title: Recent developments in flexor tendon repair techniques and factors influencing strength of the tendon repair.

text: Over the last decade, both basic researchers and surgeons have sought to identify the most appropriate techniques to be applied in flexor tendon repairs. Recent developments in experimental tendon repairs and clinical outcomes of newer repair techniques have been reviewed in an attempt to comprehensively summarize the most critical mechanical factors affecting the performance of tendon repairs and the surgical factors influencing clinical outcomes. Among them, attention to annular pulleys, the purchase and tension of the core suture, and the direction and curvature of the path of tendon motion have been found to be determining factors in the results of tendon repair.


title: Single-incision laparoscopic surgery for ileocolic resection in Crohn's disease.

text: BACKGROUND Single-incision laparoscopic surgery is a development in the field of minimally invasive surgery that is being increasingly used for colorectal procedures. OBJECTIVE We report on the short-term results of single-port laparoscopic ileocolic resection in patients with ileocecal Crohn's disease. DESIGN This investigation is a retrospective matched-pair control study. Data were obtained from a prospectively maintained single-institution inflammatory bowel disease database. SETTINGS This study was conducted at a tertiary care university hospital. PATIENTS Twenty consecutive patients receiving elective single-port ileocolic resection between April 2010 and May 2011 were included (6 male, 14 female; age, 31.6 ± 10.8 years; BMI, 21.5 ± 2.6 kg/m). Their data were compared with the data of 20 individually matched patients who had undergone standard 3-trocar laparoscopic-assisted ileocolic resection between 2007 and 2010 (6 male, 14 female; age, 31.7 ± 10.7 years; BMI, 21.2 ± 2.5 kg/m). All patients had medically refractory stenosis of the terminal ileum in histologically confirmed Crohn's disease. INTERVENTIONS Single-port laparoscopic-assisted or standard laparoscopic-assisted ileocolic resection was performed. MAIN OUTCOME MEASURES The primary outcomes measured were the surgical details and early outcome. RESULTS : The mean length of the paraumbilical single-port incision was 3.8 cm (range, 2.5-5.0 cm). Conversion rates were similar in both groups (1/20 vs 2/20, p = 0.55). Additional strictureplasties or short-segment small-bowel resections were performed in both groups. The overall complication rate was 20% (4/20) in both groups. There were no observed differences in postoperative pain scores and hospital stay duration. LIMITATIONS The limitations of this study were as follows: this study was a comparison of 2 different time points with possible selection bias, there was no prestudy power calculation, and the study might be underpowered. CONCLUSIONS Single-port ileocolic resection is a safe procedure for the surgical treatment of stenotizing Crohn's disease of the terminal ileum. Avoidance of additional trocars was the only identified benefit.


COVID-19 and a New Normal?


title: Warfarin-induced life-threatening bleeding associated with a CYP3A4 loss-of-function mutation in an acute limb ischemia patient: Case report and review of the literature.

text: Patients with acute limb ischemia, deep venous thrombosis and pulmonary artery embolism may be treated with warfarin. The dose-response interaction of warfarin is associated with numerous factors, depending on which an uncommon life-threatening bleeding may occur. The present case study reported on a patient with acute limb ischemia and a history of warfarin-induced bleeding ten years previously and who again developed life threatening bleeding associated with warfarin treatment and received vascular surgery. In this patient, a cytochrome P450 3A4 loss-of-function mutation decreased the effective dose of warfarin. Although this was a rare case, clinicians should be alert to the bleeding risk associated with such rare genetic mutations.


title: Laparoscopic Distal Pancreatectomy of a Solid Pseudopapillary Tumor (SPT) Achieves Long-Term Oncologic Safety and Multiorgan Preservation.

text: The oncological safety of a laparoscopic approach for solid pseudopapillary tumors (SPTs) of the pancreas remains a matter of debate. We present the long-term follow-up of an adolescent girl with an SPT in the pancreatic tail. A multimodality workup including magnetic resonance imaging (MRI) revealed a complex, spherical mass of 4.4 cm × 3.6 cm × 4 cm most likely located in the pancreatic tail. All routine laboratory investigations and tumor markers were within normal limits (alpha fetoprotein [AFP], cancer antigen 125 [CA125], CA 19-9, carcinoembryonic antigen [CEA], adrenocorticotropic hormone [ACTH]). Diagnostic laparoscopy was performed to verify the origin of the tumor in the pancreatic tail. In a three-port technique the tumor was mobilized of the splenic vessels until a distal pancreatectomy could be completed. Histopathological examination confirmed the complete resection of a low-grade malignant SPT. The postoperative course was unremarkable. Regular pediatric oncological follow-up examinations for 3 years, including MRI every 6 months, ruled out recurrence and confirmed preservation of splenic and pancreatic functions. While data about the technical feasibility of a laparoscopic approach to pancreatic SPT are already available, this pediatric case report adds a long-term oncological and functional success to the available literature.


title: Multicenter Experience with Stenting for Symptomatic Carotid Web.

text: Background A carotid web (CaW) is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. CaW has been associated with recurrent strokes and conventionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic CaWs. Methods Retrospective review of consecutive patients admitted to 5 comprehensive stroke centers who were identified to have a symptomatic CaW and treated with carotid stenting. A symptomatic CaW was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT angiography (CTA) and confirmed with conventional angiography in patients with negative stroke workup. Results Twenty-four patients with stented symptomatic CaW were identified (stroke in 83% and transient ischemic attack in 17%). Their median age was 47 years (IQR 41-61), 14 (58%) were female, and were 17 (71%) black. The degree of stenosis by NASCET was 0% (range 0-11). All patients were placed on dual antiplatelets and stented at a median of 9 days (IQR 4-35) after the last event. Closed-cell stents were used in 18 (75%) of the cases. No periprocedural events occurred with the exception of 2 cases of asymptomatic hypotension/bradycardia. Clinical follow-up after stent placement occurred for a median of 12 months (IQR 3-19) with no new cerebrovascular events noted. Functional independence at 90 days was achieved in 22 (91%) patients. Follow-up vascular imaging (ultrasound n = 18/CTA n = 5) was performed at a median of 10 months (IQR 3-18) and revealed no stenosis. Conclusions Stenting for symptomatic CaW appears to be a safe and effective alternative to surgical resection. Further studies are warranted.


title: Assessing the GRIP of Ventral Hernia Repair: How to Securely Fasten DIS Classified Meshes.

text: Recurrences are frequently observed after ventral hernia repair. Based on clinical data, the mesh-defect area ratio (MDAR) can lead to lower recurrence rates. Using dynamic intermittent strain (DIS) in a pig tissue model, MDAR can be modified to give a measure called grip to better assess the mechanical stability of ventral hernia repair. The focus of this experimental study is to assess the different aspects of mesh overlap (OL) and fixation only in bridging repair of ventral hernias. DIS mimics coughing actions in an ex vivo model with the repetition of submaximal impacts delivered via a hydraulically driven plastic containment. Tissue derived from pig bellies simulates a ventral hernia with varying defect sizes. MDAR is calculated from the hernia orifice and the mesh OL. Commercially available meshes were strengthened with glue, tacks, and sutures to bridge the defects. The reconstructions are strained with up to 425 dynamic impacts. The grip of each repair is assessed using MDAR modified by the strength of the fixation. The DIS classification is based on bridging of a 5 cm ventral hernia orifice with an OL of 5 cm in a sublay position. The classification discriminates meshes properties upon DIS strain. MDAR is calculated to be 9 under these conditions. Decreasing the OL or increasing the hernia orifice reduces MDAR to numbers below 9. MDAR is modified to reach GRIP. Closure of the peritoneum adds about 4 to the grip given by MDAR. The multiplying factor of a transmural suture or one tack of Securestrap® or Protack® is 0.5 times the number of tacks applied. The multiplier given by a bonding spot of Glubran® is similar to that of an Absorbatack® being 0.33. Plotting the likelihood of a bridging repair to survive more than 400 DIS impacts versus the grip estimated from the factors given above, the grip to be passed for a durable repair is 10 for Parietex Progrip®, and Dynamesh Cicat® and 25 for Dynamesh IPOM®. Clinical data previously published can be reculculated to assess MDAR and permit an estimation of the grip of the reconstruction. In these recalculations, a correlation between MDAR and long-term recurrence rates is found. A dimensionless number called grip can be calculated. The grip can be modified by fixation in a reproducible way. A higher grip can improve the durability of ventral hernia repair. We believe that a higher grip leads to lower recurrence rates in the clinical setting.


title: Transumbilical Surgery for Duodenal Stenosis in a Child with Situs Inversus: The First Report.

text: Background. Situs inversus is a rare congenital anomaly with a reported incidence of only 1 in 5,000 to 10,000 live births. Congenital duodenal stenosis complicated with situs inversus is an even rarer entity. Case Presentation. A 1-year-old girl with situs inversus who had undergone a hemi-Fontan procedure against a single ventricle in our hospital was referred to our department for vomiting and failure to thrive. An upper gastrointestinal contrast study and endoscopy revealed duodenal stenosis. A transumbilical radical operation as a minimally invasive surgery was successfully performed. After the surgery, she stopped vomiting, and the postoperative course was uneventful with good cosmetic results. Conclusions. To our knowledge, this is the first report of transumbilical surgery for congenital duodenal stenosis with situs inversus as minimally invasive surgery. Transumbilical surgery to situs inversus patient can be performed safely and lead to good cosmetic outcome.


title: Diaphragm Repair with a Novel Cross-Linked Collagen Biomaterial in a Growing Rabbit Model.

text: BACKGROUND Neonates with congenital diaphragmatic hernia and large defects often require patch closure. Acellular collagen matrices (ACM) have been suggested as an alternative to synthetic durable patches as they are remodeled by the host or could also be used for tissue engineering purposes. MATERIALS AND METHODS 2.0x1.0 cm diaphragmatic defects were created in 6-weeks old New-Zealand white rabbits. We compared reconstruction with a purpose-designed cross-linked ACM (Matricel) to 4-layer non-cross-linked small intestinal submucosa (SIS) and a 1-layer synthetic Dual Mesh (Gore-Tex). Unoperated animals or animals undergoing primary closure (4/0 polyglecaprone) served as age-matched controls. 60 (n = 25) resp. 90 (n = 17) days later, animals underwent chest x-ray and obduction for gross examination of explants, scoring of adhesion and inflammatory response. Also, uniaxial tensiometry was done, comparing explants to contralateral native diaphragmatic tissue. RESULTS Overall weight nearly doubled from 1,554±242 g at surgery to 2,837±265 g at obduction (+84%). X-rays did show rare elevation of the left diaphragm (SIS = 1, Gore-Tex = 1, unoperated control = 1), but no herniation of abdominal organs. 56% of SIS and 10% of Matricel patches degraded with visceral bulging in four (SIS = 3, Matricel = 1). Adhesion scores were limited: 0.5 (Matricel) to 1 (SIS, Gore-Tex) to the left lung (p = 0.008) and 2.5 (Gore-Tex), 3 (SIS) and 4 (Matricel) to the liver (p<0.0001). Tensiometry revealed a reduced bursting strength but normal compliance for SIS. Compliance was reduced in Matricel and Gore-Tex (p<0.01). Inflammatory response was characterized by a more polymorphonuclear cell (SIS) resp. macrophage (Matricel) type of infiltrate (p<0.05). Fibrosis was similar for all groups, except there was less mature collagen deposited to Gore-Tex implants (p<0.05). CONCLUSIONS Matricel induced a macrophage-dominated inflammatory response, more adhesions, had appropriate strength but a lesser compliance compared to native tissue. The herein investigated ACM is not a viable option for CDH repair.


Fulminant myocarditis triggered by OC43 subtype coronavirus: a disease deserving evidence-based care bundles.


title: A Multinational, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Trial to Evaluate the Efficacy of Cyclical Topical Wound Oxygen Therapy (TWO2) in the Treatment of Chronic Diabetic Foot Ulcers: The TWO2 Study.

text: OBJECTIVE Topical oxygen has been used for the treatment of chronic wounds for more than 50 years. Its effectiveness remains disputed due to the limited number of robust high-quality investigations. The aim of this study was to assess the efficacy of multimodality cyclical pressure Topical Wound Oxygen (TWO2) home care therapy in healing refractory diabetic foot ulcers (DFUs) that had failed to heal with standard of care (SOC) alone. RESEARCH DESIGN AND METHODS Patients with diabetes and chronic DFUs were randomized (double-blind) to either active TWO2 therapy or sham control therapy-both in addition to optimal SOC. The primary outcome was the percentage of ulcers in each group achieving 100% healing at 12 weeks. A group sequential design was used for the study with three predetermined analyses and hard stopping rules once 73, 146, and ultimately 220 patients completed the 12-week treatment phase. RESULTS At the first analysis point, the active TWO2 arm was found to be superior to the sham arm, with a closure rate of 41.7% compared with 13.5%. This difference in outcome produced an odds ratio (OR) of 4.57 (97.8% CI 1.19, 17.57), P = 0.010. After adjustment for University of Texas Classification (UTC) ulcer grade, the OR increased to 6.00 (97.8% CI 1.44, 24.93), P = 0.004. Cox proportional hazards modeling, also after adjustment for UTC grade, demonstrated >4.5 times the likelihood to heal DFUs over 12 weeks compared with the sham arm with a hazard ratio of 4.66 (97.8% CI 1.36, 15.98), P = 0.004. At 12 months postenrollment, 56% of active arm ulcers were closed compared with 27% of the sham arm ulcers (P = 0.013). CONCLUSIONS This sham-controlled, double-blind randomized controlled trial demonstrates that, at both 12 weeks and 12 months, adjunctive cyclical pressurized TWO2 therapy was superior in healing chronic DFUs compared with optimal SOC alone.


title: Amdoparvovirus Infection in Red Pandas ( Ailurus fulgens).

text: Aleutian mink disease virus is the type species in the genus Amdoparvovirus, and in mink and other Mustelidae can cause either subclinical disease or fatal chronic immune stimulation and immune complex disease. The authors describe a novel amdoparvovirus in the endangered red panda ( Ailurus fulgens), discovered using viral metagenomics. The authors analyzed the prevalence, tissue distribution, and disease association by PCR, in situ hybridization, electron microscopy, and histology in a group of 6 red pandas from a single zoological collection. The study incorporates a fecal shedding survey and analysis of tissues from 4 necropsied animals over a 12-year span. The tentatively named red panda amdoparvovirus (RpAPV) was detected in the feces and/or tissues of all animals tested. At necropsy of 1 geriatric animal, infection was associated with pyogranulomatous peritonitis, pancreatitis, and myocarditis. Other animals had detectable low-level viral nucleic acid in lymph nodes and both oral and intestinal epithelium at the time of necropsy. Full-length genome sequences of RpAPV strains from 2 animals had 12% sequence divergence, demonstrating genetic diversity even among in-contact animals. RpAPV is a persistent infection in this cohort of red pandas, and has variable clinical expression.


title: Gastric bypass surgery restores meal stimulation of the anorexigenic gut hormones glucagon-like peptide-1 and peptide YY independently of caloric restriction.

text: BACKGROUND The effects of gastric bypass surgery on the secretion of the anorexigenic gut-derived hormones glucagon-like peptide-1 (GLP-1) and peptide YY (PYY), independent of caloric restriction and due to different dietary macronutrients, is not well characterized. This study examines the effects of a mixed-nutrient or high-fat liquid meal on the postprandial stimulation of GLP-1 and PYY following gastric bypass or equivalent hypocaloric diet. METHODS Total PYY and active GLP-1 were measured fasting and at multiple points after standardized mixed-nutrient and high-fat liquid meals in two matched groups of obese subjects. The meal stimulation tests were performed before and 14.6 ± 3.3 days after gastric bypass (GBP, n = 10) and before and after a 7-day hypocaloric liquid diet matching the post-GBP diet (control, n = 10). RESULTS Mixed-nutrient and high-fat postprandial GLP-1 levels increased following GBP (mixed-nutrient peak: 85.0 ± 28.6-323 ± 51 pg/ml, P < 0.01; high-fat peak: 81.8 ± 9.6-278 ± 49 pg/ml, P < 0.01), but not after diet (mixed-nutrient peak: 104.4 ± 9.4-114.9 ± 15.8 pg/ml, P = NS; high-fat peak: 118.1 ± 16.4-104.4 ± 10.8 pg/ml, P = NS). The postprandial PYY response also increased after GBP but not diet, though the increase in peak PYY did not reach statistical significance (GBP mixed-nutrient peak: 134.8 ± 26.0-220.7 ± 52.9 pg/ml, P = 0.09; GBP high-fat peak: 142.1 ± 34.6-197.9 ± 12.7 pg/ml, P = 0.07; diet mixed-nutrient peak: 99.8 ± 8.0-101.1 ± 13.3 pg/ml, P = NS; diet high-fat peak: 105.0 ± 8.8-103.1 ± 11.8 pg/ml, P = NS). The postprandial GLP-1 response was not affected by the macronutrient content of the meal. However, following GBP the mixed-nutrient PYY total area under the curve (AUC(0-120)) was significantly greater than the high-fat PYY AUC(0-120) (22,081 ± 5,662 pg/ml min vs. 18,711 ± 1,811 pg/ml min, P = 0.04). CONCLUSIONS Following GBP there is an increase in the postprandial stimulation of PYY and GLP-1 that is independent of caloric restriction. The phenomenon of "bariatric surgery-induced anorexia" may be linked to the increased levels after GBP.


title: Y-stent assisted coiling of bifurcation aneurysms with Enterprise stent: long-term follow-up.

text: BACKGROUND Y-stent assisted coiling has been proposed for the treatment of wide-neck bifurcation aneurysms, but there are many technical variations. We report our single-center experience of Y-stent assisted coiling of bifurcation aneurysms with the closed cell Enterprise stent in order to evaluate the safety and long-term results of this technique. The literature on Y-stenting and its hemodynamic effects are reviewed. METHODS Fifty-two consecutive patients with wide-neck bifurcation aneurysms underwent Y-stent assisted coiling with two Enterprise stents. The procedure was completed in 48 cases (92.3%) and technical failure occurred in 4 cases (7.3%). Cases performed with other stents were excluded. All procedures were performed under double antiplatelet therapy. Periodic clinical and neuroradiological follow-up was performed. RESULTS Mean neuroradiological follow-up time was 26 months. Complete immediate occlusion was obtained in 87.5% of patients. Two remnants had regrown at follow-up and were recoiled, achieving complete occlusion. The late neuroradiological occlusion rate was: complete occlusion 93.6%, neck remnant 4.3%, sac remnant 2.1%. No in-stent stenosis was detected at follow-up. Among the 48 procedures, two complications occurred (4.2%). Mortality was 2.1%. No delayed ischemic stroke occurred. CONCLUSIONS Y-stent assisted coiling has a high immediate occlusion rate and very good long-term stability. The procedure is relatively safe, although the complication and mortality rates are not negligible. Two Enterprise stents can be safely used for Y-stenting and, indeed, offer the advantage of easier catheterization, delivery and deployment into distal and tortuous vessels than open cell stents.


Coronavirus tests: researchers chase new diagnostics to fight the pandemic.


title: Observer variability of absolute and relative thrombus density measurements in patients with acute ischemic stroke.

text: INTRODUCTION Thrombus density may be a predictor for acute ischemic stroke treatment success. However, only limited data on observer variability for thrombus density measurements exist. This study assesses the variability and bias of four common thrombus density measurement methods by expert and non-expert observers. METHODS For 132 consecutive patients with acute ischemic stroke, three experts and two trained observers determined thrombus density by placing three standardized regions of interest (ROIs) in the thrombus and corresponding contralateral arterial segment. Subsequently, absolute and relative thrombus densities were determined using either one or three ROIs. Intraclass correlation coefficient (ICC) was determined, and Bland-Altman analysis was performed to evaluate interobserver and intermethod agreement. Accuracy of the trained observer was evaluated with a reference expert observer using the same statistical analysis. RESULTS The highest interobserver agreement was obtained for absolute thrombus measurements using three ROIs (ICCs ranging from 0.54 to 0.91). In general, interobserver agreement was lower for relative measurements, and for using one instead of three ROIs. Interobserver agreement of trained non-experts and experts was similar. Accuracy of the trained observer measurements was comparable to the expert interobserver agreement and was better for absolute measurements and with three ROIs. The agreement between the one ROI and three ROI methods was good. CONCLUSION Absolute thrombus density measurement has superior interobserver agreement compared to relative density measurement. Interobserver variation is smaller when multiple ROIs are used. Trained non-expert observers can accurately and reproducibly assess absolute thrombus densities using three ROIs.


title: Radiofrequency Ablation Is Associated With Decreased Neoplastic Progression in Patients With Barrett's Esophagus and Confirmed Low-Grade Dysplasia.

text: BACKGROUND & AIMS Barrett's esophagus (BE) with low-grade dysplasia (LGD) can progress to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). Radiofrequency ablation (RFA) has been shown to be an effective treatment for LGD in clinical trials, but its effectiveness in clinical practice is unclear. We compared the rate of progression of LGD after RFA with endoscopic surveillance alone in routine clinical practice. METHODS We performed a retrospective study of patients who either underwent RFA (n = 45) or surveillance endoscopy (n = 125) for LGD, confirmed by at least 1 expert pathologist, from October 1992 through December 2013 at 3 medical centers in the United States. Cox regression analysis was used to assess the association between progression and RFA. RESULTS Data were collected over median follow-up periods of 889 days (interquartile range, 264-1623 days) after RFA and 848 days (interquartile range, 322-2355 days) after surveillance endoscopy (P = .32). The annual rates of progression to HGD or EAC were 6.6% in the surveillance group and 0.77% in the RFA group. The risk of progression to HGD or EAC was significantly lower among patients who underwent RFA than those who underwent surveillance (adjusted hazard ratio = 0.06; 95% confidence interval: 0.008-0.48). CONCLUSIONS Among patients with BE and confirmed LGD, rates of progression to a combined end point of HGD and EAC were lower among those treated with RFA than among untreated patients. Although selection bias cannot be excluded, these findings provide additional evidence for the use of endoscopic ablation therapy for LGD.


title: Association between subthreshold depression and self-care behaviors in people with type 2 diabetes: a systematic review of observational studies.

text: BACKGROUND Self-care behaviors in people living with type 2 diabetes are important to achieving optimal glycemic control. Major depression in type 2 diabetes is associated with decreased adherence to self-care behaviors. The association between subthreshold depression and self-care behaviors, however, has not previously been systematically reviewed. The objective of this review is to determine the association between subthreshold depression and self-care behaviors. METHODS A systematic search was performed in five electronic databases that included MEDLINE, EMBASE, PsycINFO, Emcare, and CINAHL. Any observational studies in adults with type 2 diabetes, investigating the association between subthreshold depression and any self-care behaviors, were included in the review. Qualitative studies, review articles, and gray literature were excluded. Two reviewers independently completed the title and abstract and full-text screening, appraised the study quality, and extracted the data. A third reviewer resolved any discrepancies between the reviewers if needed. Included articles were critically appraised using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. Meta-analyses were not conducted because criteria for conducting such analyses were not met. RESULTS A total of 6408 articles were identified through the database searching. After the abstract and full-text review, two articles met the inclusion criteria. One of the included study was cross-sectional while the other was a longitudinal study. Both studies showed inconsistent findings in the association between subthreshold depression and self-care behaviors. Important risks of bias were identified in the included studies. DISCUSSION The evidence from the two included studies on a possible association between subthreshold depression and self-care behaviors in adults with type 2 diabetes was not consistent and potentially biased. Our review established a gap in knowledge and suggests that further high-quality studies are needed to examine the association between subthreshold depression and self-care behaviors in people with type 2 diabetes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018116373.


title: Impact of advanced monitoring variables on intraoperative clinical decision-making: an international survey.

text: To assess the relationship between the addition of advanced monitoring variables and changes in clinical decision-making. A 15-questions survey was anonymously emailed to international experts and physician members of five anesthesia societies which focused on assessing treatment decisions of clinicians during three realistic clinical scenarios measured at two distinct time points. The first is when typical case information and basic monitoring (T1) were provided, and then once again after the addition of advanced monitoring variables (T2). We hypothesized that the addition of advanced variables would increase the incidence of an optimal therapeutic decision (a priori defined as the answer with the highest percentage of expert agreement) and decrease the variability among the physician's suggested treatments. The survey was completed by 18 experts and 839 physicians. Overall, adding advanced monitoring did not significantly increase physician response accuracy, with the least substantial changes noted on questions related to volume expansion or vasopressor administration. Moreover, advanced monitoring data did not significantly decrease the high level of initial practice variability in physician suggested treatments (P = 0.13), in contrast to the low variability observed within the expert group (P = 0.039). Additionally, 5-10 years of practice (P < 0.0001) and a cardiovascular subspecialty (P = 0.048) were both physician characteristics associated with a higher rate of optimal therapeutic decisions. The addition of advanced variables was of limited benefit for most physicians, further indicating the need for more in depth education on the clinical value and technical understanding of such variables.


title: Cough and upper airway disorders in elite athletes: a critical review.

text: Respiratory diseases such as asthma, chronic cough, recurrent respiratory infections and various upper airways conditions are common in elite athletes, but these conditions are often underdiagnosed and undertreated. Recurrent cough, often observed after exercise, is the most commonly reported symptom in athletes, particularly winter athletes, but it does not predict airway function; its intensity correlates with the dryness of inspired air but may not be associated with airway hyper-responsiveness. Rhinitis, either allergic or not, is highly prevalent in athletes, particularly non-allergic rhinitis in swimmers. Finally, dysfunctional breathing, including vocal cord dysfunction, may mimic or accompany asthma in a significant number of athletes. These conditions should be recognised and treated properly according to current guidelines, although how these last apply in the athlete is uncertain. Furthermore, regulatory agencies' restrictions on the type of drugs allowed for therapeutic use of these conditions in competitive athletes should be checked.


title: Genomic Sequencing and Analysis of Eight Camel-Derived Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Isolates in Saudi Arabia.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) causes severe respiratory illness in humans; the second-largest and most deadly outbreak to date occurred in Saudi Arabia. The dromedary camel is considered a possible host of the virus and also to act as a reservoir, transmitting the virus to humans. Here, we studied evolutionary relationships for 31 complete genomes of betacoronaviruses, including eight newly sequenced MERS-CoV genomes isolated from dromedary camels in Saudi Arabia. Through bioinformatics tools, we also used available sequences and 3D structure of MERS-CoV spike glycoprotein to predict MERS-CoV epitopes and assess antibody binding affinity. Phylogenetic analysis showed the eight new sequences have close relationships with existing strains detected in camels and humans in Arabian Gulf countries. The 2019-nCov strain appears to have higher homology to both bat coronavirus and SARS-CoV than to MERS-CoV strains. The spike protein tree exhibited clustering of MERS-CoV sequences similar to the complete genome tree, except for one sequence from Qatar (KF961222). B cell epitope analysis determined that the MERS-CoV spike protein has 24 total discontinuous regions from which just six epitopes were selected with score values of >80%. Our results suggest that the virus circulates by way of camels crossing the borders of Arabian Gulf countries. This study contributes to finding more effective vaccines in order to provide long-term protection against MERS-CoV and identifying neutralizing antibodies.


title: South Korea's proactive approach to the COVID-19 global crisis.

text: This article introduces South Korea's proactive approach in dealing with the COVID-19 pandemic from the mental health perspective at various levels, including national-level policies, medical systems, infrastructures, and mental health professionals, as well as establishing connections and support for citizens. Implications for the internationalization of psychology are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Katrina: Stories from the storm.


docid: wzehglsv

title: Possible involvement of human bocavirus 1 in the death of a middle-aged immunosuppressed patient.

text: An immunosuppressed 61-year-old man went to the hospital with fever, nonproductive cough, and increasing shortness of breath. The subject died 8 days later of respiratory complications. PCR of respiratory samples as well as a blood sample revealed exceptionally high DNA levels of the emerging pathogen, human bocavirus 1 (HBoV1), a recently found pathogen associated with respiratory symptoms in young children. We describe the clinical progression of the case and discuss the potential role of HBoV1 in the outcome.


title: The ICU follow-up clinic: a new paradigm for intensivists.

text: Over the last 15 years the management of patients admitted in the ICU has changed dramatically. A growing number of well designed randomized controlled studies have been published, resulting in improved medical care and reduction of short-term morbidity and mortality. Despite these important achievements, little attention has been placed on the long-term complications of subjects discharged from the ICU. This review will focus on the most common long-term outcomes post-ICU admission, and will emphasize the importance of developing ICU clinics to provide comprehensive care to ICU survivors. We also describe our experience regarding the organization, functioning, and limitations for the development of our post-ICU clinic.


title: Necessary Infrastructure of Infection Prevention and Healthcare Epidemiology Programs: A Review.

text: The scope of a healthcare institution's infection prevention and control/healthcare epidemiology program (IPC/HE) should be driven by the size and complexity of the patient population served, that population's risk for healthcare-associated infection (HAI), and local, state, and national regulatory and accreditation requirements. Essential activities of all IPC/HE programs include but are not limited to the following: ∙ Surveillance.∙ Performance improvement to reduce HAI ∙ Acute event response, including outbreak investigation ∙ Education and training of both healthcare personnel and patients ∙ Reporting of HAI to the Centers for Disease Control and Prevention's National Healthcare Safety Network as well as entities required by law.


title: Per-Ventricular Insertion of Melody Valve-in-Valve in the Neoaortic Position in a Single-Ventricle Patient.

text: Percutaneous therapies for congenital heart disease have been evolving rapidly despite limited investment from industry. The Melody transcatheter pulmonary valve (Medtronic, Inc, Minneapolis, MN USA) replacement therapy represents an important advancement in this arena. It has been approved in the United States for use in the pulmonary position, on a Humanitarian Device Exemption status. Off-label use of the Melody transcatheter pulmonary valve has extended to the mitral, pulmonary, and aortic valves, especially in previously implanted valves with prosthetic valve degeneration. The single-ventricle patient poses additional challenges. However, there exists one report in the English literature of a patient undergoing Melody transcatheter neoaortic valve replacement after the patient developed severe neoaortic regurgitation after Fontan palliation. Here, we describe a patient with hypoplastic left heart syndrome, palliated with a Norwood modified Blalock-Taussig shunt, with a progressively regurgitant quadricusp neoaortic valve who underwent bioprosthetic valve replacement. There was early prosthetic valve degeneration after a year of bioprosthesis implantation. As he was declined for transplantation, he underwent successful per-ventricular Melody valve-in-valve replacement.


WHO voices concern over rising numbers of MERS-CoV cases.


Covid-19: UK drops its own contact tracing app to switch to Apple and Google model.


title: Effects of age on outcome in the SENTIS trial: better outcomes in elderly patients.

text: BACKGROUND Increasing age is associated with poor outcome after stroke. The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke (SENTIS) trial explored the augmentation of collateral circulation to the ischemic penumbra as a novel approach to stroke treatment. The aim of this post hoc analysis was to examine the effect of age on outcomes in the SENTIS trial. METHODS Using data from the randomized controlled SENTIS trial, we explored outcomes of cerebral blood flow augmentation using the NeuroFlo™ device in patients categorized by age strata at 70 and 80 years. We evaluated outcomes of overall serious adverse event (SAE) and intracerebral hemorrhage (ICH) rates, freedom from all-cause and stroke-related mortality, and independent functional outcome as defined by the modified Rankin Scale score (mRS ≤2). RESULTS The SENTIS as-treated cohort included 251 patients ≥70 years and 107 patients ≥80 years. Elderly SENTIS patients included a higher percentage of women and Caucasians than the younger group. Patients in the older group more frequently had vascular risk factors including hypertension, previous stroke, transient ischemic attacks and atrial fibrillation. However, baseline risk-factor profile, stroke severity, and time to randomization did not differ between the treated and nontreated elderly patients. The older patients treated with NeuroFlo had significantly higher chances for survival and for obtaining an independent functional state (mRS ≤2) compared with those who were not treated. Rates of SAEs and ICHs did not differ between the treatment groups. CONCLUSIONS NeuroFlo treatment is safe and results in better outcomes for elderly patients. This may be the result of recruitment and support of already existing collateral systems in these patients.


What COVID-19 means for non-neurotypical children and their families.


A few minutes with Donna S. Watson.


title: Portal vein thrombosis due to factor 2 leiden in the post-operative course of a laparoscopic sleeve gastrectomy for morbid obesity.

text: Portal vein thrombosis can occur after laparoscopic operations. This complication has not been yet reported after laparoscopic sleeve gastrectomy. We report the case of a patient who presented mild abdominal pains 2 weeks after a laparoscopic sleeve gastrectomy achieved to cure morbid obesity. Computed tomography led to the diagnosis of portal vein thrombosis bound to a genetic disorder due to heterozygote Leiden 2 factor which impaired coagulation. Recommendations for post-surgical follow-up are discussed.


title: COVID-19 Pandemic and Otologic Surgery.

text: All around world, the COVID-19 pandemic is accelerating, and any insight we can learn from our colleagues who have either encountered or are currently going through this will be used to protect our patients, our medical staff, and ourselves. No one knows to the best of our understanding whether or not COVID-19 includes the respiratory mucosal lining the middle ear and mastoid air cell system-but it seems probable they do. Since the rest of the airways are affected, and so is the nose and nasopharynx, it seems possible that the lining of the Eustachian tube, middle ear and mastoid air cell system would all be polluted. Viral particle aerosolization, which can occur otologic surgery using powered instruments and they remain in the air for at least 3 hours. Powered air purifying respirators are supplied even shorter than N95 masks, but strongly believed they are important for our team safety and protection. This mini review provides fundamental knowledge on otologic surgery feasibility in the COVID-19 pandemic from an objective perspective.


title: Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review.

text: OBJECTIVES To summarize available tools that can assist clinicians in identifying and reducing or stopping (deprescribing) potentially inappropriate medications and that specifically consider frailty or limited life expectancy. DESIGN Systematic review and narrative synthesis. SETTING We searched MEDLINE (via Ovid SP), EMBASE (via Ovid SP), and CINAHL from inception to December 2017, along with grey literature. We included articles that described a tool to guide deprescribing of medications. PARTICIPANTS Frail older persons and older persons with limited life expectancy. MEASUREMENTS Narrative description of tools. RESULTS We identified 15 tools and organized them into three main categories: tools (n = 2) that described a model or framework for approaching deprescribing, tools (n = 9) that outlined a deprescribing approach for the entire medication list, and tools (n = 4) that provided medication-specific advice. The complexity of the tools ranged from simple lists to detailed, step-wise protocols. The development methodology varied widely, and the methods used to synthesize the tools were generally not well described. Most tools were based on expert opinion. Only four of the 15 tools have been tested in clinical practice (in very low-quality studies). CONCLUSION Tools exist to help clinicians deprescribe in frail older persons and those with limited life expectancy. These tools may assist clinicians at various stages in the deprescribing process. However, it remains to be investigated whether use of such tools in practice is likely to improve clinical outcomes or reduce inappropriate medication use. J Am Geriatr Soc 67:172-180, 2019.


title: Laparoscopic Salpingo-oophorectomy in Conscious Sedation.

text: INTRODUCTION Conscious sedation has traditionally been used for laparoscopic tubal ligation. General anesthesia with endotracheal intubation may be associated with side effects, such as nausea, vomiting, cough, and dizziness, whereas sedation offers the advantage of having the patient awake and breathing spontaneously. Until now, only diagnostic laparoscopy and minor surgical procedures have been performed in patients under conscious sedation. CASE DESCRIPTION Our report describes 5 cases of laparoscopic salpingo-oophorectomy successfully performed with the aid of conventional-diameter multifunctional instruments in patients under local anesthesia. Totally intravenous sedation was provided by the continuous infusion of propofol and remifentanil, administered through a workstation that uses pharmacokinetic-pharmacodynamic models to titrate each drug, as well as monitoring tools for levels of conscious sedation and local anesthesia. We have labelled our current procedure with the acronym OLICS (Operative Laparoscopy in Conscious Sedation). Four of the patients had mono- or bilateral ovarian cysts and 1 patient, with the BRCA1 gene mutation and a family history of ovarian cancer, had normal ovaries. Insufflation time ranged from 19 to 25 minutes. All patients maintained spontaneous breathing throughout the surgical procedure, and no episodes of hypotension or bradycardia occurred. Optimal pain control was obtained in all cases. During the hospital stay, the patients did not need further analgesic drugs. All the women reported high or very high satisfaction and were discharged within 18 hours of the procedure. DISCUSSION AND CONCLUSION Salpingo-oophorectomy in conscious sedation is safe and feasible and avoids the complications of general anesthesia. It can be offered to well-motivated patients without a history of pelvic surgery and low to normal body mass index.


title: Association between increased antenatal vaginal pH and preterm birth rate: a systematic review.

text: Background Worldwide, 14.9 million infants (11%) are born preterm each year. Up to 40% of preterm births (PTBs) are associated with genital tract infections. The vaginal pH can reflect changes in the vaginal milieu and, if elevated, indicates an abnormal flora or infection. Objective The aim of the study was to investigate whether an increased antenatal vaginal pH >4.5 in pre-labour pregnant women is associated with an increased PTB rate <37 completed weeks gestation. Search strategy Key databases included SCOPUS, EMBASE, MEDLINE, PsycInfo and the Cochrane Central Register of Controlled Trials, complemented by hand search, up to January 2017. Selection criteria Primary research reporting vaginal pH assessment in pre-labour pregnant women and PTB rate. Data collection and analysis Data extraction and appraisal were carried out in a pre-defined standardised manner, applying the Newcastle-Ottawa scale (NOS) and Cochrane risk of bias tool. Analysis included calculation of risk difference (RD) and narrative synthesis. It was decided to abstain from pooling of the studies due to missing information in important moderators. Main results Of 986 identified records, 30 were included in the systematic review. The risk of bias was considered mostly high (40%) or moderate (37%). Fifteen studies permitted a calculation of RD. Of these, 14 (93%) indicated a positive association between increased antenatal vaginal pH and PTB (RD range: 0.02-0.75). Conclusion An increased antenatal vaginal pH >4.5 may be associated with a higher risk for PTB. It is recommended to conduct a randomised controlled trial (RCT) to investigate the effectiveness of antenatal pH screening to prevent PTB. Tweetable abstract Pregnant women with an increased vaginal pH >4.5 may be at higher risk to experience preterm birth.


title: Current state of science in machine learning methods for automatic infant pain evaluation using facial expression information: study protocol of a systematic review and meta-analysis.

text: INTRODUCTION Infants can experience pain similar to adults, and improperly controlled pain stimuli could have a long-term adverse impact on their cognitive and neurological function development. The biggest challenge of achieving good infant pain control is obtaining objective pain assessment when direct communication is lacking. For years, computer scientists have developed many different facial expression-centred machine learning (ML) methods for automatic infant pain assessment. Many of these ML algorithms showed rather satisfactory performance and have demonstrated good potential to be further enhanced for implementation in real-world clinical settings. To date, there is no prior research that has systematically summarised and compared the performance of these ML algorithms. Our proposed meta-analysis will provide the first comprehensive evidence on this topic to guide further ML algorithm development and clinical implementation. METHODS AND ANALYSIS We will search four major public electronic medical and computer science databases including Web of Science, PubMed, Embase and IEEE Xplore Digital Library from January 2008 to present. All the articles will be imported into the Covidence platform for study eligibility screening and inclusion. Study-level extracted data will be stored in the Systematic Review Data Repository online platform. The primary outcome will be the prediction accuracy of the ML model. The secondary outcomes will be model utility measures including generalisability, interpretability and computational efficiency. All extracted outcome data will be imported into RevMan V.5.2.1 software and R V3.3.2 for analysis. Risk of bias will be summarised using the latest Prediction Model Study Risk of Bias Assessment Tool. ETHICS AND DISSEMINATION This systematic review and meta-analysis will only use study-level data from public databases, thus formal ethical approval is not required. The results will be disseminated in the form of an official publication in a peer-reviewed journal and/or presentation at relevant conferences. PROSPERO REGISTRATION NUMBER CRD42019118784.


title: Hiatal hernia repair with or without esophageal lengthening: is there a difference?

text: OBJECTIVE The need for esophageal lengthening (EL) as part of hiatal hernia (HH) repair is perceived to elevate perioperative risk and provide functionally inferior outcomes. Our objectives were to determine the risk factors of undergoing EL and to compare outcomes between operations with and without EL. We hypothesized that operative and functional outcomes for HH repair were similar in patients whether they required EL or not. METHODS We reviewed institutional experience with EL as part of HH repair. The patients underwent symptom evaluation before and after surgery using a validated tool. RESULTS Between 1999 and 2009, a total of 375 patients underwent HH repair. The operative approach was thoracotomy, 153 (41%); laparotomy, 18 (5%); laparoscopy, 167 (44%); or combined, 37 (10%). Of these, 168 (45%) required EL. There was a higher need for thoracotomy in the patients undergoing EL (79/168 vs 74/207, χ = 4.88, P = 0.034). The incidence of perioperative complications (leak, pneumonia, ileus, respiratory failure, and bleeding) was similar between the groups. Sixty-five selected patients undergoing EL were compared with 63 patients with comparable demographics not requiring EL. In a well-validated questionnaire that assessed symptoms before and after surgery, the patients undergoing EL showed significant improvement in their heartburn (76.8%), dysphagia (67.6%), regurgitation (71.7%), chest pain (91.9%), and nausea (86.5%) (P < 0.05). The patients not undergoing EL also showed significant improvement in their heartburn (81.1%), dysphagia (71.1%), regurgitation (64.4%), chest pain (64.1%), and nausea (61.0%) (P < 0.05). Improvement in symptoms, the continued use of antacid medications, and overall surgery satisfaction score were statistically similar between the two groups. CONCLUSIONS Operative and functional outcomes for HH repair with or without EL are acceptable and comparable. Thoracic surgeons should use EL without reservations for appropriate indications.


title: Carotid artery stenting for stroke prevention.

text: Stroke is a global epidemic with a significant economic burden to patients, families, and societies at large. In the industrialized world, stroke is the third most common cause of death, the second most common cause of dementia, and the most common reason for acquired disability in adulthood. Overall, 20%-30% of ischemic strokes are related to extracranial carotid artery stenosis. Revascularization with carotid endarterectomy (CEA) is the gold-standard treatment for patients with significant carotid stenosis. Carotid artery stenting (CAS) has become an accepted alternative to CEA over the past decade for patients at high surgical risk, and has progressively evolved into an elegant procedure over the past 3 decades, with dedicated equipment including proximal embolic occlusion devices that have minimized procedural strokes. High-surgical-risk CAS registries have established this procedure as an alternative to CEA for high-risk patients. The Carotid Revascularization Endarterectomy vs Stent Trial (CREST) has shown similar outcomes with CAS and CEA for patients at standard risk, although CAS is associated with higher minor stroke events and CEA is associated with higher myocardial infarction (MI) events. However, CAS is technically challenging and requires a meticulous approach, with a protracted learning curve that should involve experience with > 70 cases. Careful patient selection is instrumental in avoiding procedural complications, and the procedure should be avoided in patients with prohibitive anatomy. This article reviews the use of CAS for extracranial carotid artery stenosis, considering technical aspects, registry and clinical trial outcomes data, determinants of success, and contemporary guidelines.


title: Incidence of chest tube clogging after cardiac surgery: a single-centre prospective observational study.

text: OBJECTIVES Chest drainage following cardiac surgery is used to avoid complications related to the accumulation of blood and serous fluid in the chest. We aimed to determine the incidence of chest tube clogging and the role of bedside assessment in identifying the potential for failure to drain. METHODS Data from 150 patients undergoing cardiac surgery using cardiopulmonary bypass from March to October 2011 were prospectively entered into a database. Chest tubes were visually inspected and functionally assessed at four time intervals (Hours 0, 2-4, 6-8 and at removal), defining need for clearance and presence of partial or complete obstruction. RESULTS Complete data were available for 100 patients. We assessed 234 chest tubes: pericardial (n = 158); pleural (n = 76). The incidence of chest tube clogging for the entire group was 36% (any tube completely clogged at any time), with increased prevalence of clogging observed in urgent and reoperative cases and in those with increased intraoperative blood use. Among 51 tubes resulted to have a thrombus formation observed inside the chest tube at removal, 44 were clogged primarily in the internal portion of the tube, meaning that clogging could not be confirmed by simple bedside inspection of the indwelling tube. CONCLUSIONS The chest tubes can become clogged at any time after their placement. The status of urgency, reoperations and use of blood products can be contributing factors increasing the incidence of chest tube clogging. Clinicians likely underestimate the prevalence of this failure to drain, as most clogging occurs in the internal portion of the tube.


title: A randomized study comparing three groups of vein harvesting methods for coronary artery bypass grafting: endoscopic harvest versus standard bridging and open techniques.

text: OBJECTIVES The use of an open vein harvesting (OVH) technique for saphenous vein harvesting (SVH) is associated with wound complications and delayed patient mobilization. This has led to the development of minimally invasive vein harvesting (MIVH) techniques, such as standard bridging and endoscopic SVH (EVH). This randomized trial was established to assess immediate clinical outcome and patient satisfaction in our centre. METHODS A total of 150 consecutive patients were prospectively randomized into three groups. Group 1 consisted of 50 patients who underwent OVH, Group 2 consisted of 50 patients who underwent a standard bridging technique (SBT) and Group 3 consisted of 50 patients who underwent EVH. Each group was assessed for the incidence of wound infection, postoperative pain and satisfaction and the number of vein repairs using previously validated scoring systems. RESULTS The MIVH techniques reduced the pain at hospital (P < 0.001) and at 6 weeks (P < 0.001), and improved cosmesis (P < 0.001), compared with the OVH group. Patient satisfaction was greatest in the EVH group followed by the SBT and then the OVH group. The clinical markers of inflammation were reduced with an MIVHt. There were more vein repairs in the EVH compared with the OVH (P < 0.001) and the SBT (P = 0.04) groups. CONCLUSIONS This study demonstrates that MIVH reduces wound morbidity. We believe that each technique has advantages and disadvantages, which should be considered during the selection of a harvesting procedure by both the patient and the surgeon.


title: Outcome After Thrombectomy and Intravenous Thrombolysis in Patients With Acute Ischemic Stroke: A Prospective Observational Study.

text: BACKGROUND AND PURPOSE In patients with ischemic stroke, randomized trials showed a better functional outcome after endovascular therapy with new-generation thrombectomy devices compared with medical treatment, including intravenous thrombolysis. However, effects on mortality and the generalizability of results to routine clinical practice are uncertain. METHODS In a prospective observational register-based study patients with ischemic stroke treated either with thrombectomy, intravenous thrombolysis, or their combination were included. Primary outcome was the modified Rankin scale score (0 [no symptoms] to 6 [death]) at 3 months. Ordinal logistic regression was used to estimate the common odds ratio as treatment effects (shift analysis). Propensity score matching was applied to compare patients treated either with intravenous thrombolysis alone or with intravenous thrombolysis plus thrombectomy. RESULTS Among 2650 recruited patients, 1543 received intravenous thrombolysis, 504 underwent thrombectomy, and 603 received intravenous thrombolysis in combination with thrombectomy. Later time-to-treatment was associated with worse outcomes among patients treated with thrombectomy plus thrombolysis. In 241 pairs of propensity score-matched patients with a proximal intracranial occlusion, thrombectomy plus thrombolysis was associated with improved functional outcome (common odds ratio, 1.84; 95% confidence interval, 1.32-2.57), and reduced mortality (15% versus 33%; P<0.0001) compared with intravenous thrombolysis alone. Results were similar in various sensitivity analyses accounting for missing outcome data and different analytic methods. CONCLUSIONS Results from this large prospective registry show that also in routine clinical care thrombectomy plus thrombolysis compared with thrombolysis alone improved functional outcome and reduced mortality in patients with ischemic stroke. Earlier treatment was associated with better outcomes.


title: Outcome Study of the Pipeline Embolization Device with Shield Technology in Unruptured Aneurysms (PEDSU).

text: BACKGROUND AND PURPOSE The recently introduced Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield) is the third generation of Pipeline flow-diverter devices. It has a new stent-surface modification, which reduces thrombogenicity. We aimed to evaluate clinical and radiographic (safety and efficacy) outcomes of the Pipeline Shield. MATERIALS AND METHODS The 30-day and 1-year mortality and morbidity rates and the 6- and 18-month radiographic aneurysm occlusion outcomes for procedures performed between March 2016 and January 2018 were analyzed. 3D-TOF-MRA was used for follow-up. RESULTS Forty-four attempted Pipeline Shield procedures were performed for 41 patients with 44 target aneurysms (total of 52 aneurysms treated). A total of 88.5% of devices were inserted in the anterior circulation, and 11.5%, in the posterior circulation; 49/52 (94.2%) aneurysms were saccular; and 1/52 (1.9%) was fusiform. One (1.9%) aneurysm was an iatrogenic pseudoaneurysm, and 1 (1.9%) was a dissecting aneurysm. Seventy-one percent (35/49) of the saccular aneurysms were wide-neck (neck, >4 mm), 34.6% (18/52) were large (≥10 mm), and 3.8% (2/52) were giant (≥25 mm). The mean aneurysm sac maximal diameter was 9.0 mm, and the mean neck width was 5.0 mm. The cumulative mortality and morbidity rates were 2.3% and 6.8% at 1 year, respectively. The adequate occlusion rate was 78.8% at 6 months and 90.3% at 18 months. CONCLUSIONS In this pragmatic and non-industry-sponsored study, the occlusion rates and safety outcomes were similar to those seen in previously published studies with flow-diverter devices and earlier generation Pipeline Embolization Devices.


title: Single-port laparoscopic-assisted ovariohysterectomy with a modified glove-port technique in dogs.

text: OBJECTIVE To describe a single-port laparoscopic-assisted ovariohysterectomy (LOHE) with a modified glove-port technique in dogs and compare it with previously published laparoscopic techniques for LOHE in dogs. STUDY DESIGN Prospective clinical study and technique description. ANIMALS Forty-two healthy female dogs. METHODS Laparoscopic-assisted ovariohysterectomy was performed with a custom-made single-port device. The total duration of surgery from first incision to skin closure was compared with previously published durations of LOHE in dogs. Short-term complications were recorded. RESULTS The median total duration of surgery was 24 minutes (range, 17.5-39.5; mean, 25.73; SD, 6.12), which was shorter than that described in most previously reported studies of LOHE in dogs (range, 20.8 ± 4.00-60.0 ± 18.45 minutes; P < .001). Intraoperative complications were minor, but wound complications occurred in 12 of 42 (29%) dogs. CONCLUSION Single-port LOHE with the glove-port technique in combination with a wound retractor and nonarticulated instruments was completed in all dogs. This technique was faster than what has been previously reported for other LOHE, but local wound complications were common. CLINICAL RELEVANCE The glove-port technique described here offers a low-cost alternative to other commercially available single-port devices.


title: Posttraumatic anomalous pulmonary edema.

text: Focal pulmonary edema from increased venous hydrostatic pressure is most commonly seen in mitral valve regurgitation (in the right upper lobe) or in pulmonary venous obstruction/compression from neoplastic, fibrotic, or iatrogenic causes (in any lobe). We describe a case of focal pulmonary edema of the left upper lobe in a patient with partial anomalous pulmonary venous return of the left superior pulmonary vein, where the draining left brachiocephalic vein was compressed by a subluxed sternoclavicular joint after trauma. In this case, recognition of the focal edema and anomalous pulmonary vein allowed for a diagnosis of clavicular subluxation.


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title: High allelic burden of four obesity SNPs is associated with poorer weight loss outcomes following gastric bypass surgery.

text: Genome-wide association and linkage studies have identified multiple susceptibility loci for obesity. We hypothesized that such loci may affect weight loss outcomes following dietary or surgical weight loss interventions. A total of 1,001 white individuals with extreme obesity (BMI >35 kg/m(2)) who underwent a preoperative diet/behavioral weight loss intervention and Roux-en-Y gastric bypass surgery were genotyped for single-nucleotide polymorphisms (SNPs) in or near the fat mass and obesity-associated (FTO), insulin induced gene 2 (INSIG2), melanocortin 4 receptor (MC4R), and proprotein convertase subtilisin/kexin type 1 (PCSK1) obesity genes. Association analysis was performed using recessive and additive models with pre- and postoperative weight loss data. An increasing number of obesity SNP alleles or homozygous SNP genotypes was associated with increased BMI (P < 0.0006) and excess body weight (P < 0.0004). No association between the amounts of weight lost from a short-term dietary intervention and any individual obesity SNP or cumulative number of obesity SNP alleles or homozygous SNP genotypes was observed. Linear mixed regression analysis revealed significant differences in postoperative weight loss trajectories across groups with low, intermediate, and high numbers of obesity SNP alleles or numbers of homozygous SNP genotypes (P < 0.0001). Initial BMI interacted with genotype to influence weight loss with initial BMI <50 kg/m(2), with evidence of a dosage effect, which was not present in individuals with initial BMI ≥50 kg/m(2). Differences in metabolic rate, binge eating behavior, and other clinical parameters were not associated with genotype. These data suggest that response to a surgical weight loss intervention is influenced by genetic susceptibility and BMI.


title: The biology of biologics: basic science and clinical concepts.

text: The repair of complex abdominal wall defects remains one of the most challenging procedures facing reconstructive surgeons. Through these collaborative efforts, defects that were once thought to be impossible to reconstruct can now be repaired, and patients who were left to a miserable quality of life are now offered hope. Among the most important advances in this field have been the adoption of component separation and many of its modifications, the development of new lightweight synthetic mesh, and the explosion of biologic mesh into the surgical armamentarium of the reconstructive surgeon. While biologic grafts are gaining in popularity, the molecular processes and host reactions to biologic grafts are not only unclear but often misunderstood and misrepresented. As a result, comprehensive analysis of basic science concepts presented in this review should help a practicing surgeon with understanding what biologics actually do and what we can expect biologic meshes to accomplish. This article focuses on summarizing the current basic science evidence and the clinical outcomes of utilization of these grafts published in the peer-reviewed literature.


title: Tryptophan-dependent membrane interaction and heteromerization with the internal fusion peptide by the membrane proximal external region of SARS-CoV spike protein.

text: The spike (S) protein of severe acute respiratory syndrome-associated CoV (SARS-CoV) mediates membrane fusion and viral entry. These events involve structural rearrangements, including heteromerization between two heptad repeats (HR1 and HR2) to form a trimer of dimers as a six-helix bundle (6-HB), a quaternary protein structure that brings two distant clusters of hydrophobic sequences into the proximity of each other, the internal fusion peptide (IFP) preceding HR1, and the highly conserved tryptophan (Trp)-rich membrane proximal external region (MPER) following HR2. Here, we show that MPER can undergo self-oligomerization and heteromerization with IFP, events that are Trp-dependent. To delineate the roles of Trp residues of MPER in forming these quaternary structures and interacting with membranes, we employed a panel of synthetic peptides: MPER peptide (M-wt) and its alanine (Ala) and phenylalanine (Phe) analogues. Ala substitutions of Trp inhibited its association with cellular membranes. Chemical cross-linking experiments showed that M-wt can self-interact to form oligomers and cross-interact with IFP23, a synthetic IFP peptide, to form a heterohexamer. In comparison, little high-order oligomer was formed between M-wt and fusion peptide. The specific interaction between M-wt and IFP23 was confirmed by immunofluorescence staining experiments. In aqueous solutions, both M-wt and IFP23 displayed random secondary structures that became helical in hydrophobic solvents. Triple-Ala substitutions of Trp in M-wt, but not the corresponding triple-Phe analogue, disrupted oligomerization of M-wt and hetero-oligomerization of M-wt with IFP23. Overall, our results show that Trp residues of MPER play a key role in maintaining the structure and functions of MPER, allowing it to interact with IFP to form a MPER-IFP heteromer, a putative quaternary structure extending from the 6-HB, and function in membrane fusion. Finally, we showed that a MPER peptide could serve as an inhibitor in the entry process.


title: Ruptured dissecting vertebrobasilar aneurysm in childhood: what is the therapeutic strategy?

text: BACKGROUND/AIMS Pediatric aneurysms are rare, accounting for 0.5-4.6% of all intracranial aneurysms. Dissecting vertebrobasilar aneurysms (DVBA) are more frequently observed among children than adults. Cases acutely presenting with subarachnoid hemorrhage need a prompt treatment because of the higher mortality related to untreated cases. Options for an active DVBA management depend on the features of the malformation and include endovascular and surgical approaches. METHODS We refer to an 8-year-old healthy female, who presented with a sudden severe headache and vomit, followed by a half-hour loss of consciousness. A CT scan revealed subarachnoid hemorrhage, and brain MR angiography showed a lesion with mass effect on bulbar structures, suggestive of an aneurysm of the vertebrobasilar junction. The intracranial angiography confirmed this diagnosis and showed a relevant revascularization coming from the anterior cerebral circulation. RESULTS Endovascular treatment was considered as a suitable option and occlusion of both vertebral arteries, saving the left posterior inferior cerebellar artery, was performed. No neurological deficits appeared after embolization, and the patient was clinically stable at 18 months of follow-up. CONCLUSION In the 'stent era', parent vessel deconstruction throughout endovascular balloon or coil occlusion could be considered in patients with a sound collateral circulation and when cerebellar hemisphere and encephalic trunk feeding is not compromised.


title: Exploring the link between gastric motility and intragastric drug distribution in man.

text: In drug development, the stomach is often considered to be a simple, one-compartmental organ, a waiting room for transfer of an orally administered dosage form to the duodenum. However, factors such as gastric acidity and hydrodynamics in the gastric environment may influence drug disposition. Although a link between gastrointestinal drug behaviour and gastric motility has often been hypothesized, they have not been simultaneously investigated in humans yet. In this proof-of-concept study, the combination of a well-established intraluminal sampling technique with high-resolution manometric measurements in the gastrointestinal tract was evaluated. This new combination of in vivo techniques proved to be feasible from a practical point of view and yielded valuable additional information regarding intraluminal drug behaviour. As a first application, the link between fasted state gastric motility and (in)homogeneous distribution of an orally administered drug in the stomach was investigated in healthy subjects. To this end, drug concentrations were measured in different regions of the stomach after oral administration of a commercially available drug product (Gabbroral®, 250mg paromomycin) during a specific period of gastric contractile activity. A clear trend towards better mixing of an orally administered drug with gastric contents was observed when dosed in the presence of gastric contractions, resulting in a more homogeneous distribution of the drug throughout the stomach compared to dosing in the absence of gastric contractions.


title: Correction to: Anteromedial positioning of the femoral tunnel in Anterior Cruciate Ligament reconstruction is the best option to avoid revision: a single surgeon registry.

text: An amendment to this paper has been published and can be accessed via the original article.


title: Comparative pathogenesis of bovine and porcine respiratory coronaviruses in the animal host species and SARS-CoV-2 in humans.

text: Discovery of bats with severe acute respiratory syndrome (SARS)-related coronaviruses (CoVs) raised the spector of potential future outbreaks of zoonotic SARS-CoV-like disease in humans, which largely went unheeded. Nevertheless, the novel SARS-CoV-2 of bat ancestoral origin emerged to infect humans in Wuhan, China in late 2019 and then became a global pandemic. Less than 5 months after its emergence, millions of people worldwide have been infected asymptomatically or symptomatically and at least 360,000 have died. Coronavirus disease 2019 (COVID-19) in severely affected patients includes atypical pneumonia characterized by a dry cough, persistent fever, and progressive dyspnea and hypoxia, sometimes accompanied by diarrhea and often followed by multiple organ failure, especially, the respiratory and cardiovascular systems. In this mini-review, we focus on two endemic respiratory CoV infections of livestock: Bovine coronavirus (BCoV) and porcine respiratory coronavirus (PRCV). Both animal respiratory CoVs share some common features with SARS-CoV and SARS-CoV-2. BCoV has a broad host range including wild ruminants and a zoonotic potential. BCoV also has a dual tropism for the respiratory and gastrointestinal tracts. These aspects, their interspecies transmission and certain factors that impact disease severity in cattle parallel related facets of SARS-CoV or SARS-CoV-2 in humans. PRCV has a tissue tropism for the upper and lower respiratory tracts and a cellular tropism for type 1 and 2 pneumocytes in lung, but is generally a mild infection unless complicated by other exacerbating factors, such as bacterial or viral co-infections and immunosuppression (corticosteroids).


title: Prasugrel versus clopidogrel in stent-assisted coil embolization of unruptured intracranial aneurysms.

text: Background Thromboembolic complications are the main problem in stent-assisted coil embolization of unruptured intracranial aneurysms. The combination of aspirin and clopidogrel is generally used to decrease these complications, but some patients do not respond to clopidogrel and have a higher risk of stent thrombosis. In cardiology, clinical trials have shown that prasugrel reduced the incidence of ischaemic events in patients with acute coronary syndrome compared with clopidogrel but, according to several authors, prasugrel would produce an increased risk of cerebral haemorrhagic complications. Objective The purpose of this study was to determine whether prasugrel would be more effective than clopidogrel in reducing procedural events in patients with an unruptured aneurysm treated endovascularly with coils and stent. Materials and methods Two hundred consecutive patients with intracranial aneurysms were treated using coiling and stenting procedures. The first 100 patients were administered a dual antiplatelet of aspirin and clopidogrel, while the remaining 100 patients were administered a dual antiplatelet of aspirin and prasugrel. In each group data were collected on procedural and periprocedural haemorrhagic and ischaemic complications. Results Aneurysmal occlusion and haemorrhagic complications rates were identical in both groups. The number of thromboembolic events observed in the two groups of our study did not differ significantly, but the prasugrel group included more wide-neck aneurysms and more flow-diverted stents. Moreover, complications in the prasugrel group were more benign, explaining the significant difference in clinical outcomes between the two groups on Day 30. Conclusions Prasugrel reduces the clinical consequences of thromboembolic complications of endovascular treatment with stenting and coiling of unruptured intracranial aneurysms.


title: Post-disaster community tourism recovery: the tsunami and Arugam Bay, Sri Lanka.

text: Tourism is highly vulnerable to external, non-controllable events. A natural disaster can affect the local tourism industry in numerous ways, and such events are particularly devastating for small communities whose local economy is heavily dependent on the sector. Loss of infrastructure plus negative media stories can have long-term ramifications for the destination. In spite of the economic importance of tourism, post-disaster recovery efforts in this sector are often overlooked by non-governmental organisations (NGOs), which focus on more traditional livelihoods such as agriculture or fishing. This paper describes Mercy Corps' support of tourism recovery activities in Arugam Bay, a remote village on the east coast of Sri Lanka, following the 2004 tsunami. The local economic base is built largely on two sectors: community tourism and fishing. As many other actors were supporting recovery in the local fishing industry, Mercy Corps concentrated on revitalising the tourism sector.


title: Single-incision laparoscopic surgery for cholecystectomy: a retrospective comparison with 4-port laparoscopic cholecystectomy.

text: OBJECTIVES To report our experience with single-incision laparoscopic surgery (SILS) for cholecystectomy and to perform a retrospective comparison with conventional 4-port laparoscopic cholecystectomy. DESIGN, SETTING, AND PATIENTS Data were prospectively collected for all patients undergoing SILS for cholecystectomy at St Mary's Hospital, Imperial College NHS Trust, London, England (n = 41 patients between June 13, 2008, and June 30, 2009) and compared with data for those who had undergone conventional 4-port laparoscopic cholecystectomy in the preceding year (n = 58 patients between June 26, 2007, and May 30, 2008). This included patient demographic data and intraoperative and postoperative outcomes. INTERVENTIONS Four-port laparoscopic cholecystectomy and SILS for cholecystectomy. MAIN OUTCOME MEASURES Operative time, conversion to open operation, and length of hospital stay. RESULTS Operative time was longer with SILS for cholecystectomy compared with conventional laparoscopic cholecystectomy (P < .001). A correlation was seen between reducing SILS operative time and increasing experience (Spearman rank correlation coefficient, -0.29). Three patients in the SILS for cholecystectomy group required the addition of extra laparoscopic ports. No patients in the SILS for cholecystectomy group required conversion to open surgery compared with 4 patients in the standard laparoscopic cholecystectomy group. Patients stayed an average of 0.76 days following SILS for cholecystectomy and 1.53 days following conventional laparoscopic cholecystectomy. One patient in each group had a postoperative biliary leak. CONCLUSIONS Single-incision laparoscopic surgery for cholecystectomy may be equal to conventional laparoscopic cholecystectomy in terms of safety and efficacy. Further randomized studies are required to investigate any significant advantages of this new and attractive technique.


title: Tourniquet Test for Dengue Diagnosis: Systematic Review and Meta-analysis of Diagnostic Test Accuracy.

text: BACKGROUND Dengue fever is a ubiquitous arboviral infection in tropical and sub-tropical regions, whose incidence has increased over recent decades. In the absence of a rapid point of care test, the clinical diagnosis of dengue is complex. The World Health Organisation has outlined diagnostic criteria for making the diagnosis of dengue infection, which includes the use of the tourniquet test (TT). PURPOSE To assess the quality of the evidence supporting the use of the TT and perform a diagnostic accuracy meta-analysis comparing the TT to antibody response measured by ELISA. DATA SOURCES A comprehensive literature search was conducted in the following databases to April, 2016: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials, BIOSIS, Web of Science, SCOPUS. STUDY SELECTION Studies comparing the diagnostic accuracy of the tourniquet test with ELISA for the diagnosis of dengue were included. DATA EXTRACTION Two independent authors extracted data using a standardized form. DATA SYNTHESIS A total of 16 studies with 28,739 participants were included in the meta-analysis. Pooled sensitivity for dengue diagnosis by TT was 58% (95% Confidence Interval (CI), 43%-71%) and the specificity was 71% (95% CI, 60%-80%). In the subgroup analysis sensitivity for non-severe dengue diagnosis was 55% (95% CI, 52%-59%) and the specificity was 63% (95% CI, 60%-66%), whilst sensitivity for dengue hemorrhagic fever diagnosis was 62% (95% CI, 53%-71%) and the specificity was 60% (95% CI, 48%-70%). Receiver-operator characteristics demonstrated a test accuracy (AUC) of 0.70 (95% CI, 0.66-0.74). CONCLUSION The tourniquet test is widely used in resource poor settings despite currently available evidence demonstrating only a marginal benefit in making a diagnosis of dengue infection alone. REGISTRATION The protocol for this systematic review was registered at PROSPERO CRD42015020323.


title: Technical considerations, outcomes, and durability of inferior vena cava stenting.

text: OBJECTIVE Inferior vena cava (IVC) thrombosis is an uncommon condition but can cause devastating complications to those affected. Historically, this has been treated with an open surgical approach (with high morbidity) and with angioplasty in more recent years. Herein we describe technical aspects of stenting of the IVC in patients with recalcitrant chronic occlusive disease and evaluate its outcomes. METHODS We reviewed all the patients treated in an endovascular fashion for venous disease at our institution from 2005 to 2014 to identify and to include those with IVC stent placement in this study. Clinical characteristics, treatment details, and outcomes data were collected from medical records. Primary end points were technical success, symptom resolution, freedom from reintervention, and patency rate at follow-up. RESULTS Twenty-eight patients (15 men) with a mean age of 48 ± 2.7 years underwent IVC stent placement for 16 occlusions (4 congenital) and 12 high-grade stenoses. Hypercoagulable state was noted in 14 patients, 7 of whom had malignant disease. A previously placed IVC filter was present in 13 patients. Median time from onset of symptoms to presentation was 81 months (3-480 months). Lytic therapy with tissue plasminogen activator (Alteplase) was performed in 12 patients for a median of 2 days (range, 1-3 days). Self-expanding stents (Wallstent; Boston Scientific, Natick, Mass) were used most commonly in the IVC (n = 22) with or without adjunctive use of balloon-expandable stents (Palmaz stent; Cordis, New Brunswick, NJ). Technical success was 100%. At median follow-up of 10 months (range, 0-56 months), thrombotic complications requiring reintervention occurred in four patients at 1, 4, 8, and 37 months. One patient died at 2 weeks secondary to underlying malignant disease. Freedom from reintervention, patency rate, and symptom-free survival rate at 2 years were 84%, 90%, and 80%. CONCLUSIONS Endovascular stenting for chronic occlusive disease of the IVC is safe and effective in the midterm follow-up, with minimal morbidity. Reintervention rate is low, with excellent functional outcomes.


title: Early response to the emergence of influenza A(H7N9) virus in humans in China: the central role of prompt information sharing and public communication.

text: PROBLEM In 2003, China's handling of the early stages of the epidemic of severe acute respiratory syndrome (SARS) was heavily criticized and generally considered to be suboptimal. APPROACH Following the SARS outbreak, China made huge investments to improve surveillance, emergency preparedness and response capacity and strengthen public health institutions. In 2013, the return on these investments was evaluated by investigating China's early response to the emergence of avian influenza A(H7N9) virus in humans. LOCAL SETTING Clusters of human infection with a novel influenza virus were detected in China - by national surveillance of pneumonia of unknown etiology - on 26 February 2013. RELEVANT CHANGES On 31 March 2013, China notified the World Health Organization (WHO) of the first recorded human infections with A(H7N9) virus. Poultry markets - which were rapidly identified as a major source of transmission of A(H7N9) to humans - were closed down in the affected areas. Surveillance in humans and poultry was heightened and technical guidelines were quickly updated and disseminated. The health authorities collaborated with WHO in risk assessments and risk communication. New cases were reported promptly and publicly. LESSONS LEARNT The relevant infrastructures, surveillance systems and response capacity need to be strengthened in preparation for future emergencies caused by emerging or existing disease threats. Results of risk assessments and other data should be released promptly and publicly and such release should not jeopardize future publication of the data in scientific journals. Coordination between public health and veterinary services would be stronger during an emergency if these services had already undertaken joint preparedness planning.


title: Single-incision and NOTES cholecystectomy, are there clinical or cosmetic advantages when compared to conventional laparoscopic cholecystectomy? A case-control study comparing single-incision, transvaginal, and conventional laparoscopic technique for cholecystectomy.

text: BACKGROUND The aim of the present study was to compare the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC), single-port cholecystectomy (SPC), and conventional laparoscopic cholecystectomy (CLC). Recently, single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery have been developed as minimally invasive alternatives for CLC. Few comparative studies have been reported. METHODS Female patients with symptomatic gallstone disease who were treated in 2011 with SPC, TVC, or CLC were entered into a database. Patients were matched for age, body mass index, and previous abdominal surgery. After the operation all patients received a survey with questions about recovery, cosmesis, and body image. RESULTS A total of 90 patients, 30 in each group, were evaluated. Median operative time for CLC was significantly shorter (p < 0.001). There were no major complications. Length of hospital stay, postoperative pain, and postoperative complications were not significantly different. The results for cosmesis and body image after the transvaginal approach were significantly higher. None of the sexually active women observed postoperative dyspareunia. CONCLUSIONS Both SPC and TVC are feasible procedures when performed in selected patients. CLC is a faster procedure, but other clinical outcomes and complication rates were similar. SPC, and especially TVC, offer a better cosmetic result. Randomized trials are needed to specify the role of SPC and TVC in the treatment of patients with symptomatic gallstone disease.


title: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in patients with liver cirrhosis accompanied by ascites.

text: To investigate the feasibility, efficacy, and safety of laparoscopic totally extraperitoneal (TEP) repair in patients with inguinal hernia accompanied by liver cirrhosis.Between October 2015 and May 2018, 17 patients with liver cirrhosis who underwent TEP repair were included in this study. The baseline characteristics, perioperative data, and recurrence were retrospectively reviewed.Seventeen patients with a mean duration of 18.23 ± 16.80 months were enrolled. All TEP repairs were successful without conversion to trans-abdominal pre-peritoneal (TAPP) surgery or open repair, but 4 patients had peritoneum rupture during dissection. The mean operation time was 54.23 ± 10.51 minutes for unilateral hernia and 101.25 ± 13.77 minutes for bilateral hernias. We found 2 cases with contralateral inguinal hernia and 2 cases with obturator hernia during surgery. The rate of complication was 17.65% (3/17), 2 of 3 cases were Child-Turcotte-Pugh C with large ascites. During a follow-up of 19.29 ± 9.01 months, no patients had recurrence and chronic pain, but 2 patients died because of the progression of underlying liver disease.Early and elective inguinal hernia repair is feasible and effective for patients with liver cirrhosis. TEP is a feasible and safe repair option for cirrhotic patients in experienced hands.


title: Comparison of laparoendoscopic single-site hysterectomies: laparoscopic hysterectomy with some vaginal component versus laparoscopically assisted vaginal hysterectomy.

text: BACKGROUND To compare the clinical results of two types of laparoendoscopic single-site surgery (LESS) laparoscopic hysterectomy (LH): LH with some vaginal component [LH(a)] versus laparoscopically assisted vaginal hysterectomy (LAVH). SUBJECTS AND METHODS This is a retrospective comparative study. A single surgeon performed 50 LESS-LAVH procedures consecutively between March 2009 and October 2009 and 50 LESS-LH(a) procedures consecutively between January 2011 and July 2011. RESULTS Most LESS-LH(a)s/LAVH procedures were successful. Of 50 LESS-LH(a) procedures, 2 were converted to LESS-LAVH. Of 50 LESS-LAVHs, 1 required additional ports. The LESS-LH(a) group had a shorter operative time and less postoperative pain compared with the LESS-LAVH group. Operative complications were not significantly different between the groups. CONCLUSIONS LESS-LH(a) and LESS-LAVH are both feasible and safe methods, with similar surgical outcomes. In terms of operative time and postoperative pain, LESS-LH(a) is superior to LESS-LAVH.


title: From head to toe of the norovirus 3C-like protease.

text: Abstract Noroviruses are major causative agents of viral gastroenteritis in humans. Currently, there are no therapeutic medications to treat noroviral infections, nor are there effective vaccines against these pathogens. The viral 3C-like protease is solely responsible for the maturation of viral protein components. The crystal structures of the proteases were resolved at high atomic resolution. The protease was also explored by means of mutagenesis. These studies revealed the active-site amino acid residues and factors determining and affecting substrate specificity as well as the principle of architecting the protease molecule. The possible mechanism of proteolysis was also suggested. Consideration of the data accumulated thus far will be useful for development of therapeutic drugs targeting the viral protease.


title: Differing community responses to similar public health threats: a cross-disciplinary systematic literature review.

text: BACKGROUND The way in which different communities respond to similar threats to their health can vary, from outrage to indifference and public health agencies are often taken by surprise leading to potential loss of public confidence. The objective of this systematic literature review was to seek to better understand the community-level drivers that might explain the variability in response. METHODS A vigorous systematic cross-disciplinary literature review was undertaken searching thirteen bibliographic databases and a variety of grey sources were screened. The social amplification of risk framework and the risk perception management theoretical models were used to assess evidence and data were synthesised by Narrative review. FINDINGS Sixteen studies meeting the agreed inclusion criteria described eleven different threats ranging from: infectious disease outbreaks to environmental disasters to cancer clusters, affecting two or more communities were identified from medical, psychological, social science and environmental science literature. There was wide heterogeneity between the type and quality of the studies. There was a general absence of theoretical underpinning community responses. Most studies did not report sufficient data to allow an appropriate amount of validity. Very low response rates in particular were common. Potential explanatory drivers suggested included, prior experience and visibility of threat, sociodemographic characteristics, volume and type of media coverage, government reaction and availability of social support. CONCLUSIONS This review confirmed that there are significant differences. Further work is needed to develop theoretical models that apply to the community level and do not assume that a community's response is simply the aggregate of individual level responses.


title: Experimental studies on performance of ventilators stored in the Strategic National Stockpile.

text: BACKGROUND The Center for Devices and Radiological Health, Food and Drug Administration (FDA) launched a collaborative initiative with Centers for Disease Control and Prevention (CDC) to gain a better understanding of ventilators that are used during national emergencies. This initiative was intended to test reliability of ventilator devices stored long term in the CDC Strategic National Stockpile (SNS) and also used by the Department of Defense. These ventilators are intended to be used by trained operators to provide ventilatory support to adult and pediatric populations under diverse environmental conditions. The authors evaluated device performance and possible effects of long-term storage. METHODS Three SNS ventilator models: Impact Uni-Vent 754 Eagle™, Covidien (Puritan Bennett) LP10, and CareFusion LTV 1200 were used in this study. A total of 36 ventilators, 12 per model, were evaluated for performance in simulated adult populations using a test lung. The parameters evaluated included battery charge status and capability, battery longevity, positive end expiratory pressure consistency, device performance on AC and DC (battery) power, and device durability testing. RESULTS The out-of-the-box run time was equal to or higher than the manufacturer's specifications for fully charged batteries for all ventilators except 58 percent of the Impact 754 ventilators. No significant ventilator performance issues were observed in terms of tidal volume consistency, proximal pressure, oxygen consumption, and a 2000-hour run test in LP10 models. CONCLUSIONS These findings provide information about the long-term storage of ventilators that have regular maintenance, and their ability to perform reliably during a public health emergency.


Ethics of clinical science in a public health emergency: reflections on the role of research ethics boards.


title: Virally expressed interleukin-10 ameliorates acute encephalomyelitis and chronic demyelination in coronavirus-infected mice.

text: The absence of interleukin-10 (IL-10), a potent anti-inflammatory cytokine results in increased immune-mediated demyelination in mice infected with a neurotropic coronavirus (recombinant J2.2-V-1 [rJ2.2]). Here, we examined the therapeutic effects of increased levels of IL-10 at early times after infection by engineering a recombinant J2.2 virus to produce IL-10. We demonstrate that viral expression of IL-10, which occurs during the peak of virus replication and at the site of disease, enhanced survival and diminished morbidity in rJ2.2-infected wild-type B6 and IL-10(-/-) mice. The protective effects of increased IL-10 levels were associated with reductions in microglial activation, inflammatory cell infiltration into the brain, and proinflammatory cytokine and chemokine production. Additionally, IL-10 increased both the frequency and number of Foxp3(+) regulatory CD4 T cells in the infected central nervous system. Most strikingly, the ameliorating effects of IL-10 produced during the first 5 days after infection were long acting, resulting in decreased demyelination during the resolution phase of the infection. Collectively, these results suggest that the pathogenic processes that result in demyelination are initiated early during infection and that they can be diminished by exogenous IL-10 delivered soon after disease onset. IL-10 functions by dampening the innate or very early T cell immune response. Further, they suggest that early treatment with IL-10 may be useful adjunct therapy in some types of viral encephalitis.


title: Association of perfluoroalkyl substances with gestational hypertension and preeclampsia in the MIREC study.

text: BACKGROUND Perfluoroalkyl substances (PFAS) have been linked with a number of developmental, reproductive, hepatic, and cardiovascular health outcomes. However, the evidence for an association between PFAS and hypertensive disorders of pregnancy (including gestational hypertension and preeclampsia) is equivocal and warrants further investigation. OBJECTIVES To examine the relationship between background levels of perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), and perfluorohexane sulfonate (PFHxS) and the development of gestational hypertension or preeclampsia in a Canadian pregnancy cohort. We also explored the potential for effect modification according to fetal sex. METHODS Maternal plasma samples were collected in the first trimester from participants in the MIREC study and were analyzed for PFOA, PFOS, and PFHxS. Blood pressure was measured during each trimester. Gestational hypertension and preeclampsia were defined using the Society of Obstetricians and Gynaecologists of Canada guidelines. Logistic regression models were used to derive adjusted odds ratios (OR) and 95% confidence intervals (CI) for associations between PFAS concentrations (per doubling of concentration as well as according to tertiles) and gestational hypertension or preeclampsia. Linear mixed models were used to examine the association between PFAS concentrations and changes in blood pressure throughout pregnancy. RESULTS Data from 1739 participants were analyzed. 90% of women were normotensive throughout pregnancy, 7% developed gestational hypertension without preeclampsia, and 3% developed preeclampsia. In the full analyses, neither PFOA nor PFOS were associated with gestational hypertension or preeclampsia. However, each doubling of PFHxS plasma concentration was associated with higher odds of developing preeclampsia (OR = 1.32; 95% CI: 1.03, 1.70). In addition, participants in the highest PFHxS tertile (1.4-40.0 μg/L) had higher odds of developing preeclampsia relative to those in the lowest tertile (OR = 3.06; 95% CI: 1.27, 7.39). In stratified analyses, this effect was only apparent among women carrying a female fetus (OR = 4.90; 95% CI: 1.02, 22.3). However, among women carrying a male fetus, both PFOS and PFHxS were associated with gestational hypertension, but not preeclampsia. Higher plasma concentrations of all three PFAS were associated with increases in diastolic blood pressure throughout pregnancy, and PFOA and PFHxS were also associated with systolic blood pressure. Discrepant findings were similarly revealed in analyses stratified by fetal sex. CONCLUSIONS Higher levels of PFHxS were associated with the development of preeclampsia, but not gestational hypertension. Neither PFOA nor PFOS were associated with either outcome. However, we show, for the first time, that fetal sex may modify these associations, a finding which warrants replication and further study.