title: Assessing activity and inhibition of Middle East respiratory syndrome coronavirus papain-like and 3C-like proteases using luciferase-based biosensors.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) is associated with an outbreak of more than 90 cases of severe pneumonia with high mortality (greater than 50%). To date, there are no antiviral drugs or specific therapies to treat MERS-CoV. To rapidly identify potential inhibitors of MERS-CoV replication, we expressed the papain-like protease (PLpro) and the 3-chymotrypsin-like protease (3CLpro) from MERS-CoV and developed luciferase-based biosensors to monitor protease activity in cells. We show that the expressed MERS-CoV PLpro recognizes and processes the canonical CoV-PLpro cleavage site RLKGG in the biosensor. However, existing CoV PLpro inhibitors were unable to block MERS-CoV PLpro activity, likely due to the divergence of the amino acid sequence in the drug binding site. To investigate MERS-CoV 3CLpro activity, we expressed the protease in context with flanking nonstructural protein 4 (nsp4) and the amino-terminal portion of nsp6 and detected processing of the luciferase-based biosensors containing the canonical 3CLpro cleavage site VRLQS. Importantly, we found that a small-molecule inhibitor that blocks replication of severe acute respiratory syndrome (SARS) CoV and murine CoV also inhibits the activity of MERS-CoV 3CLpro. Overall, the protease expression and biosensor assays developed here allow for rapid evaluation of viral protease activity and the identification of protease inhibitors. These biosensor assays can now be used to screen for MERS-CoV-specific or broad-spectrum coronavirus PLpro and 3CLpro inhibitors.


title: Robotic Intracorporeal Padua Ileal Bladder: Surgical Technique, Perioperative, Oncologic and Functional Outcomes.

text: BACKGROUND Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder reconstruction is a challenging procedure. The need for surgical skills and the long operative times have led to concern about its reproducibility. OBJECTIVE To illustrate our technique for RARC and totally intracorporeal orthotopic Padua ileal bladder. DESIGN, SETTING, AND PARTICIPANTS From August 2012 to February 2014, 45 patients underwent this technique at a single tertiary referral centre. SURGICAL PROCEDURE RARC, extended pelvic lymph node dissection, and intracorporeal partly stapled neobladder. Surgical steps are demonstrated in the accompanying video. MEASUREMENTS Demographics, clinical, and pathological data were collected. Perioperative, 2-yr oncologic and 2-yr functional outcomes were reported. RESULTS AND LIMITATIONS Intraoperative transfusion or conversion to open surgery was not necessary in any case and intracorporeal neobladder was successfully performed in all 45 patients. Median operative time was 305min (interquartile range [IQR]: 282-345). Median estimated blood loss was 210ml (IQR: 50-250). Median hospital stay was 9 d (IQR: 7-12). The overall incidence of perioperative, 30-d and 180-d complications were 44.4%, 57.8%, and 77.8%, respectively, while severe complications occurred in17.8%, 17.8%, and 35.5%, respectively. Two-yr daytime and night-time continence rates were 73.3% and 55.5%, respectively. Two-yr disease free survival, cancer specific survival, and overall survival rates were 72.5%, 82.3%, and 82.4%, respectively. The small sample size and high caseload of the centre might affect the reproducibility of these results. CONCLUSIONS Our experience supports the feasibility of totally intracorporeal neobladder following RARC. Operative times and perioperative complication rates are likely to be reduced with increasing experience. PATIENT SUMMARY We report the outcomes of our first 45 consecutive patients who underwent robot-assisted radical cystectomy with intracorporeal neobladders. Perioperative, oncologic, and functional outcomes support this technique as a feasible and safe surgical option in tertiary referral centres.


title: The consequences of COVID-19 for gastroenterology nursing.

text: Jennie Burch, Head of Gastrointestinal Nurse Education, St Mark's Hospital, London (jburch1@nhs.net), discusses the ramifications of coronavirus and the guidelines available to professionals working in gastroenterology.


title: Laparoscopic treatment of annular pancreas in adults: report of a case.

text: The annular pancreas in adults is a rare congenital anomaly that is detected after development of complications, such as gastric outlet obstruction, recurrent pancreatitis, and peptic ulcer. Duodenal bypass is the procedure of choice for treating duodenal obstruction caused by the annular pancreas in both children and adults. Duodenoduodenostomy is routinely performed in neonates and children. In adults, duodenojejunostomy or gastrojejunostomy are recommended, because the duodenum is less mobile. We report a case of annular pancreas in a 33-year-old male that was successfully treated with laparoscopic gastrojejunostomy.


title: Impact of intracellular hemin on N-type inactivation of voltage-gated K+ channels.

text: N-type inactivation of voltage-gated K+ channels is conferred by the N-terminal "ball" domains of select pore-forming α subunits or of auxiliary β subunits, and influences electrical cellular excitability. Here, we show that hemin impairs inactivation of K+ channels formed by Kv3.4 α subunits as well as that induced by the subunits Kvβ1.1, Kvβ1.2, and Kvβ3.1 when coexpressed with α subunits of the Kv1 subfamily. In Kvβ1.1, hemin interacts with cysteine and histidine residues in the N terminus (C7 and H10) with high affinity (EC50 100 nM). Similarly, rapid inactivation of Kv4.2 channels induced by the dipeptidyl peptidase-like protein DPP6a is also sensitive to hemin, and the DPP6a mutation C13S eliminates this dependence. The results suggest a common mechanism for a dynamic regulation of Kv channel inactivation by heme/hemin in N-terminal ball domains of Kv α and auxiliary β subunits. Free intracellular heme therefore has the potential to regulate cellular excitability via modulation of Kv channel inactivation.


title: Comparison of the Performance of Common Measures of Weight Regain After Bariatric Surgery for Association With Clinical Outcomes.

text: Importance Estimates of weight regain following bariatric surgery vary widely. Objective To describe weight regain after reaching nadir weight following Roux-en-Y gastric bypass (RYGB) surgery and compare weight regain measures for association with outcomes. Design, Setting, and Participants Prospective cohort study of 2458 adults who underwent bariatric surgery at 10 hospitals in 6 US cities between March 2006 and April 2009. Assessments were conducted within 30 days' presurgery, at 6 months' postsurgery, and then annually until January 2015. Of the 1703 participants who underwent RYGB surgery, 1406 (83%) were followed up for 5 years or longer and had 5 or more weight measurements (excluding those who died or underwent surgical reversal). Exposures Weight regain assessed by 5 continuous measures (weight in kilograms, body mass index [BMI], percentage of presurgery weight, percentage of nadir weight, and percentage of maximum weight lost) and 8 dichotomous measures (per established thresholds) were compared in relation to clinical outcomes based on statistical significance, magnitude of association, and model fit. Main Outcomes and Measures Progression of diabetes, hyperlipidemia, and hypertension and declines in physical and mental health-related quality of life and satisfaction with surgery. Results Among the 1406 participants who underwent RYGB surgery, the median age was 47 years (25th-75th percentile, 38-55 years) and the median BMI was 46.3 (25th-75th percentile, 42.3-51.8) prior to surgery. Most participants were female (80.3%) and white (85.6%). The median follow-up was 6.6 years (25th-75th percentile, 5.9-7.0 years). The median percentage of maximum weight loss was 37.4% (25th-75th percentile, 31.6%-43.3%) of presurgery weight and occurred a median of 2.0 years after RYGB surgery (25th-75th percentile, 1.0-3.2 years). The rate of weight regain was highest during the first year after reaching nadir weight, but weight regain continued to increase throughout follow-up (range, a median of 9.5% of maximum weight lost [25th-75th percentile, 4.7%-17.2%] to 26.8% of maximum weight lost [25th-75th percentile, 16.7%-41.5%] 1 to 5 years after reaching nadir weight). The percentage of participants who regained weight depended on threshold (eg, 5 years after nadir weight, 43.6% regained ≥5 BMI points; 50.2% regained ≥15% of nadir weight; and 67.3% regained ≥20% of maximum weight lost). Compared with other continuous weight regain measures, the percentage of maximum weight lost had the strongest association and best model fit for all outcomes except hyperlipidemia, which had a slightly stronger association with BMI. Of the dichotomous measures, 20% or greater of maximum weight lost performed better or similarly with most of the outcomes, and was the second best measure for hyperlipidemia (after ≥10 kg of weight) and hypertension (after ≥10% of maximum weight lost). Conclusions and Relevance Among a large cohort of adults who underwent RYGB surgery, weight regain quantified as percentage of maximum weight lost performed better for association with most clinical outcomes than the alternatives examined. These findings may inform standardizing the measurement of weight regain in studies of bariatric surgery.


docid: cxitojml

title: Advancing Preparedness for Highly Hazardous Contagious Diseases: Admitting 10 Simulated Patients with MERS-CoV.

text: The Ebola outbreak of 2014-2016 highlighted the need for the development of a more robust healthcare infrastructure in the United States to provide isolation care for patients infected with a highly hazardous contagious disease. Routine exercises and skills practice are required to effectively and safely prepare care teams to confidently treat this special population of patients. The Nebraska Biocontainment Unit (NBU) at Nebraska Medicine in Omaha has been conducting exercises since 2005 when the unit was opened. Previous activities and exercises conducted by the Nebraska Biocontainment Unit have focused on transporting and caring for up to 3 patients with Ebola virus disease or other special pathogens. Changes in regional and national mandates, as well as the increased potential for receiving multiple patients at once, at a single location, have resulted in a greater demand to exercise protocols for the treatment of multiple patients. This article discusses in detail the planning, execution, and outcomes of a full-scale exercise involving 10 simulated patients with a highly infectious pathogen transmitted by the airborne route.


Surgeon preferences for liver transection: is there an ideal technique?


docid: grhqjfip

title: Pipeline embolization device deployment via an envoy distal access XB guiding catheter-biaxial platform: A technical note.

text: With the increased reliance on the Pipeline embolization device (PED) for the treatment of complex intracranial aneurysms, our experience in managing intraoperative complications and challenges continues to accumulate amid a scarcity of reports on rescue strategies and innovative techniques. We describe the case of a 50-year-old woman who presented for elective repeat embolization of a right posterior communicating artery aneurysm with some residual aneurysmal filling. During the procedure the patient developed severe vasospasm due to vessel irritation and this led us to proceed to deploy the PED through a biaxial construct composed of the 6 French Envoy MPD DA XB, and the Marksman catheters. The biaxial construct in select patients may provide the required stability while eliminating the need for an intermediate catheter, minimizing embolic risk, and allowing for less irritation to the vessel. Larger studies are required for further validation.


title: Corticosteroid Therapy for Critically Ill Patients with Middle East Respiratory Syndrome.

text: RATIONALE Corticosteroid therapy is commonly used among critically ill patients with Middle East Respiratory Syndrome (MERS), but its impact on outcomes is uncertain. Analyses of observational studies often do not account for patients' clinical condition at the time of corticosteroid therapy initiation. OBJECTIVES To investigate the association of corticosteroid therapy on mortality and on MERS coronavirus RNA clearance in critically ill patients with MERS. METHODS ICU patients with MERs were included from 14 Saudi Arabian centers between September 2012 and October 2015. We performed marginal structural modeling to account for baseline and time-varying confounders. MEASUREMENTS AND MAIN RESULTS Of 309 patients, 151 received corticosteroids. Corticosteroids were initiated at a median of 3.0 days (quartile 1 [Q1]-Q3, 1.0-7.0) from ICU admission. Patients who received corticosteroids were more likely to receive invasive ventilation (141 of 151 [93.4%] vs. 121 of 158 [76.6%]; P < 0.0001) and had higher 90-day crude mortality (112 of 151 [74.2%] vs. 91 of 158 [57.6%]; P = 0.002). Using marginal structural modeling, corticosteroid therapy was not significantly associated with 90-day mortality (adjusted odds ratio, 0.75; 95% confidence interval, 0.52-1.07; P = 0.12) but was associated with delay in MERS coronavirus RNA clearance (adjusted hazard ratio, 0.35; 95% CI, 0.17-0.72; P = 0.005). CONCLUSIONS Corticosteroid therapy in patients with MERS was not associated with a difference in mortality after adjustment for time-varying confounders but was associated with delayed MERS coronavirus RNA clearance. These findings highlight the challenges and importance of adjusting for baseline and time-varying confounders when estimating clinical effects of treatments using observational studies.


Bridging the Gap: Training and Education in the Pathology and Cytopathology Sphere.


title: Variability of interferon-λ induction and antiviral activity in Nipah virus infected differentiated human bronchial epithelial cells of two human donors.

text: Highly pathogenic Nipah virus (NiV) generally causes severe encephalitis in humans. Respiratory symptoms are infrequently observed, likely reflecting variations in infection kinetics in human airways. Supporting this idea, we recently identified individual differences in NiV replication kinetics in cultured airway epithelia from different human donors. As type III interferons (IFN-λ) represent major players in the defence mechanism against viral infection of the respiratory mucosa, we studied IFN-λ induction and antiviral activity in NiV-infected primary differentiated human bronchial epithelial cells (HBEpCs) cultured under air-liquid interface conditions. Our studies revealed that IFN-λ was upregulated in airway epithelia upon NiV infection. We also show that IFN-λ pretreatment efficiently inhibited NiV replication. Interestingly, the antiviral activity of IFN-λ varied in HBEpCs from two different donors. Increased sensitivity to IFN-λ was associated with higher expression levels of IFN-λ receptors, enhanced phosphorylation of STAT1, as well as enhanced induction of interferon-stimulated gene expression. These findings suggest that individual variations in IFN-λ receptor expression affecting IFN responsiveness can play a functional role for NiV replication kinetics in human respiratory epithelial cells of different donors.


title: Systematic review of treatment intensification using novel agents for chemoradiotherapy in rectal cancer.

text: BACKGROUND With the well established shift to neoadjuvant treatment for locally advanced rectal cancer, there is increasing focus on the use of radiosensitizers to improve the efficacy and tolerability of radiotherapy. There currently exist few randomized data exploring novel radiosensitizers to improve response and it is unclear what the clinical endpoints of such trials should be. METHODS A qualitative systematic review was performed according to the PRISMA guidelines using preset search criteria across the PubMed, Cochrane and Scopus databases from 1990 to 2017. Additional results were generated from the reference lists of included papers. RESULTS A total of 123 papers were identified, of which 37 were included; a further 60 articles were obtained from additional referencing to give a total of 97 articles. Neoadjuvant radiosensitization for locally advanced rectal cancer using fluoropyrimidine-based chemotherapy remains the standard of treatment. The oral derivative capecitabine has practical advantages over 5-fluorouracil, with equal efficacy, but the addition of a second chemotherapeutic agent has yet to show a consistent significant efficacy benefit in randomized clinical assessment. Preclinical and early-phase trials are progressing with promising novel agents, such as small molecular inhibitors and nanoparticles. CONCLUSION Despite extensive research and promising preclinical studies, a definite further agent in addition to fluoropyrimidines that consistently improves response rate has yet to be found.


title: Together we stand: Suicide risk and suicide prevention among Israeli older adults during and after the COVID-19 world crisis.

text: The outbreak of COVID-19 has increased potential risks for depression and suicide among older adults. In this paper, we discuss the specific risk factors and current status of older adults in Israel in light of the COVID-19 crisis. Following that, we suggest establishing relevant and effective measures for suicide assessment, intervention, and prevention to avert experiences of loneliness, thwarted belongingness, and perceived burdensomeness and thus prevent suicides during and after the crisis. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Correlation between cerebral blood volume values and outcomes in endovascular therapy for acute ischemic stroke.

text: BACKGROUND Neurointerventionalists do not agree about the optimal imaging protocol when evaluating patients with acute stroke for potential endovascular revascularization. Preintervention cerebrovascular blood volume (CBV) has been shown to predict outcomes in patients undergoing intra-arterial stroke therapies. OBJECTIVE To determine whether CBV can predict hemorrhagic transformation and clinical outcomes in patients selected for endovascular therapy for acute ischemic middle cerebral artery (MCA) stroke using a CT perfusion (CTP)-based imaging protocol. METHODS We retrospectively reviewed cases of acute ischemic stroke due to MCA M1 segment occlusion and correlated favorable clinical outcomes (modified Rankin scale (mRS) ≤2) and radiographic outcomes with preintervention CBV values. All patients underwent whole-brain (320-detector-row) CTP imaging, and absolute CBV values of the affected and contralateral MCA territories were obtained separately for the cortical and basal ganglia regions. RESULTS Relative CBV (rCBV) of the MCA cortical regions was significantly lower in patients with poor clinical outcomes than in those with favorable clinical outcomes (0.87±0.21 vs 1.02±0.09, p=0.0003), and a negative correlation was found between rCBV values and mRS score severity. rCBV of the basal ganglia region was significantly lower in patients with hemorrhagic infarction (p=0.004) and parenchymal hematoma (p=0.04) than in those without hemorrhagic transformation. CONCLUSIONS We found that cortical CBV loss is predictive of poor clinical outcomes, whereas basal ganglia CBV loss is predictive of hemorrhagic transformation but without translation into poor clinical outcomes. Our study findings support published results of baseline preintervention CBV as a predictor of outcomes in patients undergoing intra-arterial stroke therapies.


Another New Esophagitis: The Lymphocyte Gets Its Turn.


title: Insect cell technology is a versatile and robust vaccine manufacturing platform.

text: Baculovirus and insect cell culture technologies have mostly been limited to research laboratories for the transient expression of target proteins for drug development purposes. With the renaissance of the vaccine field and the regulatory acceptance of recombinant DNA technology, the baculovirus expression system has been more broadly adopted for the development of subunit vaccines, including virus-like particles. In the numerous clinical trials extensively discussed and cross-referenced in this article, product quality, safety and efficacy have been demonstrated for many candidate vaccines targeting infectious diseases. The 2007 market authorization of Cervarix, a bivalent human papillomavirus virus-like particle vaccine against cervical cancer, was a critical milestone for the regulatory acceptance of insect cell technology in manufacturing human vaccines, opening the door to the approval of more baculovirus-derived vaccines. Insect cell technology is now a dominant platform for veterinary vaccines. This article covers the application of recombinant baculovirus as vectored vaccines to mediate systemic and mucosal immune responses through the display or expression of foreign antigens. We will probably observe increasingly more baculovirus-derived products and market licensing of safe and efficacious vaccines.


title: The Equilibration of PCO2 in Pigs Is Independent of Lung Injury and Hemodynamics.

text: OBJECTIVES In mechanical ventilation, normoventilation in terms of PCO2 can be achieved by titration of the respiratory rate and/or tidal volume. Although a linear relationship has been found between changes in respiratory rate and resulting changes in end-tidal cO2 (△PetCO2) as well as between changes in respiratory rate and equilibration time (teq) for mechanically ventilated patients without lung injury, it is unclear whether a similar relationship holds for acute lung injury or altered hemodynamics. DESIGN We performed a prospective randomized controlled animal study of the change in PetCO2 with changes in respiratory rate in a lung-healthy, lung-injury, lung-healthy + altered hemodynamics, and lung-injury + altered hemodynamics pig model. SETTING University research laboratory. SUBJECTS Twenty mechanically ventilated pigs. INTERVENTIONS Moderate lung injury was induced by injection of oleic acid in 10 randomly assigned pigs, and after the first round of measurements, cardiac output was increased by approximately 30% by constant administration of noradrenalin in both groups. MEASUREMENTS AND MAIN RESULTS We systematically increased and decreased changes in respiratory rate according to a set protocol: +2, -4, +6, -8, +10, -12, +14 breaths/min and awaited equilibration of Petco2. We found a linear relationship between changes in respiratory rate and △PetCO2 as well as between changes in respiratory rate and teq. A two-sample t test resulted in no significant differences between the lung injury and healthy control group before or after hemodynamic intervention. Furthermore, exponential extrapolation allowed prediction of the new PetCO2 equilibrium and teq after 5.7 ± 5.6 min. CONCLUSIONS The transition between PetCO2 equilibria after changes in respiratory rate might not be dependent on moderate lung injury or cardiac output but on the metabolic production or capacity of cO2 stores. Linear relationships previously found for lung-healthy patients and early prediction of PetCO2 equilibration could therefore also be used for the titration of respiratory rate on the PetCO2 for a wider range of pathologies by the physician or an automated ventilation system.


title: Adhesion of Microdroplets on Water-Repellent Surfaces toward the Prevention of Surface Fouling and Pathogen Spreading by Respiratory Droplets.

text: Biofouling caused by the adhesion of respiratory microdroplets generated in sneezing and coughing plays an important role in the spread of many infectious diseases. Although water-repellent surfaces are widely used for the long-term repellency of aqueous solutions, their repellency to pathogen-containing microdroplets is elusive. In this work, microdroplets from picoliter to nanoliter were successfully generated in a controlled manner to mimic the exhaled microdroplets in sneezing and coughing, which allowed us to evaluate the adhesion of microdroplets on both superhydrophobic and lubricant-infused "slippery" surfaces for the first time. The impact and retention of water microdroplets on the two water-repellent surfaces are compared and investigated. Microdroplet-mediated surface biofouling and pathogen transmission were also demonstrated. Our results suggested that the adhesion of microdroplets should be duly considered in the design and application of water-repellent surfaces on biofouling prevention.


title: Nurses' preparedness for infectious disease outbreaks: A literature review and narrative synthesis of qualitative evidence.

text: AIMS AND OBJECTIVES To explore the core components that constitute nurses' preparedness in an epidemic event. BACKGROUND Healthcare service providers have worked to augment efforts to protect the public from the impact of epidemic events. While constituting the major healthcare taskforce, nurses are frequently tasked with fronting the response to an infectious disease outbreak. Given the crucial role of nurses in the management of prevailing epidemics, the constituents of their preparedness in epidemic events should be identified. DESIGN A systematic search was undertaken to identify eligible studies from the literature. A narrative synthesis approach was employed to extract and synthesise findings of the reviewed qualitative studies. METHODS Seven qualitative studies on nurses' experience and perceptions of epidemic events were examined for scientific quality using the Critical Appraisal Skills Programme Qualitative Checklist. Findings of these studies were synthesised adopting a narrative synthesis approach. RESULTS Three interplaying themes were identified as follows: (i) personal resources, (ii) workplace resources and (iii) situational influences. The findings suggest that an effective epidemic outbreak response would require further effort to reinforce the interplay between individual nurses, healthcare institutions and the governments. CONCLUSIONS The practical interplay among individual nurses, healthcare institutions and the governments is crucial in establishing an effective epidemic response. Further research on the understanding of the dynamic process of preparedness development is recommended to set future directions in research. RELEVANCE TO CLINICAL PRACTICE This study offers important insights for devising future strategies in enhancing nurses' preparedness and response to an epidemic event. These include recommendations on providing education and training to nurses regarding infectious diseases, fostering institutional assistance and support in an outbreak and revising government policies and planning.


title: Thermal ablation: update and technique at a high-volume institution.

text: In the era of nephron-sparing surgery for small renal tumors, thermal ablation is gaining popularity. Both cryoablation and radiofrequency ablation have well-demonstrated short-term oncologic efficacy and safety. This article shares the current literature and the radiofrequency ablation technique at a high-volume institution. Cases are presented that illustrate solutions to obstacles frequently encountered during percutaneous ablation of renal masses.


title: Sidestream capnographic monitoring reduces the incidence of arterial oxygen desaturation during propofol ambulatory anesthesia for surgical abortion.

text: BACKGROUND This study investigated whether early intervention based on additional use of sidestream capnography could reduce the incidence of oxygen desaturation and hypoxic events in patients receiving propofol anesthesia during surgical abortion. MATERIAL/METHODS We recruited 704 ASAI-III female patients, 18-52 years old and scheduled for planned painless surgical abortion, and randomized them into a control group (n=359) receiving standard monitoring and an experimental group (n=341) receiving standard monitoring and additional capnography. Exclusion criteria were preexisting cardiovascular disease, preexisting hypotension, bradycardia or arrhythmia, and drug allergy. Anesthesia was induced in all patients with propofol using target-controlled infusion at a target propofol plasma concentration of 4 μg/ml. All patients received flurbiprofen axetil 50 mg and 0.5 μg/kg fentanyl 5 min before anesthesia. Bispectral index was used and maintained between 45 and 60. Main outcome measures were apnea or abnormal ventilation status, rate of oxygen desaturation, occurrence of hypoxia and severe hypoxia, and perioperative side effects. RESULTS The experimental group had significantly higher rate of apnea or abnormal ventilation, significantly lower rate of oxygen desaturation, and significant lower occurrence of hypoxia and severe hypoxia compared to the control group. We found no statistically significant differences between the 2 groups in the rates of increased oxygen supplementation, assisted ventilation, bradycardia, hypotension, dosage of atropine, dosage of ephedrine or phenylephrine, and the amount of propofol consumed. CONCLUSIONS Sidestream capnographic monitoring improves early detection of alterations in ventilation parameters and reduces the incidence of oxygen desaturation and hypoxemia resulting from propofol anesthesia during surgical abortion.


Pakistan's Combat and Comeback Against COVID-19.


title: Design of Randomized, double-blind, Evaluation in secondary Stroke Prevention comparing the EfficaCy and safety of the oral Thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with Embolic Stroke of Undetermined Source (RE-SPECT ESUS).

text: RATIONALE Cryptogenic ischemic strokes constitute 20-30% of ischemic strokes, the majority of which are embolic strokes of undetermined source. The standard preventive treatment in these patients is usually acetylsalicylic acid. AIM The Randomized, double-blind, Evaluation in secondary Stroke Prevention comparing the EfficaCy and safety of the oral Thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with Embolic Stroke of Undetermined Source (RE-SPECT ESUS) is designed to determine whether the oral thrombin inhibitor dabigatran, taken within three-months after embolic stroke of undetermined source, is superior to acetylsalicylic acid for prevention of recurrent stroke and to characterize the safety of dabigatran in this setting. DESIGN Prospective, randomized, double-blind, multicenter trial in approximately 6000 patients and 550 centers with embolic stroke of undetermined source. Subjects are randomized to dabigatran or acetylsalicylic acid and treated for an expected minimum of six-months and up to approximately three-years. It is an event-driven trial aiming for 353 adjudicated primary outcome events. STUDY OUTCOMES The primary efficacy outcome is time to first recurrent stroke (ischemic, hemorrhagic, or unspecified). Key secondary outcomes are time to first ischemic stroke and time to first occurrence in the composite outcome of nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death. The primary safety outcome is major hemorrhage, including symptomatic intracranial hemorrhage. DISCUSSION Acetylsalicylic acid is the most common antithrombotic given to patients with embolic strokes of undetermined source to reduce recurrence risk. This trial will determine whether anticoagulation with dabigatran is more effective than acetylsalicylic acid, and acceptably safe.


title: Awake intubation and awake prone positioning of a morbidly obese patient for lumbar spine surgery.

text: We describe the awake fibreoptic intubation followed by awake prone positioning of a woman weighing 180 kg with body mass index of 62 kg.m(-2) requiring emergency lumbar discectomy for cauda equina syndrome. This approach was taken to overcome difficulties in transfering an anaesthetised patient on to the operating table. Following topical anaesthesia with lidocaine and low-dose remifentanil infusion, oral intubation was performed using a split oral airway to guide the fibrescope. The patient positioned herself on the Jackson operating table, following which general anaesthesia was induced. This technique optimised protection of the patient's eyes and other pressure areas while preventing undue cardiorespiratory compromise. The patient tolerated the procedure well, and later confirmed that she would consent to undergoing the same procedure again if further surgery became necessary.


title: Endocrine significance of SARS-CoV-2's reliance on ACE2.

text: The current COVID-19 pandemic is the most disruptive event in the last 50 years with global impact on healthcare and world economies. It is caused by SARS-CoV-2, a coronavirus that uses angiotensin converting enzyme 2 (ACE2), as an entry point to the cells. ACE2 is a transmembrane carboxypeptidase and member of the renin-angiotensin system. This mini-review, summarizes the main findings regarding ACE2 expression and function in endocrine tissues. We discuss rapidly evolving knowledge on the potential role of ACE2 and SARS coronaviruses in endocrinology and the development of diabetes mellitus, hypogonadism, pituitary and thyroid diseases.


title: Profiling COVID-19 pneumonia progressing into the cytokine storm syndrome: results from a single Italian Centre study on tocilizumab versus standard of care

text: OBJECTIVE: Approximately 5% of patients with coronavirus disease 2019 (COVID-19) develop a life-threatening pneumonia that often occurs in the setting of increased inflammation or “cytokine storm”. Anti-cytokine treatments are being evaluated but optimal patient selection remains unclear, and the aim of our study is to address this point. METHODS: Between February 29 to April 6, 2020, 111 consecutive hospitalized patients with COVID-19 pneumonia were evaluated in a single centre retrospective study. Patients were divided in two groups: 42 severe cases (TOCI) with adverse prognostic features including raised CRP and IL-6 levels, who underwent anti-cytokine treatments, mostly tocilizumab, and 69 standard of care patients (SOC). RESULTS: In the TOCI group, all received anti-viral therapy and 40% also received glucocorticoids. In TOCI, 62% of cases were ventilated and there were 3 deaths (17.8 ± 10.6 days, mean follow up) with 7/26 cases remaining on ventilators, without improvement, and 17/26 developed bacterial superinfection. One fatality occurred in the 15 TOCI cases treated on noninvasive ventilation and 1 serious bacterial superinfection. Of the 69 cases in SOC, there was no fatalities and no bacterial complications. The TOCI group had higher baseline CRP and IL-6 elevations (p < 0.0001 for both) and higher neutrophils and lower lymphocyte levels (p = 0.04 and p = 0.001, respectively) with the TOCI ventilated patients having higher markers than non-ventilated TOCI patients. CONCLUSION: Higher inflammatory markers, more infections and worse outcomes characterized ventilated TOCI cases compared to ward based TOCI. Despite the confounding factors, this suggests that therapy time in anti-cytokine randomized trials will be key.


title: Spatial methods for infectious disease outbreak investigations: systematic literature review.

text: Investigations of infectious disease outbreaks are conventionally framed in terms of person, time and place. Although geographic information systems have increased the range of tools available, spatial analyses are used relatively infrequently. We conducted a systematic review of published reports of outbreak investigations worldwide to estimate the prevalence of spatial methods, describe the techniques applied and explore their utility. We identified 80 reports using spatial methods published between 1979 and 2013, ca 0.4% of the total number of published outbreaks. Environmental or waterborne infections were the most commonly investigated, and most reports were from the United Kingdom. A range of techniques were used, including simple dot maps, cluster analyses and modelling approaches. Spatial tools were usefully applied throughout investigations, from initial confirmation of the outbreak to describing and analysing cases and communicating findings. They provided valuable insights that led to public health actions, but there is scope for much wider implementation and development of new methods.


title: Transvaginal specimen extraction after combined laparoscopic splenectomy and hysterectomy: Introduction to NOSE (Natural Orifice Specimen Extraction) in a community hospital.

text: INTRODUCTION Developments in the field of minimally invasive surgery have led to interest in NOTES (natural orifice transluminal endoscopic surgery). Even as technologies continue to evolve and develop, interest in some of the advantages of specimen retrieval transvaginally has been roused and we describe a case of combined laparoscopic splenectomy and hysterectomy with transvaginal retrieval of both specimens. PRESENTATION OF CASE Patient underwent laparoscopic splenectomy and robot-assisted hysterectomy with transvaginal delivery of specimens. Total operative time was 245min with no complications. Closure of the colpotomy was achieved laparoscopically. Post-operative course was unremarkable. Patient has done well clinically at 18 months follow-up except for an episode of post-coital spotting, which resolved spontaneously. DISCUSSION We explored the technical feasibility of concurrent laparoscopic splenectomy and hysterectomy along with transvaginal retrieval of both solid organs without morcellation. We wanted to illustrate the fact that transvaginal organ extraction may be performed safely in a community or district hospital with standard instruments without incurring additional cost, morbidity or increased operating time. CONCLUSION Transvaginal specimen retrieval was technically easy to accomplish. Our patient has not experienced any infectious complications or sexual dysfunction to date. For surgeons exploring an alternative to transabdominal specimen retrieval, transvaginal NOSE is an attractive proposition with several advantages. When combined with a gynecological procedure that involves a colpotomy, this may present a unique opportunity to explore the utility of NOSE.


title: Stomach intestinal pylorus sparing surgery (SIPS) with laparoscopic fundoplication (LF): a new approach to gastroesophageal reflux disease (GERD) in the setting of morbid obesity.

text: The increase in the prevalence of obesity and gastroesophageal reflux disease (GERD) has paralleled one another. Laparoscopic fundoplication (LF) (Nissen or Toupet) is a minimally invasive form of anti-reflux surgery. The duodenal switch is a highly effective weight loss surgery with a proven record of long term weight loss success. However, fundoplication alone does not give satisfactory results when used for GERD in morbidly obese patients. Here we present a novel approach combining stomach intestinal pylorus sparing surgery (SIPS) with LF for morbidly obese patients with GERD. The data from patients who underwent the SIPS procedure along with LF in past year was retrospectively analyzed. The variables collected were age, sex, height, weight, intra-operative and post-operative complications, length of stay, operative time, and estimated blood loss. All revisions were excluded. Descriptive statistics such as mean and standard deviation were used to analyze the data. The total sample size of the study was 5 patients, with a mean age of 59.6 ± 16.4 years, a mean weight of 292.1 ± 73.6 lbs., and a mean body mass index (BMI) of 43.4 ± 6.3. Weight loss patterns were the same as those without LF. All the 5 patients had resolution or improvement in their GERD symptoms within 6 months. SIPS with LF provides substantial and sustained weight loss and GERD resolution. Long term follow ups and further study on this novel surgical technique is recommended.


title: The evidence for the physiological effects of lactate on the cerebral microcirculation: a systematic review.

text: Lactate's role in the brain is understood as a contributor to brain energy metabolism, but it may also regulate the cerebral microcirculation. The purpose of this systematic review was to evaluate evidence of lactate as a physiological effector within the normal cerebral microcirculation in reports ranging from in vitro experiments to in vivo studies in animals and humans. Following pre-registration of a review protocol, we systematically searched the PubMed, EMBASE, and Cochrane databases for literature covering themes of 'lactate', 'the brain', and 'microcirculation'. Abstracts were screened, and data extracted independently by two individuals. We excluded studies evaluating lactate in disease models. Twenty-eight papers were identified, 18 of which were in vivo animal experiments (65%), four on human studies (14%), and six on in vitro or ex vivo experiments (21%). Approximately half of the papers identified lactate as an augmenter of the hyperemic response to functional activation by a visual stimulus or as an instigator of hyperemia in a dose-dependent manner, without external stimulation. The mechanisms are likely to be coupled to NAD+ /NADH redox state influencing the production of nitric oxide. Unfortunately, only 38% of these studies demonstrated any control for bias, which makes reliable generalizations of the conclusions insecure. This systematic review identifies that lactate may act as a dose-dependent regulator of cerebral microcirculation by augmenting the hyperemic response to functional activation below 5 mmol/kg, and by initiating a hyperemic response above 5 mmol/kg. OPEN SCIENCE BADGES: This article has received a badge for *Pre-registration* because it made the data publicly available. The data can be accessed at www.radboudumc.nl/getmedia/53625326-d1df-432c-980f-27c7c80d1a90/THollyer_lactate_protocol.aspx. The complete Open Science Disclosure form for this article can be found at the end of the article. More information about the Open Practices badges can be found at https://cos.io/our-services/open-science-badges/.


title: Management of gastric conduit dehiscence with self-expanding metal stents: a case report on salvaging the gastric conduit.

text: BACKGROUND Three-hole minimally invasive esophagectomy (3HMIE) is one of the most radical procedures in gastrointestinal surgery. It involves thoracoscopic dissection of the esophagus followed by creation of a gastric conduit in the abdomen with anastomosis in the neck, and is associated with significant morbidity. Gastric conduit dehiscence is one of the most morbid complications following esophagectomy. Historically, the standard of care in this situation has been conduit diversion with delayed esophageal reconstruction. CASE PRESENTATION Here, we report two patients with a timely diagnosis of gastric conduit dehiscence of staple line after 3HMIE who were salvaged successfully with endoscopic placement of self-expanding metal stents. CONCLUSION Endoscopic stents may be used in selected cases of gastric conduit dehiscence after 3HMIE to salvage the conduit.


title: Immunoinformatics and its relevance to understanding human immune disease.

text: Immunology research is characterized by the production of increasingly vast amounts of data, fuelled by genomics and proteomics projects and large-scale screening of pathogen- and antigen-host interactions. The need to store, manage and analyze this rapidly growing resource of experimental, clinical and epidemiologic data has given rise to the field known as immunoinformatics. Immunoinformatics represents computational methods and resources that are used in the study of immune function. It lies at the intersection of experimental and computational sciences and encompasses domain-specific databases, computational models and strategies drawn from artificial intelligence. For example, computational or artificial intelligence models are increasingly being used to simulate and improve our understanding of immune system behavior, such as antigen processing and presentation, as well as for analysis of host and pathogen genomes. Systemic models focus on simulating the behavior of cells or whole organs and can be used for applications such as tracking the course of infection or optimization of immunization protocols. Immunomics, the large-scale screening of immune processes, which includes powerful immunoinformatic tools, offers great promise for future translation of basic immunology research advances into clinical practice. Immunoinformatics is central to the research fields of immunogenomics, immunoproteomics and computational vaccinology.


title: Technical Feasibility of Enterotomy Closure with Knotless Barbed Suture Material (V-Loc 180) in Esophagojejunostomy Using Linear Stapler during Totally Laparoscopic Total Gastrectomy for Gastric Cancer.

text: PURPOSE Intra-corporeal esophagojejunostomy (EJ) using a linear stapler creates a stapler entry hole that requires secure closure during the totally laparoscopic total gastrectomy (TLTG) procedure for gastric cancer. Since a standard method has not been established yet, the feasibility of using V-loc 180 (Covidien, Mansfield, MA, USA) suture material was evaluated in this study. MATERIALS AND METHODS During January 2012 to March 2015, 25 patients who underwent linear stapling EJ and V-loc 180 closure of remaining enterotomy were included in this study. Basic clinico-pathological characteristics, surgical outcomes, and short-term complications were analyzed. RESULTS The mean patient age was 60.4 ± 8.5 years. Nineteen males and six females were included in this study. The mean body mass index was 25.3 ± 2.3 kg/m2. There were 22 stage-I, 2 stage-II, and 1 stage-III gastric cancer patients. The mean operation time was 240.5 ± 44.6 min, and the time for anastomosis was 38.8 ± 11.2 min. The procedures were successfully performed in all cases without any intra-operative complications. There was one case of EJ leakage that occurred at the corner of EJ staple line and not at the enterotomy closure site. CONCLUSIONS The closure of the remaining enterotomy site using V-loc 180 suture following linear stapler EJ is technically feasible and safe during the TLTG procedure. However, further experience and results from other surgeons are necessary to generalize this procedure.


title: Epidemiology of COVID-19 in an Urban Dialysis Center.

text: BACKGROUND During the coronavirus disease 2019 (COVID-19) epidemic, many countries have instituted population-wide measures for social distancing. The requirement of patients on dialysis for regular treatment in settings typically not conducive to social distancing may increase their vulnerability to COVID-19. METHODS Over a 6-week period, we recorded new COVID-19 infections and outcomes for all adult patients receiving dialysis in a large dialysis center. Rapidly introduced control measures included a two-stage routine screening process at dialysis entry (temperature and symptom check, with possible cases segregated within the unit and tested for SARS-CoV-2), isolated dialysis in a separate unit for patients with infection, and universal precautions that included masks for dialysis nursing staff. RESULTS Of 1530 patients (median age 66 years; 58.2% men) receiving dialysis, 300 (19.6%) developed COVID-19 infection, creating a large demand for isolated outpatient dialysis and inpatient beds. An analysis that included 1219 patients attending satellite dialysis clinics found that older age was a risk factor for infection. COVID-19 infection was substantially more likely to occur among patients on in-center dialysis compared with those dialyzing at home. We observed clustering in specific units and on specific shifts, with possible implications for aspects of service design, and high rates of nursing staff illness. A predictive epidemic model estimated a reproduction number of 2.2; cumulative cases deviated favorably from the model from the fourth week, suggesting that the implemented measures controlled transmission. CONCLUSIONS The COVID-19 epidemic affected a large proportion of patients at this dialysis center, creating service pressures exacerbated by nursing staff illness. Details of the control strategy and characteristics of this epidemic may be useful for dialysis providers and other institutions providing patient care.


Student mental health in the midst of the COVID-19 pandemic: A call for further research and immediate solutions.


Severe Acute Respiratory Syndrome Coronavirus 2 Vaccines: Setting Expectations Appropriately.


title: No infectious risk of COVID-19 patients with long-term fecal 2019-nCoV nucleic acid positive.

text: OBJECTIVE It has recently been reported that some COVID-19 patients have long-term positive fecal nucleic acid after discharging from the hospital with negative nucleic acid in the respiratory tract, but it is unclear whether COVID-19 patients with positive long-term fecal nucleic acid tests have the risk of self-infection. PATIENTS AND METHODS From January 25, 2020 to March 9, 2020, 5 COVID-19 patients with negative respiratory tract nucleic acid and positive fecal nucleic acid were observed and studied to explore whether these patients can re-infect themselves. Five patients with COVID-19 accompanied by diarrhea as the main gastrointestinal symptoms were carefully observed through clinical symptoms, imaging and other auxiliary examinations. The RT-PCR technology was used to continuously detect fecal and respiratory viral nucleic acids. The IgM antibody was detected on the 7th day of admission and IgM/IgG at the time of discharge. RESULTS All 5 patients had symptoms of fever and diarrhea upon admission. The fecal nucleic acid was positive, as well as the throat swab was positive. All COVID-19 patients had positive IgM antibodies on the 7th day of admission and positive IgM and IgG at the time of discharge, and there were no abnormalities in the gastrointestinal examination on discharge. All 5 fecal nucleic acid tests were positive at the time of discharge. After continuous dynamic follow-up for 3-15 days, no clinical symptoms recurred, and the last nucleic acid test was negative. CONCLUSIONS There is no risk of self-infection for COVID-19 patients with long-term 2019-nCoV nucleic acid positive in feces.


title: Protective immunity to H7N9 influenza viruses elicited by synthetic DNA vaccine.

text: Despite an intensive vaccine program influenza infections remain a major health problem, due to the viruses' ability to change its envelope glycoprotein hemagglutinin (HA), through shift and drift, permitting influenza to escape protection induced by current vaccines or natural immunity. Recently a new variant, H7N9, has emerged in China causing global concern. First, there have been more than 130 laboratory-confirmed human infections resulting in an alarmingly high death rate (32.3%). Second, genetic changes found in H7N9 appear to be associated with enabling avian influenza viruses to spread more effectively in mammals, thus transmitting infections on a larger scale. Currently, no vaccines or drugs are effectively able to target H7N9. Here, we report the rapid development of a synthetic consensus DNA vaccine (pH7HA) to elicit potent protective immunity against the H7N9 viruses. We show that pH7HA induces broad antibody responses that bind to divergent HAs from multiple new members of the H7N9 family. These antibody responses result in high-titer HAI against H7N9. Simultaneously, this vaccine induces potent polyfunctional effector CD4 and CD8T cell memory responses. Animals vaccinated with pH7HA are completely protected from H7N9 virus infection and any morbidity associated with lethal challenge. This study establishes that this synthetic consensus DNA vaccine represents a new tool for targeting emerging infection, and more importantly, its design, testing and development into seed stock for vaccine production in a few days in the pandemic setting has significant implications for the rapid deployment of vaccines protecting against emerging infectious diseases.


title: Epstein-barr virus encodes three bona fide ubiquitin-specific proteases.

text: Manipulation of the ubiquitin proteasome system (UPS) is emerging as a common theme in viral pathogenesis. Some viruses have been shown to encode functional homologs of UPS enzymes, suggesting that a systematic identification of these products may provide new insights into virus-host cell interactions. Ubiquitin-specific proteases, collectively known as deubiquitinating enzymes (DUBs), regulate the activity of the UPS by hydrolyzing ubiquitin peptide or isopeptide bonds. The prediction of viral DUBs based on sequence similarity with known enzymes is hampered by the diversity of viral genomes. In this study sequence alignments, pattern searches, and hidden Markov models were developed for the conserved C- and H-boxes of the known DUB families and used to search the open reading frames (ORFs) of Epstein-Barr virus (EBV), a large gammaherpesvirus that has been implicated in the pathogenesis of a broad spectrum of human malignancies of lymphoid and epithelial cell origin. The searches identified a limited number of EBV ORFs that contain putative DUB catalytic domains. DUB activity was confirmed by functional assays and mutation analysis for three high scoring candidates, supporting the usefulness of this bioinformatics approach in predicting distant homologues of cellular enzymes.


title: Bridging Therapy Versus Direct Mechanical Thrombectomy in Patients with Acute Ischemic Stroke due to Middle Cerebral Artery Occlusion: A Clinical-Histological Analysis of Retrieved Thrombi.

text: Mechanical thrombectomy (MT) is effective in managing patients with acute ischemic stroke (AIS) caused by large-vessel occlusions and allows for valuable histological analysis of thrombi. However, whether bridging therapy (pretreatment with intravenous thrombolysis before MT) provides additional benefits in patients with middle cerebral artery (MCA) occlusion remains unclear. Therefore, this study aimed to compare the effects of direct MT and bridging therapy, and to elucidate the correlation between thrombus composition and stroke subtypes. Seventy-three patients with acute ischemic stroke who received MT, were eligible for intravenous thrombolysis, and had MCA occlusion were included. We matched 21 direct MT patients with 21 bridging therapy patients using propensity score matching and compared their 3rd-month clinical outcomes. All MCA thrombi (n = 45) were histologically analyzed, and the red blood cell (RBC) and fibrin percentages were quantified. We compared the clot composition according to stroke etiology (large-artery atherosclerosis and cardioembolism) and intravenous thrombolysis application. The baseline characteristics showed no difference between groups except for a higher atrial fibrillation rate and NIHSS score on admission in the direct MT group. We performed a supportive analysis using propensity score matching but could not find any differences in the functional outcome, mortality, and intracerebral hemorrhage. In the histological clot analysis, the cardioembolic clots without intravenous thrombolysis pretreatment had higher RBC (P = 0.042) and lower fibrin (P = 0.042) percentages than the large-artery atherosclerosis thrombi. Similar findings were observed in the thrombi treated with recombinant tissue plasminogen activator (P = 0.012). In conclusion, there was no difference in the functional outcomes between the direct MT and bridging therapy groups. However, randomized trials are needed to elucidate the high ratio of cardioembolism subtype in our group of patients. The histological MCA thrombus composition differed between cardioembolism and large-artery atherosclerosis, and this finding provides valuable information on the underlying pathogenesis and thrombus origin.


docid: btzvxcxg

title: Magnetic-assisted single-port sleeve gastrectomy.

text: BACKGROUND Sleeve gastrectomy is a recent, purely restrictive procedure in bariatric surgery that has shown results similar to gastric bypass over the short and middle term. At the same time, single-port access surgery has fostered the development of new techniques and methods seeking better cosmetic results and less postoperative pain, while maintaining the satisfactory results obtained by the standard laparoscopic approach. One of the problems associated to single-access surgery is the lack of traction and the difficulties to retract the liver. The authors' aim was to try to avoid additional trocars or sutures in order to perform pure single-incision surgery, using 2 magnetic forceps. METHODS The authors present the case of a 51-year-old morbidly obese female (body mass index = 44.82) who underwent a pure single-access laparoscopic sleeve gastrectomy with no additional trocars or sutures and assisted by 2 neodymium magnetic forceps: one to retract the liver and the other to retract the stomach in order to provide sufficient triangulation for adequate exposure of the surgical field during dissection. RESULTS The procedure was completed in 120 minutes. No preoperative or postoperative complications were recorded, and the patient was discharged 2 days after surgery. CONCLUSION Single-port access sleeve gastrectomy assisted by magnetic forceps is feasible and safe in the hands of experienced laparoscopic surgeons, solving one of the problems associated to this type of surgery, that is, the need for an additional trocar and needles or sutures to retract the liver and stomach in order to perform the operation.


title: Device and imaging-specific volumetric analysis of clot lysis after percutaneous mechanical thrombectomy for iliofemoral DVT.

text: PURPOSE To determine the most accurate method of assessing clot lysis after percutaneous mechanical thrombectomy for iliofemoral deep vein thrombosis (DVT) and to evaluate the effectiveness of two different pharmacomechanical thrombectomy devices. METHODS Between 2004 and 2009, 33 patients (18 women; mean age 47 years) with iliofemoral DVT underwent pharmacomechanical thrombectomy using the AngioJet (n = 18) or Trellis (n = 15) devices with 10 mg of tenecteplase. Intravascular ultrasound (IVUS) and venography were performed over the iliofemoral segments before and after treatment. Cross-sectional vessel and lumen diameters were measured from the IVUS scans and the post-procedure anteroposterior and lateral venograms at 3 points (proximal, mid-section, and distal) along each iliofemoral vein by 2 independent observers blinded to the treatment method. Volumes of the recanalized segments were calculated and compared to volumes of the original venous segments to assess clot lysis with each PMT device. IVUS scans and venograms were also compared for their ability to identify residual lesions or clot in need of treatment. Repeatability between and among observers was analyzed using the Bland and Altman method. RESULTS All procedures were successfully completed; there were only 2 minor bleeding complications. The mean volume of the recanalized segment was 2255+/-66 mm(3) by IVUS, representing 80% lysis of the clot compared to what was perceived as >90% lysis with venography (p<0.05). IVUS was able to delineate significant residual thrombus, stenosis, or May-Thurner anatomy requiring ancillary interventions in 100% of patients versus 48% (16/33) on the venograms (p<0.01). Quantitative assessments of the diameters of the involved venous segments from the venograms and IVUS were consistent between and among observers. Comparing the similar patient subgroups, AngioJet resulted in greater clot lysis (88%) versus the Trellis device (72%; p<0.01), corresponding to recanalized venous segment volumes of 2486+/-74 and 2025+/-57 mm(3) and total venous segment volumes of 2826+/-84 and 2813+/-79 mm(3), respectively. CONCLUSION IVUS is superior to venography for detection of residual thrombus and underlying venous pathology after pharmacomechanical thrombectomy. While greater clot lysis was seen with the AngioJet system, both the AngioJet and Trellis devices resulted in excellent clinical clot lysis.


title: Altered activation of the tibialis anterior in individuals with Pompe disease: Implications for motor unit dysfunction.

text: INTRODUCTION Pompe disease is a progressive disease that affects skeletal muscles and leads to loss of ambulation. We investigated the activation of the tibialis anterior (TA) in late-onset Pompe disease (LOPD) individuals during maximal voluntary contraction (MVC) and evoked involuntary responses. METHODS Four LOPD patients and matched control subjects performed MVC of the TA using dorsiflexion and TA evoked responses. Activation of the TA was recorded with surface electromyography. RESULTS The Pompe patients exhibited greater power at frequencies below 60 Hz and reduced power above 100 Hz. They also exhibited a reduced increase in M-wave and prolonged M-wave latency and duration in response to stimulation. CONCLUSIONS These results provide evidence that LOPD individuals have an altered activation pattern of the TA during maximal contractions. The observed activation pattern may reflect impairments in voluntary command, neuromuscular junction pathology, or compensatory drive due to a reduced number of functional motoneurons.


title: Location of Sentinel Lymph Node in Cervical Carcinoma and Factors Associated With Unilateral Detection.

text: OBJECTIVE The aims of this study were to assess locality of the sentinel lymph node (SLN) in cervical carcinoma and examine factors affecting bilateral SLN detection. METHODS This was a retrospective review of SLN data (anatomical location, count and laterality) in patients with early-stage cervical cancer (International Federation of Gynecology and Obstetrics stage IA1 with lymphovascular space invasion to stage IIA) using intraoperative gamma probe and blue dye. The preoperative single-photon emission computed tomography with computed tomography was used to detect laterality, number of the SLNs, and rare locations. Patients were treated between January 2005 to January 2015 at the West Kent Gynaecological Oncology Centre, Maidstone Hospital, Maidstone, United Kingdom. RESULTS A total of 132 women were investigated. The most common SLN location was the external iliac (38.6%) followed by obturator (25.3%) and internal iliac (23.6%) regions. A small percentage was identified in presacral (1.4%) and para-aortic regions (0.7%). Older age (P = 0.01) and an elevated body mass index (P = 0.03) were associated with decreased SLN count by preoperative single-photon emission computed tomography with computed tomography, and only age affected SLN count by gamma probe (P = 0.01). Initial surgery, large loop excision of the transformation zone, or cone biopsy of the cervix had no effect on SLN count. There was no difference observed in bilateral detection with respect to surgical approach (open: n = 48/laparoscopic: n = 84). However, older age was independently associated with a decrease in bilateral SLN detection (P = 0.003). In these patients who underwent unilateral full pelvic lymphadenectomy, all the nonsentinel nodes were negative. CONCLUSIONS The majority of SLNs were located in the external iliac, obturator, and internal iliac regions. Both older age and an elevated body mass index were associated with a reduced SLN count. Unilateral detection of SLN was independently associated with older age, which may be due to sclerosis in the lymphatic vessels or reduced perfusion in the pelvis in these women. If no SLN is detected on one side, the consensus is to perform a full pelvic lymphadenectomy on that side of the pelvis.


Community Health Workers: The Authors Reply.


Balloon Guide Catheter in Complex Anterior Circulation Mechanical Thrombectomy: Beyond Proximal Occlusion and Flow Reversal.


title: Enhanced detection of respiratory pathogens with nanotrap particles.

text: The Influenza virus is a leading cause of respiratory disease in the United States each year. While the virus normally causes mild to moderate disease, hospitalization and death can occur in many cases. There are several methodologies that are used for detection; however problems such as decreased sensitivity and high rates of false-negative results may arise. There is a crucial need for an effective sample preparation technology that concentrates viruses at low abundance while excluding resident analytes that may interfere with detection. Nanotrap particles are hydrogel particles that are coupled to chemical dye affinity baits that bind a broad range of proteins and virions. Within minutes (<30 minutes), Nanotrap particles concentrate low abundant proteins and viruses from clinically complex matrices. Nanotrap particles with reactive red baits concentrated numerous respiratory viruses including various strains and subtypes of Influenza virus, Coronavirus, and Respiratory Syncytial Virus from saliva, nasal fluid swab specimens, and nasal aspirates. Detection was enhanced more than 10-fold when coupled to plaque assays and qRT-PCR. Importantly, Nanotrap particle can efficiently capture and concentrate multiple viral pathogens during a coinfection scenario. These results collectively demonstrate that Nanotrap particles are an important tool that can easily be integrated into various detection methodologies.


title: The Effect of Inadequate Presample Blood Volume Withdrawal from Intravenous Catheter and Extension Sets on Measured Circulating L-Blood Lactate Concentration in Horses Receiving Lactated Ringer's Solution.

text: BACKGROUND Circulating l-lactate concentration is commonly measured in hospitalized horses by sampling from indwelling intravenous (IV) catheters. However, there are no published evidence-based recommendations to prevent contamination by lactated Ringer's solution (LRS). HYPOTHESIS Withdrawing 10 mL of blood from the LRS-containing extension set connected to the IV catheter before obtaining the sample for analysis should be adequate to obtain accurate measurement of blood lactate concentration (BLC). ANIMALS Thirty-three adult hospitalized horses receiving constant rate infusion of LRS. METHODS Immediately after disconnecting the LRS, 5 sequential 5 mL blood samples were obtained by aspiration from an extension set connected to an indwelling IV catheter, followed by 3 samples collected by direct venipuncture of the contralateral jugular vein. Samples were analyzed with 1 portable blood lactate analyzer. A linear mixed model was used to examine differences in lactate concentrations among samples collected from the catheter and by direct venipuncture. RESULTS After considering differences in age, breed, sex, and reason for hospitalization, BLCs were higher (P < .001) in the first and second 5 mL samples collected through the extension set/catheter than in all other extension set/catheter samples or the direct venipuncture samples. The largest difference observed between the third and subsequent catheter or venipuncture samples was 0.34 mmol/L with an upper 95% CI of 1.12 mmol/L. CONCLUSIONS AND CLINICAL IMPORTANCE Withdrawing 15 mL of blood from a LRS-containing extension set connected to an IV catheter (5.9 mL total volume capacity) before obtaining the sample for blood lactate analysis is suggested to optimize accuracy of BLC measurements.


title: Prevention of Postoperative Cerebrospinal Fluid Leaks After Translabyrinthine Tumor Resection With Resorbable Mesh Cranioplasty.

text: OBJECTIVES To evaluate the effectiveness of resorbable mesh cranioplasty at reducing postoperative cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine tumor resection. STUDY DESIGN Case series with chart review. SETTING Tertiary academic referral center. PATIENTS Fifty-three consecutive cases using a resorbable mesh cranioplasty after translabyrinthine tumor resection were reviewed. INTERVENTION Temporal bone defects were repaired with a dural substitute, layered fat graft, and a resorbable mesh plate secured with screws. MAIN OUTCOME MEASURES Primary outcome measures included the incidence of postoperative CSF wound leak or rhinorrhea, pseudomeningocele formation, and surgical site infection. RESULTS Fifty-three cases (average age, 54.0 yr; range, 19.3-75.1 yr) were analyzed. The average body mass index was 30.8 kg/m2 (range, 17.9-48.3 kg/m2), and the average tumor size was 18.8 mm (range, 8-38 mm). One patient (1.9%) experienced CSF rhinorrhea on postoperative Day 16, which resolved after transmastoid middle ear and eustachian tube packing. One patient (1.9%) experienced a surgical site infection requiring surgical debridement and mesh removal 4 months after surgery. Compared with 1,441 prior translabyrinthine surgeries analyzed from our institution using a traditional fat graft closure without mesh, the rate of postoperative CSF leak was significantly less using the resorbable mesh cranioplasty technique (p = 0.0483). CONCLUSION Resorbable mesh cranioplasty is a safe and effective method to reduce postoperative CSF leak and pseudomeningocele formation after translabyrinthine craniotomy for tumor excision.


title: Clinical Practice Guidelines for Pancreatic Cancer 2016 From the Japan Pancreas Society: A Synopsis.

text: OBJECTIVES Clinical Practice Guidelines for Pancreatic Cancer based on Evidence-Based Medicine 2006 were first published by the Japan Pancreas Society, and they were revised to Clinical Practice Guidelines for Pancreatic Cancer 2009 in July 2009 and were further revised to Clinical Practice Guidelines for Pancreatic Cancer 2013 in October 2013. These guidelines were established according to evidence-based medicine. In October 2016, the Clinical Practice Guidelines for Pancreatic Cancer were newly revised in Japanese. METHODS In the revised version, we introduced the concepts of GRADE - grading recommendations assessment, development, and evaluation approach for better understanding of the current guidelines. RESULTS The guidelines show algorithms for the diagnosis, treatment, and chemotherapy of pancreatic cancer and address 7 subjects: diagnosis, surgical therapy, adjuvant therapy, radiation therapy, chemotherapy, stent therapy, and palliative medicine. They include 51 clinical questions and 76 statements. There are statements corresponding to clinical questions, evidence levels, recommended strengths, and agreement rates. CONCLUSIONS These guidelines represent the most standard clinical and practical management at this time in Japan. This is the English synopsis of the Clinical Practice Guidelines for Pancreatic Cancer 2016 in Japanese, which aims to disseminate the Japanese guidelines worldwide for the introduction of Japanese clinical management of these diseases.


docid: jmwjxpah

title: Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port video-assisted thoracoscopic surgery.

text: BACKGROUND The current trend in thoracoscopic surgery is to use fewer ports to decrease postoperative pain, chest wall paresthesia, and duration of hospital stay. In this study we compared the results of our current experience with single-incision thoracoscopic surgery (SITS) and conventional three-port video-assisted thoracoscopic surgery (3P-VATS). METHODS From October 2011 to August 2012, 37 consecutive patients underwent thoracoscopic surgery. This is a non-randomized retrospective study. Among these patients, 19 (SITS group) were treated using single port method (SITS), whereas 18 (3P-VATS group) were treated using the conventional three-port methods (3P-VATS). The surgical duration, number of resected lesions, duration of chest drainage, duration of hospital stay, inpatient pain scores, and patient satisfaction scores were compared between both groups. RESULTS The mean age at surgery, indication, gender, body mass index, and the side involved were similar in both groups. The procedures performed in the SITS group were similar to those performed in the 3P-VATS group. The mean operative time was longer in the SITS group compared with the 3P-VATS group. Duration of postoperative drainage days and hospital stay was shorter in the SITS group compared with the 3P-VATS group, although these differences were not statistically significant. Pain scores on postoperative days 0,1, and 3 were significantly higher in patients who underwent 3P-VATS compared with those who underwent SITS (p = 0.012, 0.039, and 0.037, respectively). The SITS group reported higher patient satisfaction scores than the 3P-VATS group, patients in the 3P-VATS group tended to receive higher total doses of analgesics (NSAIDs) after surgery compared with those in the SITS group, although these differences were not statistically significant. CONCLUSIONS Our experience demonstrated that SITS decreased postoperative pain and resulted in higher patient satisfaction compared with the conventional three-port VATS. However, a prospective, randomized study is needed to confirm our preliminary findings. To overcome the technological limitations of SITS, the development of new instruments is needed.


title: Negligence, trauma and nervous shock.

text: Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers whether nurses who have suffered psychological trauma because of the negligent handling of the COVID-19 outbreak can claim compensation.


title: Vibration signals of snoring as a simple severity predictor for obstructive sleep apnea.

text: BACKGROUND AND AIM Polysomnography (PSG), which involves simultaneous monitoring of various physiological monitors, is the current comprehensive tool for diagnosing obstructive sleep apnea (OSA). We aimed at validating vibrating signals of snoring as a single physiological parameter for screening and evaluating severity of OSA. METHODS Totally, 111 subjects from the sleep center of a tertiary referral center were categorized into four groups according to the apnea hypopnea index (AHI) obtained from PSG: simple snoring group (5 > AHI, healthy subjects, n = 11), mild OSA group (5 ≤ AHI < 15, n = 11), moderate OSA group (15 ≤ AHI < 30, n = 30) and severe OSA group (AHI ≥ 30, n = 59). Anthropometric parameters and sleep efficiency of all subjects were compared. Frequencies of amplitude changes of vibrating signals on anterior neck during sleep were analyzed to acquire a snoring burst index (SBI) using a novel algorithm. Data were compared with AHI and index of arterial oxygen saturation (Δ Index). RESULTS There were no significant differences in age and sleep efficiency among all groups. Bland-Altman analysis showed better agreement between SBI and AHI (r = 0.906, P < 0.001) than Δ Index and AHI (r = 0.859, P < 0.001). Additionally, receiver operating characteristic (ROC) showed substantially stronger sensitivity and specificity of SBI in distinguishing between patients with moderate and severe OSA compared with Δ Index (sensitivity: 81.4% vs 66.4%; specificity: 96.7% vs 86.7%, for SBI and Δ Index, respectively). CONCLUSION SBI may serve as a portable tool for screening patients and assessing OSA severity in a non-hospital setting.


title: Mucoepidermoid Carcinoma of the Tracheobronchial Tree.

text: Primary salivary type lung cancers are extremely rare intrathoracic malignancies. Mucoepidermoid tumor is one of the salivary gland tumors that originates from submucosal glands of the tracheobronchial tree. These are very slow-growing low-grade malignant tumors. Surgery is the mainstay of treatment and rarely requires adjuvant therapy. In this case report we describe a 65-year-old woman who presented with a solitary cough yet on further investigation was found to have a mucoepidermoid tumor originating from the hilum of the left lung.


title: [Pet ownership in inmunocompromised patients: update and veterinary and medical considerations].

text: Pet ownership offers undisputed benefits to immunocompromised (IC) patients, however, it poses the risk for potentially serious zoonoses. Mechanisms of transmission and manifestation of major zoonotic infections in dogs and cats that may affect IC patients are described. We also provide updated international information and local data. Recommendations are given to choose and care for pets ensuring safe and responsible ownership. This will help to prevent, detect and treat infections timely.


title: Correction: Communicable Diseases Prioritized According to Their Public Health Relevance, Sweden, 2013.

text: [This corrects the article DOI: 10.1371/journal.pone.0136353.].


docid: khzzgqoc

title: An inclusive approach to developing an undergraduate syllabus.


title: Coronavirus disease 2019 (COVID-19): two case reports from a family cluster.

text: The coronavirus disease 2019 (COVID-19) is a new infectious disease, firstly appeared in Wuhan city and has rapidly spread to 114 countries outside China, which is receiving worldwide attention. As two important means of examination, computed tomography (CT) and real-time reverse transcription polymerase chain reaction (RT-PCR) have always been controversial in the clinical diagnosis of COVID-19 pneumonia. Here, we report a family cluster case of a father and a son diagnosed as COVID-19 at our hospital, and described the clinical manifestations, laboratory results, CT changes, diagnosis and treatment strategy of these two patients. Focus on the value of these two methods in the diagnosis and treatment of diseases, as well as their respective deficiencies. For patient 1 (father), the efficacy of RT-PCR is not satisfactory either in terms of diagnosis or follow-up, which may cause misdiagnosis and delay treatment. For patient 2 (son), the clinical symptoms were not obvious, but CT imaging clearly displayed dynamic changes of the lung lesions. Meanwhile, the two patients respectively underwent five chest CT examinations during their hospitalization and discharge follow-up, showing the potential harm of radiation. Therefore, in clinical work, doctors should make full use of the advantages of CT and RT-PCR, and take other measures to make up for their disadvantages.


title: Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.

text: Background Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. Methods Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15 years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90 days was prospectively measured and used to estimate procedure and inpatient care costs (US$ reference year 2014). Results There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15 (IQR 12-19). The median (IQR) disability-weighted utility score at 90 days was 0.65 (0.00-0.91) in the alteplase-only versus 0.91 (0.65-1.00) in the endovascular group (p = 0.005). Modeled life expectancy was greater in the endovascular versus alteplase-only group (median 15.6 versus 11.2 years, p = 0.02). The endovascular thrombectomy group had fewer simulated DALYs lost over 15 years [median (IQR) 5.5 (3.2-8.7) versus 8.9 (4.7-13.8), p = 0.02] and more QALY gained [median (IQR) 9.3 (4.2-13.1) versus 4.9 (0.3-8.5), p = 0.03]. Endovascular patients spent less time in hospital [median (IQR) 5 (3-11) days versus 8 (5-14) days, p = 0.04] and rehabilitation [median (IQR) 0 (0-28) versus 27 (0-65) days, p = 0.03]. The estimated inpatient costs in the first 90 days were less in the thrombectomy group (average US$15,689 versus US$30,569, p = 0.008) offsetting the costs of interhospital transport and the thrombectomy procedure (average US$10,515). The average saving per patient treated with thrombectomy was US$4,365. Conclusion Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90 days. There was evidence of clinically relevant improvement in long-term survival and quality of life. Clinical Trial Registration http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).


title: Treatment of posterior circulation non-saccular aneurysms with flow diverters: a single-center experience and review of 56 patients.

text: BACKGROUND AND PURPOSE Non-saccular aneurysms of the posterior fossa are an uncommon pathology with no clear treatment strategy. The use of flow-diverting stents (FDS) has had mixed results. We sought to evaluate our experience of FDS for the treatment of this pathology. METHODS We retrospectively reviewed our database of prospectively collected information for all patients treated only with flow diversion for an unruptured non-saccular aneurysm of the posterior circulation between February 2009 and April 2016. The aneurysms were classified as dolichoectasia, fusiform or transitional, and imaging characteristics including maximal diameter, disease vessel segment, MRI features (intra-aneurysmal thrombus, T1 hyperintensity in the aneurysmal wall, infarctions in the territory of the posterior circulation, and mass effect) were recorded alongside clinical and follow-up data. RESULTS We identified 56 patients (45 men) with 58 aneurysms. The average age of the patients was 63.5 years. Twenty-two patients were symptomatic from the aneurysms at presentation. The majority of the lesions were vertebrobasilar in location (44.8%) with isolated vertebral lesions representing 29.3% of aneurysms. Transitional aneurysms were the most common (48.2%). The mean maximal diameter of the aneurysms was 11 mm. Angiographic exclusion of the aneurysms was seen in 57.4% of aneurysms with follow-up (n=47). During the follow-up period nine patients died. CONCLUSIONS Treatment of non-saccular aneurysms of the posterior fossa is technically possible. Early treatment, particularly of the fusiform and transitional subtypes, is recognized, as is treatment prior to the development of symptoms. A 'watch and wait' strategy with regular imaging follow-up could be employed for asymptomatic dolichoectasia.


title: Prospective acute ischemic stroke outcomes after endovascular therapy: a real-world experience.

text: OBJECTIVE To report results of endovascular therapy for acute ischemic stroke (AIS) in patients who were not candidates for intravenous thrombolysis (IVT) or in whom IVT failed. METHODS Prospectively collected data for patients treated between January 2006 and June 2009 were analyzed retrospectively. After careful patient and therapy selection, 213 AIS patients with a mean NIHSS score of 14.2 at presentation underwent intervention. End points analyzed were Thrombolysis in Myocardial Infarction (TIMI) 2/3 reperfusion, symptomatic intracranial hemorrhage (SICH) rates, and 90-day outcomes (modified Rankin Scale [mRS] and mortality). Multivariate binary logistic regression analysis was used to assess independent predictors of end points. RESULTS Of 189 patients with anterior circulation occlusions, 135 were treated within 0-8 hours, 33 were treated after 8 or more hours, and 21 were treated after wake-up stroke (WUS). Among 24 patients treated with posterior circulation occlusions, 4 had WUS. After treatment, 72.3% patients had TIMI 2/3 reperfusion; SICH rate was 8.7%; at 90 days, 36.6% recovered to mRS 2 or less. SICH rate was higher in patients with anterior circulation strokes who received treatment 8 or more hours after symptom onset (odds ratio [OR] = 3.8) and patients with WUS (OR = 4.9). In patients treated within 8 hours of onset of symptoms of anterior circulation stroke, SICH rate was only 6.7%. There was no difference in outcomes in patients with WUS compared with patients treated less than 8 hours after stroke onset. CONCLUSIONS This is the first and largest prospective study to the authors' knowledge that shows endovascular therapy for AIS patients in a real-world setting. High recanalization rates with low SICH rates were achieved using careful patient and therapy selection.


title: Why is COVID-19 so mild in children?

text: There is an urgent need to understand why the course of the coronavirus that started in late 2019 (COVID-19) is affecting different groups of individuals with varying severity during the ongoing global pandemic. Greater knowledge of the disease, which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), will help us to prioritise our limited health resources. Because the virus is new, and no vaccine is yet available, everyone is naïve and susceptible to being infected with SARS-CoV2. The virus will continue to spread until an effective vaccine exists or sufficient members of our global population have been infected to establish herd immunity. At the moment, the best way to minimize loss of life and severe cases requiring intensive care is to try and shelter vulnerable groups of individuals and slow down the spread of the virus.


Severe Covid-19.


title: Single-port versus conventional three-port laparoscopic totally extraperitoneal inguinal hernia repair: a randomized controlled trial.

text: BACKGROUND Single-port laparoscopic surgery (SPLS) has been introduced for totally extraperitoneal (TEP) inguinal hernia repair. Clinically, however, the benefits of single-port TEP (SP TEP) are unclear. This study aimed to compare short-term surgical outcomes between SP TEP and conventional laparoscopic TEP(CL TEP) inguinal hernia repair. METHODS Between January 2013 and February 2015, 99 men with primary unilateral inguinal hernia were randomized to the single-port or conventional 3-port TEP procedures. The primary end point was postoperative pain. Secondary end points were complications, postoperative hospital stay, days to return to daily normal activities, cosmesis, and quality of life (QOL). RESULTS We randomized 50 patients to SP TEP and 49 to CL TEP repair. The SP TEP group patients had significantly lower pain scores (visual analog scale) 7 days postoperation (p = 0.017). However, there were no significant differences between the two groups in postoperative pain scores 24 h (p = 0.44) and 4 weeks (p = 0.677) after operation and analgesic requirements on the operation day (p = 0.303) and 7 days after the operation (p = 0.204). Operation time, postoperative hospital stay, and complications were comparable between the two groups. The days to return to daily normal activities, QOL, and cosmetic satisfaction were not different between the two groups. CONCLUSION The outcomes of SP TEP hernia repair for operation time and morbidities were comparable to CL TEP, and postoperative pain was lower at 7 days than in CL TEP hernia repair. The SP TEP technique can be recommended as an alternative treatment for inguinal hernia repair in experienced hands.


title: Caudocranial scan direction and patient-specific injection protocols optimize ECG-gated and non-gated thoracic CTA.

text: OBJECTIVES Caudocranial scan direction and contrast injection timing based on measured patient vessel dynamics can significantly improve artery opacification and reduce contrast dose in the assessment of acute aortic syndrome using gated and non-gated thoracic CTA. This study aimed to investigate enhancement of the thoracic aorta using caudocranial scan direction and a patient-specific contrast regimen. METHODS Electrocardiogram-gated (n = 120) and non-gated (n = 200) thoracic computed tomography angiography was performed on patients with nontraumatic acute aortic syndrome. Patients were assigned to one of 2 acquisition/contrast regimens, namely, regimen A, craniocaudal scan direction with 120 mL contrast, and regimen B, caudocranial scan direction using a patient-specific contrast formula. Opacity of 9 arterial and venous segments was measured, arteriovenous contrast ratio calculated, and values compared using Mann-Whitney U statistics. Receiver operating characteristic analyses and visual grading characteristic assessed diagnostic efficacy and clinical image quality. Interobserver variations were investigated using κ methods. RESULTS Regimen B when compared to A, for both scanning/contrast techniques, demonstrated higher opacification in the aorta (P < 0.01) and lower opacification in the venous system (P < 0.0001). For protocol B, arteriovenous contrast ratio was significantly increased (P < 0.0001) and mean contrast volume reduced (P < 0.05) during gated [94 (10 mL)] and non-gated [78 (5 mL)] thoracic computed tomography angiography compared to A. Receiver operating characteristic analysis Az scores and interobserver agreement were significantly higher with regimen B than A (P < 0.05). CONCLUSIONS Caudocranial scan direction and injection timing based on patient-specific vessel dynamics can optimize artery opacification and diagnostic efficacy while reducing contrast volumes.


title: An improved estimation of daily clear-sky biologically EER from broadband global solar radiation.

text: To establish a relation between biologically effective erythemal radiation (EER) and global solar radiation, the hourly and daily clear-sky broadband (310-2,800 nm) global solar radiation (G) and spectral ultraviolet radiation incident on a horizontal surface at Esfahan, Iran (32 degrees 37'N, 51 degrees 40'E) were measured during the period 2001-2005. Good correlations at statistically significant levels between the daily values of EER and the daily G were found. The seasonal variability of EER/G is also discussed and the correction factors are determined for inclusion of vertical column ozone and solar zenith angle (SZA) cycles. The comparison of the estimated daily EER against the independent observed EER revealed that under clear sky conditions the estimations are accurate to 10% or better over SZA of 10-60 degrees and column ozone of 250-350 Dobson. The comparison of the results with the similar works that have used shorter period of experimental data showed more accurate estimates. The deduced relations could be used to a rough estimate of the daily EER from G in arid climate regions, where there is no measured UV radiation or there are instrumental and other difficulties encountered in measuring UV radiation.


title: Transthoracic Extracorporeal Gastric Conduit Preparation for Minimally Invasive Ivor-Lewis Esophagectomy.

text: OBJECTIVE During totally minimally invasive esophagectomy (MIE), the gastric conduit is typically constructed via laparoscopy. Trauma from laparoscopic instruments, inability to palpate the gastroepiploic arcade, and challenges in optimal positioning of the stomach for intra-abdominal stapling have led to the widespread use of laparotomy as part of hybrid MIE procedures. Our objective was to evaluate the safety of transthoracic extracorporeal gastric conduit preparation. We hypothesize that this alternative technique is equivalent in safety to the laparoscopic approach. METHODS This is a retrospective comparison of laparoscopic and transthoracic extracorporeal gastric conduit preparation with regard to anastomotic and respiratory outcomes. RESULTS During a 3-year period, 30 patients underwent MIE with a right intrathoracic anastomosis (extracorporeal conduit, 15; laparoscopic conduit, 15). Mean age (58.6 vs 67 years, P = 0.59), tumor location (gastroesophageal junction vs middle and lower esophageal, P = 0.27), and histology (adenocarcinoma vs other 26.7%, P = 0.68) were similar between groups. Anastomotic technique and operating surgeon were the same for all patients. Patients in the laparoscopic gastric conduit group were more likely to have undergone induction chemoradiotherapy (40% vs 80%, P = 0.030). There was no significant difference between groups with respect to anastomotic complications, including anastomotic leak and anastomotic stricture (20% vs 13.3%, P = 0.70). Transthoracic gastric conduit preparation was not associated with increased respiratory complications (8% vs 12%, P = 0.09). CONCLUSIONS Transthoracic gastric conduit preparation is a simple, minimally invasive alternative laparotomy for gastric conduit preparation during MIE. No additional incision is required. The technique may help surgeons overcome shortcomings of the laparoscopic approach without impacting perioperative risk.


title: Clinical Research in Vulnerable Populations: Variability and Focus of Institutional Review Boards' Responses.

text: BACKGROUND Children and patients with cognitive deficits may find it difficult to understand the implication of research. In the European Union (EU), clinical studies outside the EU directives concerning medicinal products or medical devices, i.e., "miscellaneous clinical studies", have no legally mandated timelines for institutional review boards' (IRB) decisions. GOAL To evaluate the review process of IRBs for two different "miscellaneous" multicenter clinical research protocols involving vulnerable subjects (children and adult stroke patients). METHODS Descriptive and comparative statistics. Protocol 1 is a prospective, multicenter, cross-sectional screening study of a symptomatic pediatric population at risk for Fabry disease involving genetic testing (NCT02152189). Protocol 2 is a prospective, multicenter, randomized, controlled, open-label, blinded endpoint post-market study to evaluate the effectiveness of stent retrievers (NCT02135926). After having obtained positive initial IRB votes at the main study site, both protocols were subsequently submitted to the remaining IRBs. RESULTS Protocol 1 was submitted to 19 IRBs. No IRB objected to the study. Median time-to-final vote was 34 (IQR 10-65; range 0 to 130) days. Two IRBs accepted the coordinating center's IRB votes without re-evaluation. Changes to the informed consent documents were asked by 7/19 IRBs, amendments to the protocol by 2. Protocol 2 was submitted to 16 IRBs. Fifteen decisions were made. No IRB objected to the study. Median time-to final vote was 59 (IQR 10 to 65; range 0 to 128) days, which was not statistically significantly different compared with protocol 1 (Wilcoxon test). Two IRBs accepted a previous IRB decision and did not conduct an independent review. Eight/16 IRBs required changes to the informed consent documents; two IRBs recommended an amendment of the protocol. CONCLUSION Both clinical research protocols involving vulnerable populations were well accepted. IRB workflows and decision times varied substantially. Some IRBs accepted a previous IRB decision without the necessity of another reevaluation process. Requested changes were focused on the informed consent documents. A more standardized approach across jurisdictions is desirable.


title: [Nursing Education Strategies During the COVID-19 Epidemic].

text: The ongoing new coronavirus disease (COVID-19) pandemic, which arose at the end of 2019, poses a severe challenge to world public health systems. Frontline medical staffs bear a great burden to provide health care services. The Taiwan government has taken rapid and decisive actions to reduce the risk of community transmission and campus cluster infection. Nursing education includes both classroom teaching and clinical practicum components. In preparing for their practicum, students must learn not only fundamental nursing care knowledge but also basic knowledge on emerging infectious diseases. All schools nationwide have complied with the Ministry of Education order to postpone the opening of the fall semester in response to the rapid evolution of the COVID-19 pandemic. Campus epidemic prevention measures were implemented through student counseling networks, and flexible teaching strategies, including online teaching and distance teaching, were implemented to protect the learning rights of students. This paper explores the strategies implemented in response to emerging infectious diseases in nursing education based on the core values of professional nursing. Examining the precautions taken at campuses and teaching strategies adopted in response to the COVID 19 pandemic may provide valuable insights that may be applied to the future development of nursing education.


title: Effects of sedatives and opioids on trigger and cycling asynchronies throughout mechanical ventilation: an observational study in a large dataset from critically ill patients.

text: BACKGROUND In critically ill patients, poor patient-ventilator interaction may worsen outcomes. Although sedatives are often administered to improve comfort and facilitate ventilation, they can be deleterious. Whether opioids improve asynchronies with fewer negative effects is unknown. We hypothesized that opioids alone would improve asynchronies and result in more wakeful patients than sedatives alone or sedatives-plus-opioids. METHODS This prospective multicenter observational trial enrolled critically ill adults mechanically ventilated (MV) > 24 h. We compared asynchronies and sedation depth in patients receiving sedatives, opioids, or both. We recorded sedation level and doses of sedatives and opioids. BetterCare™ software continuously registered ineffective inspiratory efforts during expiration (IEE), double cycling (DC), and asynchrony index (AI) as well as MV modes. All variables were averaged per day. We used linear mixed-effects models to analyze the relationships between asynchronies, sedation level, and sedative and opioid doses. RESULTS In 79 patients, 14,166,469 breaths were recorded during 579 days of MV. Overall asynchronies were not significantly different in days classified as sedatives-only, opioids-only, and sedatives-plus-opioids and were more prevalent in days classified as no-drugs than in those classified as sedatives-plus-opioids, irrespective of the ventilatory mode. Sedative doses were associated with sedation level and with reduced DC (p < 0.0001) in sedatives-only days. However, on days classified as sedatives-plus-opioids, higher sedative doses and deeper sedation had more IEE (p < 0.0001) and higher AI (p = 0.0004). Opioid dosing was inversely associated with overall asynchronies (p < 0.001) without worsening sedation levels into morbid ranges. CONCLUSIONS Sedatives, whether alone or combined with opioids, do not result in better patient-ventilator interaction than opioids alone, in any ventilatory mode. Higher opioid dose (alone or with sedatives) was associated with lower AI without depressing consciousness. Higher sedative doses administered alone were associated only with less DC. TRIAL REGISTRATION ClinicalTrial.gov, NCT03451461.


Coronavirus blood-clot mystery intensifies.


Covid-19 makes the future of UK clinical research uncertain.