endothelial growth factor C complements the ability of positron emission tomography to predict nodal disease in lung cancer.

text: OBJECTIVE Vascular endothelial growth factors (VEGFs) C and D are biologically rational markers of nodal disease that could improve the accuracy of lung cancer staging. We hypothesized that these biomarkers would improve the ability of positron emission tomography (PET) to predict nodal disease among patients with suspected or confirmed non-small cell lung cancer (NSCLC). METHODS A cross-sectional study (2010-2013) was performed of patients prospectively enrolled in a lung nodule biorepository, staged by computed tomography (CT) and PET, and who underwent pathologic nodal evaluation. Enzyme-linked immunosorbent assay was used to measure biomarker levels in plasma from blood drawn before anesthesia. Likelihood ratio testing was used to compare the following logistic regression prediction models: ModelPET, ModelPET/VEGF-C, ModelPET/VEGF-D, and ModelPET/VEGF-C/VEGF-D. To account for 5 planned pairwise comparisons, P values <.01 were considered significant. RESULTS Among 62 patients (median age, 67 years; 48% men; 87% white; and 84% NSCLC), 58% had fluorodeoxyglucose uptake in hilar and/or mediastinal lymph nodes. The prevalence of pathologically confirmed lymph node metastases was 40%. Comparisons of prediction models revealed the following: ModelPET/VEGF-C versus ModelPET (P = .0069), ModelPET/VEGF-D versus ModelPET (P = .1886), ModelPET/VEGF-C/VEGF-D versus ModelPET (P = .0146), ModelPET/VEGF-C/VEGF-D versus ModelPET/VEGF-C (P = .2818), and ModelPET/VEGF-C/VEGF-D versus ModelPET/VEGF-D (P = .0095). In ModelPET/VEGF-C, higher VEGF-C levels were associated with an increased risk of nodal disease (odds ratio, 2.96; 95% confidence interval, 1.26-6.90). CONCLUSIONS Plasma levels of VEGF-C complemented the ability of PET to predict nodal disease among patients with suspected or confirmed NSCLC. VEGF-D did not improve prediction.


title: Safety and feasibility for single-incision laparoscopic cholecystectomy in local community hospital: a retrospective comparison with conventional 4-port laparoscopic cholecystectomy.

text: BACKGROUND The aim of this study was to evaluate the safety and feasibility for single-incision laparoscopic cholecystectomy (SILC) by retrospective comparison with conventional laparoscopic cholecystectomy (CLC) in a local community hospital. METHODS SILC was introduced and performed in 57 patients for benign gallbladder diseases. Their clinical data were compared with those of 62 patients treated with CLC. They included patient demographic data and operative outcomes. RESULTS SILC was attempted in 57 patients and 52 cases (91.2%) were successfully completed. There were no statistical differences between the 2 groups in terms of operative time, blood loss, and postoperative complications. The length of hospital stay in the SILC group was significantly shorter compared with CLC (P < 0.0001). CONCLUSIONS SILC has been successfully introduced in a local community hospital. The safety and feasibility was also confirmed. The SILC procedure may become 1 standard option for the treatment of benign gallbladder diseases.


20 years a-publishing - the development of FEMS Yeast Research.


Health inequalities: the hidden cost of COVID-19 in NHS hospital trusts?


title: Clinical Outcome After Mechanical Thrombectomy in Non-elderly Patients with Acute Ischemic Stroke in the Anterior Circulation: Primary Admission Versus Patients Referred from Remote Hospitals.

text: BACKGROUND AND PURPOSE Stroke networks have been installed to increase access to advanced stroke specific treatments like mechanical thrombectomy (MT). This concept often requires patients to be transferred to a comprehensive stroke center (CSC) offering MT. Do patient referral, transportation, and logistic effort translate into clinical outcomes comparable to patients admitted primarily to the CSC? MATERIAL AND METHODS We categorized 112 patients with acute ischemic stroke in the anterior circulation, who received MT at our institution, into primary admissions (A) and referrals from either local (B) or regional (C) hospitals, assessed the clinical outcome, and tested the impact of distance and delay of transportation from the referring remote hospital. RESULTS The median time from symptom onset to initial CT was similar in all groups (p = 0,939). Patients who were transferred to the CSC had significantly increasing median time between initial CT and MT (in minutes (interquartile range [IQR]); A: 83 [68-120]; B: 174 [159-208]; C: 220 [181-235]; p < 0.001) and median time between onset to MT (in minutes [IQR]; A: 178 [150-210]; B: 274 [238-349]; C: 293 [256-329]; p < 0.001). After 90 days of MT there was no significant difference in clinical outcome (modified Rankin Scale ≤ 2) between primary admitted and referred patients (p = 0.502). CONCLUSION Clinical outcome in patients who received MT after transfer from either local or regional remote hospitals was not significantly worse than in patients primarily admitted to the CSC. In the event of an acute ischemic stroke patients living in urban or rural areas should, despite a possible delay, have access to MT.


title: Use of biological mesh versus standard wound care in infected incisional ventral hernias, the SIMBIOSE study: a study protocol for a randomized multicenter controlled trial.

text: BACKGROUND In infected incisional ventral hernias (IVHs), the use of a synthetic non-absorbable mesh is not recommended and biological meshes hold promise. However, the level of evidence for their safety and efficacy remains low. METHODS The SIMBIOSE trial is a multicenter, phase III, randomized, controlled trial comparing the use of a biological mesh versus traditional wound care in patients with an IVH. The primary end point is 6-month infectious and/or wound morbidity. Secondary end points are wound infection and recurrent hernia rates, post-operative pain, quality of life, time to heal, reoperation need, impact of the cross-linked mesh structure, and a medico-economic evaluation. One hundred patients need to be included. RESULTS The main results expected with biological mesh use are a significant decrease of post-operative morbidity, hernia recurrence, time to heal, and costs with an improved quality of life. CONCLUSIONS For the first time, the impact of biological meshes in the treatment of IVHs will be evaluated in an academic, randomized, phase III trial to provide scientific evidence (NCT01594450). TRIAL REGISTRATION ClinicalTrial.gov, NCT01594450.