title: Surgeon-Centered Analysis of Robot-Assisted Needle Driving Under Different Force Feedback Conditions.

text: Robotic assisted minimally invasive surgery (RAMIS) systems present many advantages to the surgeon and patient over open and standard laparoscopic surgery. However, haptic feedback, which is crucial for the success of many surgical procedures, is still an open challenge in RAMIS. Understanding the way that haptic feedback affects performance and learning can be useful in the development of haptic feedback algorithms and teleoperation control systems. In this study, we examined the performance and learning of inexperienced participants under different haptic feedback conditions in a task of surgical needle driving via a soft homogeneous deformable object-an artificial tissue. We designed an experimental setup to characterize their movement trajectories and the forces that they applied on the artificial tissue. Participants first performed the task in an open condition, with a standard surgical needle holder, followed by teleoperation in one of three feedback conditions: (1) no haptic feedback, (2) haptic feedback based on position exchange, and (3) haptic feedback based on direct recording from a force sensor, and then again with the open needle holder. To quantify the effect of different force feedback conditions on the quality of needle driving, we developed novel metrics that assess the kinematics of needle driving and the tissue interaction forces, and we combined our novel metrics with classical metrics. We analyzed the final teleoperated performance in each condition, the improvement during teleoperation, and the aftereffect of teleoperation on the performance when using the open needle driver. We found that there is no significant difference in the final performance and in the aftereffect between the 3 conditions. Only the two conditions with force feedback presented statistically significant improvement during teleoperation in several of the metrics, but when we compared directly between the improvements in the three different feedback conditions none of the effects reached statistical significance. We discuss possible explanations for the relative similarity in performance. We conclude that we developed several new metrics for the quality of surgical needle driving, but even with these detailed metrics, the advantage of state of the art force feedback methods to tasks that require interaction with homogeneous soft tissue is questionable.


title: Evidence and ethics in public health: the experience of SARS in Canada.

text: Making decisions on the basis of evidence is a central tenet of all health-care disciplines, including public health. However, it is not entirely clear what it means to base decisions on evidence; debates on evidence-based approaches often lack a clear understanding of the nature of evidence and obscure the normative underpinnings of evidence. Public health decision making requires an acceptance of limitations such as the availability of funding for research to provide complete evidence for any given decision, the ethical constraints on the creation of certain types of evidence and the ongoing dilemma between the need to take action and the need to gather more information. Using the example of the SARS outbreak in Canada, the inter-relationships between evidence and ethics are explored. I outline a set of critical questions for the global public health community to discuss regarding the nature of the relationship between evidence-based public health practice and ethics.


title: Time for a neonatal-specific consensus definition for sepsis.

text: OBJECTIVE To review the accuracy of the pediatric consensus definition of sepsis in term neonates and to determine the definition of neonatal sepsis used. STUDY SELECTION The review focused primarily on pediatric literature relevant to the topic of interest. CONCLUSIONS Neonatal sepsis is variably defined based on a number of clinical and laboratory criteria that make the study of this common and devastating condition very difficult. Diagnostic challenges and uncertain disease epidemiology necessarily result from a variable definition of disease. In 2005, intensivists caring for children recognized that as new drugs became available, children would be increasingly studied and thus, pediatric-specific consensus definitions were needed. Pediatric sepsis criteria are not accurate for term neonates and have not been examined in preterm neonates for whom the developmental stage influences aberrations associated with host immune response. Thus, specific consensus definitions for both term and preterm neonates are needed. Such definitions are critical for the interpretation of observational studies, future training of scientists and practitioners, and implementation of clinical trials in neonates.


Minimally invasive intrathoracic esophagogastric anastomosis.


title: Living with the enemy: viral persistent infections from a friendly viewpoint.

text: Persistent infection is a situation of metastability in which the pathogen and the host coexist. A common outcome for viral infections, persistence is a widespread phenomenon through all kingdoms. With a clear benefit for the virus and/or the host at the population level, persistent infections act as modulators of the ecosystem. The origin of persistence being long time elusive, here we explore the concept of 'endogenization' of viral sequences with concomitant activation of the host immune pathways, as a main way to establish and maintain viral persistent infections. Current concepts on viral persistence mechanisms and biological role are discussed.


title: Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

text: AIM Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery. METHOD This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage. RESULTS A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P < 0.0001). CONCLUSION In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.


title: Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients.

text: INTRODUCTION Laparoscopic sleeve gastrectomy has been accepted as an option for surgical treatment of obesity. After surgery, some patients present reflux symptoms associated with endoscopic esophagitis, therefore PPI's treatment must be indicated. PURPOSE This study aims to evaluate the manometric characteristic of the lower esophageal sphincter (LES) before and after sleeve gastrectomy MATERIAL AND METHOD This prospective study includes 20 patients submitted to esophageal manometry in order to determine the resting pressure, and total and abdominal LES length before and after the sleeve gastrectomy. Statistical variations on the LESP were validated according to Student's "t" test. RESULTS Seventeen female and three male patients were included, with a mean age of 37.6 +/- 12.6 years. All patients reduced their body weight, from an initial BMI of 38.3 kg/m(2) to 28.2 kg/m(2) 6 months after surgery. No postoperative complications were observed in these patients. Preoperative mean LESP was 14.2 +/- 5.8 mmHg. Postoperative manometry decreased in 17/20 (85%), with a mean value of 11.2 +/- 5.7 mmHg (p = 0.01). Seven of them presented LESP <12 mmHg and ten patients <6 mmHg after the operation. Furthermore, the abdominal length and total length of the high pressure zone at the esophagogastric junction were affected. CONCLUSION A sleeve gastrectomy produces an important decrease in LES pressure, which can in turn cause the appearance of reflux symptoms and esophagitis after the operation due to a partial resection of the sling fibers during the gastrectomy.


title: Flawed Self-Assessment: Implications for Health, Education, and the Workplace.

text: Research from numerous corners of psychological inquiry suggests that self-assessments of skill and character are often flawed in substantive and systematic ways. We review empirical findings on the imperfect nature of self-assessment and discuss implications for three real-world domains: health, education, and the workplace. In general, people's self-views hold only a tenuous to modest relationship with their actual behavior and performance. The correlation between self-ratings of skill and actual performance in many domains is moderate to meager-indeed, at times, other people's predictions of a person's outcomes prove more accurate than that person's self-predictions. In addition, people overrate themselves. On average, people say that they are "above average" in skill (a conclusion that defies statistical possibility), overestimate the likelihood that they will engage in desirable behaviors and achieve favorable outcomes, furnish overly optimistic estimates of when they will complete future projects, and reach judgments with too much confidence. Several psychological processes conspire to produce flawed self-assessments. Research focusing on health echoes these findings. People are unrealistically optimistic about their own health risks compared with those of other people. They also overestimate how distinctive their opinions and preferences (e.g., discomfort with alcohol) are among their peers-a misperception that can have a deleterious impact on their health. Unable to anticipate how they would respond to emotion-laden situations, they mispredict the preferences of patients when asked to step in and make treatment decisions for them. Guided by mistaken but seemingly plausible theories of health and disease, people misdiagnose themselves-a phenomenon that can have severe consequences for their health and longevity. Similarly, research in education finds that students' assessments of their performance tend to agree only moderately with those of their teachers and mentors. Students seem largely unable to assess how well or poorly they have comprehended material they have just read. They also tend to be overconfident in newly learned skills, at times because the common educational practice of massed training appears to promote rapid acquisition of skill-as well as self-confidence-but not necessarily the retention of skill. Several interventions, however, can be introduced to prompt students to evaluate their skill and learning more accurately. In the workplace, flawed self-assessments arise all the way up the corporate ladder. Employees tend to overestimate their skill, making it difficult to give meaningful feedback. CEOs also display overconfidence in their judgments, particularly when stepping into new markets or novel projects-for example, proposing acquisitions that hurt, rather then help, the price of their company's stock. We discuss several interventions aimed at circumventing the consequences of such flawed assessments; these include training people to routinely make cognitive repairs correcting for biased self-assessments and requiring people to justify their decisions in front of their peers. The act of self-assessment is an intrinsically difficult task, and we enumerate several obstacles that prevent people from reaching truthful self-impressions. We also propose that researchers and practitioners should recognize self-assessment as a coherent and unified area of study spanning many subdisciplines of psychology and beyond. Finally, we suggest that policymakers and other people who makes real-world assessments should be wary of self-assessments of skill, expertise, and knowledge, and should consider ways of repairing self-assessments that may be flawed.


title: Middle East Respiratory Syndrome (MERS).

text: Since the identification of the first patients with Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012, over 1,600 cases have been reported as of February 2016. Most cases have occurred in Saudi Arabia or in other countries on or near the Arabian Peninsula, but travel-associated cases have also been seen in countries outside the Arabian Peninsula. MERS-CoV causes a severe respiratory illness in many patients, with a case fatality rate as high as 40%, although when contacts are investigated, a significant proportion of patients are asymptomatic or only have mild symptoms. At this time, no vaccines or treatments are available. Epidemiological and other data suggest that the source of most primary cases is exposure to camels. Person-to-person transmission occurs in household and health care settings, although sustained and efficient person-to-person transmission has not been observed. Strict adherence to infection control recommendations has been associated with control of previous outbreaks. Vigilance is needed because genomic changes in MERS-CoV could result in increased transmissibility, similar to what was seen in severe acute respiratory syndrome coronavirus (SARS-CoV).


Radiofrequency ablation is a treatment option for early stages of verrucous esophageal carcinoma.


title: Fenestra Obscura: Flow Diverter Reconstruction of a Complex Vertebrobasilar Aneurysm Through an Obscured Fenestration Limb: Technical Case Report.

text: BACKGROUND AND IMPORTANCE Basilar fenestration aneurysms are rare, challenging intracranial vascular lesions with atypical anatomy. The posterior circulation represents a difficult therapeutic dilemma because of the close proximity of crucial life-sustaining brainstem structures. The use of flow diverter technology has been very limited in posterior circulation vessels. CLINICAL PRESENTATION We present the case of a 49-year-old female patient, who was diagnosed with a symptomatic large vertebrobasilar junction aneurysm, which was initially thought to be a proximal basilar dilatation. The aneurysm was later verified to arise from the proximal end of a basilar fenestration, distended by the aneurysm fundus. The small-caliber fenestration limbs were the only connection to the distal basilar artery, but were stretched laterally and concealed by the aneurysm fundus. This complex lesion was successfully treated by flow diverter deployment through one of the fenestration limbs, followed by coiling of the aneurysm fundus, and sacrificing the contralateral vertebral artery. A 6-month follow-up angiogram showed remodeling of the basilar artery and complete occlusion of the aneurysm with good clinical outcome. Careful diagnostic workup, multidisciplinary discussions, and the innovative use of versatile endovascular technology were crucial to achieve an optimal result in this case. CONCLUSION This is the first report of a successful basilar artery reconstruction for the treatment of a large atypical vertebrobasilar junction fenestration aneurysm by deployment of a flow diverter device directly in a small, obscured fenestration limb.


title: Hemostatic Therapy Using Tranexamic Acid and Coagulation Factor Concentrates in a Model of Traumatic Liver Injury.

text: BACKGROUND The potential clinical benefits of targeted therapy with coagulation factor concentrates (e.g., fibrinogen) and antifibrinolytic agents (e.g., tranexamic acid [TXA]) for the treatment of trauma-induced coagulopathy are increasingly recognized. We hypothesized that human fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC), administered as combined therapy with TXA, would provide additive effects for reducing blood loss in an animal trauma model. METHODS Thirty-six pigs were subjected to 2 consecutive blunt liver injuries, resulting in severe hemorrhagic shock and coagulopathy. Intervention comprised saline (control group); TXA (15 mg kg, TXA group); TXA and FC (90 mg kg, TXA-FC); or TXA, FC, and PCC (20 U kg, TXA-FC-PCC). Blood loss, thromboelastometry (ROTEM), measures of thrombin generation, platelet activation, and global coagulation variables were monitored for 4 hours. Tissue sections were examined to determine the occurrence of thromboembolic events. RESULTS Total blood loss was similar in the TXA-FC and TXA-FC-PCC groups (mean ± SD: 1012 ± 86 mL and 1037 ± 118 mL, respectively; P = 1.000). These values were both lower (P < 0.001) than the TXA group (1579 ± 306 mL). Blood loss in all 3 intervention groups was lower (P < 0.001) than in the control group (2376 ± 478 mL). After trauma and resuscitation, but before study intervention, plasma fibrinogen levels were severely depleted (median for the whole study population: 66 mg dL; interquartile range: 51-108 mg dL) and clot strength was decreased (EXTEM whole-blood maximum clot firmness [MCF]: 53 ± 5 mm). Compared with controls, TXA inhibited fibrinolysis and stabilized MCF and clotting time. The addition of FC restored and stabilized hemostasis to a greater extent than TXA alone; the addition of PCC had no statistically significant impact on blood loss, clot strength (MCF), or clotting time, but it increased thrombin generation. There were no significant differences among the study groups regarding platelet activation. No thrombi or microthrombi were observed in any group at necropsy. CONCLUSIONS The early use of TXA and FC reduced blood loss and improved coagulation measurements in a porcine model of blunt liver injury and hemorrhagic shock. FC, administered in addition to TXA, was highly effective in reducing blood loss. The lack of statistically significant reduction in blood loss when PCC was added to TXA and FC may be attributable to the absence of thrombin generation impairment in this model.


title: Antibiotic-releasing microspheres prevent mesh infection in vivo.

text: BACKGROUND Infection remains a dreaded complication after implantation of surgical prosthetics, particularly after hernia repair with synthetic mesh. We previously demonstrated the ability of a newly developed polymer to provide controlled release of an antibiotic in a linear fashion over 45 d. We subsequently showed that coating mesh with the drug-releasing polymer prevented a Staphylococcus aureus (SA) infection in vivo. To broaden the applicability of this technology, the polymer was synthesized as isolated "microspheres" and loaded with vancomycin (VM) before conducting a noninferiority analysis. MATERIALS AND METHODS Seventy-three mice underwent creation of a dorsal subcutaneous pocket that was inoculated with 104 colony forming units (CFU) of green fluorescent protein (GFP)-labeled SA (105 CFU/mL). Multifilament polyester mesh (7 × 7 mm) was placed into the pocket, and the skin was closed. Mesh was either placed alone (n = 16), coated with VM-loaded polymer (n = 20), placed next to VM-loaded microspheres (n = 20) or unloaded microspheres (n = 10), or flushed with VM solution (n = 7). Quantitative tissue/mesh cultures were performed at 2 and 4 week. Mice with open wounds and explanted mesh were excluded. RESULTS Twenty-two of 23 (96%) tissue-mesh samples from mesh alone or empty miscrospheres were positive for GFP-labeled SA at 2 and 4 wk. Six of seven (86%) samples from the VM flush group were positive for GFP SA at 4 wk. Thirty-eight of 38 (100%) VM-loaded crosslinked cyclodextrin polymers-coated mesh or VM-loaded microspheres were negative for GFP SA at 2 and 4 wk. CONCLUSIONS Slow affinity-based drug-releasing polymers in the form of microspheres are able to adequately clear a bacterial burden of SA and prevent mesh infection.


title: Myeloid-derived suppressor cells in obstetrical and gynecological diseases.

text: Myeloid-derived suppressor cells (MDSCs) are a heterogeneous group of myeloid-origin cells which have immunosuppressive activities in several conditions, such as cancer and inflammation. Recent research has also associated MDSCs with numerous obstetrical and gynecological diseases. During pregnancy, MDSCs accumulate to ensure maternal-fetal immune tolerance, whereas they are decreased in patients who suffer from early miscarriage or preeclampsia. While the etiology of endometriosis is still unknown, abnormal accumulation of MDSCs in the peripheral blood and peritoneal fluid, alongside an increased level of reactive oxygen species (ROS) has been observed in these patients, which is central to the cellular immune regulations by MDSCs. Additionally, the regulation of MDSCs observed in tumors is also applicable to gynecologic neoplasms, including ovarian cancer and cervical cancer. More recently, emerging evidence has shown that there are high levels of MDSCs in premature ovarian failure (POF) and in vitro fertilization (IVF), but the underlying mechanisms are unknown. In this review, the generation and mechanisms of MDSCs are summarized. In particular the modulation of these cells in immune-related obstetrical and gynecological diseases is discussed, including potential treatment options targeting MDSCs.


title: Inhibition and Degradation of Amyloid Beta (Aβ40) Fibrillation by Designed Small Peptide: A Combined Spectroscopy, Microscopy, and Cell Toxicity Study.

text: A designed nontoxic, nonhemolytic 11-residue peptide, NF11 (NAVRWSLMRPF), not only inhibits the aggregation of amyloid beta (Aβ40) protein but also disaggregates the preformed oligomers and mature Aβ fibrils, thereby reducing associated-toxicity. NMR experiments provide evidence of NF11's ability to inhibit fibril formation, primarily through interaction with the N-terminus region as well as the central hydrophobic cluster of Aβ40. NF11 has micromolar binding affinity toward both monomeric and aggregated species for efficient clearance of toxic aggregates. From these in vitro results, the future development of a next generation peptidomimetic therapeutic agent for amyloid disease may be possible.


title: Emerging evidence for neuropsycho-consequences of COVID-19.

text: The pandemic novel coronavirus disease (COVID-19) has become a global concern in which respiratory system is not the only one involved. Previous researches have presented the common clinical manifestations including respiratory symptoms (i.e., fever and cough), fatigue and myalgia. However, there is limited evidence for neurological and psychological influences by SARS-CoV-2. In this review, we discuss the common neurological manifestations of COVID-19 including acute cerebrovascular disease (i.e., cerebral hemorrhage) and muscle ache. Possible viral transmission to the nervous system may occur via circulation, an upper nasal transcribrial route and/or conjunctival route. Also, we cannot ignore the psychological influence on the public, medical staff and confirmed patients. Dealing with public psychological barriers and performing psychological crisis intervention are an important part of public health interventions.


title: Bimodal electric tissue ablation (BETA) compared with the Cool-Tip RFA system.

text: BACKGROUND Bimodal electric tissue ablation (BETA) incorporates the process of electrolysis into radiofrequency ablation (RFA) to increase the size of tissue ablation. This study investigated whether BETA could increase the efficacy of the Cool-Tip RF system (Covidien, Boulder, CO, USA) to produce larger ablations. It also investigated whether applying electrolysis only during the pretreatment phase (called electrochemical treatment (ECT)/RFA group) is as effective as BETA (where electrolysis was used during both the pretreatment and RFA phases). METHODS A Cool-Tip RF system (Covidien) was used to test three types of ablations (RFA, BETA, and ECT/RFA) in a pig liver model. In BETA, 9 V of direct current was provided for 10 min, after which the RF generator was started and both electrical circuits were allowed to run concurrently. In ECT/RFA, however, the direct current circuit was switched off after 10 min of pretreatment and only RFA was performed as described above. Ablation sizes were measured in three dimensions. RESULTS The size of ablations (transverse diameter A and B) produced by BETA and ECT/RFA was significantly larger compared with standard RFA (P < 0/001). BETA also created larger ablations compared with ECT/RFA (P < 0.001). CONCLUSION BETA could improve the efficacy of the Cool-Tip RF system (Covidien) to achieve larger ablations. The increased tissue hydration improved delivery of electrical energy to the tissues and delayed the process of desiccation, thus allowing the ablation process to continue for longer periods of time to produce larger ablations. BETA could be used to treat larger liver tumours more effectively than standard RFA.


Reopening Schools in the Time of Pandemic: Look to the School Nurses.


title: Fixed target combined with spectral mapping: approaching 100% hit rates for serial crystallography.

text: The advent of ultrafast highly brilliant coherent X-ray free-electron laser sources has driven the development of novel structure-determination approaches for proteins, and promises visualization of protein dynamics on sub-picosecond timescales with full atomic resolution. Significant efforts are being applied to the development of sample-delivery systems that allow these unique sources to be most efficiently exploited for high-throughput serial femtosecond crystallography. Here, the next iteration of a fixed-target crystallography chip designed for rapid and reliable delivery of up to 11 259 protein crystals with high spatial precision is presented. An experimental scheme for predetermining the positions of crystals in the chip by means of in situ spectroscopy using a fiducial system for rapid, precise alignment and registration of the crystal positions is presented. This delivers unprecedented performance in serial crystallography experiments at room temperature under atmospheric pressure, giving a raw hit rate approaching 100% with an effective indexing rate of approximately 50%, increasing the efficiency of beam usage and allowing the method to be applied to systems where the number of crystals is limited.


title: Single-incision transabdominal preperitoneal and totally extraperitoneal repair for inguinal hernia: early experience from a single center in Asia.

text: INTRODUCTION Laparoscopic inguinal hernia repair is currently one of the most commonly performed minimally invasive surgical procedures. In recent years, single-incision operations have been developed to further reduce the invasiveness of the surgery. Herein, we report our early experience with single-incision laparoscopic inguinal hernia repair in Asia, with both the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) approaches. METHODS This is a retrospective review of prospectively collected data on a cohort of consecutive patients with inguinal hernia who underwent single-incision laparoscopic inguinal hernia repair in a minimal access surgical center in Hong Kong between January 2010 and January 2011. RESULTS Our cohort consists of 15 patients who underwent single-incision laparoscopic inguinal hernia; 13 were unilateral and two were bilateral hernias. The mean age was 59.8 years old (range, 28-74 years). The overall mean operative time was 59.53 min (range, 25-120 min). For unilateral hernia repair, the mean operative time was 56 min (range, 25-75 min) and 48.5 min (range, 41-55 min) for TAPP and TEP, respectively. In all cases single-incision laparoscopic hernia repair was successfully performed, no additional trocars were required, and there were no conversions to conventional laparoscopic or open inguinal hernia repair. All patients were discharged on the same day as the procedure. CONCLUSION Single-incision laparoscopic inguinal hernia is feasible in both TEP and TAPP approaches. The procedure should be performed by laparoscopic surgeons with a high level of experience in single-incision surgery. Further randomized trials should be performed to evaluate the full potential and clinical application of single-incision TAPP and TEP.


title: Impact of single-port cholecystectomy on postoperative pain.

text: BACKGROUND This study compared postoperative pain following four-port laparoscopic cholecystectomy (LC) and single-port cholecystectomy (SPC). METHOD This prospective, quasi-randomized, single-centre trial focusing on postoperative pain included 49 patients undergoing elective surgery with either a conventional LC, or SPC using a surgical glove port. Postoperative pain was evaluated using a visual analogue scale (VAS) and postoperative analgesic use as primary outcome measures. Total duration of operation, length of hospital stay, blood test results on the day after surgery and total port cost were secondary outcome measures. RESULTS Twenty-five LCs and 24 SPCs were undertaken. The VAS score on day 1 after surgery was significantly less in the SPC group than in the LC group: median (range) 24 (12-38) versus 45 (33-57) mm (P = 0·002). Significantly fewer patients in the SPC group required analgesia (9 of 24 versus 19 of 25 in the LC group; P = 0·007). There were no significant differences in total duration of operation, length of hospital stay, and blood test results on the day after surgery. CONCLUSION Single-port surgery using a surgical glove port reduces postoperative pain compared with conventional LC.


docid: qdxccgea

title: COVID-19 Waves: Importance of Accumulative Mortality per Million Inhabitants.

text: The reported number of new cases underestimates the real spread of COVID-19 pandemic because of non-tested asymptomatic people and limited global access to reliable diagnostic tests. In this context, COVID-19 mortality with confirmed diagnosis becomes an attractive source of information to be included in the analysis of perspectives and proposals. Objective data are required to calculate the capacity of resources provided by health systems. New strategies are needed to stabilize or minimize the mortality surge. However, we will not afford this goal until more alternatives were available. We still need an effective treatment, an affordable vaccine, or a collective achievement of sufficient immunity (reaching up to 70% of the whole population). At any time, the arriving waves of the pandemic are testing the capacity of governments. The health services struggle to keep the plateau in a steady-state below 100 deaths per million inhabitants. Therefore, it is necessary to increase the alternatives and supplies based on the current and near-future expected demands imposed by the number of deaths by COVID-19. Estimating COVID-19 mortality in various scenarios with the gradual release of social constraints will help predict the magnitude of those arriving waves.


title: Cost-effectiveness analysis of genetic diagnostic strategies for Lynch syndrome in Italy.

text: Lynch syndrome (LS) is an autosomal dominant condition caused by pathogenic variants in mismatch repair (MMR) genes that predispose individuals to different malignancies, such as colorectal cancer (CRC) and endometrial cancer. Current guidelines recommended testing for LS in individuals with newly diagnosed CRC to reduce cancer morbidity and mortality in relatives. Economic evaluations in support of such approach, however, are not available in Italy. We developed a decision-analytic model to analyze the cost-effectiveness of LS screening from the perspective of the Italian National Health System. Three testing strategies: the sequencing of all MMR genes without prior tumor analysis (Strategy 1), a sequential IHC and MS-MLPA analysis (Strategy 2), and an age-targeted strategy with a revised Bethesda criteria assessment before IHC and methylation-specific MLPA for patients ≥ than 70 years old (Strategy 3) were analyzed and compared to the "no testing" strategy. Quality Adjusted Life Years (QALYs) in relatives after colonoscopy, aspirin prophylaxis and an intensive gynecological surveillance were estimated through a Markov model. Assuming a CRC incidence rate of 0.09% and a share of patients affected by LS equal to 2.81%, the number of detected pathogenic variants among CRC cases ranges, in a given year, between 910 and 1167 depending on the testing strategy employed. The testing strategies investigated, provided one-time to the entire eligible population (CRC patients), were associated with an overall cost ranging between €1,753,059.93-€10,388,000.00. The incremental cost-effectiveness ratios of the Markov model ranged from €941.24 /QALY to €1,681.93 /QALY, thus supporting that "universal testing" versus "no testing" is cost-effective, but not necessarily in comparison with age-targeted strategies. This is the first economic evaluation on different testing strategies for LS in Italy. The results might support the introduction of cost-effective recommendations for LS screening in Italy.


title: Electromagnetic navigation system combined with High-Frequency-Jet-Ventilation for CT-guided hepatic ablation of small US-Undetectable and difficult to access lesions.

text: Objectives: To report the feasibility and efficacy of percutaneous ablation of small hepatic malignant tumors that are invisible on ultrasound and inaccessible using in-plane CT guidance, using a combination of high-frequency jet-ventilation (HFJV) and electromagnetic (EM) needle tracking. Methods: This study reviewed 27 percutaneous ablations of small hepatic tumors (<2 cm) performed using EM navigation-based probe placement and HFJV. All lesions were invisible on ultrasound and difficult to reach on CT requiring a double-oblique approach. The primary outcome was technical efficacy, defined as complete lesion coverage, and evaluated on contrast enhanced MRI after 3 and 6 months. Needle placement accuracy, the number of control CT acquisitions, procedure time, complications and radiation doses were assessed. Results: Twenty-one patients with 27 treated lesions (14 hepatocellular carcinomas and 13 metastases) were included in this study. Mean tumor size was 12 ± 5.7 mm. Thirty-three percent of the lesions were located on the hepatic dome. Complete ablation was obtained in 100% at the 3- and 6-month MRI follow-up. The ablation probe was correctly placed on the first pass in 96%, with a mean path-to-tumor angle of 7 ± 4 degrees and a mean tip-to-tumor distance of 22 ± 19mm. A readjustment for additional overlapping application resulted in complete treatment in 4 patients. Needle placement took a mean 23 ± 12 min with mean radiation doses of 558 mGy*cm. No major complications were reported. Conclusion: Percutaneous liver ablation of lesions that cannot be seen on US and requiring out-of-plane CT access can be successfully and safely treated using electromagnetic-based navigation and jet-ventilation.


Coronavirus Disease 2019 and Children: What Pediatric Health Care Clinicians Need to Know.


title: Effects of cataract surgery and intra-ocular lens implantation on visual function and quality of life in age-related cataract patients: a systematic review protocol.

text: BACKGROUND Cataract is the leading cause of blindness and low vision worldwide. Presently, cataract surgery is the only treatment for cataract and is very effective in restoring sight. In cataract surgery, the natural lens of the eye that becomes clouded is removed and replaced with an artificial intraocular lens. There are multiple techniques for removal of lens as well as many types of intraocular lenses available for implantation. For this reason, it becomes imperative to monitor the impact of different surgical techniques and different intraocular lenses on health-related quality of life (HRQoL) of the patients. This systematic review aims to evaluate HRQoL evidences on effects of different types of cataract surgeries and intraocular lenses on visual function and quality of life in age-related cataract patients. METHOD Databases like Cochrane, EMBASE, SCOPUS, NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) database, MEDLINE, ClinicalTrials.gov , Current Controlled Trials and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) will be searched systematically. Two reviewers will independently screen studies using predefined inclusion and exclusion criteria along with the extraction of data, and assessment of methodological quality using a standard checklist. DISCUSSION This systematic review will help in understanding how different types of cataract surgeries and intraocular lenses make a difference on quality of life of age-related cataract patients in terms of visual function and health-related quality of life. As the review attempts to bring together all the cataract-related HRQoL evidences pertaining to different cataract surgical techniques, different intraocular lenses and cataract-related complications, it will also identify gaps in evidence. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018092377.


The safety of the blood supply--time to raise the bar.


title: Esophagojejunostomy With Linear Staplers in Laparoscopic Total Gastrectomy: Experience With 168 Cases in 5 Consecutive Years.

text: PURPOSE We evaluate surgical outcomes of intracorporeal esophagojejunostomy in laparoscopic total gastrectomy using 2 linear stapler methods. MATERIALS AND METHODS The functional end-to-end anastomosis (FEEA) method was chosen as a first choice. The overlap method was chosen in cases with esophageal invasion. We retrospectively analyzed the early and late surgical outcomes of consecutive 168 laparoscopic total gastrectomy cases from April 2011 to December 2016. RESULTS AND CONCLUSIONS The FEEA method was selected in 120 cases, and the overlap method was selected in 48 cases. The mean time of esophagojejunostomy for the FEEA and overlap method was 13.2 and 36.5 minutes, respectively. Two cases with FEEA method and 3 cases with overlap method experienced complications due to esophagojejunostomy leakage. These cases were treated without performing a reoperation. One case with FEEA method was complicated due to esophagojejunostomy stenosis. This case was endoscopically treated. Our procedures are safe and feasible.


title: New versus Conventional Helmet for Delivering Noninvasive Ventilation: A Physiologic, Crossover Randomized Study in Critically Ill Patients.

text: BACKGROUND The helmet is a well-tolerated interface for noninvasive ventilation, although it is associated with poor patient-ventilator interaction. A new helmet (NH) has proven to attenuate this limitation of the standard helmet (SH) in both bench study and healthy volunteers. The authors compared a NH and a SH in intensive care unit patients receiving noninvasive ventilation for prevention of postextubation respiratory failure; both helmets were also compared with the endotracheal tube in place before extubation. METHODS Fourteen patients underwent 30-min trials in pressure support during invasive ventilation and then with a SH and a NH in a random order. The authors measured comfort, triggering delays, rates of pressurization (airway pressure-time product [PTP] of the first 300 [PTP(300-index)] and 500 [PTP(500-index)] ms from the onset of effort, and the first 200 ms from the onset of insufflation [PTP200]), time of synchrony between effort and assistance (Time(synch)/Ti(neu)), respiratory drive and frequency, arterial blood gases (ABGs), and rate of asynchrony. RESULTS Compared with SH, NH improved comfort (5.5 [5.0 to 6.0] vs. 8.0 [7.8 to 8.0]), respectively, P < 0.001), inspiratory trigger delay (0.31 [0.22 to 0.43] vs. 0.25 [0.18 to 0.31] s, P = 0.007), and pressurization (PTP(300-index): 0.8 [0.1 to 1.8] vs. 2.7 [7.1 to 10.0]%; PTP(500-index): 4.8 [2.5 to 9.9] vs. 27.3 [16.2 to 34.8]%; PTP200: 13.6 [10.1 to 19.6] vs. 30.4 [24.9 to 38.4] cm H2O/s, P < 0.01 for all comparisons) and Time(synch)/Ti(neu) (0.64 [0.48 to 0.72] vs. 0.71 [0.61 to 0.81], P = 0.007). Respiratory drive and frequency, ABGs, and rate of asynchrony were not different between helmets. Endotracheal tube outperformed both helmets with respect to all variables, except for respiratory rate, ABGs, and asynchronies. CONCLUSIONS Compared with a SH, a NH improved comfort and patient-ventilator interaction.


title: Endoscopic Resection of a Giant Left Atrial Appendage.

text: A 23-year-old woman with a history of arterial hypertension presented to our institution complaining of dyspnea and chest pain. Her workup including echocardiography and magnetic resonance imaging revealed an aneurysm of the left atrial appendage. No thrombus was identified in the aneurysm or left atrial appendage, and the patient was in sinus rhythm. She was started on prophylactic anticoagulation, and surgical resection of the aneurysm was recommended as a definitive treatment of this lesion. The surgery was performed using a minimally invasive left-sided thoracoscopy approach. The entire left atrial appendage including the aneurysm was removed at its base using an articulating endoscopic stapler device. On postoperative echocardiography, no residual left atrial appendage tissue was evident. The patient could be taken off oral anticoagulation and left the hospital in good condition.


title: Stroke and mechanical thrombectomy in patients with COVID-19: technical observations and patient characteristics.

text: BACKGROUND COVID-19 infections have been shown to be associated with a range of thromboembolic disease. OBJECTIVE To describe our endovascular experience in a consecutive series of patients with COVID-19 who presented with large vessel occlusions, and to describe unique findings in this population. METHODS Mechanical thrombectomy was performed on five consecutive patients with COVID-19 with large vessel occlusions. A retrospective study of these patients was performed. Patient demographics, laboratory values, mechanical thrombectomy technique, and clinical and angiographic outcomes were reviewed. RESULTS Four patients with COVID-19 presented with anterior circulation occlusions and one patient with COVID-19 presented with both anterior and posterior circulation occlusions. All patients had coagulation abnormalities. Mean patient age was 52.8 years. Three patients presented with an intracranial internal carotid artery occlusion. Two patients presented with an intracranial occlusion and a tandem thrombus in the carotid bulb. One patient presented with an occlusion in both the internal carotid and basilar arteries. Clot fragmentation and distal emboli to a new vascular territory were seen in two of five (40%) patients, and downstream emboli were seen in all five (100%) patients. Patient clinical outcome was generally poor in this series of patients with COVID-19 large vessel occlusion. CONCLUSION Our series of patients with COVID-19 demonstrated coagulation abnormalities, and compared with our previous experience with mechanical thrombectomy in large vessel occlusion, this group of patients were younger, had tandem or multiple territory occlusions, a large clot burden, and a propensity for clot fragmentation. These patients present unique challenges that make successful revascularization difficult.


title: Disability and quality of life before and during the COVID-19 outbreak: A cross-sectional study in inflammatory bowel disease patients.

text: Background/Aim Inflammatory bowel disease (IBD) is a chronic disorder affecting patients' health-related quality of life (HRQoL) which adds to their disability. Little is known about the impact of the COVID-19 pandemic on HRQoL of IBD patients. We aimed to evaluate HRQoL in IBD patient's pre- and post-COVID-19 pandemic using the IBD-disk questionnaire and explore associations between socio demographic factors, disease types, severity and impaired HRQoL in patients with IBD. Patients and Methods A cross-sectional study was conducted at a tertiary care centre in Saudi Arabia between November 2019 and March 2020 at the outpatient IBD clinics. The HRQoL of patients was assessed using the 10-item IBD-disk questionnaire. Results A total of 59 IBD patients (40 Crohn's disease, 19 Ulcerative colitis) with a mean disease duration of 3.5 years were included. Most of the patients (77.97%) were on biologics while 35.59% were on immune modulators, 16.94% on 5-ASA, and 3.38% were on corticosteroids. There was no difference between any of the 10 IBD-disk variables pre and post-COVID-19 pandemic apart from the perception of body image, where there was a slightly more negative perception with an increase from 2.53 to 3.39 (P = 0.05) There was no significant difference in HRQoL between patients with ulcerative colitis and Crohn's disease in any of domains. Conclusion The current study showed that disability and HRQoL appears to be unaffected by the COVID-19 pandemic among our cohort, however further studies with longer follow up and larger sample size is needed.


title: Cutaneous manifestations in COVID-19: a first perspective.

text: In December 2019 unexplained pneumonia cases were initially reported in Wuhan, China. The pathogen, a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was isolated from lower respiratory tract samples of infected patients and the resultant disease was termed as COVID-19 (Coronavirus Disease 2019)1 . By Feb 15, COVID-19 has rapidly spread throughout China and across the world, until a pandemic condition was announced by March 112 .


title: Meta-analysis of the role of granulomas in the recurrence of Crohn disease.

text: PURPOSE This study used meta-analytical techniques to compare the recurrence of granulomatous vs nongranulomatous Crohn disease. METHODS Comparative studies published between 1954 and 2007 of granulomatous vs nongranulomatous Crohn disease were included. Using a random effects model, end points evaluated were the number of recurrences and reoperations, and the time to recurrence and reoperation, of granulomatous vs nongranulomatous Crohn disease. Heterogeneity was assessed and sensitivity analysis was performed to account for bias in patient selection. RESULTS Twenty-one studies (14 nonrandomized retrospective, 7 nonrandomized prospective) reported on 2236 patients with Crohn disease, of whom 1050 (47.0%) had granulomas (granulomatous group) and 1186 (53.0%) had no granulomas (nongranulomatous group). The number of recurrences and reoperations was found to be significantly higher in the granulomatous group compared to the nongranulomatous group (odds ratio 1.37, P = .04; odds ratio 2.38, P < .001; respectively), with significant heterogeneity between studies (P = .06; P < .001; respectively). The time to recurrence and reoperation was significantly shorter in the granulomatous group compared with the nongranulomatous group (hazard ratio 1.63, P = .001; hazard ratio 1.62, P = .002; respectively), with no significant heterogeneity between studies. The number of recurrences and reoperations remained significantly higher in the granulomatous group compared to the nongranulomatous group during sensitivity analysis of higher-quality studies, more recent studies, and studies with a larger group of patients. CONCLUSIONS Granulomatous Crohn disease appears to be associated with a higher number of recurrences and reoperations and a shorter time to recurrence and reoperation compared to nongranulomatous Crohn disease. Because of significant heterogeneity between studies, further studies should be undertaken to confirm these findings.


docid: humoykni

title: COVID-19: How has the scientific community risen to the challenge?

text: As the novel coronavirus SARS-CoV-2 spreads around the world, scientists have raced to develop vaccines and tests in order to curb the infection.


title: Moral injury in the wake of coronavirus: Attending to the psychological impact of the pandemic.

text: Moral injury is a helpful lens through which we can better understand and prepare for the downstream psychosocial impact faced by health care providers during the coronavirus pandemic. Moral injury is psychological weight caused by a transgression of one's own or shared morals and values and can manifest as guilt, shame, inability to self-forgive, demoralization, and, in the worst case, self-harming behaviors. Given the morally challenging and life-threatening decisions our health care workers need to make daily in the face of consistent and ongoing death and loss, it is important to prepare for moral injury and the psychological toll by offering psychological support early and as often as needed at both the personal and institutional level. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Media coverage and public reaction to a celebrity cancer diagnosis.

text: BACKGROUND Celebrity diagnoses can have important effects on public behaviour. UK television celebrity Jade Goody died from cervical cancer in 2009. We investigated the impact of her illness on media coverage of cervical cancer prevention, health information seeking behaviour and cervical screening coverage. METHODS National UK newspaper articles containing the words 'Jade Goody' and 'cancer' were examined for public health messages. Google Insights for Search was used to quantify Internet searches as a measure of public health information seeking. Cervical screening coverage data were examined for temporal associations with this story. RESULTS Of 1203 articles, 116 (9.6%) included a clear public health message. The majority highlighted screening (8.2%). Fewer articles provided advice about vaccination (3.0%), number of sexual partners (1.4%), smoking (0.6%) and condom use (0.4%). Key events were associated with increased Internet searches for 'cervical cancer' and 'smear test', although only weakly with searches for 'HPV'. Cervical screening coverage increased during this period. CONCLUSION Increased public interest in disease prevention can follow a celebrity diagnosis. Although media coverage sometimes included public health information, articles typically focused on secondary instead of primary prevention. There is further potential to maximize the public health benefit of future celebrity diagnoses.


title: What evidence is used to underpin the design of strength-based exercise interventions evaluated in randomised controlled trials for rheumatoid arthritis? A systematic review protocol.

text: INTRODUCTION Healthcare researchers designing strength-based exercise interventions must choose an appropriate dose to test before evaluating its effect using a definitive/phase-III randomised controlled trial (RCT). Compared with early phase testing employed by pharmaceutical trials, it is questionable whether exercise-based trials employ the same rigour for establishing tolerated dosage. Consequently, it is unclear if participants are initially prescribed optimal doses of exercise, which may potentially impact on study outcomes. Using trials of strength-based exercise interventions in adults with rheumatoid arthritis (RA) as an exemplar, the aims of this review are to (1) identify the proportion of RCTs that use phase I/II trials with dose escalation methodology for setting prescription parameters, (2) determine type and level of evidence used to justify prescription parameters of strength-based exercise interventions evaluated by RCTs, (3) explore consistency and applicability of the evidence underpinning prescription parameters in RCTs and (4) explore if a relationship exists between risk of bias for RCTs evaluating strength-based interventions and the level of evidence used to underpin prescription parameters. METHODS AND ANALYSIS Focusing on RCT's evaluating strength-based exercise interventions in adults with RA published after 2000, the following databases will be searched: Allied and Complementary Medicine Database, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, Medline and Physiotherapy Evidence Database. For each RCT, we will identify the evidence used to underpin prescription parameters. Both trial and underpinning evidence will have key information about the intervention extracted using the template for intervention description and replication checklist. Risk of bias will be assessed according to Cochrane. Levels of evidence will be assessed against the Oxford Centre for Evidence-Based Medicine and relationships between RCT and underpinning evidence explored and described narratively. Two independent assessors will be involved throughout data selection and extraction with recourse to a third reviewer should agreement not be reached. ETHICS AND DISSEMINATION No ethical issues are identified. Dissemination will be via publication. PROSPERO REGISTRATION NUMBER CRD42018090963.


title: Inhaled PGE1 in neonates with hypoxemic respiratory failure: two pilot feasibility randomized clinical trials.

text: BACKGROUND Inhaled nitric oxide (INO), a selective pulmonary vasodilator, has revolutionized the treatment of neonatal hypoxemic respiratory failure (NHRF). However, there is lack of sustained improvement in 30 to 46% of infants. Aerosolized prostaglandins I2 (PGI2) and E1 (PGE1) have been reported to be effective selective pulmonary vasodilators. The objective of this study was to evaluate the feasibility of a randomized controlled trial (RCT) of inhaled PGE1 (IPGE1) in NHRF. METHODS Two pilot multicenter phase II RCTs are included in this report. In the first pilot, late preterm and term neonates with NHRF, who had an oxygenation index (OI) of ≥15 and <25 on two arterial blood gases and had not previously received INO, were randomly assigned to receive two doses of IPGE1 (300 and 150 ng/kg/min) or placebo. The primary outcome was the enrollment of 50 infants in six to nine months at 10 sites. The first pilot was halted after four months for failure to enroll a single infant. The most common cause for non-enrollment was prior initiation of INO. In a re-designed second pilot, co-administration of IPGE1 and INO was permitted. Infants with suboptimal response to INO received either aerosolized saline or IPGE1 at a low (150 ng/kg/min) or high dose (300 ng/kg/min) for a maximum duration of 72 hours. The primary outcome was the recruitment of an adequate number of patients (n = 50) in a nine-month-period, with fewer than 20% protocol violations. RESULTS No infants were enrolled in the first pilot. Seven patients were enrolled in the second pilot; three in the control, two in the low-dose IPGE1, and two in the high-dose IPGE1 groups. The study was halted for recruitment futility after approximately six months as enrollment targets were not met. No serious adverse events, one minor protocol deviation and one pharmacy protocol violation were reported. CONCLUSIONS These two pilot RCTs failed to recruit adequate eligible newborns with NHRF. Complex management RCTs of novel therapies for persistent pulmonary hypertension of the newborn (PPHN) may require novel study designs and a longer period of time from study approval to commencement of enrollment. TRIAL REGISTRATION CLINICALTRIALS.GOV: Pilot one: NCT number: 00598429 registered on 10 January 2008. Last updated: 3 February 2011. Pilot two: NCT number: 01467076 17 October 2011. Last updated: 13 February 2013.


docid: enhafmrj

title: Call for Papers.


title: Biodegradable elastomers for biomedical applications and regenerative medicine.

text: Synthetic biodegradable polymers are of great value for the preparation of implants that are required to reside only temporarily in the body. The use of biodegradable polymers obviates the need for a second surgery to remove the implant, which is the case when a nondegradable implant is used. After implantation in the body, biomedical devices may be subjected to degradation and erosion. Understanding the mechanisms of these processes is essential for the development of biomedical devices or implants with a specific function, for example, scaffolds for tissue-engineering applications. For the engineering and regeneration of soft tissues (e.g., blood vessels, cardiac muscle and peripheral nerves), biodegradable polymers are needed that are flexible and elastic. The scaffolds prepared from these polymers should have tuneable degradation properties and should perform well under long-term cyclic deformation conditions. The required polymers, which are either physically or chemically crosslinked biodegradable elastomers, are reviewed in this article.


title: A framework for assessing glaucoma progression using structural and functional indices jointly.

text: PURPOSE While many tests and indices are available to identify glaucoma progression, using them in combinations may decrease overall specificity. The aim of this study was to develop a framework for assessing glaucoma progression using structural and functional indices jointly for a fixed specificity. METHODS The study included 337 eyes of 207 patients with ocular hypertension or primary open-angle glaucoma selected from the Diagnostic Innovations in Glaucoma Study or the African Descent and Glaucoma Evaluation Study. All patients had at least 9 visits. Each visit had retinal nerve fiber layer thickness (RNFLT) and mean sensitivity from static automated perimetry (SAP MS) measured within a one-month window. Simple linear regression was applied to assess deterioration in each index for series of 5 to 9 visits. To identify progression using the two indices jointly, marginal significance levels set at a specificity of 95% were derived for two criteria: ANY (worsening on either RNFLT or SAP MS) and ALL (worsening on both RNFLT and SAP MS). Positive rate (percentage of eyes flagged as progressing) was determined individually for each index, as well as for the ANY and ALL criteria. RESULTS Compared to SAP MS, RNFLT had higher positive rates (15% to 45%) for all series lengths. For the joint analyses, the positive rate was on average 12% higher for the ANY criterion compared to the ALL criterion. While RNFLT-alone had comparable positive rates and time-to-detection as the ANY criterion, each uniquely identified a subset of eyes (Kappa = 0.55 to 0.75). CONCLUSIONS This study provides a simple framework for assessing glaucoma progression with data from two tests jointly, without compromising specificity. This framework can be extended to include two or more parameters, can accommodate global or regional indices, and can eventually be used with novel parameters identified as predictive of glaucoma progression.


title: Pneumonia with bacterial and viral coinfection.

text: PURPOSE OF REVIEW We aim to review the epidemiology of pneumonia with bacterial and viral coinfection, the pathogenesis and clinical impact of coinfection along with the current state of treatment and outcomes. RECENT FINDINGS Emphasis is given to the pathogenesis of bacterial and viral co-infection including specific highlighting on influenza, rhinovirus, respiratory syncytial virus and cytomegalovirus. Updates on the current state of diagnosis and management are included, as well as on areas where future research can be directed to improve patient clinical outcomes regarding viral and bacterial coinfection. SUMMARY Bacterial and viral coinfection is increasingly recognized as an underlying etiology for community- and hospital-acquired infections. Coinfections may be a risk factor for ICU admission, severity of disease, and mortality. Clinicians must be aware of these coinfections for appropriate management and prognostication, as well as for the prevention of nosocomial spread of viral illness.


title: A single-incision laparoscopic hepatectomy for hepatocellular carcinoma: initial experience in a Japanese patient.

text: Minimally invasive approaches for small liver tumors are desirable. We describe a single-incision laparoscopic hepatectomy (SILH) using total laparoscopic surgery (TLS) technique. SILH was performed to remove a solitary 2-cm hepatocellular carcinoma located at segment 3. The technique included a one-inch skin incision with three ports (one 12 mm and two of 5 mm each). The liver was sealed and dissected by three different devices: Harmonic scalpel, TissueLink sealing dissector, and Endoclip. Operation time was 70 minutes and blood loss was trivial. The patient required no analgesia postoperatively and walked unaided the next day. Various aspects of the procedure were not different from TLS. SILH is a safe procedure with several advantages. The procedure is promising as minimally invasive liver surgery.


title: Image-Guided Resection of Glioblastoma and Intracranial Implantation of Therapeutic Stem Cell-seeded Scaffolds.

text: Glioblastoma (GBM), the most common and aggressive primary brain cancer, carries a life expectancy of 12-15 months. The short life expectancy is due in part to the inability of the current treatment, consisting of surgical resection followed by radiation and chemotherapy, to eliminate invasive tumor foci. Treatment of these foci may be improved with tumoricidal human mesenchymal stem cells (MSCs). MSCs exhibit potent tumor tropism and can be engineered to express therapeutic proteins that kill tumor cells. Advancements in preclinical models indicate that surgical resection induces premature MSC loss and reduces therapeutic efficacy. Efficacy of MSC treatment can be improved by seeding MSCs on a biodegradable poly(lactic acid) (PLA) scaffold. MSC delivery into the surgical resection cavity on a PLA scaffold restores cell retention, persistence, and tumor killing. To study the effects of MSC-seeded PLA implantation on GBM, an accurate preclinical model is needed. Here we provide a preclinical surgical protocol for image-guided tumor resection of GBM in immune-deficient mice followed by MSC-seeded scaffold implantation. MSCs are engineered with lentiviral constructs to constitutively express and secrete therapeutic TNFα-related apoptosis-inducing ligand (TRAIL) as well as green fluorescent protein (GFP) to allow fluorescent tracking. Similarly, the U87 tumor cells are engineered to express mCherry and firefly luciferase, providing dual fluorescent/luminescent tracking. While currently used for investigating stem cell mediated delivery of therapeutics, this protocol could be modified to investigate the impact of surgical resection on other GBM interventions.


title: Intercontinental aeromedical evacuation of patients with traumatic brain injuries during Operations Iraqi Freedom and Enduring Freedom.

text: Traumatic brain injury contributes significantly to military combat morbidity and mortality. No longer maintaining comprehensive medical care facilities throughout the world, the US military developed a worldwide trauma care system making the patient the moving part of the system. Life-saving interventions are performed early, and essential care is delivered at forward locations. Patients then proceed successively through increasingly capable levels of care culminating with arrival in the US. Proper patient selection and thorough mission preparation are crucial to the safe and successful intercontinental aeromedical evacuation of critical brain-injured patients during Operations Iraqi Freedom and Enduring Freedom.


title: Quantification of muscle co-contraction using supersonic shear wave imaging.

text: Muscle stiffness estimated using shear wave elastography can provide an index of individual muscle force during isometric contraction and may therefore be a promising method for quantifying co-contraction. We estimated the shear modulus of the lateral gastrocnemius (LG) muscle using supersonic shear wave imaging and measured its myoelectrical activity using surface electromyography (sEMG) during graded isometric contractions of plantar flexion and dorsiflexion (n=7). During dorsiflexion, the average shear modulus was 26 ± 6 kPa at peak sEMG amplitude, which was significantly less (P=0.02) than that measured at the same sEMG level during plantar flexion (42 ± 10 kPa). The passive tension during contraction was estimated using the passive LG muscle shear modulus during a passive ankle rotation measured at an equivalent ankle angle to that measured during contraction. The passive shear modulus increased significantly (P<0.01) from the plantar flexed position (16 ± 5 kPa) to the dorsiflexed position (26 ± 9 kPa). Once this change in passive tension from joint rotation was accounted for, the average LG muscle shear modulus due to active contraction was significantly greater (P<0.01) during plantar flexion (26 ± 8 kPa) than at sEMG-matched levels of dorsiflexion (0 ± 4 kPa). The negligible shear modulus estimated during isometric dorsiflexion indicates negligible active force contribution by the LG muscle, despite measured sEMG activity of 19% of maximal voluntary plantar flexion contraction. This strongly suggests that the sEMG activity recorded from the LG muscle during isometric dorsiflexion was primarily due to cross-talk. However, it is clear that passive muscle tension changes can contribute to joint torque during isometric dorsiflexion.


title: Effects of a closed system suction connector on airway resistance in ventilated neonates.

text: BACKGROUND/AIM Increased airway resistance reduces the effectiveness of ventilation treatment. Endotracheal tubes (ETTs) and connectors contribute to resistance. However, the effect of a closed system suction (CSS) connector is not well known. We compared the in vivo resistance occurring with a CSS connector with that of the standard connector. MATERIALS AND METHODS This prospective study was conducted at Gazi University Hospital's neonatal intensive care unit. Intubated neonates were studied for two cycles; each cycle contained two periods of ETT + connector pairs (15 min/period) as follows: cycle 1 [A: long ETT + standard connector; B: long ETT + CSS connector] and cycle 2 [C: shortened ETT + standard connector; D: shortened ETT + CSS connector]. Resistance of 40 breaths/period was averaged for each case, and the means were analyzed by Wilcoxon test for pairwise comparisons between standard and CSS connectors. As each case provided two cycle data, 16 cycle data were compared. RESULTS The CSS connector increased resistance by 13.8% (range: 3.0%-22.1%) compared to the standard connector; P < 0.001. The resistance increase was similar between long [17.3% (range: 3.0%-17.7%)] and shortened ETTs [15.3% (range: 5.0%-29.6%)]; P = 0.834. CONCLUSION CSS connectors were found to increase airway resistance in ventilated neonates. The contribution of CSS should be considered during ventilation, particularly in the presence of difficulty in providing sufficient tidal volume.


title: Assessment of Polyethylene Glycol Hydrogel Spacer and Its Effect on Rectal Radiation Dose in Prostate Cancer Patients Receiving Proton Beam Radiation Therapy.

text: Purpose To assess the efficacy of placing a polyethylene glycol (PEG) spacing hydrogel in patients undergoing proton beam radiation therapy for prostate cancer. This study also aims to assess the effect on rectal radiation dose of prostate-rectum separation in various anatomic planes. Methods and Materials Seventy-two consecutive prostate cancer patients undergoing conventionally fractionated pencil beam scanning proton radiation therapy with and without hydrogel placement were compared. Magnetic resonance images taken after hydrogel placement measured prostate-rectum separation and were correlated to rectal dosing and rectal toxicity. Univariate analysis of clinical variables and radiation dosing was conducted using nonparametric Wilcoxon rank-sum test with continuity correction between groups (hydrogel spacer vs controls). Spearman's rank correlation coefficient assessed relationships between the various anatomic dimensions of perirectal space and rectal radiation dosing. Results Fifty-one patients had hydrogel placement before therapy and 21 did not. There was a 42.2% reduction in rectal dosing (mL3 rectum) in hydrogel patients (P < .001). Increasing midline sagittal lift resulted in a greater mitigation of total rectal dose (P = .031). The degree of prostate surface area coverage on coronal plane did not correlate with further reductions in rectal radiation dose (P = .673). Patients who had PEG hydrogels placed reported more rectal side effects during treatment compared with those patients who did not (35.3% vs 9.5%, P = .061). At median 9.5-month follow-up, there was no difference in reporting of grade ≤2 rectal toxicity between the 2 groups (7.7% vs 7.1%, P = .145). Conclusions Polyethylene glycol hydrogel placement before pencil proton beam radiation therapy for prostate cancer reduced rectal radiation dose. The most important factor reducing total rectal dose was the degree of sagittal midline separation created by the PEG hydrogel. This is the largest study with the longest follow-up to investigate hydrogel placement in the proton beam radiation setting.


title: [Consideration on improving public health emergency management ability of current medical health system].

text: COVID-19 is a Public Health Emergency of International Concern (PHEIC). Direct economic loss is expected to be much more than that of SARS outbreak in 2003. The risk factors of COVID-19 epidemic at the early stage incluede the misjudgment of the epidemic, delay in reporting this emerging infectious disease, nosocomial infection-caused transmission of the virus into local communities, and weak public health interventions. The infection rate (or the incidence) reflects the prophylactic effect in population. Case fatality reflects the therapeutic effect of clinical intervention. There were sufficient medical resources at the national top levels accumulated in Wuhan. Furthermore, medical professionals and sufficient medical supplies from other provinces have been assigned to join in the fighting against the epidemic in Wuhan. However, the case fatality in Wuhan has being kept the highest in China, indicating that clinical treatment for this virus-caused emerging infectious disease, whose pathogenesis remains to be elucidated, had a limited effect in controlling this epidemic. The unusual, extremely costly public health interventions including the temporarily city quarantine and transportation ban issued by the central government are crucial in controlling this epidemic. The control of epidemic indicates the importance of public health measures but also reflected its insufficient capacity in China. Recently, profit-seeking mechanism run in Chinese health service system disorganized the balance of clinical service and public health service patterns in China, promoting the vicious circle of "attaching importance to clinical treatment and despising disease prophylaxis" , damaging the infrastructure of public health capacity, thus contributing to the formation of the inevitability in various fortuities of public health emergency. To strength the capacity of our medical service system to respond to public health emergency efficiently, two key issues should be considered. First, public health service, which should be fixed as the health section of the governments' public services by the law, must be greatly improved to meet the increasing health needs of the publics. Second, the vicious circle of profit-seeking-caused "attaching importance to clinical treatment and despising disease prophylaxis" should be immediately broken to optimize the national health service system in China by increasing the investment in public health service.


title: Anaesthetic effects in the ferret of alfaxalone alone and in combination with medetomidine or tramadol: a pilot study.

text: Alfaxalone is a neurosteroid with anaesthetic effects and it has been used successfully in several animal species. However, there are no data, to our knowledge, about its efficacy and safety in ferrets (Mustela putorius furo). We evaluated a variety of anaesthetic regimens in ferrets, namely, alfaxalone at 20, 10 and 5 mg/kg (n = 1, 10 and 9, respectively; intravenously); medetomidine at 20 µg/kg (n = 3; intramuscularly); medetomidine (20 µg/kg, intramuscularly) plus alfaxalone (2.5 mg/kg, intravenously; n = 7); and tramadol (5 mg/kg, intramuscularly) plus alfaxalone (5 mg/kg, intravenously; n = 2). Two animals treated with alfaxalone at 10 mg/kg and 20 mg/kg, respectively, died. At 5 mg/kg alfaxalone produced anaesthesia with a similar onset but a shorter duration of anaesthesia and analgesia than alfaxalone at 10 mg/kg. The medetomidine-alfaxalone combination produced anaesthesia and analgesia of a longer duration than alfaxalone administered alone at 5 mg/kg (P < 0.0001 and P < 0.001, respectively). Under this anaesthetic regimen, there was a progressive decrease in pulse rate during the first 30 min before the pulse rate stabilized. Respiratory parameters were maintained at acceptable levels. When tramadol was administered, all the animals exhibited a strong excitation reaction and in no case was the toe-pinch reflex clearly abolished. Thus, alfaxalone plus medetomidine provided safe and effective anaesthesia in ferrets. Alfaxalone, alone or in combination with tramadol, did not produce satisfactory results for use as an anaesthetic for this species.


title: Endovascular management of aneurysms associated with spinal arteriovenous malformations.

text: BACKGROUND Spinal aneurysms are rare among spinal arteriovenous malformations (SAVMs). There are few reports of endovascular management of spinal aneurysms associated with SAVM. OBJECTIVE To present endovascular management of aneurysms associated with SAVM. METHODS Of 91 patients with SAVMs,eight (9%) presented with aneurysms. Of these, three were male and five were female with a median age of 18 years (range 11-38). We evaluated the presenting pattern, lesion level, type of the target aneurysm related to the presenting pattern and AVM nidus, and the result obtained after embolization or open surgery. Clinical status was evaluated by Aminoff-Logue (ALS) gait and micturition scale scores. RESULTS The presenting patterns were subarachnoid hemorrhage (SAH, n=3) or mass effect caused by extrinsic (n=4) or intrinsic (n=1) cord compression. Aneurysms were located in four cervical, two thoracic, and two lumbar enlargement areas. There were two prenidal (arterial), three nidal, and three postnidal (venous) aneurysms. The mean diameter of the aneurysms was 9 mm (range 3-27). Glue embolization (n=6), open surgery (n=1), and combined surgery and embolization (n=1) was performed to obliterate the aneurysms. Obliteration of the target aneurysms resulted in improvement of symptoms and clinical stabilization of SAVMs in all patients during a mean of 55 months (range 7-228) of follow-up. CONCLUSIONS Identification of a symptomatic aneurysm should be associated with clinical presentation pattern. Targeted obliteration of the aneurysm by embolization and/or surgery resulted in improvement of symptoms and stabilization of SAVM.


title: A Randomized Comparison of Laparoendoscopic Single-Site Hysterectomies: Total Laparoscopic Hysterectomy Versus Laparoscopically Assisted Vaginal Hysterectomy.

text: BACKGROUND To compare surgical outcomes of two procedures for laparoendoscopic single-site (LESS) hysterectomy: total laparoscopic hysterectomy (TLH) and laparoscopically assisted vaginal hysterectomy (LAVH). MATERIALS AND METHODS Seventy-six patients who had an indication for hysterectomy for benign uterine disease were randomized to LESS-TLH or LESS-LAVH. Surgical outcomes were assessed and compared between the two groups. RESULTS There were no differences in baseline demographics between the two groups. Surgical outcomes such as operative time, estimated blood loss, length of hospital stay, and complication rate were similar between the two groups. The failure rate in the LESS-TLH group was higher than that in the LESS-LAVH group (5/38 [11%] versus 0/38 [0%]), although this difference did not reach statistical significance (P=.054). Among the 5 cases that failed in the LESS-TLH group, 4 were related to a large lower uterine segment prohibiting visualization during colpotomy. The postoperative pain scores at 18 and 36 hours after surgery were significantly lower in the LESS-TLH group than in the LESS-LAVH group (all P<.001). Vaginal discharge at 1 and 4 weeks after surgery was significantly lower in the LESS-TLH group than in the LESS-LAVH group (all P<.001). CONCLUSIONS LESS-TLH and LESS-LAVH are both safe, feasible procedures with similar surgical outcomes. LESS-TLH was associated with less postoperative pain and less postoperative vaginal discharge, whereas LESS-LAVH may be preferred in patients with a uterus with a large lower uterine segment.


title: The gap-prepulse inhibition deficit of the cortical N1-P2 complex in patients with tinnitus: The effect of gap duration.

text: The present study aimed to investigate whether gap-prepulse inhibition (GPI) deficit in patients with tinnitus occurred in the N1-P2 complex of the cortical auditory evoked potential. Auditory late responses to the intense sound of the GPI paradigm were obtained from 16 patients with tinnitus and 18 age- and hearing loss-matched controls without tinnitus. The inhibition degrees of the N1-P2 complex were assessed at 100-, 50-, and 20-ms gap durations with tinnitus-pitch-matched and non-matched frequency background noises. At the 20-ms gap condition with the tinnitus-pitch-matched frequency background noise, only the tinnitus group showed an inhibition deficit of the N1-P2 complex. The inhibition deficits were absent in both groups with longer gap durations. These findings suggested that the effect of tinnitus emerged depending on the cue onset timing and duration of the gap-prepulse. Since inhibition deficits were observed in both groups at the same 20-ms gap condition, but with the tinnitus-pitch-non-matched frequency background noise, the present study did not offer proof of concept for tinnitus filling in the gap. Additional studies on the intrinsic effects of different background frequencies on the gap processing are required in the future.


title: [Molecular epidemiological study of human coronavirus OC43 in Shanghai from 2009-2016].

text: Objective: To understand the epidemiological characteristics of Human coronavirus (HCoV), the patterns of emergence and circulation, and the genotype distribution of human coronavirus OC43 (HCoV-OC43) from November, 2009 to April, 2016 in Shanghai. Methods: A total of 6 059 respiratory specimens, including pharyngeal swab, sputum, nasopharyngeal aspirates and alveolar lavage fluid, as well as relative clinical data were collected from patients with acute respiratory infections from seven sentinel hospitals during November, 2009 to April, 2016 in Shanghai. Respiratory specimens were tested by RT-PCR with HCoV-conserved primers and subsequently genotyped by DNA sequencing. Using specific primers to amplify and sequence full-length Spike (S), RNA-dependent RNA polymerase (RDRP) and nucleocapsid (N) gene from HCoV-OC43 positive samples. Further genotype and phylogenetic analysis of HCoV-OC43 were performed by conducting phylogenetic trees. Results: Among 6 059 patients, the total frequency of HCoV was 63 (1.04%), in which HCoV-OC43 was the most frequently detected species with 34 positive samples, followed by human coronavirus 229E (HCoV-229E) and human coronavirus HKU1 (HCoV-HKU1) with 18 and 10 positive sample respectively. However, other HCoV like human coronavirus NL63 (HCoV-NL63), severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle-East Respiratory Syndrome Coronavirus (MERS-CoV), were not been detected, which illustrated that HCoV-OC43 was the dominant subtype. The full-length of S, RDRP and N gene were obtained from 29 HCoV-OC43 positive samples. According to the sequence-analysis, 27 of which was genotype D, 2 of which was genotype B and others genotype, including genotype E, F and G, were not detected. The result indicated that the genotype D may be the dominant genotype. Further analysis of S protein that help HCoV-OC43 to entry host cell and stimulate the host immune system to produce neutralizing antibody found that two important functional domains in S protein, N-terminal domain (NTD) and receptor-binding domain (RBD) contained more amino acid substitution and positive selection sites, accompanied with amino acid insertion/deletion. 13 positive selection sites were all located in the NTD or RBD, 10 of which were located in the NTD and 3 in the RBD. Conclusion: Human coronavirus OC43 was the major circulation human coronaviurs in Shanghai from 2009 to 2016, in which genotype D was the dominant genotype. NTD and RBD regions of the S protein were hypervariable region during HCoV-OC43 evolution, and had amino acid substitutions as well as amino acid insertion/deletion.


title: Improving outcomes for neonates with gastroschisis in low-income and middle-income countries: a systematic review protocol.

text: Introduction There is a significant disparity in outcomes for neonates with gastroschisis in high-income countries (HICs) compared with low-income and middle-income countries (LMICs). Many LMICs report mortality rates between 75% and 100% compared with <4% in HICs. Aim To undertake a systematic review identifying postnatal interventions associated with improved outcomes for gastroschisis in LMICs. Methods and analysis Three search strings will be combined: (1) neonates; (2) gastroschisis and other gastrointestinal congenital anomalies requiring similar surgical care; (3) LMICs. Databases to be searched include MEDLINE, EMBASE, Scopus, Web of Science, ProQuest Dissertations and Thesis Global, and the Cochrane Library. Grey literature will be identified through Open-Grey, ClinicalTrials.gov, WHO International Clinical Trials Registry and ISRCTN registry (Springer Nature). Additional studies will be sought from reference lists of included studies. Study screening, selection, data extraction and assessment of methodological quality will be undertaken by two reviewers independently and team consensus sought on discrepancies. The primary outcome of interest is mortality. Secondary outcomes include complications, requirement for ventilation, parenteral nutrition duration and length of hospital stay. Tertiary outcomes include service delivery and implementation outcomes. The methodology of the studies will be appraised. Descriptive statistics and outcomes will be summarised and discussed. Ethics and dissemination Ethical approval is not required since no new data are being collected. Dissemination will be via open access publication in a peer-reviewed medical journal and distribution among global health, global surgery and children's surgical collaborations and international conferences. Conclusion This study will systematically review literature focused on postnatal interventions to improve outcomes from gastroschisis in LMICs. Findings can be used to help inform quality improvement projects in low-resource settings for patients with gastroschisis. In the first instance, results will be used to inform a Wellcome Trust-funded multicentre clinical interventional study aimed at improving outcomes for gastroschisis across sub-Saharan Africa. PROSPERO registration number CRD42018095349.


title: [Analysis of variation and evolution of SARS-CoV-2 genome].

text: OBJECTIVE To analyze the evolution and variation of SARS-CoV-2 during the epidemic starting at the end of 2019. METHODS We downloaded the full-length genome sequence of SARS-CoV-2 from the databases of GISAID and NCBI. Using the software for bioinformatics including MEGA-X, BEAST, and TempEst, we constructed the genomic evolution tree, inferred the time evolution signal of the virus, calculated the tMRCA time of the virus and analyzed the selection pressure of the virus during evolution. RESULTS The phylogenetic tree showed that SARS-CoV-2 belonged to the Sarbecovirus subgenus of β Coronavirus genus together with bat coronavirus BetaCoV/bat/Yunnan/RaTG13/2013, bat-SL-CoVZC45, bat-SL-CoVZXC21 and SARS-CoV. The genomic sequences of SARS-CoV-2 isolated from the ongoing epidemic showed a weak time evolution signal with an average tMRCA time of 73 days (95% CI: 38.9-119.3 days). No positive time evolution signal was found between SARS-CoV-2 and BetaCoV/bat/Yunnan/RaTG13/2013, but the former virus had a strong positive temporal evolution relationship with bat-SL-CoVZC45 and SARS-CoV. The major cause for mutations of SARS-CoV-2 was the pressure of purification selection during the epidemic. CONCLUSIONS SARS-CoV-2 may have emerged as early as November, 2019, originating most likely from bat-associated coronavirus. This finding may provide evidence for tracing the sources and evolution of the virus.


Variation in hospital mortality associated with inpatient surgery--an S.O.S.


title: Single-incision laparoscopic right hemicolectomy: safety and feasibility in a series of consecutive cases.

text: BACKGROUND Single-incision laparoscopic colectomy (SILC) is rapidly emerging in the field of minimally invasive colon and rectal surgery. This report presents the safety and feasibility of performing SILC right hemicolectomy with the SILS™ Port Multiple Instrument Access Port. METHODS Between July 2009 and October 2009, SILC right hemicolectomy was performed for 13 consecutive, unselected patients presenting with benign or malignant pathology. Demographic data, intraoperative parameters, and postoperative outcomes were assessed. RESULTS For 11 of the 13 patients (84.6%), the SILC procedure was performed with a mean incision length of 3.1 ± 1.1 cm (range, 2.5-6.0 cm) and a mean operative time of 131.5 ± 36.2 min (range, 79-180 min). Two cases required conversion to hand-assisted technique. Overall, the operative time was found to be significantly longer for the patients with a body mass index (BMI) greater than 25 kg/m(2) (152.1 ± 26.6 min) compared with the patients with a BMI less than 25 kg/m(2) (93.3 ± 11.6 min) (p < 0.002). For the subset of patients with malignant disease (five adenocarcinomas and one carcinoid), the mean number of lymph nodes extracted was 26.7 ± 14.5. There were no intraoperative complications, and the overall mean hospital stay was 2.5 ± 0.7 days (range, 2-4 days). One postoperative complication occurred (7.7%). CONCLUSION The SILC procedure is a safe and feasible method for benign and malignant diseases requiring a right hemicolectomy. This method results in a low complication rate and a short postoperative hospital stay.


title: Abstracts from the 6th Annual Congress of the Association of Vascular Access and Interventional Renal Physicians (AVATAR).

text: Abstracts from the 6th Annual Congress of the Association of Vascular Access and Interventional Renal Physicians (AVATAR) | July 21-22, 2017 | Goa, India.


Letter to the Editor: Support Through Social Networks of e-Health in Adults with Primary Immunodeficiencies During COVID-19 Pandemic.


title: Opportunities and challenges of the pulmonary route for vaccination.

text: INTRODUCTION The respiratory tract is an attractive target for the delivery of vaccine antigens. Potential advantages of drug delivery by means of the pulmonary route include accessibility, non-invasiveness, ease of administration, and the possibility to reach an elaborate mucosal network of antigen-presenting cells. AREAS COVERED This review discusses current pulmonary vaccination strategies and their advantages and disadvantages. EXPERT OPINION To improve efficiency of vaccination and develop new strategies, a well-founded knowledge about composition and characterization of antigen-presenting cell populations throughout the respiratory tract is essential. In particular, respiratory tract dendritic cells, as key antigen-presenting cells in the lung, constitute an ideal target for vaccine delivery. Furthermore, particle size is a key factor when designing new inhalable vaccines, as size determines not only deposition in different respiratory tract compartments, but also how an antigen and its carrier will interact with lung tissue components and immune cells. An increased knowledge of different respiratory tract antigen-presenting cell populations and their interactions with other components of the immune system will enable new targeting strategies to improve the efficacy of pulmonary vaccination.


title: [Practice and thinking of acute respiratory infection surveillance for the response of emerging respiratory diseases in Shanghai].

text: Shanghai Municipal Center for Disease Control and Prevention has implemented an active comprehensive surveillance project of acute respiratory infections in adults in Shanghai, including influenza like illness (ILI) and severe acute respiratory infection (SARI). By testing and identifying a variety of respiratory pathogens, it was found that influenza viruses were the main pathogens in 172 ILI cases in 2019. The positive rates of influenza A (H1N1) pdm09 virus, influenza A (H3N2) virus and influenza B virus Victoria lineage were 30.81%, 14.53% and 30.55%, respectively. The positive detection of influenza A (H1N1) pdm09 virus peaked in the first quarter. The positive rate of enterovirus/human rhinovirus was 6.40%, with a positive detection peak in the third quarter, while the positive rate of adenovirus was 4.65% with a positive detection peak in the second quarter of the year. Two human coronavirus (HCoV)-OC43 positive samples, 1 HCoV-HKU1 positive sample and 1 HCoV-NL63 positive sample were detected, respectively, and no HCoV-229E positive sample was detected. The detection rate of Staphylococcus aureus was 17.44%, and the detection rate of Klebsiella pneumoniae was 9.88%. Influenza viruses were also the main pathogens in 1 447 SARI cases. The positive rates of influenza A (H1N1) pdm09 virus, influenza A (H3N2) virus and influenza B virus Victoria lineage were 5.46%, 1.73% and 0.30%, respectively. The positive detection of influenza A (H1N1) pdm09 virus (17.50%) peaked in the first quarter. The total positive detection rate of enterovirus/human rhinovirus was 2.97%, the positive detection peaked in the first quarter. The positive rate of Mycoplasma pneumoniae was 3.25% and the positive rate of Legionella was 1.04%. 5 HCoV-229E positive samples, 10 HCoV-OC43 positive samples, 7 HCoV-HKU1 positive samples and 6 HCoV-NL63 positive samples were detected. Eight strains of Staphylococcus aureus, 4 strains of Pseudomonas aeruginosa and 3 strains of Klebsiella pneumoniae were detected after cultures. By implementing the active surveillance, we not only detected a case of human infection with avian influenza A(H7N9) virus in time, but also preliminary understood the pathogenic spectrum characteristics and seasonality of ILI and SARI in Shanghai. In recent years, the surveillance methods have been continuously improved and the number of sentinel hospitals has increased gradually. In particular, for the response to COVID-19, the Surveillance Information Reporting System of Acute Respiratory Infection based on HIS system has been promoted to cover the whole city, which might lay a foundation for the active surveillance and early warning of emerging infectious diseases in the future.


title: Tools for detection of Mycoplasma amphoriforme: a primary respiratory pathogen?

text: Mycoplasma amphoriforme is a recently described organism isolated from the respiratory tracts of patients with immunodeficiency and evidence of chronic infection. Novel assays for the molecular detection of the organism by real-time quantitative PCRs (qPCRs) targeting the uracil DNA glycosylase gene (udg) or the 23S rRNA gene are described here. The analytical sensitivities are similar to the existing conventional M. amphoriforme 16S rRNA gene PCR, with the advantage of being species specific, rapid, and quantitative. By using these techniques, we demonstrate the presence of this organism in 17 (19.3%) primary antibody-deficient (PAD) patients, 4 (5%) adults with lower respiratory tract infection, 1 (2.6%) sputum sample from a patient attending a chest clinic, and 23 (0.21%) samples submitted for viral diagnosis of respiratory infection, but not in normal adult control subjects. These data show the presence of this microorganism in respiratory patients and suggest that M. amphoriforme may infect both immunocompetent and immunocompromised people. Further studies to characterize this organism are required, and this report provides the tools that may be used by other research groups to investigate its pathogenic potential.


title: Transmastoid reshaping of the sigmoid sinus: preliminary study of a novel surgical method to quiet pulsatile tinnitus of an unrecognized vascular origin.

text: OBJECTIVE A dominant sigmoid sinus with focal dehiscence or thinning (DSSD/T) of the overlying bony wall is a commonly encountered, but frequently overlooked, cause of vascular pulsatile tinnitus (VPT). Also, the pathophysiological mechanism of sound perception in patients with VPT remains poorly understood. In the present study, a novel surgical method, termed transmastoid SS-reshaping surgery, was introduced to ameliorate VPT in patients with DSSD/T. The authors reviewed a case series, analyzed the surgical outcomes, and suggested the pathophysiological mechanism of sound perception. The theoretical background underlying VPT improvement after transmastoid SS-reshaping surgery was also explored. METHODS Eight patients with VPT that was considered attributable to DSSD/T underwent transmastoid SS-reshaping surgery between February 2010 and February 2015. The mean postoperative follow-up period was 9.5 months (range 4-13 months). Transmastoid SS-reshaping surgery featured simple mastoidectomy, partial compression of the SS using harvested cortical bone chips, and reinforcement of the bony SS wall with bone cement. Perioperative medical records, imaging results, and audiological findings were comprehensively reviewed. RESULTS In 7 of the 8 patients (87.5%), the VPT abated immediately after surgery. Statistically significant improvements in tinnitus loudness and distress were evident on numeric rating scales. Three patients with preoperative ipsilesional low-frequency hearing loss exhibited postoperative improvements in their low-frequency hearing thresholds. No major postoperative complications were encountered except in the first subject, who experienced increased intracranial pressure postoperatively. This subsided after a revision operation for partial decompression of the SS. CONCLUSIONS Transmastoid SS-reshaping surgery may be a good surgical option in patients with DSSD/T, a previously unrecognized cause of VPT. Redistribution of severely asymmetrical blood flow, reinforcement of the bony SS wall with bone cement to reconstruct a soundproof barrier, and disconnection of a problematic sound conduction route via simple mastoidectomy silence VPT.


title: Autologous Collagen Matrix (ACM): Lower Pole Support With a Supero-Anterior Capsular Flap in Secondary Subpectoral Breast Augmentation.

text: Background Secondary aesthetic breast surgery is a complex and challenging scenario. It requires the surgeon to identify contributing factors, provide patient education, make a further management plan, and optimize the conditions for a favorable result. Various techniques have been described in literature but the rate of reoperation is still high. The first author has been using a supero-anterior capsular flap with a neopectoral subcapsular pocket and an implant change in these cases. Objectives To review the patient characteristics, indications, and early results of using part of the existing implant capsule for secondary subpectoral breast augmentations. Methods All patients who underwent secondary breast augmentation, over a period of 2 years by the first author (P.M.), using the supero-anterior capsular flap technique were included. The technique involves dissection of a new subpectoral pocket and uses the existing implant capsule as an internal brassiere. Results A total of 36 patients were operated by this technique. Of these, 17 patients had developed a complication while 19 patients wanted a change in size only. At a mean follow up of 10.2 months, there was no bottoming out, double bubble, or capsular contracture. Conclusions This reliable technique provides stable results as shown by low rate of complications with the existing follow up. Level of Evidence 4


title: Intermediate catheter placement distal to the cerebral aneurysm during flow diversion embolization with the Surpass device.

text: PURPOSE We present the preliminary angiographic and clinical results of the combined utilization of an AXS Catalyst 5 (Cat5) distal access catheter and a Surpass flow diverter (SFD) for the endovascular treatment of intracranial aneurysms. MATERIALS AND METHODS Interventional neuroradiology case records were evaluated retrospectively to identify patients treated with an SFD in combination with Cat5. Demographic data, technical success, location of the catheter tip, aneurysm occlusion rate, and procedure-related morbidity and mortality were noted. RESULTS The analysis yielded 24 patients with 25 aneurysms with a mean age of 52.3±19.7 years. The mean aneurysm diameter was 15.7±8.8 mm. Twenty-one were anterior circulation (seven supraclinoid, one middle cerebral, one anterior choroidal and 12 petrocavernous) and four were posterior circulation (three basilar tip, one posterior inferior cerebellar) aneurysms. Only two of these aneurysms were re-treatments for recurrences. For SFD deployment, the distal tip of Cat5 was placed intradurally and at, or distal to, M1 segment in 88% and 48% of patients, respectively. Aneurysms were bypassed with Cat5 in 80% of the procedures. In one patient, flow diversion was abandoned totally due to arterial tortuosity. With the exclusion of this patient, the technical success rate was 91.7%. There was no permanent procedure-related morbidity or mortality. Of the 22 aneurysms treated successfully with the Surpass device, 20 had imaging follow-up at 6.3±3.8 months and 95% were totally occluded. CONCLUSION The Cat5 catheter, which was manufactured for the navigation of large-bore stent-like devices, is a useful adjunct to the Surpass device and allowed us to deploy the device safely.