title: Albuminuria, cognitive functioning, and white matter hyperintensities in homebound elders.

text: BACKGROUND Albuminuria, a kidney marker of microvascular disease, may herald microvascular disease elsewhere, including in the brain. STUDY DESIGN Cross sectional. SETTING & PARTICIPANTS Boston, MA, elders receiving home health services to maintain independent living who consented to brain magnetic resonance imaging. PREDICTOR Urine albumin-creatinine ratio (ACR). OUTCOME Performance on a cognitive battery assessing executive function and memory by using principal components analysis and white matter hyperintensity volume on brain imaging, evaluated in logistic and linear regression models. RESULTS In 335 participants, mean age was 73.4 +/- 8.1 years and 123 participants had microalbuminuria or macroalbuminuria. Each doubling of ACR was associated with worse executive function (beta = -0.05; P = 0.005 in univariate and beta = -0.07; P = 0.004 in multivariable analyses controlling for age, sex, race, education, diabetes, cardiovascular disease, hypertension, medications, and estimated glomerular filtration rate [eGFR]), but not with worse memory or working memory. Individuals with microalbuminuria or macroalbuminuria were more likely to be in the lower versus the highest tertile of executive functioning (odds ratio, 1.18; 95% confidence interval, 1.06 to 1.32; odds ratio, 1.19; 95% confidence interval, 1.05 to 1.35 per doubling of ACR in univariate and multivariable analyses, respectively). Albuminuria was associated with qualitative white matter hyperintensity grade (odds ratio, 1.13; 95% confidence interval, 1.02 to 1.25; odds ratio, 1.15; 95% confidence interval, 1.02 to 1.29 per doubling of ACR) in univariate and multivariable analyses and with quantitative white matter hyperintensity volume (beta = 0.11; P = 0.007; beta = 0.10; P = 0.01) in univariate and multivariable analyses of log-transformed data. Results were similar when excluding individuals with macroalbuminuria. LIMITATIONS Single measurement of ACR, indirect creatinine calibration, and reliance on participant recall for elements of medical history. CONCLUSIONS Albuminuria is associated with worse cognitive performance, particularly in executive functioning, as well as increased white matter hyperintensity volume. Albuminuria likely identifies greater brain microvascular disease burden.


title: Anxiolysis in the Surgical Management of a Compound Odontoma in a Pediatric Patient.

text: Among odontogenic tumors, odontoma is the most frequent. The common treatment contemplates a conservative approach. While this procedure is generally accepted and tolerated, some difficulties may be encountered in the case of pediatric patients. Indeed, negative feelings of tension, apprehension, nervousness, and fear are likely to occur. The present report is aimed at discussing the management of a compound odontoma in a pediatric patient under anxiolysis with diazepam on an outpatient basis. The surgery was carried out without complications, and the discharge was completed safely. Oral premedication with diazepam should be considered to avoid more invasive sedation procedures in anxious pediatric patients.


title: The influence of esmolol on right ventricular function in early experimental endotoxic shock.

text: The mechanism by which heart rate (HR) control with esmolol improves hemodynamics during septic shock remains unclear. Improved right ventricular (RV) function, thereby reducing venous congestion, may play a role. We assessed the effect of HR control with esmolol during sepsis on RV function, macrocirculation, microcirculation, end-organ-perfusion, and ventricular-arterial coupling. Sepsis was induced in 10 healthy anesthetized and mechanically ventilated sheep by continuous IV administration of lipopolysaccharide (LPS). Esmolol was infused after successful resuscitation of the septic shock, to reduce HR and stopped 30-min after reaching targeted HR reduction of 30%. Venous and arterial blood gases were sampled and the small intestines' microcirculation was assessed by using a hand-held video microscope (CytoCam-IDF). Arterial and venous pressures, and cardiac output (CO) were recorded continuously. An intraventricular micromanometer was used to assess the RV function. Ventricular-arterial coupling ratio (VACR) was estimated by catheterization-derived single beat estimation. The targeted HR reduction of >30% by esmolol infusion, after controlled resuscitation of the LPS induced septic shock, led to a deteriorated RV-function and macrocirculation, while the microcirculation remained depressed. Esmolol improved VACR by decreasing the RV end-systolic pressure. Stopping esmolol showed the reversibility of these effects on the RV and the macrocirculation. In this animal model of acute severe endotoxic septic shock, early administration of esmolol decreased RV-function resulting in venous congestion and an unimproved poor microcirculation despite improved cardiac mechanical efficiency.


title: A rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

text: Late complications after a laparoscopic inguinal hernia repair are extremely rare and have only recently entered into the literature. One such late complication is mesh infection, of which there have been a handful of cases reported in the literature. Mesh infections occurring many years after inguinal hernia repairs are not only of significance because they are not well documented in the literature, and the pathogenesis and risk factors contributing to their development are not well understood. This report details a rare case of mesh infection 3 years after a laparoscopic totally extraperitoneal inguinal hernia repair, describes our management of the condition, highlights the current options for management, and attempts to define its pathophysiology.


title: Anterolateral Versus Medial Plating of Distal Extra-articular Tibia Fractures: A Biomechanical Model.

text: Both medial and anterolateral plate applications have been described for the treatment of distal tibia fractures, each with distinct advantages and disadvantages. The objective of this study was to compare the biomechanical properties of medial and anterolateral plating constructs used to stabilize simulated varus and valgus fracture patterns of the distal tibia. In 16 synthetic tibia models, a 45° oblique cut was made to model an Orthopedic Trauma Association type 43-A1.2 distal tibia fracture in either a varus or valgus injury pattern. Each fracture was then reduced and plated with a precontoured medial or anterolateral distal tibia plate. The specimens were biomechanically tested in axial and torsional loading, cyclic axial loading, and load to failure. For the varus fracture pattern, medial plating showed less fracture site displacement and rotation and was stiffer in both axial and torsional loading (P<.05). For the valgus fracture pattern, there was no statistically significant difference between medial and anterolateral plating. There were no significant differences between the 2 constructs for either fracture pattern with respect to ultimate load, displacement, or energy absorption in load to failure testing. When used to stabilize varus fracture patterns, medial plates showed superior biomechanical performance compared with anterolateral plates. In this application, the medial plates functioned in anti-glide mode. For valgus fracture patterns, no biomechanical differences between anterolateral and medial plating were observed. In clinical practice, surgeons should take this biomechanical evidence into account when devising a treatment strategy for fixation of distal tibia fractures.


title: Bariatric surgery for type 2 diabetes.

text: Bariatric surgery provides substantial, sustained weight loss and major improvements in glycaemic control in severely obese individuals with type 2 diabetes. However, uptake of surgery in eligible patients is poor, and the barriers are difficult to surmount. We examine the indications for and efficacy and safety of conventional bariatric surgical procedures and their effect on glycaemic control in type 2 diabetes. How surgical gastrointestinal interventions achieve these changes is of great research interest, and is evolving rapidly. Old classifications about restriction and malabsorption are inadequate, and we explore understanding of putative mechanisms. Some bariatric procedures improve glycaemic control in people with diabetes beyond that expected for weight loss, and understanding this additional effect could provide insights into the pathogenesis of type 2 diabetes and assist in the development of new procedures, devices, and drugs both for obese and non-obese patients.


title: Next-generation sequence analysis of genes associated with obesity and nonalcoholic fatty liver disease-related cirrhosis in extreme obesity.

text: OBJECTIVES Genome-wide association studies (GWAS) have led to the identification of single nucleotide polymorphisms in or near several loci that are associated with the risk of obesity and nonalcoholic fatty liver disease (NAFLD). We hypothesized that missense variants in GWAS and related candidate genes may underlie cases of extreme obesity and NAFLD-related cirrhosis, an extreme manifestation of NAFLD. METHODS We performed whole-exome sequencing on 6 Caucasian patients with extreme obesity [mean body mass index (BMI) 84.4] and 4 obese Caucasian patients (mean BMI 57.0) with NAFLD-related cirrhosis. RESULTS Sequence analysis was performed on 24 replicated GWAS and selected candidate obesity genes and 5 loci associated with NAFLD. No missense variants were identified in 19 of the 29 genes analyzed, although all patients carried at least 2 missense variants in the remaining genes without excess homozygosity. One patient with extreme obesity carried 2 novel damaging mutations in BBS1 and was homozygous for benign and damaging MC3R variants. In addition, 1 patient with NAFLD-related cirrhosis was compound heterozygous for rare damaging mutations in PNPLA3. CONCLUSIONS These results indicate that analyzing candidate loci previously identified by GWAS analyses using whole-exome sequencing is an effective strategy to identify potentially causative missense variants underlying extreme obesity and NAFLD-related cirrhosis.


title: The effectiveness of an oral opioid rescue medication algorithm for postoperative pain management compared to PCIA : A cohort analysis.

text: BACKGROUND Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA). MATERIAL AND METHODS This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0-10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management. RESULTS Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st-3rd quartile: 6 (3.75-8) vs. 5 (3-7), p = 0.023; maximum pain intensity: 7 (5-9) vs. 5 (3-8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47-154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = -2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = -1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management. CONCLUSION In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.


title: Robotic extended pelvic lymphadenectomy for intermediate- and high-risk prostate cancer.

text: BACKGROUND Accurate staging of prostate cancer is enhanced by a thorough evaluation of the pelvic lymph nodes. Limited data are available regarding robotic extended pelvic lymphadenectomy (PLA) in this setting. OBJECTIVE Analyze our experience performing robotic extended PLA. DESIGN, SETTING, AND PARTICIPANTS A total of 143 consecutive men with intermediate- or high-risk clinically localized adenocarcinoma of the prostate underwent robotic extended PLA and radical prostatectomy between September 2010 and November 2011 by a single surgeon. SURGICAL PROCEDURE Lymph node packets were sent separately from bilateral common, external, and internal iliacs, obturators, node of Cloquet, and anterior prostatic fat. MEASUREMENTS Descriptive statistics were used to summarize lymph node yields and positive nodes. Clinical variables were examined in logistic regression models to predict lymph node positivity. RESULTS AND LIMITATIONS Median lymph node yield was 20 (range: 9-65, interquartile range: 15-25). Eighteen patients (13%) were found to have metastatic prostate cancer in the lymph nodes. The mean number of positive nodes found was 2.9 (range: 1-11). In 14 of 18 node-positive patients (78%), the extent of nodal invasion was outside the boundaries of a limited PLA. For four patients with positive nodes (22%), prostate biopsy predicted unilateral disease but PLA revealed contralateral positive lymph nodes. A total of 82% of patients experienced no complications, and most Clavien grade 1-2 complications consisted of anastomotic leakage, urinary retention, ileus, and lymphocele. Only 4% of patients experienced a grade 3 complication. Under multivariate regression analysis, prostate-specific antigen (PSA), clinical stage, and maximum biopsy core tumor volume were identified as significant predictors of finding positive pelvic lymph nodes (area under the curve: 91%). The main limitations include short follow-up and lack of randomization. CONCLUSIONS Robotic extended bilateral PLA for prostate cancer up to the common iliac bifurcation increases nodal yield and positive nodal rate and can be performed safely. PSA, clinical stage, and maximum biopsy core volume are predictors for lymph node invasion. Long-term follow-up is needed to evaluate for therapeutic benefit.


title: Minimally invasive esthetic ridge preservation with growth-factor enhanced bone matrix.

text: OBJECTIVES Extraction socket preservation procedures are critical to successful esthetic implant therapy. Conventional surgical approaches are technique sensitive and often result in alteration of the soft tissue architecture, which then requires additional corrective surgical procedures. This case series report presents the ability of flapless surgical techniques combined with a growth factor-enhanced bone matrix to provide esthetic ridge preservation at the time of extraction for compromised sockets. CLINICAL CONSIDERATIONS When considering esthetic dental implant therapy, preservation, or further enhancement of the available tissue support at the time of tooth extraction may provide an improved esthetic outcome with reduced postoperative sequelae and decreased treatment duration. Advances in minimally invasive surgical techniques combined with recombinant growth factor technology offer an alternative for bone reconstruction while maintaining the gingival architecture for enhanced esthetic outcome. The combination of freeze-dried bone allograft (FDBA) and rhPDGF-BB (platelet-derived growth factor-BB) provides a growth-factor enhanced matrix to induce bone and soft tissue healing. CONCLUSIONS The use of a growth-factor enhanced matrix is an option for minimally invasive ridge preservation procedures for sites with advanced bone loss. Further studies including randomized clinical trials are needed to better understand the extent and limits of these procedures. CLINICAL SIGNIFICANCE The use of minimally invasive techniques with growth factors for esthetic ridge preservation reduces patient morbidity associated with more invasive approaches and increases the predictability for enhanced patient outcomes. By reducing the need for autogenous bone grafts the use of this technology is favorable for patient acceptance and ease of treatment process for esthetic dental implant therapy.


title: RECENT CHANGES IN INFECTIOUS DISEASES IN EUROPEAN WILDLIFE.

text: Many infectious diseases originating from, or carried by, wildlife affect wildlife conservation and biodiversity, livestock health, or human health. We provide an update on changes in the epidemiology of 25 selected infectious, wildlife-related diseases in Europe (from 2010-16) that had an impact, or may have a future impact, on the health of wildlife, livestock, and humans. These pathogens were selected based on their: 1) identification in recent Europe-wide projects as important surveillance targets, 2) inclusion in European Union legislation as pathogens requiring obligatory surveillance, 3) presence in recent literature on wildlife-related diseases in Europe since 2010, 4) inclusion in key pathogen lists released by the Office International des Epizooties, 5) identification in conference presentations and informal discussions on a group email list by a European network of wildlife disease scientists from the European Wildlife Disease Association, or 6) identification as pathogens with changes in their epidemiology during 2010-16. The wildlife pathogens or diseases included in this review are: avian influenza virus, seal influenza virus, lagoviruses, rabies virus, bat lyssaviruses, filoviruses, canine distemper virus, morbilliviruses in aquatic mammals, bluetongue virus, West Nile virus, hantaviruses, Schmallenberg virus, Crimean-Congo hemorrhagic fever virus, African swine fever virus, amphibian ranavirus, hepatitis E virus, bovine tuberculosis ( Mycobacterium bovis), tularemia ( Francisella tularensis), brucellosis ( Brucella spp.), salmonellosis ( Salmonella spp.), Coxiella burnetii, chytridiomycosis, Echinococcus multilocularis, Leishmania infantum, and chronic wasting disease. Further work is needed to identify all of the key drivers of disease change and emergence, as they appear to be influencing the incidence and spread of these pathogens in Europe. We present a summary of these recent changes during 2010-16 to discuss possible commonalities and drivers of disease change and to identify directions for future work on wildlife-related diseases in Europe. Many of the pathogens are entering Europe from other continents while others are expanding their ranges inside and beyond Europe. Surveillance for these wildlife-related diseases at a continental scale is therefore important for planet-wide assessment, awareness of, and preparedness for the risks they may pose to wildlife, domestic animal, and human health.


title: Initial experience of transanal total mesorectal excision with rigid or flexible transanal platforms in cadavers.

text: BACKGROUND Transanal total mesorectal excision (taTME) is expected to provide benefits in the removal of the complete mesorectum for low rectal lesions, and several clinical studies regarding this technique have been reported. However, a transanal platform has not yet been standardized, and diverse transanal endoluminal surgery access devices have been used, based on individual surgeon preferences. In the present study, we performed laparoscopy-assisted taTME in cadavers and compared the characteristics of four different platforms. METHODS Between January 2013 and April 2015, laparoscopy-assisted taTME was performed on six fresh cadavers. Flexible [SILS™ Port (Covidien), GelPOINT(®) Path Transanal Access Platform (Applied Medical)] and rigid [TEO(®) (Karl Storz Endoskope), TEM (Richard Wolf)] transanal access platforms were used on three cadavers each. RESULTS All cadavers were male, with a mean age of 69.2 (range 57-86) years. The mean operation time was 146.3 (range 140-155) min with flexible platforms and 206.7 (range 150-260) min with rigid platforms. The mean specimen length was 23 (range 18-26) cm. Complete or nearly complete mesorectal specimens were obtained in all cases, except for one case using the TEM platform. Flexible platforms (SILS and GelPOINT) provided a short set-up time, relatively atraumatic retraction, and easy application of familiar laparoscopic instruments; a narrow operative field was its limitation. The rigid platforms (TEO and TEM) enabled larger and more stable operative fields and space than did the SILS platform, but they were limited by a narrow view, prolonged set-up time, rigidity, and long channels relative to the short distance from the anus to the rectal closure site. CONCLUSION In this preliminary study, laparoscopy-assisted taTME was a feasible and safe procedure using both rigid and soft platforms, despite some limitations of each platform.


title: Two-Phase Contiguous Supported Lipid Bilayer Model for Membrane Rafts via Polymer Blotting and Stenciling.

text: The supported lipid bilayer has been portrayed as a useful model of the cell membrane compatible with many biophysical tools and techniques that demonstrate its appeal in learning about the basic features of the plasma membrane. However, some of its potential has yet to be realized, particularly in the area of bilayer patterning and phase/composition heterogeneity. In this work, we generate contiguous bilayer patterns as a model system that captures the general features of membrane domains and lipid rafts. Micropatterned polymer templates of two types are investigated for generating patterned bilayer formation: polymer blotting and polymer lift-off stenciling. While these approaches have been used previously to create bilayer arrays by corralling bilayers patches with various types of boundaries impenetrable to bilayer diffusion, unique to the methods presented here, there are no physical barriers to diffusion. In this work, interfaces between contiguous lipid phases define the pattern shapes, with continuity between them allowing transfer of membrane-bound biomolecules between the phases. We examine effectors of membrane domain stability including temperature and cholesterol content to investigate domain dynamics. Contiguous patterning of supported bilayers as a model of lipid rafts expands the application of the SLB to an area with current appeal and brings with it a useful toolset for characterization and analysis. These combined tools should be helpful to researchers investigating lipid raft dynamics and function and biomolecule partitioning studies. Additionally, this patterning technique may be useful for applications such as bioseparations that exploit differences in lipid phase partitioning or creation of membranes that bind species like viruses preferentially at lipid phase boundaries, to name a few.


Validating QT-Interval Measurement Using the Apple Watch ECG to Enable Remote Monitoring During the COVID-19 Pandemic.


title: Transanal total mesorectal excision: surgical technique description and outcomes.

text: Minimally invasive techniques (MIS) have been evolving quickly in colorectal surgery during the last two decades. Transanal total mesorectal excision (taTME) was developed as a combination of skills acquired from different MIS approaches such as Transanal Endoscopic Microsurgery (TEM), Transanal Minimally Invasive Surgery (TAMIS) and Natural Orifices Transluminal Endoscopic Surgery (NOTES). TaTME allows for a better visualization of surgical planes of dissection and achievement of rectal resection following oncologic principles. We here present the standardized taTME technique in use at the Hospital Clínic de Barcelona and our published outcomes in rectal cancer.


High-Flow Nasal Cannula to Prevent Desaturation in Endotracheal Intubation: A Word of Caution.


docid: pecldgnr

title: Initiation of Levodopa-Carbidopa Intestinal Gel Infusion Using Telemedicine (Video Communication System) Facilitates Efficient and Well-Accepted Home Titration in Patients with Advanced Parkinson's Disease.

text: BACKGROUND Levodopa-carbidopa intestinal gel (LCIG; Duodopa®) is used for continuous infusion in advanced Parkinson's disease. To achieve optimal effect, the LCIG dose is individually titrated, traditionally conducted during hospitalization in Sweden. However, dose adjustment depends on surrounding conditions, physical activity, and emotional stress, which is why titration at home could be beneficial. Telemedicine (TM) using a video communication system offers alternative titration procedures, allowing LCIG initiation at home. OBJECTIVE Study objectives were to show the feasibility of TM for LCIG home titration, evaluate resource use, and assess patient, neurologist, and nurse satisfaction. METHODS Four clinics enrolled 15 patients to observe efficiency and feasibility of TM-based monitoring. RESULTS Patient median (range) age was 67 (52-73) years and time since diagnosis was 10 (7-23) years. Median time between LCIG initiation and end of TM-assisted titration was 2.8 (2.0-13.8) days. Median time required for home titration by neurologists, nurses, and patients was (hours:minutes) 1 : 14 (0 : 29-1 : 52), 5 : 49 (2 : 46-10 : 3), and 8 : 53 (4 : 11-14 : 11), respectively. Neurologists and nurses considered this to be less time than required for hospital titration. TM allowed patients 92% free time from start to end of titration. Technical problems associated with TM contacts were rare, mostly related to digital link, and quickly resolved. Patients, neurologists, and nurses were satisfied using TM. No serious adverse events were reported; there was one device complaint (tube occlusion). CONCLUSIONS In this study, TM-assisted LCIG titration at home was resource-efficient, technically feasible, well-accepted and was deemed satisfactory by patients, neurologists, and nurses.


title: Diffusion-weighted imaging score of the brain stem: A predictor of outcome in acute basilar artery occlusion treated with the Solitaire FR device.

text: BACKGROUND AND PURPOSE The prognosis for ischemic stroke due to acute basilar artery occlusion is very poor: Early recanalization remains the main factor that can improve outcomes. The baseline extent of brain stem ischemic damage can also influence outcomes. We evaluated the validity of an easy-to-use DWI score to predict clinical outcome in patients with acute basilar artery occlusion treated by mechanical thrombectomy. MATERIALS AND METHODS We analyzed the baseline clinical and DWI parameters of 31 patients with acute basilar artery occlusion, treated within 24 hours of symptom onset by using a Solitaire FR device. The DWI score of the brain stem was assessed with a 12-point semiquantitative score that separately considered each side of the medulla, pons, and midbrain. Clinical outcome was assessed at 180 days by using the mRS. According to receiver operating characteristic analyses, the cutoff score determined the optimal positive predictive value for outcome. The Spearman rank correlation coefficient assessed the correlation between the DWI brain stem score and baseline characteristics. RESULTS Successful recanalization (Thrombolysis in Cerebral Infarction 3-2b) was achieved in 23 patients (74%). A favorable outcome (mRS ≤ 2) was observed in 11 patients (35%). An optimal DWI brain stem score of <3 predicted a favorable outcome. The probability of a very poor outcome (mRS ≥ 5) if the DWI brain stem score was ≥5 reached 80% (positive predictive value) and 100% if this score was ≥6. Interobserver reliability of the DWI brain stem score was excellent, with an intraclass correlation coefficient of 0.97 (95% CI, 0.96-0.99). The DWI brain stem score was significantly associated with baseline tetraplegia (P = .001) and coma (P = .005). CONCLUSIONS In patients with acute basilar artery occlusion treated by mechanical thrombectomy, the baseline DWI brain lesion score seems to predict clinical outcome.


title: Informing critical care drug requirements in response to the COVID-19 pandemic.

text: OBJECTIVES The main aim was to develop a process to estimate critical care drug requirements to robustly inform regional procurement planning and preparedness in response to the COVID-19 pandemic. The objectives were to identify critical care drugs required, obtain patient usage data and consider current regional practice to establish the requirement. METHOD Health and Social Care (HSC) Trusts across Northern Ireland (NI) identified critical care drugs required and an estimation of average daily usage data. The Microsoft Excel database was constructed to compile Trust data and establish regional requirement. The database was refined further according to real-world data from NI HSC Trusts, Intensive Care National Audit and Research Centre report on COVID-19 in critical care, daily regional COVID-19 figures and other available National data. Components of a tool originally developed for H1N1 and updated for COVID-19 were adapted to reflect the NI context and used in the regional database. The database was clinically reviewed to ensure that it accurately reflected current regional practice given the evolving nature of the pandemic. RESULTS The critical care drugs required in the pandemic, usage data and current regional practice were identified to establish requirement. A regional database was constructed and used to produce a model for calculating approximate critical drug requirements. The model was used to map critical drug requirements to available stock in Trusts and wholesalers/suppliers, enabling the identification of treatment capacity for these medicines regionally, both currently and for projected surges. Data have also been used in the preparation of weekly regional situation reports provided to both the HSC Board and the Department of Health. CONCLUSION The process developed is a robust approach to assist in informing regional critical care drug requirements in response to the COVID-19 pandemic. Further application has been demonstrated in regional procurement planning and preparedness.


title: Orthopaedic Guidelines for the COVID-19 Post-Outbreak Period: Experience from Wuhan, People's Republic of China.

text: Currently, the coronavirus disease 2019 (COVID-19) crisis has rapidly spread worldwide. As the earliest outbreak area of the pandemic, Wuhan, People's Republic of China, is gradually recovering to its normal state under the effective control of government authorities. Outpatient services in major hospitals are now being restored. An accumulation of asymptomatic infections is a potential risk for medical personnel, especially when there is crowding in hospitals. As the biggest center for orthopaedic patients in Wuhan, our orthopaedic outpatient department admits >300 patients per day. Optimal guidelines on how to handle this huge number of patients during the post-outbreak stage of the COVID-19 pandemic, particularly with regard to potential asymptomatic infection, are urgently needed for orthopaedic surgeons. We have developed and proposed applicable guidelines to fill this knowledge gap, including the necessary protective strategies for medical personnel in orthopaedic outpatient and inpatient wards as well as during surgery. We also have provided mental health recommendations for health-care workers. To the best of our knowledge, these guidelines are the first of their kind for orthopaedic surgeons who are slowly reestablishing medical activity following the pandemic.


title: COVID-19 in Neonates and Infants: Progression and Recovery.

text: Between March 10, 2020 and April 17, 2020, of 8/70 (11.4%) SARS-CoV-2 positive infants that presented, 5/8 (63%) developed fever, 4/8 (50%) had lower respiratory tract involvement, 2/8 (25%) had neutropenia and thrombocytosis, and 4/8 infants (50%) were treated for suspected sepsis with broad-spectrum antibiotics. Only 1/8 (13%) required pediatric intensive care. All patients were eventually discharged home well.


COVID-19 & Allergy: Allergists Workload During the Pandemic.


title: Sickness absence after carpal tunnel release: a systematic review of the literature.

text: Objectives The aim of this systematic review was to provide an overview of time to return to work (RTW) after carpal tunnel release (CTR), including return to different occupations and working patterns. Methods A systematic search from inception to 2016 was conducted using nine electronic databases, trial registries and grey literature repositories. Randomized controlled trials and observational studies reporting RTW times after CTR were included. Study risk of bias was assessed using Cochrane risk of bias assessment tools. Time to RTW was summarized using median and range. Results A total of 56 relevant studies were identified: 18 randomized controlled trials and 38 observational studies. Only 4 studies were rated as having a low risk of bias. Reported RTW times ranged from 4-168 days. Few studies reported occupational information. Among 6 studies, median time to return to non-manual work was 21 days (range 7-41), compared with 39 days for manual work (range 18-101). Median time to return to modified or full duties was 23 days (ranges 12-50 and 17-64, respectively), as reported by 3 studies. There was no common method of defining, collecting or reporting RTW data. Conclusions This review highlights wide variation in reported RTW times after CTR. Whilst occupational factors may play a role, these were poorly reported, and there is currently limited evidence to inform individual patients of their expected duration of work absence after CTR. A standardized definition of RTW is needed, as well as an agreed method of collecting and reporting related data.


title: Short-term Outcome of Robot-assisted and Open IPAA: An Observational Single-center Study.

text: BACKGROUND The potential advantages of robot-assisted laparoscopy are being increasingly investigated, although data on its efficacy in benign colorectal surgery are scarce. OBJECTIVE We compared the early postoperative outcome in robot-assisted IPAA with open surgery procedures. DESIGN This was an observational study based on prospectively collected data obtained from chart reviews. SETTING The single-center data set covers patients operated on from January 13, 2004, to September 16, 2014, at a specialist center. PATIENTS Patients with ulcerative colitis undergoing IPAA surgery were included. MAIN OUTCOME MEASURES Study end points included the duration of operation, admission length, complications (Clavien-Dindo), reoperations, and readmissions. RESULTS Eighty-one robot-assisted and 170 open IPAA procedures were performed. The duration of operation was significantly longer for robot-assisted laparoscopic procedures (mean difference, 154 minutes; CI, 140-170). During a mean follow-up of 102 days, no significant differences in the distribution of complications were found (Spearman p = 0.12; p = 0.07), and no postoperative deaths occurred in either group. Postoperative admission length was shorter following robot-assisted procedures (mean difference, -1.9; CI, -3.5 to -0.3), whereas 40% of patients were readmitted, compared with 26% of patients who had open surgery (OR, 1.9; CI, 1.1-3.4). Pouch failure occurred in 3 patients (1 following robot-assisted laparoscopy; 2 following open surgery). On multivariate regression analyses, robot-assisted laparoscopy was associated with a significantly longer duration of operation (mean difference, 159 minutes; CI, 144-174), and more readmissions for any cause (OR, 2; CI, 1.1-3.7). LIMITATIONS This was a nonrandomized, single-center observational study. CONCLUSION In this implementation phase, robot-assisted IPAA surgery offers acceptable short-term outcomes. The limitations of this observational study call for randomized controlled trials with long-term follow-up and exploration of functional results.


title: Predictors of bleeding in patients with acute coronary syndromes treated with prasugrel.

text: BACKGROUND When considering antiplatelet therapy for acute coronary syndrome (ACS), it is essential to balance benefits (less thrombotic/ischaemic events) versus bleeding risks related to intense platelet inhibition via antagonism of P2Y12 receptors. This analysis aimed to identify predictors of bleeding events among A Comparison of Prasugrel at the Time of PCI or as Pretreatment at the Time of Diagnosis in Patients with NSTEACS (ACCOAST) study population. METHODS AND RESULTS The ACCOAST study randomised 4033 patients with non-ST-segment elevation myocardial infarction (NSTEMI) to (A) a 30 mg prasugrel loading dose (LD) followed by coronary angiography with an additional 30 mg prasugrel at the time of percutaneous coronary intervention (PCI) or (B) a placebo LD followed by a 60 mg prasugrel at the time of PCI. Patients received standard of care, including use of aspirin. Independent predictors of Thrombolysis in Myocardial Infarction (TIMI) major bleeding not related to coronary artery bypass grafting (CABG) within 7 days were assessed using stepwise Cox proportional model for time to first occurrence of the event. Non-CABG-related TIMI major or minor bleeding was similarly analysed. Non-CABG-related TIMI major bleeding occurred in 36 (0.9%) patients, and TIMI major or minor bleeding occurred in 81 (2.0%) patients. Independent predictors for TIMI major bleeding alone were pretreatment with prasugrel LD (HR 3.02; 95% CI 1.42 to 6.43), femoral access (HR 2.45; 95% CI 1.11 to 5.38), female sex (HR 2.57; 95% CI 1.32 to 5.00), placement of >1 stent (HR 2.50; 95% CI 1.26 to 4.95) and age (HR 1.05; 95% CI 1.02 to 1.09). Pretreatment with prasugrel LD (HR 3.05; 95% CI 1.84 to 5.07), femoral access (HR 3.06; 95% CI 1.74 to 5.38), female sex (HR 2.62; 95% CI 1.67 to 4.12), performed PCI (HR 2.21; 95% CI 1.23 to 3.99), therapy with glycoprotein IIb/IIIa inhibitors (HR 1.88; 95% CI 1.06 to 3.33) and age (increased bleed per year of age HR 1.04; 95% CI 1.02 to 1.06) were independent predictors of TIMI major or minor bleeding through 7 days. CONCLUSIONS Pretreatment, age, gender and procedural variables predicted bleeding risk in patients with NSTEMI. CLINICAL REGISTRATION NO NCT01015287.


title: The timing, extent, progression and regression of deep vein thrombosis in immobile stroke patients: observational data from the CLOTS multicenter randomized trials.

text: BACKGROUND Deep vein thrombosis (DVT) is an important complication of stroke, but the evidence to support commonly used prophylactic strategies is conflicting. OBJECTIVES To describe the incidence, extent, associated clinical features and evolution of DVT after stroke. PATIENTS/METHODS The CLOTS trials 1 and 2 together randomized 5632 immobile stroke patients in 135 hospitals in nine countries. We screened patients for asymptomatic DVT with compression duplex ultrasound (CDU) at about 7-10 days and again at about 25-30 days after enrollment. RESULTS Six hundred and forty-one (11.4%) of 5632 patients had DVT detected on the first CDU scan at a median of 8 days (interquartile range [IQR] 7-10 days) after enrollment, and an additional 176 (3.1%) had a DVT on the second CDU scan at a median of 28 days (IQR 26-30 days). Of the 817 with DVTs, 289 (35%) were symptomatic and 39 (5%) had pulmonary embolism (PE) confirmed by imaging. Six hundred and seventy-six (83%) were unilateral, 141 (17%) were bilateral, 322 (39%) were limited to calf veins, 172 (21%) were popliteal, and 323 (40%) were femoral. Among the 542 patients with DVT and a weak leg, the DVT affected the weaker leg in 396 (73%), the stronger leg in 59 (11%), and was bilateral in 87 (16%). Among the 318 patients with a DVT detected on the first CDU scan who had a second scan, the DVT regressed in 148 (47%), stayed the same in 140 (44%), and progressed in only 30 (9%). CONCLUSIONS Although most DVTs develop within the first week, some develop later, and some early DVTs progress. Any prophylaxis needs to be started early but ideally continued for at least 4 weeks.


title: Non-antipsychotic catecholaminergic drugs for antipsychotic-induced tardive dyskinesia.

text: BACKGROUND Tardive dyskinesia (TD) is a disabling movement disorder associated with the prolonged use of antipsychotic medication. Several strategies have been examined in the treatment of TD. Currently, however, there is no clear evidence of the effectiveness of these drugs in TD and they have been associated with many side effects. One particular strategy would be to use pharmaceutical agents which are known to influence the catecholaminergic system at various junctures. OBJECTIVES 1. To determine the effects of any of the following drugs for antipsychotic-induced TD in people with schizophrenia or other chronic mental illnesses.i. Drugs which influence the noradrenergic system.ii. Dopamine receptor agonists.iii. Dopamine receptor antagonists.iv. Dopamine-depletor drugs.v. Drugs that increase the production or release of dopamine.2. To examine whether any improvement occurred with short periods of intervention (less than 6 weeks) and, if this did occur, whether this effect was maintained at longer periods of follow-up.3. To examine if there was a differential effect for the various compounds.4. To examine whether the use of non-antipsychotic catecholaminergic drugs are most effective in those with more recent onset TD (less than five years). SEARCH METHODS We retrieved 712 references from searching the Cochrane Schizophrenia Group Trials Register (July 2015 and April 2017). We also inspected references of all identified studies for further trials and contacted authors of trials for additional information. SELECTION CRITERIA We selected studies if they were randomised controlled trials focusing on people with schizophrenia or other chronic mental illnesses and antipsychotic-induced tardive dyskinesia. We compared the use of catecholaminergic interventions versus placebo, no intervention, or any other intervention for the treatment of antipsychotic-induced tardive dyskinesia. DATA COLLECTION AND ANALYSIS We independently extracted data from these trials and we estimated risk ratios (RRs) with 95% confidence intervals (CIs). We assumed that people who left the studies early had no improvement. MAIN RESULTS There are 10 included trials (N = 261) published between 1973 and 2010; eight are new from the 2015 and 2017 update searches. Forty-eight studies are excluded. Participants were mostly chronically mentally ill inpatients in their 50s, and studies were primarily of short (2 to 6 weeks) duration. The overall risk of bias in these studies was unclear, mainly due to poor reporting of allocation concealment and generation of the sequence. Studies were also not clearly blinded and we are unsure if data are incomplete or selectively reported, or if other biases were operating.One small, three-arm trial found that both alpha-methyldopa (N = 20; RR 0.33, 95% CI 0.14 to 0.80; low-quality evidence) and reserpine (N = 20; RR 0.52 95% CI 0.29 to 0.96; low-quality evidence) may lead to a clinically important improvement in tardive dyskinesia symptoms compared with placebo after 2 weeks' treatment, but found no evidence of a difference between alpha-methyldopa and reserpine (N = 20; RR 0.60, 95% CI 0.19 to 1.86; very low quality evidence). Another small trial compared tetrabenazine and haloperidol after 18 weeks' treatment and found no evidence of a difference on clinically important improvement in tardive dyskinesia symptoms (N = 13; RR 0.93, 95% CI 0.45 to 1.95; very low quality evidence). No study reported on adverse events.For remaining outcomes there was no evidence of a difference between any of the interventions: alpha-methyldopa versus placebo for deterioration of tardive dyskinesia symptoms (1 RCT; N = 20; RR 0.33, 95% CI 0.02 to 7.32; very low quality evidence), celiprolol versus placebo for leaving the study early (1 RCT; N = 35; RR 5.28, 95% CI 0.27 to 102.58; very low quality evidence) and quality of life (1 RCT; N = 35; RR 0.87, 95% CI 0.68 to 1.12; very low quality evidence), alpha-methyldopa versus reserpine for deterioration of tardive dyskinesia symptoms (1 RCT; N = 20; not estimable, no reported events; very low quality evidence), reserpine or carbidopa/levodopa versus placebo for deterioration of tardive dyskinesia symptoms (2 RCTs; N = 37; RR 1.18, 95% CI 0.35 to 3.99; very low quality evidence), oxypertine versus placebo for deterioration of mental state (1 RCT; N = 42; RR 2.20, 95% CI 0.22 to 22.45; very low quality evidence), dopaminergic drugs (amantadine, bromocriptine, tiapride, oxypertine, carbidopa/levodopa) versus placebo for leaving the study early (6 RCTs; N = 163; RR 1.29, 95% CI 0.65 to 2.54; very low quality evidence), and tetrabenazine versus haloperidol for deterioration of tardive dyskinesia symptoms (1 RCT; N = 13; RR 1.17, 95% CI 0.09 to 14.92) and leaving the study early (1 RCT; N = 13; RR 0.23, 95% CI 0.01 to 4.00). AUTHORS' CONCLUSIONS Although there has been a large amount of research in this area, many studies were excluded due to inherent problems in the nature of their cross-over designs. Usually data are not reported before the cross-over and the nature of TD and its likely response to treatments make it imprudent to use this data. The review provides little usable information for service users or providers and more well-designed and well-reported studies are indicated.


title: Laboratory surveillance for SARS-CoV-2 in India: Performance of testing & descriptive epidemiology of detected COVID-19, January 22 - April 30, 2020.

text: Background & objectives India has been reporting the cases of coronavirus disease 2019 (COVID-19) since January 30, 2020. The Indian Council of Medical Research (ICMR) formulated and established laboratory surveillance for COVID-19. In this study, an analysis of the surveillance data was done to describe the testing performance and descriptive epidemiology of COVID-19 cases by time, place and person. Methods The data were extracted from January 22 to April 30, 2020. The frequencies of testing performance were described over time and by place. We described cases by time (epidemic curve by date of specimen collection; seven-day moving average), place (area map) and person (attack rate by age, sex and contact status), and trends were represented along with public health measures and events. Results Between January 22 and April 30, 2020, a total of 1,021,518 individuals were tested for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Testing increased from about 250 individuals per day in the beginning of March to 50,000 specimens per day by the end of April 2020. Overall, 40,184 (3.9%) tests were reported positive. The proportion of positive cases was highest among symptomatic and asymptomatic contacts, 2-3-fold higher than among those with severe acute respiratory infection, or those with an international travel history or healthcare workers. The attack rate (per million) by age was highest among those aged 50-69 yr (63.3) and was lowest among those under 10 yr (6.1). The attack rate was higher among males (41.6) than females (24.3). The secondary attack rate was 6.0 per cent. Overall, 99.0 per cent of 736 districts reported testing and 71.1 per cent reported COVID-19 cases. Interpretation & conclusions The coverage and frequency of ICMR's laboratory surveillance for SARS-CoV-2 improved over time. COVID-19 was reported from most parts of India, and the attack rate was more among men and the elderly and common among close contacts. Analysis of the data indicates that for further insight, additional surveillance tools and strategies at the national and sub-national levels are needed.


title: Wire escalation in emergent revascularization procedures of internal carotid artery occlusions: the use of high tip stiffness microguidewires.

text: OBJECTIVE We examined the usefulness and safety of high tip stiffness cardiac microguidewires in the endovascular revascularization of selected cases of internal carotid artery (ICA) occlusion. METHODS Files of patients with acute ischemic symptoms due to ICA occlusions managed from August 2010 to August 2016 by urgent endovascular revascularization were retrospectively reviewed with a waiver of informed consent. Cases where there was escalation to stiff tipped cardiovascular microguidewires after at least two failed attempts to cross the carotid occlusion with standard neuro-microguidewires were included. Radiological and interventional data were recorded. RESULTS 63 patients with acute carotid occlusions underwent emergent endovascular revascularization in the study period; 5/63 patients met the inclusion criteria. In 4/5 patients, there was no angiographic evidence of the remnant origin of the ICA; in 1/5 there was a wide round shaped proximal calcified cap that precluded soft guidewire entry. In all cases, antegrade wiring was achieved only after switching to stiffer guidewires designed for the management of chronic cardiac occlusions. The use of these stiffer tip wires was considered of critical importance in achieving the successful performance of the ICA revascularization procedure. In all patients, revascularization was achieved, and 90 day modified Rankin Scale score ranged from 0 to 2. CONCLUSIONS When regular neuro-guidewires do not allow antegrade wiring in cases of ICA occlusion, wire escalation to high tip stiffness guidewires may improve success. These wires, designed to deal with chronic total coronary occlusions, can serve as a platform for new neuro-guidewires to be used in the challenging field of resistant supra-aortic occlusions.


title: Risk factors analysis and nomogram construction of non-survivors in critical patients with COVID-19.

text: A pandemic named coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbroke in China since December 2019. This disease has caused more than 70000 deaths worldwide. We intend to analyze the risk factors of death and establish a prognosis nomogram for critical patients with COVID-19. We analyzed the clinical data of COVID-19 patients in Zhongnan Hospital of Wuhan University who were critical cases with COVID-19 before March 20, 2020. Data were collected at admission and compared between survivors and non-survivors and analyzed by univariable and multivariable logistic regression analysis. Finally, 104 patients were included, and 50 of whom died. Age [ OR 5.73 (95% CI, 1.14-28.81)], chest tightness [OR 5.50 (95%CI, 1.02-29.64)], AST [OR 6.57 (95%CI, 1.33-32.48)]and BUN [5.59 (95%CI, 1.05-29.74)] at admission were considered to predict the risk of death in critical patients and were selected to construct the nomogram. Subsequently, we established a nomogram model and validated it. The sensitivity and specificity of the nomogram were 96.0% and 74.1%, respectively. The AUC was 0.893 (95% CI, 0.807-0.980).


title: The Silver Lining to COVID-19: Avoiding Diabetic Ketoacidosis Admissions with Telehealth.

text: Background: The Stay at Home order in Colorado and The Stay Safe at Home order in California during COVID-19 pandemic have forced a majority of the endocrinologists/diabetologists to adapt to providing diabetes care remotely through telehealth. This may provide increased access to diabetes health care in certain settings. However, health care disparities continue to challenge availability of diabetes technologies for underprivileged communities. We report our experience with two patients providing diabetes care effectively and preventing hospital admissions by using telehealth. Methods: Two adult patients with type 1 diabetes (T1D): one new onset and the other one with established T1D are presented where telehealth facilitated by Clarity Software and the "Share" feature with the use of Dexcom G6 continuous glucose monitoring (CGM) for management of diabetic ketosis and hyperglycemia. Results: Both patients were managed effectively virtually despite higher risk of diabetic ketoacidosis (DKA). Shared glucose data through CGM facilitated frequent insulin dose adjustments, increased fluid and carbohydrate intake, and prevented hospital admissions in both cases. In the case of new onset patient with T1D, most of the education was done remotely by certified diabetes care and education specialists. Conclusion: Acute diabetes complication like DKA increases morbidity and mortality in addition to adding cost to the health care system. The current pandemic of COVID-19 has allowed newer ways (with the help of newer technologies) to manage high-risk patients with T1D and DKA through telehealth and may result in lasting benefits to people with T1D.


title: COVID-19 in a Long-Term Care Facility - King County, Washington, February 27-March 9, 2020.

text: On February 28, 2020, a case of coronavirus disease (COVID-19) was identified in a woman resident of a long-term care skilled nursing facility (facility A) in King County, Washington.* Epidemiologic investigation of facility A identified 129 cases of COVID-19 associated with facility A, including 81 of the residents, 34 staff members, and 14 visitors; 23 persons died. Limitations in effective infection control and prevention and staff members working in multiple facilities contributed to intra- and interfacility spread. COVID-19 can spread rapidly in long-term residential care facilities, and persons with chronic underlying medical conditions are at greater risk for COVID-19-associated severe disease and death. Long-term care facilities should take proactive steps to protect the health of residents and preserve the health care workforce by identifying and excluding potentially infected staff members and visitors, ensuring early recognition of potentially infected patients, and implementing appropriate infection control measures.


title: Utility of nociceptive flexion reflex threshold and bispectral index to predict movement responses under propofol anaesthesia.

text: INTRODUCTION The nociceptive flexion reflex threshold (NFRT) is a promising tool to monitor analgesia during general anaesthesia. Clinical studies have shown that the NFRT allows to predict movement responses to painful stimuli under a combined anaesthetic regime of sedative and opioid agents. Experimental studies indicated that the NFRT is also able to predict such movement responses under an exclusively sedative regime like propofol mono-anaesthesia. Therefore, we performed this study to investigate the ability of the NFRT to predict movement responses to painful stimuli in patients during a clinical propofol mono-anaesthesia. METHODS We investigated 140 cardiac surgery patients during their postoperative phase under propofol mono-anaesthesia. NFRT and bispectral index (BIS) were determined in each patient right before endotracheal suctioning or painful electrical test stimulation. Prediction probabilities were calculated to quantify how accurate each measure is able to predict movement responses to the stimuli. RESULTS The 124 patients included in the analysis received a median propofol dosage of 3.2 (2.5-3.9) [median (IQR)] mg/kg/h. The included patients showed 287 movement responses after a total of 725 investigated stimuli. The prediction probabilities for positive movement responses were 0.63 (95%CI: 0.59-0.67) for the NFRT and 0.69 (95%CI: 0.65-0.73) for the BIS. CONCLUSIONS The NFRT allows the prediction of movement responses under propofol mono-anaesthesia, which confirms its utility as a monitor to predict movement responses under general anaesthesia. The BIS allows an even more accurate prediction, although it does not reflect the physiological structures of movement suppression, but correlates closely with the dose of propofol. TRIAL REGISTRATION German clinical trial register (DRKS00003062, Deutsches Register Klinischer Studien).


Understanding the cytokine storm during COVID-19: Contribution of preexisting chronic inflammation.


title: Evaluation of methods based on creatinine and cystatin C to estimate glomerular filtration rate in chronic kidney disease.

text: PURPOSE Estimated glomerular filtration rate (GFR) is a useful tool for the detection of chronic kidney disease (CKD). Several methods have been proposed, but findings can vary in specific groups such as patients with diabetes, elderly and high and low body mass index and, also, with the stage of CKD. The objective of this study was comparing the accuracy of the currently used equations for estimating GFR with that of the gold standard technetium-(99m)-diethylene triamine pentaacetic acid (99mTc-DTPA). METHODS We performed a cross-sectional study of 129 patients with all five CKD stages. GFR was estimated using the following: 24-h urine creatinine clearance, Cockcroft-Gault equation, MDRD equation, CKD-EPI equation, Hoek's cystatin C equation, and isotopic 99mTc-DTPA (as gold standard). We evaluated agreement in the whole study population and according to age, sex, weight, and diabetes. RESULTS All methods had good agreement. The best agreement was observed with the cystatin C [intraclass coefficient correlation (ICC) 95 % confidence interval (95 % CI), 0.87 (0.82-0.91)], followed by CKD-EPI [ICC 0.83 (0.77-0.88)]. Twenty-four-hour urine creatinine clearance showed the worst agreement in patients older than 65 years [ICC 0.70 (0.56-0.79)]. The Cockcroft-Gault equation showed the worst agreement in younger than 65 years [ICC 0.64 (0.42-0.79)]. The best agreement for classification in the correct CKD stage was with the cystatin C equation [κ = 0.80 (0.74-0.87)]. GFR was overestimated with all methods in CKD stages 4 and 5. CONCLUSIONS The methods used in clinical practice are adequate for classification of CKD. Cystatin C is the most accurate method, followed by CKD-EPI. The Cockcroft-Gault equation is not accurate in young patients. Twenty-four-hour urine creatinine clearance loses accuracy in patients aged older than 65 years.


title: Routine Shunting During Carotid Endarterectomy in Patients With Acute Watershed Stroke.

text: AIM To evaluate the protective role of routine shunting in patients with acute watershed stroke (WS) undergoing carotid endarterectomy (CEA). METHODS A total of 138 patients with symptomatic carotid stenosis (SCS) who underwent CEA after acute ischemic stroke from March 2008 to March 2015 were included in this study. Transient ischemic attacks were excluded. These patients were divided into 2 groups according to the topographic pattern of the stroke on magnetic resonance imaging: group 1, territorial strokes (TS) caused by emboli of carotid origin, and group 2, WS caused by a hemodynamic mechanism related to an SCS. Primary end points were 30-day mortality and postoperative neurological morbidity. The insertion of a Pruitt carotid shunt was performed systematically. RESULTS Ninety (65.2%) patients presented a TS of carotid origin and were included in group 1, and 48 (34.8%) of the 138 patients had a WS related to an SCS and were included in group 2. The median time between clinical onset of the cerebral ischemic event and surgery was 9 days (range: 0-89 days). Postoperative mortality was 0%. Seven (5.1%) patients had an aggravation of the neurological status during the postoperative period, of whom 2 presented a complete regression of the symptoms in less than 1 hour (definitive postoperative neurologic morbidity: 3.6%). Postoperative neurologic morbidity rate was significantly higher in the TS group (7 of 90; 7.8%) compared to the WS group (0 of 48; P = .04). No other independent predictive factor of neurologic morbidity after CEA for an SCS was found. CONCLUSIONS Our results suggest that routine shunting should be considered in case of acute WS since it may play a protective role. Further studies are eagerly awaited to better define the timing and the best treatment option for both acute WS and TS related to an SCS in order to reduce postoperative neurologic morbidity.


Early clinical response to a high consequence infectious disease outbreak: insights from COVID-19.


title: Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients.

text: Background and Purpose- Sustained successful reperfusion is an important prognostic factor for good clinical outcome in acute ischemic stroke. We aimed to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies within a prospective cohort. Methods- A total of 711 stroke patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b/3) followed with magnetic resonance or computed tomographic angiography at 24 to 48 hours were included. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. Results are displayed as adjusted odds ratio (aOR) and 95% CI. Improvement in accuracy of additional imaging findings on angiography control runs after the intervention was evaluated by area under the curve. Results- Early reocclusion was observed in 16 of 711 successfully reperfused patients (2.3%; 95% CI, 1.1-3.3; median delay: 20 hours). Suggestive predictors were higher platelets on admission (aOR, 1.01; 95% CI, 1.01-1.02), prestroke functional dependence (aOR, 7.12; 95% CI, 1.49-34.03), and stroke of undetermined or other specified pathogenesis in the TOAST classification (aOR, 7.19; 95% CI, 1.10-47.05 and aOR, 36.50; 95% CI, 4.47-298.11, respectively). When implementing residual embolic fragments or stenosis at the thrombectomy site into the logistic regression model, discrimination between patients with and without reocclusion improved significantly (area under the curve, 0.955 versus 0.854; P=0.023). Early reocclusion was an independent predictor of unfavorable outcome at 90 days (aOR for modified Rankin Scale ≤2, 0.13; 95% CI, 0.03-0.57). Conclusions- Early reocclusion within 48 hours after successful mechanical thrombectomy is rare but associated with poor outcome. Patients with high platelets on admission and residual embolic fragments or stenosis at the thrombectomy site are at high risk for reocclusion, which may be prevented or corrected after carefully re-evaluating the last angiographic run.


title: Emerging, evolving, and established infectious diseases and interventions.

text: Planning, implementing, and evaluating interventions against infectious diseases depend on the nature of the infectious disease; the availability of intervention measures; and logistical, economic, and political constraints. Infectious diseases and vaccine- or drug-based interventions can be loosely categorized by the degree to which the infectious disease and the intervention are well established. Pertussis, polio, and measles are three examples of long-known infectious diseases for which global vaccination has dramatically reduced the public health burden. Pertussis vaccination was introduced in the 1940s, polio vaccination in the 1950s, and measles vaccination in the 1960s, nearly eliminating these diseases in many places.


title: Network Properties in Transitions of Consciousness during Propofol-induced Sedation.

text: Reliable electroencephalography (EEG) signatures of transitions between consciousness and unconsciousness under anaesthesia have not yet been identified. Herein we examined network changes using graph theoretical analysis of high-density EEG during patient-titrated propofol-induced sedation. Responsiveness was used as a surrogate for consciousness. We divided the data into five states: baseline, transition into unresponsiveness, unresponsiveness, transition into responsiveness, and recovery. Power spectral analysis showed that delta power increased from responsiveness to unresponsiveness. In unresponsiveness, delta waves propagated from frontal to parietal regions as a traveling wave. Local increases in delta connectivity were evident in parietal but not frontal regions. Graph theory analysis showed that increased local efficiency could differentiate the levels of responsiveness. Interestingly, during transitions of responsive states, increased beta connectivity was noted relative to consciousness and unconsciousness, again with increased local efficiency. Abrupt network changes are evident in the transitions in responsiveness, with increased beta band power/connectivity marking transitions between responsive states, while the delta power/connectivity changes were consistent with the fading of consciousness using its surrogate responsiveness. These results provide novel insights into the neural correlates of these behavioural transitions and EEG signatures for monitoring the levels of consciousness under sedation.


What's in a name? Issues to consider when naming Mendelian disorders.


title: Digital health and the COVID-19 epidemic: an assessment framework for apps from an epidemiological and legal perspective.

text: As COVID-19 spreads across the globe, crowdsourced digital technology harbours the potential to improve surveillance and epidemic control, primarily through increased information coverage, higher information speed, fast case tracking and improved proximity tracing. Targeting those aims, COVID-19-related smartphone and web-based health applications are continuously emerging, leading to a multitude of options, raising ethical and legal challenges and potentially overwhelming end users. Building on an existing trustworthiness checklist for digital health applications, we searched the literature and developed a framework to guide the assessment of smartphone and web-based applications that aim to contribute to controlling the current epidemic or mitigating its effects. It further integrates epidemiological subject knowledge and a legal analysis, outlining the mechanisms through which new applications can support the fight against COVID-19. The resulting framework includes 40 questions across 8 domains on “purpose”, “usability”, “information accuracy”, “organisational attributes / reputation”, “transparency”, “privacy” and “user control / self-determination”. All questions should be primarily answerable from publicly available data, as provided by application manufacturers. The framework aims to guide end users in choosing a transparent, safe and valuable application and suggests a set of information items that developers ideally make available to allow a balanced judgement and facilitate the trustworthiness of their products.


docid: okmtkqao

title: Incidental detection of asymptomatic migration of Hem-o-lok clip into the bladder after laparoscopic radical prostatectomy.

text: Hem-o-lok clips have been widely used in laparoscopic or robot-assisted surgery. We report a case of an incidentally discovered Hem-o-lok migration into the bladder after laparoscopic radical prostatectomy. The patient was a 75-year-old man with localized prostate cancer who underwent laparoscopic radical prostatectomy in July 2009. At 3 postoperative years, follow-up ultrasonography revealed a small round mass in the bladder. No lower urinary tract symptoms were reported, and urinalysis results had never indicated hematuria or pyuria. Cystoscopy revealed a Hem-o-lok clip in the bladder, near the vesicourethral anastomotic site. We could not remove it with forceps in the outpatient clinic, so we performed the procedure again under general anesthesia and successfully removed the Hem-o-lok clip. To our knowledge, this is the first report of an asymptomatic Hem-o-lok migration into the bladder.


title: Single- versus multiple-port thoracoscopic lobectomy for lung cancer: a propensity-matched study†.

text: OBJECTIVES In this retrospective study, we aimed to compare single-port (SP) and multiport (MP) video-assisted thoracoscopic surgery (VATS) for the surgical resection of non-small-cell lung cancer (NSCLC). METHODS Between October 2013 and October 2014, a total of 411 consecutive NSCLC patients who underwent VATS lobectomy in the Department of Thoracic Surgery, Zhongshan Hospital of Fudan University, were enrolled. Propensity-matched analysis, incorporating preoperative clinical features, was used to compare the perioperative outcomes and analyse the safety and efficacy between SP and MP VATS lobectomies for NSCLCs. RESULTS There were 115 patients in the SP group, and 296 patients in the MP group from October 2013 to October 2014. Propensity matching produced 100 pairs in this retrospective study. During the operation, the lobectomy took less time in the SP than in the MP (65.7 ± 14.8 vs 81.3 ± 13.6, P < 0.001) group, while the duration of lymphadenectomy was longer in the SP group (29.6 ± 16.7 vs 17.4 ± 13.3, P < 0.001). The total operation duration, the volume of estimated blood loss (55.1 ± 9.0 ml vs 58.7 ± 7.1 ml, P = 0.22) and the length of postoperative hospital stay (4.7 ± 1.2 days vs 5.3 ± 1.4 days, P = 0.05) were similar between the two groups. Postoperatively, SP and MP groups showed similar results in terms of morbidity and mortality. CONCLUSIONS In comparison with conventional VATS, SP VATS lobectomy showed better safety and efficacy in the surgical resection of NSCLCs. Further studies based on larger populations and better methodology are required to determine its further benefits towards patients.


docid: rmpoxuua

title: The Preoperative Prognostic Nutritional Index for the Prediction of Outcomes in Patients with Early-Stage Ovarian Clear Cell Carcinoma.

text: The prognostic nutritional index (PNI), which reflects preoperative malnutrition, is useful for predicting the incidence of postoperative complications and has been reported in recent years to predict the long-term prognosis of various malignancies. The purpose of this study was to clarify the significance of PNI as a prognostic factor for early-stage clear cell ovarian carcinoma. A total of 82 patients with stage I-II (FIGO 2014) ovarian clear cell carcinoma undergoing primary surgery at our hospital from January 2005 to December 2017 were enrolled. PNI was calculated using the formula: 10 × serum albumin (g/ dL) + 0.005 × peripheral blood lymphocyte count (/mm3). Preoperative PNI exhibited relatively high area under the curve value (0.709) for 5 year survival, and the optimal cutoff value was 46.5. The overall survival was significantly shorter in the PNI-low group than in the PNI-high group. Multivariate analysis showed that high PNI was a significant independent prognostic factor for favorable prognosis (hazard ratio = 0.102, p = 0.010). There was no significant difference in recurrence-free survival between the two groups (p = 0.220), but the postrecurrence survival was significantly longer in the PNI-high group than in the PNI-low group (p = 0.0383). The preoperative PNI was a useful predictor of prognosis, even in early-stage ovarian clear cell carcinoma.


title: NLR: A Cost-effective Nomogram to Guide Therapeutic Interventions in COVID-19.

text: COVID-19 exhibits a non-yet elucidated heterogeneity dominated by mild form of the illness. Nevertheless, mortality is frequent among patients with a delayed innate immune response that suddenly exacerbates during the second week after admission leading to a lethal over inflammation. Therefore, this rapid and unpredictable deterioration requires timely prediction of COVID-19 refractoriness and critical illness. The two biomarkers readily available in routine laboratories, blood lymphocytes and neutrophil counts, are expected to provide an accurate clinical tool to incline reasonable medication and care because lymphopenia marks immune exhaustion while neutrophilia demonstrates the immunological exuberation. Meanwhile, combining the two parameters as a Neutrophil-to-lymphocyte ratio (NLR) helps to constitute a powerful predictive and prognostic nomogram. This scoring tool allows clinicians to stratify COVID-19 severities on admission and guide early interventions to accelerate recovery and shorten the course of disease in order to alleviate the shortage of medical resources and reduce mortality.


title: Obesity and Higher Risk for Severe Complications of Covid-19: What to do when the two pandemics meet.

text: The coronavirus disease 2019 (COVID-19) pandemic has spread around the globe, infecting more than ten million individuals, with more than 500,000 dead; about one half of the infected people have recovered. Despite this fact, a subgroup of individuals affected by COVID-19 is at greater risk of developing worse outcomes and experience a high rate of mortality. Data on the association between obesity and COVID-19 are growing; the available studies, have reported a high prevalence of overweight and obesity in patients experiencing a severe COVID-19 course, with serious complications requiring hospitalization and admission to intensive care units. This paper attempts to highlight potential mechanisms behind the greater vulnerability to COVID-19 of individuals with obesity. The presence of uncontrolled chronic obesity-related comorbidities, particularly pulmonary diseases, can present a primary fertile soil for respiratory tract infection. Combined with immune system impairments, such as alteration in the T-cell proliferation and macrophage differentiation, and the high pro-inflammatory cytokine production by the adipose organ, this may worsen the general condition toward a systemic diffusion of infection. Prevention remains the first line of intervention in these patients that can be achieved by adhering to social distancing and adopting hygiene precautions, combined with a healthy lifestyle. Patients with obesity require preferential access dedicated to primary care services to ensure they are regularly taking their medications for the treatment of any concurrent chronic diseases. Finally, their physicians must promptly manage any medical signs or symptoms in the case of suspected severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) infection to prevent the risk of severe outcomes.


title: Molecular characterization of infectious bronchitis virus isolates from Russia and neighbouring countries: identification of intertypic recombination in the S1 gene.

text: Infectious bronchitis virus (IBV) isolates recovered in Russia, Ukraine, and Kazakhstan between 2007 and 2010 were subjected to molecular characterization and compared with those isolated a decade ago. The IBV genome was detected in 202 out of 605 field samples from chickens with various clinical signs. Partial sequencing of the S1 gene revealed 153 vaccine strains and 49 field isolates of several genetic groups. Massachusetts, 793/B and D274 remained the predominant IBV genotypes along with QX, whereas B1648, Italy-02, Arkansas and variants accounted for about 12% of the total number. Three IBVs contained recombinant S1 gene sequences comprising genome fragments of QX-type field isolates and vaccine strains H120 (UKR/02/2009) or 4/91 (RF/03/2010), and vaccine strains H120 and D274 (RF/01/2010). The results of the present study showed a significant decline in prevalence of variant IBVs and a further spread of QX-type isolates in commercial chicken flocks in Russia as compared with the 1998 to 2002 data.


Editorial: Clinical trial design in the era of COVID-19.


docid: zpmhirii

title: Prevalence and predictors of medication non-adherence among patients with multimorbidity: A systematic review protocol.

text: Introduction: Patients with multimorbidity are expected to adhere to complex medication regimens in order to manage their multiple chronic conditions. It has been reported the likelihood of adherence decreases as patients are prescribed more medications. Much medication adherence research to date is dominated by a single-disease focus, which is at odds with the rising prevalence of multimorbidity and may artificially underestimate the complexity of managing chronic illness. This review aims to describe the prevalence of medication non-adherence among patients with multimorbidity, and to identify potential predictors of non-adherence in this population. Methods: A systematic review will be conducted and reported according to PRISMA guidelines. PubMed, EMBASE, CINAHL and PsycINFO will be searched using a predefined search strategy from 2009-2019. Quantitative studies will be considered eligible for review if prevalence of medication non-adherence among adults with two or more chronic conditions is reported. Studies will be included in the review if available in English full text. Titles and abstracts will be screened by single review, with 20% of screening cross-checked by a second reviewer. Full-text articles will be screened by two independent reviewers, noting reasons for exclusions. Data extraction will be performed using a predefined extraction form. Quality and risk of bias assessment will be conducted using criteria for observational studies outlined by Sanderson et al. (2007). A narrative synthesis and, if feasible, meta-analysis will be conducted. Discussion: By exploring medication non-adherence from a multimorbidity perspective, the review aims to inform an evidence base for intervention development which accounts for the rising prevalence of patients with multiple chronic conditions. Study registration: The systematic review is prospectively registered in PROSPERO ( CRD42019133849); registered on 12 June 2019.


title: Analysis of neuron-specific enolase and S100B as biomarkers of cognitive decline following surgery in older people.

text: BACKGROUND/AIMS Post-operative cognitive decline is frequent in older individuals following major surgery; however, biomarkers of this decline are less clearly defined. METHODS Sixty-eight participants over the age of 60 provided blood samples at baseline and 24 h post-surgery. Cognitive decline was measured at baseline and 52 weeks post-surgery using the Cambridge Assessment for Mental Disorder in the Elderly, section B (CAMCOG) score. Plasma levels of neuron-specific enolase (NSE) and S100B were measured by ELISA. RESULTS Baseline NSE and the change in NSE levels between baseline and 24 h were correlated with the change in CAMCOG score between baseline and 52 weeks. CONCLUSION NSE concentrations may be a useful predictor of individuals at risk of more severe long-term cognitive decline.


title: Flexibility of Finger Activation Patterns Elicited through Non-invasive Multi-Electrode Nerve Stimulation.

text: The inability to effectively activate and control skeletal muscles is a common impairment following a variety of neurological conditions or injuries. One common approach to restoring or augmenting this impairment is the use of external electrical stimulation of the muscles, called functional electrical stimulation (FES). Typically targeted directly at the anatomical muscle belly, existing methodologies often involve high current amplitudes, limited superficial muscle activation, and early onset of muscle fatigue. We have recently explored the capabilities of a non-invasive peripheral nerve stimulation method for the dexterous control of finger and hand muscles. Further development of our stimulation system has enabled us to manually search across a variety of stimulation locations with increased consistency and efficiency. This study examined the preliminary results in two subjects of an automated stimulation system which can rapidly characterize a large combination of stimulation electrodes. Our preliminary findings suggested that the stimulation grid was able to produce a number of clustered EMG activities and finger forces. This robust ability to flexibly generate different grasp patterns demonstrates the promise of the methodology in future applications for FES and rehabilitation.


title: Pediatric Microlaryngoscopy and Bronchoscopy in the COVID-19 Era.

text: Importance As an aerosol-generating procedure, traditional pediatric microlaryngoscopy and bronchoscopy techniques must be adapted in order to reduce the risk of transmission of severe acute respiratory syndrome coronavirus 2. Objective To describe a modified technique for pediatric microlaryngoscopy and bronchoscopy for use in the COVID-19 era and present a case series of patients for whom the technique has been used. Design, Setting, and Participants Observational case series of pediatric patients undergoing emergency or urgent airway procedures performed at a tertiary pediatric otolaryngology department in Australia. Procedures were completed between March 23 and April 9, 2020, with a median (range) follow-up of 24.5 (11-28) days. Exposures Modified technique for microlaryngoscopy and bronchoscopy, minimizing aerosolization of respiratory tract secretions. Main Outcomes and Measures The main outcome was the feasibility of technique, which was measured by ability to perform microlaryngoscopy and bronchoscopy with comparable success to the usual technique (ie, adequate examination of the patient for diagnostic procedures and ability to perform interventional procedures). Results The technique was used successfully in 8 patients (median [range] age, 160 days [27 days to 2 years 6 months]); 5 patients were male, and 3 were female. Intervention was performed on 6 patients; 2 balloon dilations for subglottic stenosis, 2 injections of hyaluronic acid for type 1 clefts, and 2 cold-steel supraglottoplasties. No adverse events occurred. Conclusions and Relevance In this case series, feasibility of a modified technique for pediatric microlaryngoscopy and bronchoscopy was demonstrated. By reconsidering the surgical approach in light of specific COVID-19 infection risks, this technique may be associated with reduced spread of aerosolized respiratory secretions perioperatively and intraoperatively, but the technique and patient outcomes require further study.


title: Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective.

text: The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making.


Diabetes and COVID-19.


title: Endotracheal tube cuff--small important part of a big issue.

text: Many of the complications related to prolonged ventilation are related to inappropriate handling of endotracheal tube (ETT) cuff. This article reviews the possible complications associated with the ETT cuff, and the landmark development made in that field. The article challenges the present paradigm of cuff use and reviews the current clinical practice in that area.


title: Pharmacokinetics and pharmacodynamics of propofol: changes in patients with frontal brain tumours.

text: Background Models of propofol pharmacokinetics and pharmacodynamics developed in patients without brain pathology are widely used for target-controlled infusion (TCI) during brain tumour excision operations. The goal of this study was to determine if the presence of a frontal brain tumour influences propofol pharmacokinetics and pharmacodynamics and existing PK-PD model performance. Methods Twenty patients with a frontal brain tumour and 20 control patients received a propofol infusion to achieve an induction-emergence-induction anaesthetic sequence. Propofol plasma concentration was measured every 4 min and at each transition of the conscious state. Bispectral index (BIS) values were continuously recorded. We used non-linear mixed-effects modelling to analyse the effects of the presence of a brain tumour on the pharmacokinetics and pharmacodynamics of propofol. Subsequently we calculated the predictive performance of Marsh, Schnider, and Eleveld models in terms of median prediction error (MdPE) and median absolute prediction error (MdAPE). Results Patients with brain tumours showed 40% higher propofol clearance than control patients. Performance of the Schnider model (MdPEpk -20.0%, MdAPEpk 23.4%) and Eleveld volunteer model (MdPEpk -8.58%, MdAPEpk 21.6%) were good. The Marsh model performed less well (MdPEpk -14.3%, MdAPEpk 41.4%), as did the Eleveld patient model (MdPEpk -30.8%, MdAPEpk 32.1%). Conclusions Brain tumours might alter the pharmacokinetics of propofol. Caution should be exerted when using propofol TCI in patients with frontal brain tumours due to higher clearance. Trial registry number NCT01060631.


title: Corridor-based endonasal endoscopic surgery for pediatric skull base pathology with detailed radioanatomic measurements.

text: BACKGROUND Pediatric anatomy is more restricted, and the propagation of endonasal endoscopic approaches in the pediatric population has been limited. OBJECTIVE To demonstrate the feasibility of the endonasal endoscopic approach in a variety of age groups and to perform measurements of the corridors and spaces available for surgery as a guide for case selection. METHODS Only patients <18 years were included. The choice of operative corridor/approach is described in relation to pathological entity and location. Preoperative/postoperative visual fields and endocrine panels, extent of resection, as well as postoperative long-term complications are described. Prospective magnetic resonance image-based anatomic measurements of key distances were performed to determine age-dependent surgical indications and limitations. RESULTS Forty purely endoscopic procedures were performed in 33 pediatric patients (5-18 years of age) harboring a variety of skull base lesions, from benign tumors to congenital malformations. For the 20 patients in whom gross total resection was the intended goal of surgery, gross total resection was attained in 15 (75%). There were 2 infections (5%) and no cerebrospinal fluid leaks. Significant improvement was shown in 58.3% of patients with visual deficits. Hormone overproduction resolved in 75% of patients, while preoperative hormone insufficiency only improved in 29.2%. Wider intercarotid distance at the superior clivus (P = .01) and shorter nare-dens working distance (P = .001) predicted improved outcomes and fewer postoperative complications. CONCLUSION Endonasal endoscopic skull base approaches are viable in the pediatric population, they are not impeded by sphenoid sinus aeration, and they have minimal risk of cerebrospinal fluid leak and meningitis. Outcomes and complications can be predicted based on specific radio anatomical skull base measurements rather than age.


title: Hospital Variation in Functional Recovery After Stroke.

text: BACKGROUND Functional status is a key patient-centric outcome, but there are little data on whether functional recovery post-stroke varies among hospitals. This study examined the distribution of functional status 3 months after stroke, determined whether these outcomes vary among hospitals, and identified hospital characteristics associated with better (or worse) functional outcomes. METHODS AND RESULTS Observational analysis of the AVAIL study (Adherence Evaluation After Ischemic Stroke-Longitudinal) included 2083 ischemic stroke patients enrolled from 82 US hospitals participating in Get With The Guidelines-Stroke and AVAIL. The primary outcome was dependence or death at 3 months (modified Rankin Scale [mRS] score of 3-6). Secondary outcomes included functional dependence (mRS score of 3-5), disabled (mRS score of 2-5), and mRS evaluated as a continuous score. By 3 months post-discharge, 36.5% of patients were functionally dependent or dead. Rates of dependence or death varied widely by discharging hospitals (range: 0%-67%). After risk adjustment, patients had lower rates of 3-month dependence or death when treated at teaching hospitals (odds ratio, 0.72; 95% confidence interval, 0.54-0.96) and certified primary stroke centers (odds ratio, 0.69; 95% confidence interval, 0.53-0.91). In contrast, a composite measure of hospital-level adherence to acute stroke care performance metrics, stroke volume, and bed size was not associated with downstream patient functional status. Findings were robust across mRS end points and sensitivity analyses. CONCLUSIONS One third of acute ischemic stroke patients were functionally dependent or dead 3 months postacute stroke; functional recovery rates varied considerably among hospitals, supporting the need to better determine which care processes can maximize functional outcomes.


title: Changing attitudes and improving skills: demonstrating the value of the SAGES flexible endoscopy course for fellows.

text: BACKGROUND The purpose of this study was to examine the effectiveness of the SAGES flexible endoscopy course in improving fellows' attitudes, confidence, and skills related to implementing endoscopy in practice. METHODS Fellows participated in a 2-day course consisting of case presentations, expert panels, and hands-on laboratory training. Before and after the course, fellows completed a questionnaire assessing demographics, experiences in residency, practice plans, plans to implement flexible endoscopy in practice, and level of confidence performing 15 endoscopic procedures. Half of the fellows were randomly assigned to complete pre- and post-skills testing using a previously validated endoscopic targeting model. RESULTS Fifty-four fellows (90 %; age 33.5 ± 2.8; 58 % male) completed the pre- and post-questionnaire. All MIS fellowship types were represented. Almost half (48 %) reported none or very little flexible endoscopy in their current fellowship. The average prior case volume among those completing an ACGME-approved residency (42/54) was 76 upper and 75 lower endoscopies with one-third reporting no experience in therapeutic EGD (33 %) or polypectomy (31 %). Intentions to implement flexible endoscopy in practice significantly improved after the course overall (3.72 ± .85-3.92 ± .69, p < 0.05; 1 = never; 5 = very frequently). Prior to the course, 39 % of fellows reported plans to use endoscopy in practice "occasionally" or "rarely." After, this decreased to 28 with 72 % planning to implement "frequently" or "very frequently." Mean levels of confidence performing all 15 endoscopic tasks improved significantly after the course. Skills performance for the 27 fellows improved significantly as well; participants decreased their time to perform the targeting task by 40 % (222.3 ± 119.8-133.0 ± 70.1 s; p < 0.001) and decreased errors by 49 % (2.9 ± 1.7-1.5 ± 1.5; p < 0.001). CONCLUSIONS These results indicate that the SAGES flexible endoscopy course increases fellow confidence to implement endoscopic techniques, expands the ways in which they plan to include endoscopy in practice, and enhances their endoscopic skills.


docid: frbfbswv

title: Antenatal Corticosteroids for Pregnant Women at High Risk of Preterm Delivery with COVID-19 Infection: A Decision Analysis.

text: OBJECTIVE Antenatal corticosteroids given prior to preterm deliveries reduce the risk of adverse neonatal outcomes. However, steroid administration in the setting of a viral respiratory infection can worsen maternal outcomes. Therefore, the decision to administer corticosteroids must balance the neonatal benefits with the potential harm to the mother if she is infected with the novel coronavirus disease 2019 (COVID-19). This study aimed to determine the gestational ages for which administering antenatal corticosteroids to women at high risk of preterm labor with concurrent COVID-19 infection results in improved combined maternal and infant outcomes. STUDY DESIGN A decision-analytic model using TreeAge (2020) software was constructed for a theoretical cohort of hospitalized women with COVID-19 in the United States. All model inputs were derived from the literature. Outcomes included maternal intensive care unit (ICU) admission and death, along with infant outcomes of death, respiratory distress syndrome, intraventricular hemorrhage, and neurodevelopmental delay. Quality-adjusted life years (QALYs) were assessed from the maternal and infant perspectives. Sensitivity analyses were performed to determine if the results were robust over a range of assumptions. RESULTS In our theoretical cohort of 10,000 women delivering between 24 and 33 weeks of gestation with COVID-19, corticosteroid administration resulted in 2,200 women admitted to the ICU and 110 maternal deaths. No antenatal corticosteroid use resulted in 1,500 ICU admissions and 75 maternal deaths. Overall, we found that corticosteroid administration resulted in higher combined QALYs up to 31 weeks of gestation in all hospitalized patients, and up to 29 weeks of gestation in ICU patients. CONCLUSION Administration of antenatal corticosteroids at less than 32 weeks of gestation for hospitalized patients and less than 30 weeks of gestation for patients admitted to the ICU resulted in higher combined maternal and infant outcomes compared with expectant management for women at high risk of preterm birth with COVID-19 infection. These results can guide clinicians in their counseling and management of these pregnant women. KEY POINTS · Antenatal steroids reduce adverse neonatal outcomes.. · Steroids worsen maternal outcomes in COVID-19.. · Steroids given < 32 weeks result in improved outcomes..


title: Bacterial contamination of suction catheter tips during aortic valve replacement surgery: a prospective observational cohort study.

text: BACKGROUND Bacterial mediastinitis is a severe complication after open heart surgery. The infection causes prolonged hospitalization and an increased mortality risk. Observations from orthopaedic surgery showed that the suction catheter used during surgery is commonly contaminated with bacteria. The aim of this study was to describe the prevalence of suction catheter contamination in cardiac surgery and to study if suction time influences the contamination risk. METHODS Fifty suction catheter tips were collected during 25 aortic valve replacement operations. The suction tip was exchanged once during the operation (after aortotomy closure). The tips were subjected to bacterial contamination analysis. RESULTS In 20 of the 25 investigated cases (80%), bacterial contamination was detected on one or both tips. The tip used during the beginning of the operation showed bacterial contamination in 13/25 cases (52%) and the second tip in 12/25 (48%). In 5/25 cases (20%) both tips were contaminated. There was no association between bacterial contamination and suction time. Coagulase-negative staphylococcus was the most commonly detected microorganism. CONCLUSIONS The suction device should be considered as a potential source of bacterial contamination in cardiac surgery. The results suggest that the suction catheter should be replaced before key moments like valve implantation and sternal closure.


Do Right to Try Laws Undermine the FDA'S Authority? An Examination of the Consequences of Unlimited Access to Unapproved Drugs.


title: Provision of Psychotherapy during the COVID-19 Pandemic among Czech, German and Slovak Psychotherapists.

text: Psychotherapists around the world are facing an unprecedented situation with the outbreak of the novel coronavirus disease (COVID-19). To combat the rapid spread of the virus, direct contact with others has to be avoided when possible. Therefore, remote psychotherapy provides a valuable option to continue mental health care during the COVID-19 pandemic. The present study investigated the fear of psychotherapists to become infected with COVID-19 during psychotherapy in personal contact and assessed how the provision of psychotherapy changed due to the COVID-19 situation and whether there were differences with regard to country and gender. Psychotherapists from three European countries: Czech Republic (CZ, n = 112), Germany (DE, n = 130) and Slovakia (SK, n = 96), with on average 77.8% female participants, completed an online survey. Participants rated the fear of COVID-19 infection during face-to-face psychotherapy and reported the number of patients treated on average per week (in personal contact, via telephone, via internet) during the COVID-19 situation as well as (retrospectively) in the months before. Fear of COVID-19 infection was highest in SK and lowest in DE (p < 0.001) and was higher in female compared to male psychotherapists (p = 0.021). In all countries, the number of patients treated on average per week in personal contact decreased (p < 0.001) and remote psychotherapies increased (p < 0.001), with more patients being treated via internet than via telephone during the COVID-19 situation (p < 0.001). Furthermore, female psychotherapists treated less patients in personal contact (p = 0.036), while they treated more patients via telephone than their male colleagues (p = 0.015). Overall, the total number of patients treated did not differ during COVID-19 from the months before (p = 0.133) and psychotherapy in personal contact remained the most common treatment modality. Results imply that the supply of mental health care could be maintained during COVID-19 and that changes in the provision of psychotherapy vary among countries and gender.


title: Clinical negligence claims following the COVID-19 pandemic.

text: John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses how the Courts may view clinical negligence claims brought by families who have lost loved ones during the pandemic.