title: Piezosurgery for the Lingual Split Technique in Lingual Positioned Impacted Mandibular Third Molar Removal: A Retrospective Study.

text: The aim of this study was to evaluate the effect and safety of lingual split technique using piezosurgery for the extraction of lingual positioned impacted mandibular 3rd molars with the goal of proposing a more minimally invasive choice for this common surgery.Eighty-nine consecutive patients with 110 lingual positioned impacted mandibular 3rd molars requiring extraction were performed the lingual split technique using piezosurgery. One sagittal osteotomy line and 2 transverse osteotomy line were designed for lingual and occlusal bone removal. The success rate, operative time, postoperative outcome, and major complications (including nerve injury, mandible fracture, severe hematoma or edema, and severe pyogenic infection) were documented and analyzed.All impacted mandibular 3rd molars were successfully removed (110/110). The average time of operation was 14.6 minutes (ranged from 7 to 28 minutes). One hundred and seven extraction sites (97.3%) were primary healing. Pain, mouth opening, swelling, and PoSSe scores on postoperative 7-day were 0.34 ± 0.63, 3.88 ± 0.66(cm), 2.4 ± 0.2(cm), and 23.7 ± 5.9, respectively. There were 6 cases (5.5%) had lingual nerve disturbance and 3 cases (2.7%) developed inferior alveolar nerve impairment, and achieved full recovery within 2 months by neurotrophic drug treatment.Our study suggested piezosurgery for lingual split technique provided an effective way for the extraction of lingual positioned and deeply impacted mandibular 3rd molar.


Anesthesia Case of the Month.


title: Initial experience using the Penumbra coil 400: comparison of aneurysm packing, cost effectiveness, and coil efficiency.

text: BACKGROUND/OBJECTIVE This was a retrospective single operator experience of aneurysm coiling at the Ochsner Clinic, comparing the Penumbra coil 400 with the other most commonly used coil types, Orbit and Galaxy. METHODS 40 aneurysms treated exclusively with Orbit or Galaxy coils and 18 aneurysms treated only with Penumbra coils from 2010 to February 2012 were compared. Measurements included packing density, number of coils per unit aneurysm volume, and total coil length per unit aneurysm volume. RESULTS Mean packing density of 33.7% using Penumbra coils was significantly greater than 24.4% for Orbit/Galaxy coils. The number of coils per aneurysm volume of 0.026 coils/mm(3) for the Penumbra coil was significantly lower than 0.114 coils/mm(3) for the Orbit/Galaxy coils. Aneurysm occlusion rates were similar in both groups. CONCLUSIONS Compared with the Orbit/Galaxy coils, our analysis suggests that the Penumbra coil is more efficient and cost effective in the treatment of intracranial aneurysms.


title: Culture-negative periprosthetic joint infections.

text: Culture-negative periprosthetic joint infections (CN-PJI) pose a significant challenge in terms of diagnosis and management. The reported incidence of CN-PJI is reported to be between 7% and 15%.Fungi and mycobacterium are thought to be responsible for over 85% of such cases with more fastidious bacteria accounting for the rest.With the advent of polymerase chain reaction, mass spectrometry and next generation sequencing, identifying the causative organism(s) may become easier but such techniques are not readily available and are very costly.There are a number of more straightforward and relatively low-cost methods to help surgeons maximize the chances of diagnosing a PJI and identify the organisms responsible.This review article summarizes the main diagnostic tests currently available as well as providing a simple diagnostic clinical algorithm for CN-PJI. Cite this article: EFORT Open Rev 2019;4:585-594. DOI: 10.1302/2058-5241.4.180067.


title: Expression of OX40 ligand in microglia activated by IFN-gamma sustains a protective CD4+ T-cell response in vitro.

text: T-cell-dependent immunity in the central nervous system (CNS) is beneficial for neuroprotection, neurogenesis and even behavior. As a highly specialized site, the CNS is speculated to possess the means to maintain T-cell immune responses through its own resident cells. Therefore, we investigated whether microglia, the most potent antigen-presenting cells residing in the CNS, could sustain T-cell responses in vitro. We showed that interferon-gamma (IFN-gamma)-activated microglia (MG(IFN-gamma)) inducibly expressed an important immune co-stimulatory molecule, OX40 ligand (OX40L). Co-culture of activated CD4(+) T cells with MG(IFN-gamma) significantly increased T-cell proliferation and decreased apoptosis, and these effects were markedly inhibited by addition of a neutralizing anti-OX40L monoclonal antibody. In addition, ligation of OX40L in MG(IFN-gamma) enhanced their production of insulin-like growth factor I (IGF-I). These results suggest that the expression of OX40L in microglia provides a molecular basis for the maintenance of T-cell survival, expansion of T cells and increased secretion of remedial growth factor from MG(IFN-gamma), which may contribute to the protective effect in the CNS.


Is a "Cytokine Storm" Relevant to COVID-19?


title: Omalizumab Updosing in Chronic Spontaneous Urticaria: an Overview of Real-World Evidence.

text: Chronic spontaneous urticaria (CSU) is defined as the spontaneous development of itchy hives and/or angioedema due to known or unknown causes that last for at least 6 weeks. At any given time, CSU is believed to affect 0.5-1% of the global population. Omalizumab (a recombinant, humanized anti-immunoglobulin-E antibody) is the only approved treatment for antihistamine refractory CSU. However, ~ 30% of patients remain symptomatic at licensed doses of omalizumab 150 mg and 300 mg, even after a treatment period of over 6 months. In the recent years, there have been several studies on updosing of the drug, suggesting that the individualized approach for urticaria treatment with omalizumab is useful. In this article, we provide an overview of these studies and the real-world data on omalizumab updosing as it became necessary to obtain complete CSU symptom control in a proportion of patients. Published observational studies (from June 2003 to October 2019) on the updosing of omalizumab in CSU were identified using PubMed and Ovid databases. Reports mainly show that updosing/dose adjustment evaluated with the assessment of disease activity (Urticaria Activity Score) and control (Urticaria Control Test) achieves better clinical response to omalizumab with a good safety profile in a pool of patients with CSU. These real-world data will provide an overview of updosing of omalizumab in CSU and aid in setting informed clinical practice treatment expectations.


title: Long-Term Quality of Life Following Endoscopic Therapy Compared to Esophagectomy for Neoplastic Barrett's Esophagus.

text: INTRODUCTION Endoscopic therapy (ET) and esophagectomy result in similar survival for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC), but the long-term quality of life (QOL) has not been compared. AIMS We aimed to compare long-term QOL between patients who had undergone ET versus esophagectomy. METHODS Patients were included if they underwent ET or esophagectomy at the University of Michigan since 2000 for the treatment of HGD or T1a EAC. Two validated survey QOL questionnaires were mailed to the patients. We compared QOL between and within groups (ET = 91, esophagectomy = 62), adjusting for covariates. RESULTS The median time since initial intervention was 6.8 years. Compared to esophagectomy, ET patients tended to be older, had a lower prevalence of EAC, and had a shorter duration since therapy. ET patients had worse adjusted physical and role functioning than esophagectomy patients. However, the adjusted odds ratio (OR) of having symptoms was significantly less with ET for diarrhea (0.287; 95% confidence interval [CI] = 0.114, 0.724), trouble eating (0.207; 0.0766, 0.562), choking (0.325; 0.119, 0.888), coughing (0.291; 0.114, 0.746), and speech difficulty (0.306; 0.0959, 0.978). Amongst the ET patients, we found that the number of therapy sessions and need for dilation were associated with worse outcomes. DISCUSSION Multiple measures of symptom status were better with ET compared to esophagectomy following treatment of BE with HGD or T1a EAC. We observed worse long-term physical and role functioning in ET patients which could reflect unmeasured baseline functional status rather than a causal effect of ET.


docid: qjcrvkkx

title: Comparative Effectiveness and Safety of Radiofrequency Ablation Versus Argon Plasma Coagulation for Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis.

text: BACKGROUND AND AIMS Although argon plasma coagulation (APC) is the current standard endoscopic treatment for gastric antral vascular ectasia (GAVE), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study was to perform a systematic review and meta-analysis to evaluate the comparative effectiveness and safety of RFA and APC in the treatment of GAVE. MATERIALS AND METHODS Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases along with major gastroenterology annual meetings were performed through March 2017. Measured outcomes for comparative effectiveness and safety including improvement in hemoglobin levels, transfusion dependence, number of treatment sessions, complications, follow-up, and author-reported endoscopic success were compared among RFA and APC studies. RESULTS In total, 24 studies (n=508) involving APC and 9 studies (n=104) on RFA were included. Mean age of patients included was comparable in both groups (65.33±7.80 y for APC vs. 66.96±6.23 y for RFA; P=0.98). Pooled mean follow-up was significantly longer for APC compared with RFA (19.52±13.11 vs. 7.43±3.72 mo; P<0.001). In total, 47% of RFA patients were refractory to previous treatment with APC. RFA required fewer mean treatment sessions compared with APC (2.10 vs. 3.39, respectively; P<0.001). RFA resulted in fewer and less severe complications as compared with APC (1.92% vs. 5.12%, respectively; P<0.001). Although the reported endoscopic success was better with RFA compared with APC (97% vs. 66%; P<0.001), the posttreatment pooled hemoglobin increase and reduction in transfusion dependence was higher for APC compared with RFA [weighted mean difference 3.10 g/dL (95% confidence interval, 2.92-3.28) vs. 1.95 g/dL (95% confidence interval, 1.62-2.26); P<0.001; and 88% vs. 66%; P<0.001, for APC and RFA, respectively]. CONCLUSIONS There is limited long-term data on RFA for GAVE; however, available evidence suggests RFA has a comparable efficacy and tolerability compared with APC. In addition, RFA seems to be effective for APC-refractory GAVE patients. Future controlled trials are needed to directly compare treatment efficacy, long-term durability, safety, and cost-effectiveness between these interventions.


title: Ascending Aortic Repair and Simultaneous Femoro-Femoral Crossover Bypass for Acute DeBakey Type I Dissection with Leg Ischemia.

text: A 61-year-old man was admitted with acute Type A aortic dissection DeBakey Type I with clinical and radiographic signs of left iliac artery occlusion and leg ischemia. He underwent simultaneous ascending aortic repair and surgical femoro-femoral crossover bypass with immediate restoration of leg perfusion as assessed with peripheral near-infrared spectroscopy. The postoperative course was uneventful. Follow-up computed tomography demonstrated occlusion of the left external iliac artery and patent crossover bypass.


docid: feofrgug

title: Single-port laparoscopic resection for diverticular disease: experiences with more than 300 consecutive patients.

text: BACKGROUND Single-port laparoscopic surgery (SILS) is a new minimally invasive technique, which has been developed to minimize the surgical access trauma. For colorectal resection, the access trauma can be limited to the one incision, which is needed for specimen extraction anyways, but dissection might be more demanding than in multiport laparoscopic surgery. The aim of this study was to evaluate the usefulness of SILS for the treatment of diverticular disease of the sigmoid colon. METHODS Between July 2009 and December 2013, a total of 329 consecutive patients with intended SILS sigmoid colectomy for complicated or frequently recurring diverticulitis were studied. Clinical data were collected in a prospective database. Telephone follow-ups were performed to evaluate long-term morbidity and quality of life. RESULTS Of the 329 patients (139 male) with intended SILS sigmoid colectomy, 309 were successfully operated on in SILS technique, while 20 (6.1%) were converted to open surgery. The mean duration of surgery was 153.5 (65-434) min. Total morbidity rate was 18.3%. Anastomotic leakage was the most serious complication occurring in 13 patients (leak rate 4%) with one consecutive death (mortality rate 0.3%). Quality of life had significantly improved 6 months after surgery in comparison with the preoperative value. At a mean follow-up of 18.6 months, 16 patients (4.9%) had incisional hernia and one patient had recurrent diverticulitis. CONCLUSION In spite of almost 5% incisional hernia 6 months after surgery, single-incision sigmoid colectomy for diverticulitis is feasible and save and is therefore an alternative to multiport laparoscopic surgery. Further trials are necessary to evaluate its benefits over multiport laparoscopic surgery.


Turbulent Gas Clouds and Respiratory Pathogen Emissions: Potential Implications for Reducing Transmission of COVID-19.


title: Early Experience with LigaSure Thyroidectomy in a Nigeria Teaching Hospital.

text: Background The principles of safe and efficient thyroid surgery had been established and the technique has remained the same for over the century without any major significant changes. The introductions of electrosurgical devices constitute a major shift in the technique of thyroid surgery. Objective We present our early experience with the use of LIGASURE vessel sealing system for the procedure of thyroidectomy. Materials and Methods This was a quasi-experimental study comparing outcome of LigaSure thyroidectomy in a prospective nonrandomized cohort with another retrospective cohort of preintervention clamp-and-tie thyroidectomy. Results A total of 30 patients with a clinical diagnosis of goiter were recruited into the study. There were two males and 28 females with a mean age of 42.6 years. Diagnosis was simple multinodular goiter 24 (80%), controlled toxic nodular goiter 3 (10%), grave disease 1 (3.3%), and multinodular goiter with retrosternal extension 2 (6.7%). The mean thyroid weight was 121.0 g. The mean duration of surgery was 59 min compared to 128 min for traditional technique (P < 0.01). The mean blood loss of 116 ml was significantly less than 328 ml following the traditional technique (P < 0.01). Mean duration of hospital stay was 1.9 days, compared to 3.55 days in the traditional technique group (P = 0.02). Troubling postoperative complications of change in voice quality occurred in only one patient (3.3%). Conclusion LigaSure thyroidectomy was found to be easier and faster to carry out with no learning curve and easy to learn and adapt.


title: Supreme Laryngeal Mask Airway achieves faster insertion times than Classic LMA during chest compressions in manikins.

text: BACKGROUND According to the 2010 European Resuscitation Council guidelines on cardiopulmonary resuscitation (CPR), one can appreciate that the classic laryngeal mask airway (CLMA) is acceptable as an alternative airway device to endotracheal intubation for airway management in cardiac arrest victims. OBJECTIVE To compare a relatively new supraglottic airway device, the Supreme Laryngeal Mask Airway (SLMA), with the CLMA in a cardiac arrest scenario. METHODS Fifty healthcare professionals inexperienced in advanced airway management attempted to insert both airway devices in a manikin in 2 scenarios: in the first, chest compressions were not performed (non-CPR scenario), and in the second, uninterrupted chest compressions were performed (CPR scenario). The primary end points were insertion time and success rate at first attempt. The level of self-confidence of each participant was recorded. RESULTS SLMA achieves faster insertion times both in the non-CPR (SLMA: 10.4 ± 2.7 seconds vs CLMA: 13.4 ± 3.2 seconds, P < .05) and in the CPR scenario (SLMA: 9.9 ± 2.0 seconds Vs CLMA: 11.9 ± 2.3 seconds, P < .05). The difference between first attempt success rates was not statistically significant both in the non-CPR (SLMA: 96% vs CLMA: 90%, P = .18) and in the CPR scenario (SLMA: 98% vs CLMA: 94%, P = .32). The participants are more self-confident using SLMA instead of CLMA (P < .001) and 94% of them would prefer SLMA for future use. CONCLUSION SLMA could be a useful alternative to CLMA during CPR in the hands of healthcare professionals with minimal experience in airway management.


title: Early effects of gastric bypass on endothelial function, inflammation, and cardiovascular risk in obese patients.

text: BACKGROUND Obesity is associated with a chronic low-grade inflammatory state, insulin resistance, and endothelial dysfunction, all of which contribute to increased risk of cardiovascular disease. We hypothesized that gastric bypass would produce rapid improvements in endothelial function, reduce inflammation, and lead to a decrease in cardiovascular risk. METHODS We performed a prospective study of morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB). Clinical data, biochemical markers of inflammation, and parameters indicative of cardiovascular risk were collected preoperatively and at 3 and 6 months postoperatively. Metabolic and inflammatory mediators that were quantified included C-reactive protein, fibrinogen, PAI-1, IL-6, IL-10, IL-1Ra, adiponectin, leptin, triglycerides, total cholesterol, HDL, LDL, glucose, insulin, and HbA1c. Brachial artery reactivity testing (BART) was performed to assess peripheral arterial endothelial function, and Framingham cardiovascular risk score (FRS) was calculated on all study participants pre- and postoperatively. RESULTS Fifteen patients (11 female) were enrolled (age = 49.2 ± 10.4 years; BMI = 48.1 ± 5.3 kg/m(2)). Six months post RYGB, mean BMI decreased to 35.4 ± 4.5, corresponding to 51.7% excess weight loss (P < 0.001). Mean waist circumference decreased significantly from 132 cm at baseline to 110 cm at 3 months (P = 0.003) and 107 cm at 6 months (P < 0.001). Six months after RYGB, weight loss led to significant improvements in clinical parameters indicative of cardiovascular disease or risk, including brachial artery diameter, endothelial independent vasodilation, and FRS. Favorable improvements in the proinflammatory markers CRP (P = 0.01) and leptin (P = 0.005), the anti-inflammatory mediator adiponectin (P = 0.002), and insulin sensitivity (HOMA-IR, P = 0.007) were evident at 3 months. At 6 months, improvements in CRP, leptin, and fasting insulin were maintained and fibrinogen levels also decreased (P = 0.047). Adiponectin continued to increase at 6 months (P = 0.004). CONCLUSION Gastric bypass is associated with early reversal of endothelial dysfunction, a more favorable inflammatory milieu, and, most importantly, a reduction in cardiovascular risk.


title: Accurate structure prediction of peptide-MHC complexes for identifying highly immunogenic antigens.

text: Designing an optimal HIV-1 vaccine faces the challenge of identifying antigens that induce a broad immune capacity. One factor to control the breadth of T cell responses is the surface morphology of a peptide-MHC complex. Here, we present an in silico protocol for predicting peptide-MHC structure. A robust signature of a conformational transition was identified during all-atom molecular dynamics, which results in a model with high accuracy. A large test set was used in constructing our protocol and we went another step further using a blind test with a wild-type peptide and two highly immunogenic mutants, which predicted substantial conformational changes in both mutants. The center residues at position five of the analogs were configured to be accessible to solvent, forming a prominent surface, while the residue of the wild-type peptide was to point laterally toward the side of the binding cleft. We then experimentally determined the structures of the blind test set, using high resolution of X-ray crystallography, which verified predicted conformational changes. Our observation strongly supports a positive association of the surface morphology of a peptide-MHC complex to its immunogenicity. Our study offers the prospect of enhancing immunogenicity of vaccines by identifying MHC binding immunogens.


title: A different technique in gasless laparoendoscopic single-site hysterectomy.

text: The aim of this study was to show a different technique for a gasless laparoendoscopic single-site (LESS) hysterectomy and to present advantages and limitations of this technique. Women undergoing gasless LESS hysterectomy with a different technique were evaluated. A total of 14 LESS hysterectomies were performed using this gasless technique and rigid laparoscopic instruments by one surgeon. The mean age of the patients was 48.6 (±4.6). The average blood loss was 80 ± 35 ml. The average time between an umbilical incision and starting hysterectomy was 5 (±2,1) min. The time between starting hysterectomy and umbilical incision closure was 120 (±24) min in the laparoscopic suture group and 88 (±16) min in the vaginal suture group. The mean uterus weight was 188 (±95) g. In conclusion, this different technique is feasible and low cost, especially in non-obese patients. But further studies with large participants are needed to elucidate the safety. Impact statement Conventional CO2 pneumoperitoneum has many adverse effects on cardiopulmonary function, haemodynamic, metabolic and neurologic systems due to high-intraperitoneal pressure. The usage of gasless technique eliminates these adverse effects and postoperative shoulder pain. The satisfaction of patients is higher in laparoendoscopic single-site (LESS) hysterectomy due to improved cosmesis and reduced postoperative analgesic requirements. In the literature, there are a few studies showing techniques combining LESS and gasless laparoscopy for hysterectomy. In this study, a different approach for creating operational space in gasless laparoscopy is described. Creation of intraabdominal operational space is convenient and takes a short time in this technique. The average time between an umbilical incision and starting a hysterectomy is five minutes. Additional training is not needed for experienced surgeons in LESS. Also, cost-effectiveness is one of important advantages. It is quite safe, no possibility of vascular injury, including inferior epigastric or superficial epigastric vessels. Also suturing the vaginal cuff and knot tying is easier in this technique. This technique can be used safely in patients with poor cardiopulmonary reserve. Also, by means of its cost effectiveness, it can be preferred in developing countries. As a result, it may be a good alternative to conventional LESS hysterectomy.


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title: Favipiravir--a prophylactic treatment for Ebola contacts?


docid: ctawzzon

title: Association between nasopharyngeal load of Streptococcus pneumoniae, viral coinfection, and radiologically confirmed pneumonia in Vietnamese children.

text: BACKGROUND The interplay between nasopharyngeal bacterial carriage, viral coinfection, and lower respiratory tract infections (LRTIs) is poorly understood. We explored this association in Vietnamese children aged less than 5 years. METHODS A hospital-based case-control study of pediatric LRTIs was conducted in Nha Trang, Vietnam. A total of 550 hospitalized children (274 radiologically confirmed pneumonia [RCP] and 276 other LRTIs) were enrolled and 350 healthy controls were randomly selected from the community. Polymerase chain reaction-based methods were used to measure bacterial loads of Streptococcus pneumoniae (SP), Haemophilus influenzae, and Moraxella catarrhalis and to detect 13 respiratory viruses and bacterial serotypes in nasopharyngeal samples of study participants. RESULTS The median nasopharyngeal bacterial load of SP was substantially higher in children with RCP compared with healthy controls or children with other LRTIs (P < 0.001). SP load was 15-fold higher in pneumonia children with viral coinfection compared with those children without viral coinfection (1.4 x 10⁷/mL vs. 9.1 x 10⁵/mL; P 0.0001). SP load was over 200-fold higher in serotypeable SP compared with nontypeable SP (2.5 x 10⁶/mL vs. 1 x 10⁴/mL; P < 0.0001). These associations were independent of potential confounders in multiple regression models. No clear association was found between nasopharyngeal load of Haemophilus influenzae or Moraxella catarrhalis and viral coinfection in either RCP or other LRTIs groups. CONCLUSIONS An increased load of SP in the nasopharynx was associated with RCP, viral coinfection, and presence of pneumococcal capsule.


docid: cxsyqutr

title: Covid-19: healthcare students face unique mental health challenges.


title: Initial experience of the feasibility of single-incision laparoscopic appendectomy in different clinical conditions.

text: Introduction. Single-incision laparoscopic surgery (SILS) is a new technique developed for performing operations without a visible scar. Preliminary studies have reported the use of the technique mainly in cholecystectomy and appendectomy. We evaluated the feasibility of the technique in various appendicitis conditions including children, fertile women and obese patients. Materials and Methods. SILS technique was used in a random sample of patients hospitalised for suspected appendicitis. The ordinary diagnostic laparoscopy was performed and the appendix was removed if needed. The ligation of appendix was performed by thread loop, absorbable clip or endoscopic stapler. The details regarding the recovery of patients were collected prospectively. Results. Ten SILS procedures were performed without conversions or complications. The patient series included uncomplicated and complicated appendicitis patients. The mean age of the patients was 37 years (range 13-63), mean BMI was 26 (range 18-31), mean operative time was 40 minutes (range 18-31), and mean postoperative stay was 2 days (range 1-5). Conclusions. SILS technique is feasible for obese patients, uncomplicated and complicated appendicitis as well as for exploratory laparoscopy. Most common methods to ligate appendix are feasible with SILS technique. The true benefit of the technique should be assessed by randomised controlled trials.


title: Comparison of economic and clinical outcomes between patients undergoing laparoscopic bariatric surgery with powered versus manual endoscopic surgical staplers.

text: AIMS To compare economic and clinical outcomes between patients undergoing laparoscopic Roux-en-Y gastric bypass (LRY) or laparoscopic sleeve gastrectomy (LSG) with use of powered vs manual endoscopic surgical staplers. MATERIALS AND METHODS Patients (aged ≥21 years) who underwent LRY or LSG during a hospital admission (January 1, 2012-September 30, 2015) were identified from the Premier Perspective Hospital Database. Use of powered vs manual staplers was identified from hospital administrative billing records. Multivariable analyses were used to compare the following outcomes between the powered and manual stapler groups, adjusting for patient and hospital characteristics and hospital-level clustering: hospital length of stay (LOS), total hospital costs, medical/surgical supply costs, room and board costs, operating room costs, operating room time, discharge status, bleeding/transfusion during the hospital admission, and 30, 60, and 90-day all-cause readmissions. RESULTS The powered and manual stapler groups comprised 9,851 patients (mean age = 44.6 years; 79.3% female) and 21,558 patients (mean age = 45.0 years; 78.0% female), respectively. In the multivariable analyses, adjusted mean hospital LOS was 2.1 days for both the powered and manual stapler groups (p = .981). Adjusted mean total hospital costs ($12,415 vs $13,547, p = .003), adjusted mean supply costs ($4,629 vs $5,217, p = .011), and adjusted mean operating room costs ($4,126 vs $4,413, p = .009) were significantly lower in the powered vs manual stapler group. The adjusted rate of bleeding and/or transfusion during the hospital admission (2.46% vs 3.22%, p = .025) was significantly lower in the powered vs manual stapler group. The adjusted rates of 30, 60, and 90-day all-cause readmissions were similar between the groups (all p > .05). Sub-analysis by manufacturer showed similar results. LIMITATIONS This observational study cannot establish causal linkages. CONCLUSIONS In this analysis of patients who underwent LRY or LSG, the use of powered staplers was associated with better economic outcomes, and a lower rate of bleeding/transfusion vs manual staplers in the real-world setting.


title: Quality improvement during the COVID-19 pandemic.

text: In response to the COVID-19 pandemic, quality improvement teams at Cleveland Clinic initiated a number of measures to guide the care of patients with suspected or confirmed COVID-19 infection and protect care givers. This included increasing the frequency of team meetings from monthly to daily or weekly and creating task forces to create protocols for patient transport, airway management, and management of personal protective equipment and medications in short supply. Enterprise wide, we postponed non-essential surgeries, set up an overflow intensive care unit onsite, created a web-based COVID-19 toolkit for all care givers, and sent daily emails about the most recent developments, decisions, and recommendations from national and international societies.


Domestic abuse in the time of coronavirus.


title: Comparison of cardiac output and hemodynamic responses of intubation among different videolaryngoscopies in normotensive and hypertensive patients.

text: Tracheal intubation with Macintosh laryngoscope (MAC) might result in severe cardiovascular complications. The results of conducted studies investigating the effects of videolaryngoscopies on hemodynamic response of tracheal intubation are conflicting. We know little about the effects of videolaryngoscopies on cardiac output changes during tracheal intubation. We compared cardiac output (COP) and hemodynamic responses in normal blood pressure (n=60) and hypertensive patients (n=60) among 3 intubation devices: the MAC, the UE videolaryngoscopy ® (UE), and the UE video intubation stylet ® (VS). Cardiac index (CI), stroke volume index (SVI), heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded using LidcoRapid (V2)® preinduction, preintubation, and every minute for the first 5 min after intubation. We assessed oropharyngeal and laryngeal structures injury as well. Intubation time was significantly shorter than MAC groups (P<0.001) only in UE group of normotensive and hypertensive patients. In normotensive patients, there were no significant differences in any of COP variables or hemodynamic variables among the three devices. In hypertensive patients, SBP and DBP in the MAC group were significantly higher (P<0.05 or <0.01) than the UE and VS groups at 1, 2 and 3 min after intubation, but there were no significant differences in CI, SVI and HR among the three devices. There was no significant difference in oropharyngeal and laryngeal structures injury among all groups. It was concluded that both the UE and VS attenuate only the hemodynamic response to intubation as compared with the MAC in hypertensive patients, but not in normotensive patients.


title: Ex vivo comparison of the giant and transfixing knot in equine open and closed castration.

text: REASONS FOR PERFORMING STUDY In equine castration, application of a ligature on the spermatic cord to prevent complications such as haemorrhage and evisceration has been reported with controversial results. Characteristics of commonly used knots have not been studied. OBJECTIVES To compare the modified transfixing and giant knots and the emasculator in open and closed equine castration techniques. STUDY DESIGN Ex vivo experiment. METHODS A total of 144 testicles were randomly assigned to 2 groups for open or closed castration. Both groups were divided into 3 subgroups of 18 specimens each: emasculator only, emasculator plus giant knot and emasculator plus transfixing knot and the open castration group also contained 2 further subgroups of 18 testicles each: giant knot only and transfixing knot only. The length of suture material used was measured for each knot and the leaking pressure of the testicular artery measured using dye injection. In the closed castration group, parietal tunic tensile strength was measured with a tensiometer. RESULTS Leaking pressure was higher in open compared with closed castration, with no significant difference among subgroups. In the closed castration group, minimum leaking pressure for the emasculator plus transfixing knot and emasculator only subgroups were close to standard physiological arterial pressures. The giant knot required less suture material than the transfixing knot. Parietal tunic tensile strength was higher when ligatures were applied. CONCLUSIONS The giant and transfixing knot techniques have comparable haemostatic capability and parietal tunic tensile strength, but the giant knot requires less suture material. In open castration, using the emasculator alone may produce adequate haemostasis. In closed castration, using the giant knot in combination with the emasculator increases the bursting pressure and possibly reduces the incidence of haemorrhage. In closed castration, application of a ligature may reduce the risk of evisceration.


title: The need for psychosocial support amid COVID-19 crises in Nigeria.

text: With the closure of all public places, the stay-at-home order and the worsening economic indices occasioned by the fall in the price of crude oil with no foreseeable end, learned helplessness, negative emotions, and other psychosocial problems are bound to thrive. Interventions to improve social capital, coping resources, resilience, and good community and family cohesion are needed to promote psychosocial well-being during and after the COVID-19 pandemic in Nigeria. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Antibody tests for COVID-19: drawing attention to the importance of analytical specificity.


title: Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff.

text: BACKGROUND In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed. OBJECTIVES To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020. SELECTION CRITERIA We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate. MAIN RESULTS Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only. AUTHORS' CONCLUSIONS We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.


Are patients with systemic lupus erythematosus at increased risk for COVID-19?


title: Disease Outbreak Surge Response: How a Singapore Tertiary Hospital converted a multi-storey carpark into a Flu Screening Area to respond to the COVID-19 pandemic.

text: COVID-19, first documented in December 2019, was declared a public health emergency by the World Health Organisation (WHO) on 30th January 20201. The disease, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has affected more than 9 million people and contributed to at least 490,000 deaths globally as of June 2020, with numbers on the rise2.Increased numbers of patients seeking medical attention during disease outbreaks can overwhelm healthcare facilities, hence requiring an equivalent response from healthcare services. Surge capacity is a concept that has not only been defined as the "ability to respond to a sudden increase in patient care demands3" but also to "effectively and rapidly expand capacity4".This narrative review discusses how Singapore's largest tertiary hospital has encapsulated the elements of surge capability and transformed a peacetime multi-storey carpark into a flu screening area in response to the COVID-19 disease outbreak.


Kidney Paired Donation Protocol for Participating Donors 2014.


title: Blood count and C-reactive protein evolution in gastric cancer patients with total gastrectomy surgery.

text: BACKGROUND The complete blood count (CBC) and C-reactive protein (CRP) are useful inflammatory parameters for ruling out acute postoperative inflammatory complications. AIM To determine their changes in gastric cancer patients submitted to total gastrectomy. METHODS This is a prospective study, with 36 patients with gastric cancer who were submitted to elective total gastrectomy. On the first, third and fifth postoperative day (POD), blood count and CRP changes were assessed. Patients with postoperative complications were excluded. RESULTS Twenty-one (58%) were men and 15 (42%) women. The mean age was 65 years. The leukocytes peaked on the 1st POD with a mean of 13,826 u/mm³, and decreased to 8,266 u/mm³ by the 5th POD. The bacilliforms peaked on the 1st POD with a maximum value of 1.48%. CRP reached its maximum level on the 3rd POD with a mean of 144.64 mg/l±44.84. Preoperative hematocrit (HCT) was 35% and 33.67% by the 5th POD. Hemoglobin, showed similar values. CONCLUSIONS Leukocytes increased during the 1st POD but reached normal values by the 5th POD. CRP peaked on the 3rd POD but did not reach normal values by the 5th POD.


title: A review of randomised controlled trials comparing ultrasound-guided foam sclerotherapy with endothermal ablation for the treatment of great saphenous varicose veins.

text: OBJECTIVE The last 10 years have seen the introduction into everyday clinical practice of a wide range of novel non-surgical treatments for varicose veins. In July 2013, the UK National Institute for Health and Care Excellence recommended the following treatment hierarchy for varicose veins: endothermal ablation, ultrasound-guided foam sclerotherapy, surgery and compression hosiery. The aim of this paper is to review the randomised controlled trials that have compared endothermal ablation and ultrasound-guided foam sclerotherapy to determine if the level 1 evidence base still supports an "endothermal ablation first" strategy for the treatment of varicose veins. METHODS A PubMed and OVID literature search (until 31 January 2015) was performed and randomised controlled trials comparing endothermal ablation and ultrasound-guided foam sclerotherapy were obtained. RESULTS Although anatomical success appeared higher with endothermal ablation than ultrasound-guided foam sclerotherapy, clinical success and patient-reported outcomes measures were similar. Morbidity and complication rates were very low and not significantly different between endothermal ablation and ultrasound-guided foam sclerotherapy. Ultrasound-guided foam sclerotherapy was consistently less expensive that endothermal ablation. CONCLUSIONS All endovenous modalities appear to be successful and have a role in modern day practice. Although further work is required to optimise ultrasound-guided foam sclerotherapy technique to maximise anatomical success and minimise retreatment, the present level 1 evidence base shows there is no significant difference in clinical important outcomes between ultrasound-guided foam sclerotherapy and endothermal ablation. As ultrasound-guided foam sclerotherapy is less expensive, it is likely to be a more cost-effective option in most patients in most healthcare settings. Strict adherence to the treatment hierarchy recommended by National Institute for Health and Care Excellence seems unjustified.


title: COVID-19, Quarantines, Sheltering-in-Place, and Human Rights: The Developing Crisis.

text: As COVID-19 has spread across the globe, quarantines and sheltering-in-place orders have become important public health tools but, as currently implemented, have eroded human rights, particularly for the marginalized, including essential workers, detainees, women, and children. Quarantines and sheltering-in-place orders must include explicit guarantees of human rights protections. We outline protections for the quarantined that communities and governments should strive to guarantee.


title: Lethal concentration of perfluoroisobutylene induces acute lung injury in mice mediated via cytokine storm, oxidative stress and apoptosis.

text: Perfluoroisobutylene (PFIB) is a highly toxic gas that targets the lungs. Low-level inhalation of the gas can lead to acute lung injury (ALI), pulmonary edema and even death. No specific anti-PFIB drugs are currently available and the pathogenesis of PFIB-induced ALI is not fully understood. Early direct oxidative injury and a secondary hyper-inflammatory response are recognized as the primary mechanisms of PFIB-induced ALI. In the present study, our data demonstrate for the first time that a cytokine storm is associated with PFIB-induced ALI. Levels of 10 pro-inflammatory cytokines and one anti-inflammatory cytokine were significantly increased in lung tissues of PFIB-exposed mice. PFIB inhalation additionally led to significant oxidative stress in lung tissue. Inflammation-associated CD11b+Ly6G+Ly6Cint neutrophils and CD11b+Ly6G-Ly6Chi monocytes were significantly increased in blood in association with PFIB-induced ALI. Bcl-2/Bax-mediated lung cell apoptosis was significantly increased at 1 h, followed by a sustained decrease after 1 h, which was significant at 4-8 h in PFIB-exposed mice. This suppression of apoptosis is possibly associated with the Akt-signaling pathway.


title: The prognosis of infants with neonatal respiratory inhibition syndrome.

text: OBJECTIVE The goal of this study was to investigate the prognosis of infants with neonatal respiratory inhibition syndrome (NRIS). METHODS Infants with a gestational age of at least 36 weeks and a birth weight of at least 2000 g who were born at Nara Prefecture General Medical Center, in Nara, Japan, between March 2013 and June 2016 were screened for NRIS using our established method. NRIS was defined as severe hypoxemia caused by respiratory inhibition immediately after crying (RIAC) or gastroesophageal reflux (RIGER) or as a respiratory pause during feeding (feeding hypoxemia), accompanied clinically by central cyanosis and a decrease in SpO2 to less than 70%. All infants were monitored using pulse oximetry immediately after birth. Diagnosis of RIAC, feeding hypoxemia, and RIGER are based on observation by both parents and medical staff as well as on on-screen computer analysis using specific software. All infants were examined at a one-month check-up. Parents of the infants who experienced one or more episodes of NRIS accompanied by a decrease in SpO2 to less than 70% for more than approximately 60 s received a questionnaire by mail about their child's development. We conducted a logistic regression analysis with developmental problems as the dependent variable. RESULTS NRIS was observed in 362 (28.5%) infants; 216 (17.0%) infants showed RIAC, 254 (20.0%) infants showed feeding hypoxemia, and 54 (4.2%) infants showed RIGER. Although all infants were monitored in the maternity ward nursery, 184 (85.2%) infants with RIAC and 111 (43.7%) infants with feeding hypoxemia were overlooked. All infants with NRIS were found to have successfully recovered at one month after birth. Sixty-two cases were examined in the follow-up study by the mailed questionnaire. The median age of the subjects at time of study was 22 months. Fourteen cases (22.6%) exhibited developmental problems including delayed speech development, stereotyped interests and behaviors, sensory disturbance, hyperactivity, delayed motor development, and short stature. Developmental problems tended to relate to shorter gestational age (odds ratio, 0.622; p = .068; 95% CI, 0.373-1.036), smaller birth weight (odds ratio, 0.998; p = .069; 95% CI, 0.997-1.000), and maximum duration of SpO2 to less than 70% by RIAC (odds ratio, 1.009; p = .086; 95% CI, 0.999-1.020). All cases had experienced severe hypoxemia accompanied by a decrease in SpO2 to less than 60%. Seven cases had experienced prolonged hypoxemia accompanied by a decrease in SpO2 to less than 70% for at least 2 min. Among the subjects, 19 infants were examined closely, and their natural course of NRIS was observed in the neonatal intensive care unit. No cases demonstrated abnormal findings with blood examinations, chest-abdominal X-ray, echocardiogram, laryngoendoscopy, hearing loss screening, or mass screening. Only one case had a small intracranial hemorrhage as evidenced in a magnetic resonance imaging of the head. CONCLUSIONS The infants with severe NRIS tended to have developmental problems. Spreading knowledge about NRIS worldwide is thought to be very important.


docid: gwvtmvzq

title: Human bocavirus: clinical significance and implications.

text: PURPOSE OF REVIEW Human bocavirus (HBoV), a parvovirus, was discovered in 2005 with the use of nonspecific genome amplification techniques. Since its discovery, HBoV has been identified worldwide. This review will focus on the epidemiology and clinical features associated with HBoV infection. RECENT FINDINGS Initial studies demonstrated the presence of HBoV DNA in respiratory specimens of individuals with respiratory tract disease. Data from some studies suggest that HBoV may be the etiological agent responsible for respiratory tract disease, particularly in young children. HBoV, however, is frequently detected in the presence of other common respiratory viruses. HBoV is not confined to the respiratory tract as evidence of the virus has been detected in serum and stool, the significance of which remains unclear. Presence of the virus in respiratory secretions, serum and stool suggests that this virus may cause systemic illness. SUMMARY HBoV is an emerging human parvovirus. The full spectrum of disease associated with HBoV remains to be defined.


title: Laparoscopic ovariectomy in dogs: comparison between laparoendoscopic single-site and three-portal access.

text: This study was conducted to evaluate the feasibility and therapeutic safety of laparoendoscopic single-site ovariectomy (LESS-OVE) and 3-portal laparoscopic ovariectomy (Lap-OVE) in dogs. Ten female mixed breed dogs were included in the study. Dogs were divided into group 1 (LESS-OVE; n = 5) and group 2 (Lap-OVE; n = 5). All procedures were performed by laparoscopic-skilled surgeons, and the anesthetic protocol was the same for all patients. In both groups, the ovarian vascular pedicle and ligaments were transected using a bipolar vessel sealer/divider device. The mean total surgical time was slightly longer in LESS-OVE (36.6 ± 3.5 min) than Lap-OVE (32.0 ± 3.0 min); however, the differences were not significant. Perioperative complications were not reported in any group. Both laparoscopic techniques were shown to be equally feasible and safe for patients. However, surgeons found LESS-OVE to require more skill than Lap-OVE. Therefore, additional studies should be conducted to evaluate this novel approach in clinical veterinary practice, and a proper laparoscopic training program for veterinary surgeons should be developed.


docid: eblvntnu

title: Motor cortical and corticospinal function differ during an isometric squat compared with isometric knee extension.

text: NEW FINDINGS What is the central question of this study? In order to discern information about testing modalities when assessing neuroplastic responses to squat resistance training, the present study investigated whether corticospinal and intracortical function was different between a joint-angle-matched isometric squat and isometric knee extension. What is the main finding and its importance? The present data show poor agreement of corticospinal and intracortical function between the isometric squat and isometric knee extension. The data reinforce the notion that task specificity is of the utmost importance for assessing neuroplasticity. ABSTRACT It has been suggested that task-specific changes in neurophysiological function (neuroplasticity) should be assessed using testing modalities that replicate the characteristics of the intervention. The squat is a commonly prescribed resistance exercise that has been shown to elicit changes in CNS function. However, previous studies have assessed squat-induced neuroplasticity using isometric knee extension, potentially confounding the results. The aim of the present study was to assess the agreement between corticospinal and intracortical activity relating to the knee extensors during isometric knee extension compared with an isometric squat task. Eleven males completed a neurophysiological assessment in an isometric squat (IS) and knee-extension (KE) task matched for joint angles (hip, knee and ankle). Single- and paired-pulse transcranial magnetic stimulation was delivered during isometric contractions at a range of intensities to assess short-interval cortical inhibition (SICI) and corticospinal excitability. Group mean values for SICI (70 ± 14 versus 63 ± 12% of unconditioned motor evoked potential during IS and KE, respectively) and corticospinal excitability (mean differences 2-5% of the maximal compound muscle action potential at 25, 50, 75 and 100% maximal voluntary contraction between the IS and KE) were not different between the two tasks (P > 0.05) in the vastus lateralis. However, limits of agreement were wide, with poor-to-moderate average intraclass correlation coefficients (ICCs) (SICI, ICC3,1 = 0.15; corticospinal excitability, average ICC3,1 range = 0.0-0.63), indicating disparate corticospinal and intracortical activity between the IS and KE. These data highlight the importance of task specificity when assessing the modulation of corticospinal excitability and SICI in response to interventions resulting in neuroplastic changes.


docid: gjgpznqx

title: Therapeutic decisions in inflammatory bowel disease in the SARS-Cov-2 pandemic.


docid: wxnmogxx

title: Is postal postoperative follow-up in urogynaecology feasible?

text: Postoperative follow-up after urogynaecological surgery has been little investigated. Traditionally, it is done in hospital but there is wide variation in the assessments and timing. We aimed to determine the viability of postal follow-up in women undergoing urogynaecological surgery. This is a retrospective review of prospectively collected data. All women who underwent prolapse and/or urinary incontinence surgery between January and June 2010 were included. Validated ICIQ questionnaires for prolapse and/or incontinence, as appropriate, were used, before surgery and at 6 months postoperatively. The primary outcome was the response rate to postal follow-up. A total of 70 women had urogynaecology surgery during the study period; 65 (93%) women returned the questionnaires (95% CI 84-97%, p < 0.0001). The postoperative questionnaires scores showed a statistically significant improvement compared with the preoperative scores. This results in only a small proportion of women needing hospital attendance for follow-up (10%). We conclude that postal follow-up is feasible.


title: The prevalence, characteristics and prevention status of skin injury caused by personal protective equipment among medical staff in fighting COVID-19: A multi-center, cross-sectional study.

text: OBJECTIVE To investigate the prevalence, characteristics and preventive status of skin injuries caused by personal protective equipment (PPE) in medical staff. APPROACH A cross-sectional survey was conducted online for understanding skin injuries among medical staff fighting against COVID-19 in February 8-22, 2020. Participants voluntarily answered and submitted the questionnaire with cellphone. The questionnaire items included demographic data, grade of PPE and daily wearing time, skin injuries types, anatomical sites, and preventive measures. Univariable analyses and logistic regression analyses were employed to explore the risk factors associated with skin injuries. RESULTS A total of 4,308 respondents were collected from 161 hospitals and 4,306 respondents were valid. The overall prevalence of skin injuries was 42.8% (95% CI 41.30%-44.30%) with three types of device-related pressure injuries, moist associated skin damage and skin tear. Co-skin injuries and multiple locations injuries were 27.4% and 76.8%, respectively. The logistic regression analysis indicated that sweating (95%CI for OR 87.52-163.11), daily wearing time (95% CI for OR1.61-3.21), male (95% CI for OR 1.11-2.13) and grade 3 PPE (95% CI for OR1.08-2.01) were associated with skin injuries. Only 17.7% respondents took prevention and 45.0% skin injuries were treated. INNOVATION This the first cross-sectional survey to understand skin injuries in medical staff caused by PPE, which is expected to be a benchmark. CONCLUSION The skin injuries among medical staff are serious, with insufficient prevention and treatment. A comprehensive program should be taken in future.


title: X-ray indices of chest drain malposition after insertion for drainage of pneumothorax in mechanically ventilated critically ill patients.

text: Background Chest drain (CD) migration in the pleural cavity may result in inadequate drainage of pneumothorax. The aim of this study was to assess several parameters that might help in diagnosing CD migration on chest X-ray (CXR). Methods Patients with a CD inserted from the safe triangle with a subsequent supine CXR and CT scan performed less than 24 hours apart were assessed for CD foreshortening, angle of inclination of the CD, and CD tortuosity. CD foreshortening was expressed as a ratio between CD length measured in coronal plane only and CD length inside the pleural cavity measured on CT. The angle of inclination of the CD was measured as the angle between the horizontal line and CD at the pleural space entry on CXR. CD tortuosity was calculated as a ratio between the distance from CD pleural space entry to the tip of the CD and the length of CD from the pleural space entry to its tip on CXR. Results Altogether 28 patients were included in the study. The median time between the CXR and CT examinations was 5.4 hours (IQR, 3.8-6.9 hours). CD foreshortening was the best clue of a misplaced CD with AUC of 0.93, 100% sensitivity and 88% specificity for a cut-off value of 82%. The angle of CD inclination was greater in patients with misplaced CD with AUC of 0.83, 75% sensitivity and 92% specificity for a cut-off of 50 degrees. The performance of CD tortuosity was poor. Conclusions Greater foreshortening of the CD and a steep angle of inclination of the CD above the horizontal at chest entry should raise suspicion of CD migration and mandate further investigation by chest ultrasound to rule out residual pneumothorax occult on CXR.


title: Videoscopic basilic vein harvest for creation of transposed brachiobasilic arteriovenous fistulae.

text: INTRODUCTION Due to the extensive dissection required during the standard transposed brachiobasilic arterial venous fistula (BB-AVF) procedure and the potential for postoperative complications, many surgeons are reluctant to construct BB-AVFs. Less invasive vein harvest has been performed for this procedure with good results, but this procedure remains rarely used. METHODS We began to perform videoscopic-assisted BB-AVF creation in selected patients at our institution in 2006. Vein harvesting from the antecubital fossa to the level of the axilla is performed by an experienced surgical technician under the guidance of the dialysis access surgeon. Perioperative data and postoperative outcomes were retrospectively reviewed with institutional review board approval. RESULTS From 2006 to 2010, we performed videoscopic-assisted BB-AVF in 21 patients. Median age was 59 years and median body mass index was 30; women comprised 52% of the cohort. Previous vascular access procedures had been performed on 81% of patients. Of the 21 attempts with the video-assisted approach, only 1 required conversion to a standard open procedure. Of the remaining cases, there were no significant intraoperative or postoperative surgical complications with a median operative time of 159 minutes and maximum length of stay of 1 night. Maturation of the fistula sufficient for cannulation and use occurred in 80% of patients, with the median time to first access in patients who matured being 60 days. At 3 years follow-up, 47% of fistulas that matured were still functional, with 33% lost to death or successful renal transplantation. CONCLUSION Videoscopic-assisted transposition of the basilic vein is a reasonable option for BB-AVF placement. The procedure can be performed in an acceptable expeditious fashion with near elimination of infection, wound breakdown, lymph drainage, nerve injury, and satisfactory maturation (80%) and patency rates. Technicians experienced in lower extremity vein harvest can perform this procedure successfully under the supervision of an experienced access surgeon.


title: SAIL--stereo-array isotope labeling.

text: Optimal stereospecific and regiospecific labeling of proteins with stable isotopes enhances the nuclear magnetic resonance (NMR) method for the determination of the three-dimensional protein structures in solution. Stereo-array isotope labeling (SAIL) offers sharpened lines, spectral simplification without loss of information and the ability to rapidly collect and automatically evaluate the structural restraints required to solve a high-quality solution structure for proteins up to twice as large as before. This review gives an overview of stable isotope labeling methods for NMR spectroscopy with proteins and provides an in-depth treatment of the SAIL technology.


The clinical cutting edge.


Therapeutic approaches for genetic and infectious diseases.


title: Safety and efficiency of gasless laparoscopy: a systematic review protocol.

text: BACKGROUND Gasless laparoscopy, developed in the early 1990s, was a means to minimize the clinical and financial challenges of pneumoperitoneum and general anaesthesia. It has been used in a variety of procedures such as in general surgery and gynecology procedures including diagnostic laparoscopy. There has been increasing evidence of the utility of gasless laparoscopy in resource limited settings where diagnostic imaging is not available. In addition, it may help save costs for hospitals. The aim of this study is to conduct a systematic review of the available evidence surrounding the safety and efficiency of gasless laparoscopy compared to conventional laparoscopy and open techniques and to analyze the benefits that gasless laparoscopy has for low resource setting hospitals. METHODS This protocol is developed by following the Preferred Reporting Items for Systematic review and Meta-Analysis-Protocols (PRISMA-P). The PRISMA statement guidelines and flowchart will be used to conduct the study itself. MEDLINE (Ovid), Embase, Web of Science, Cochrane Central, and Global Index Medicus (WHO) will be searched and the National Institutes of Health Clinical Trials database. The articles that will be found will be pooled into Covidence article manager software where all the records will be screened for eligibility and duplicates removed. A data extraction spreadsheet will be developed based on variables of interest set a priori. Reviewers will then screen all included studies based on the eligibility criteria. The GRADE tool will be used to assess the quality of the studies and the risk of bias in all the studies will be assessed using the Cochrane Risk assessment tool. The RoB II tool will assed the risk of bias in randomized control studies and the ROBINS I will be used for the non-randomized studies. DISCUSSION This study will be a comprehensive review on all published articles found using this search strategy on the safety and efficiency of the use of gasless laparoscopy. The systematic review outcomes will include safety and efficiency of gasless laparoscopy compared to the use of conventional laparoscopy or laparotomy. TRIAL REGISTRATION The study has been registered in PROSPERO under registration number: CRD42017078338.


Creating misinformation: how a headline in The BMJ about covid-19 spread virally.


title: Effect of X-Ray Attenuation of Arterial Obstructions on Intravenous Thrombolysis and Outcome after Ischemic Stroke.

text: OBJECTIVE To assess whether the x-ray attenuation of intra-arterial obstruction measured on non-contrast CT in ischemic stroke can predict response to thrombolysis and subsequent functional outcome. METHODS The Third International Stroke Trial (IST-3) was a multicenter randomized-controlled trial of intravenous thrombolysis (rt-PA) given within six hours of ischemic stroke. Ethical approval and informed consent were obtained. In a subgroup of 109 IST-3 patients (38 men, median age 82 years), a single reader, masked to all clinical and other imaging data, manually measured x-ray attenuation (Hounsfield Units, HU) on non-contrast CT at the location of angiographically-proven intra-arterial obstructions, pre-randomization and at 24-48 hour follow-up. We calculated change in attenuation between scans. We assessed the impact of pre-randomization arterial obstruction attenuation on six-month functional outcome. RESULTS Most arterial obstructions (64/109, 59%) were hyperattenuating (mean 51.0 HU). Compared with control, treatment with rt-PA was associated with a greater, but non-significant, reduction in obstruction attenuation at follow-up (-8.0 HU versus -1.4 HU in patients allocated control, p = 0.117). In multivariable ordinal regression analysis controlled for patient age, stroke severity, location and extent of obstruction, time from stroke onset to baseline scan and rt-PA treatment allocation, the attenuation of pre-randomization arterial obstruction was not independently associated with six-month outcome (odds ratio = 0.99, 95% confidence interval = 0.94-1.03, p = 0.516). CONCLUSIONS In ischemic stroke, the x-ray attenuation of the arterial obstruction may decline more rapidly from baseline to 24-48 hours following treatment with thrombolysis but we found no evidence that baseline arterial obstruction attenuation predicts six-month outcome.


title: Research NoteBacterial Community Assessed by Utilization of Single Carbon Sources in Broiler Ground Meat after Treatment with an Antioxidant, Carnosine, and Cold Plasma.

text: Contaminated poultry meat is a major source of human foodborne illnesses. Many interventions have been developed to reduce and/or eliminate human foodborne pathogens in poultry products; however, treatments with cold plasma or carnosine or a combination of both interventions have not been extensively investigated. In this communication, the bacterial microflora of poultry meat samples after treatments with cold plasma and carnosine were characterized with EcoPlates ™ in the OmniLog ® system. The plates were incubated at 25 o C for seven days in the OmniLog ® chamber, and bacterial growth was monitored by recording formazan production every 30 minutes at OD 590 nm . The kinetics of lag, log and stationary phases of the bacterial growth patterns followed the Gompertz sigmoidal model, but with different inflection times and asymptotes at the log phase and the stationary phase, respectively. Results indicated that treating poultry meat samples with cold plasma technology and carnosine could inhibit growth of the bacteria in the treated meat samples. Of 31 chemicals tested, phenylethylamine, α- D -lactose, D,L -α-glycerol phosphate, 2-hydroxybenzoic acid, γ-hydroxybutyric acid, α-ketobutyric acid or D -malic acid could not be metabolized by bacteria in the meat samples. Future research is required to determine whether these seven chemicals that inhibit growth of bacteria from the meat samples can be used as food preservatives for extending shelf-life of these products. Whether the bacterial flora be as an indicator of effectiveness for meat samples treated with cold plasma, carnosine or both needs further study.


Classic concepts and modern developments in transplant infectious disease: the work of Robert H. Rubin.


title: Delayed Gastric Emptying Following Laparoscopic Repair of Very Large Hiatus Hernias Impairs Quality of Life.

text: BACKGROUND Delayed gastric emptying (DGE) following hiatus hernia surgery may affect a substantial number of patients with adverse clinical consequences. Here, we aim to evaluate the impact of DGE following laparoscopic repair of very large hiatus hernias on patients' quality of life, gastrointestinal symptomatology, and daily function. METHODS Analysis of data collected from a multicenter prospective randomised trial of patients who underwent laparoscopic mesh versus sutured repair of very large hiatus hernias (>50% of stomach in chest). DGE was defined as gastric food retention visualised at endoscopy after 6 h of fasting at 6 months post-surgery. Quality of life (QOL), gastrointestinal symptomatology, and daily function were assessed with the SF-36 questionnaire, Visick scoring and structured surveys administered prior to surgery and at 1, 3, 6 and 12 months after surgery. RESULTS Nineteen of 102 (18.6%) patients had DGE 6 months after surgery. QOL questionnaires were completed in at least 80% of patients across all time points. Compared with controls, the DGE group demonstrated significantly lower SF-36 physical component scores, delayed improvement in health transition, more adverse gastrointestinal symptoms, higher Visick scores and a slower rate of return to normal daily activities. These differences were still present 12 months after surgery. CONCLUSIONS DGE following large hiatus hernia repair is associated with a negative impact on quality of life at follow-up to 12 months after surgery.


docid: vqciwpff

title: Telotristat etiprate for carcinoid syndrome: a single-arm, multicenter trial.

text: CONTEXT Carcinoid syndrome (CS) is associated with elevated serotonin, diarrhea, flushing, and increased risk of valvular heart disease. Many patients respond to somatostatin analogs initially, but response diminishes in most patients. Additional options are needed. OBJECTIVE To assess whether telotristat etiprate (TE) can reduce gastrointestinal symptoms in CS and reduce urinary 5-hydroxyindoleacetic acid (u5-HIAA; a biomarker of serotonin). DESIGN A prospective, exploratory, dose-escalating 12-week, open-label, multicenter study of TE with efficacy and safety analyses. SETTING A multicenter study. PATIENTS Eligible patients had metastatic, well-differentiated, neuroendocrine tumors and CS with ≥ four bowel movements (BMs) per day. Somatostatin analog use was allowed. INTERVENTIONS TE, a novel oral inhibitor of peripheral serotonin synthesis. MAIN OUTCOME MEASURES Primary: safety. Secondary: daily BMs, stool form, and u5-HIAA. RESULTS Fifteen patients were enrolled, and 14 completed the treatment period. All patients experienced reductions in BMs per day (mean decrease, 43.5%). A 74.2% mean reduction in u5-HIAA, the main metabolite of serotonin, was observed, with generally greater reductions in patients with greater reductions in BMs per day. Nine patients (75%) reported "adequate relief" of gastrointestinal symptoms at 12 weeks, compared with two (17%) at baseline. Stool form and flushing also improved. Adverse events were mostly gastrointestinal (n = 10; 67%), consistent with underlying illness; three adverse events were serious (abdominal pain, diarrhea, and gastroenteritis) but were judged unrelated. CONCLUSION TE was generally safe and well tolerated. Patients experienced substantial improvement in CS and reductions in u5-HIAA, consistent with the mechanism of action of TE. These results support further evaluation in phase 3 studies.


title: HydroCoils reduce recurrence rates in recently ruptured medium-sized intracranial aneurysms: a subgroup analysis of the HELPS trial.

text: BACKGROUND AND PURPOSE The HydroCoil Endovascular Aneurysm Occlusion and Packing Study (HELPS) was a randomized, controlled trial comparing HydroCoils with bare-platinum coils. The purpose of this study was to perform a subgroup analysis of angiographic and clinical outcomes of medium-sized aneurysms in the HELPS trial. MATERIALS AND METHODS Patients with medium-sized aneurysms (5-9.9 mm) were selected from the HELPS trial. Outcomes compared between the HydroCoil and bare-platinum groups included the following: 1) any recurrence, 2) major recurrence, 3) retreatment, and 4) mRS score of ≤2. Subgroup analysis by rupture status was performed. Multivariate logistic regression analysis adjusting for aneurysm neck size, shape, use of adjunctive device, and rupture status was performed. RESULTS Two hundred eighty-eight patients with medium-sized aneurysms were randomized (144 in each group). At 15-18 months posttreatment, the major recurrence rate was significantly lower in the HydroCoil group than in controls (18.6% versus 30.8%, P = .03, respectively). For patients with recently ruptured aneurysms, the major recurrence rate was significantly lower for the HydroCoil group than for controls (20.3% versus 47.5%, P = .003), while rates were similar between groups for unruptured aneurysms (16.7% versus 14.8%, P = .80). Multivariate analysis of patients with recently ruptured aneurysms demonstrated a lower odds of major recurrence with HydroCoils (OR = 0.27; 95% CI, 0.12-0.58; P = .0007). No difference in retreatment rates or mRS of ≤2 was seen between groups. CONCLUSIONS HydroCoils were associated with statistically significant and clinically relevant lower rates of major recurrence for recently ruptured, medium-sized aneurysms in the HELPS trial. Because this was not a prespecified subgroup analysis, these results should not alter clinical practice but, rather, provide insight into the design of future clinical trials comparing bare platinum with second-generation coils.


title: Investigating the effectiveness of school health services delivered by a health provider: A systematic review of systematic reviews.

text: Schools are the only institution regularly reaching the majority of school-age children and adolescents across the globe. Although at least 102 countries have school health services, there is no rigorous, evidence-based guidance on which school health services are effective and should be implemented in schools. To investigate the effectiveness of school health services for improving the health of school-age children and adolescents, a systematic review of systematic reviews (overview) was conducted. Five databases were searched through June 2018. Systematic reviews of intervention studies that evaluated school-based or school-linked health services delivered by a health provider were included. Review quality was assessed using a modified Ballard and Montgomery four-item checklist. 1654 references were screened and 20 systematic reviews containing 270 primary studies were assessed narratively. Interventions with evidence for effectiveness addressed autism, depression, anxiety, obesity, dental caries, visual acuity, asthma, and sleep. No review evaluated the effectiveness of a multi-component school health services intervention addressing multiple health areas. From the limited amount of information available in existing systematic reviews, the strongest evidence supports implementation of anxiety prevention programs, indicated asthma education, and vision screening with provision of free spectacles. Additional systematic reviews are needed that analyze the effectiveness of comprehensive school health services, and specific services for under-researched health areas relevant for this population.


title: Laparoscopic Resection of Recurrence from Hepatocellular Carcinoma after Liver Transplantation: Case Reports and Review of the Literature.

text: Background. Recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) indicates a poor prognosis. Surgery is considered the only curative option for selected patients with HCC recurrence following LT. Traditionally, the preference is given to the open approach. Methods. In this report, we present two cases of laparoscopic resections (LR) for recurrent HCC after LT, performed at Oslo University Hospital, Rikshospitalet. Results. Both procedures were executed without intraoperative and postoperative adverse events. Whereas one of the patients had a recurrence one year after LR, the other patient did not have any sign of disease during 3-year follow-up. Conclusions. We argue that, in selected cases, patients with HCC recurrence following LT may benefit from LR due to its limited tissue trauma and timely start of subsequent treatment if curative resection cannot be obtained. In patients with relatively favorable prognosis, LR facilitates postoperative recovery course and avoids unnecessary laparotomy.


A26 Transmission patterns and evolution of RSV in a community outbreak identified by genomic analysis.


title: Randomized clinical study for assessment of incision characteristics and pain associated with LESS versus laparoscopic cholecystectomy.

text: BACKGROUND Laparoendoscopic single-site surgery (LESS) has emerged as a technique that uses a natural scar, the umbilicus, within which a multiple-entry portal is placed into a 3.0-4.0-cm single incision to perform operations. The objective of this study was to compare incision size, wound complications, and postoperative pain of LESS compared with those of laparoscopic cholecystectomy (LC). METHODS A prospective randomized controlled study was conducted between January and June 2011 at two university hospitals in Rio de Janeiro, Brazil. Fifty-seven patients were randomly assigned to undergo laparoscopic or LESS cholecystectomy. Skin and aponeurosis wound sizes were recorded. A 10-point visual analog scale (VAS) was used to assess pain at postoperative hours 3 and 24. Healing and wound complications were assessed at follow-up. RESULTS A total of 57 patients, 53 women and 4 men with a mean age of 48.7 years, were randomly assigned to undergo LESS (n = 28) or LC (n = 29). The mean length of the umbilical skin incision was 4.0 cm (range = 2.1-5.8) in LESS and 2.7 cm (1.5-5.1) in LC (p < .0001). The mean internal aponeurosis diameter was 3.5 cm (2.0-5.5) in LESS and 2.3 cm (1.2-3.5) in LC (p < .0001). The mean operative time was 60.3 min (32-128) for LESS and 51.3 min (25-120) for LC (p = 0.11). Gallbladder perforation at detachment occurred in 15.69 % of the LESS cases and in 5.88 % of the LC cases (p = 0.028). The mean VAS score for pain at hour 3 was 2.0 points (0-7) for the LESS group and 4.0 (0-10) for the LC group (p = 0.07), and at postoperative hour 24 it was 0.3 points (0-6) for LESS and 2.3 (0-10) for LC (p = 0.03). There were no significant differences in wound complications. Incisional hernias were not found in either group. CONCLUSIONS The LESS single-port (SP) operations demand a bigger incision than LC surgery. However, there were no differences in healing, wound infections, and hernia development. We found a tendency of less postoperative pain associated with LESS/SP than with LC.


title: Collateral flow as causative of good outcomes in endovascular stroke therapy.

text: BACKGROUND Endovascular reperfusion techniques are a promising intervention for acute ischemic stroke (AIS). Prior studies have identified markers of initial injury (arrival NIH stroke scale (NIHSS) or infarct volume) as predictive of outcome after these procedures. We sought to define the role of collateral flow at the time of presentation in determining the extent of initial ischemic injury and its influence on final outcome. METHODS Demographic, clinical, laboratory, and radiographic data were prospectively collected on a consecutive cohort of patients who received endovascular therapy for acute cerebral ischemia at a single tertiary referral center from September 2004 to August 2010. RESULTS Higher collateral grade as assessed by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) grading scheme on angiography at the time of presentation was associated with improved reperfusion rates after endovascular intervention, decreased post-procedural hemorrhage, smaller infarcts on presentation and discharge, as well as improved neurological function on arrival to the hospital, discharge, and 90 days later. Patients matched by vessel occlusion, age, and time of onset demonstrated smaller strokes on presentation and better functional and radiographic outcome if found to have superior collateral flow. In multivariate analysis, lower collateral grade independently predicted higher NIHSS on arrival. CONCLUSIONS Improved collateral flow in patients with AIS undergoing endovascular therapy was associated with improved radiographic and clinical outcomes. Independent of age, vessel occlusion and time, in patients with comparable ischemic burdens, changes in collateral grade alone led to significant differences in initial stroke severity as well as ultimate clinical outcome.


The COVID-19 Pandemic: Critical Care Allocated in Extremis.


title: Early Phase of the COVID-19 Outbreak in Hungary and Post-Lockdown Scenarios.

text: COVID-19 epidemic has been suppressed in Hungary due to timely non-pharmaceutical interventions, prompting a considerable reduction in the number of contacts and transmission of the virus. This strategy was effective in preventing epidemic growth and reducing the incidence of COVID-19 to low levels. In this report, we present the first epidemiological and statistical analysis of the early phase of the COVID-19 outbreak in Hungary. Then, we establish an age-structured compartmental model to explore alternative post-lockdown scenarios. We incorporate various factors, such as age-specific measures, seasonal effects, and spatial heterogeneity to project the possible peak size and disease burden of a COVID-19 epidemic wave after the current measures are relaxed.


title: Heliox for mechanically ventilated newborns with bronchopulmonary dysplasia.

text: OBJECTIVE We assessed the safety and studied the influence of short-term helium-oxygen (heliox) mechanical ventilation (MV) on respiratory function, gas exchange and oxygenation in infants with bronchopulmonary dysplasia (BPD) or at high risk for BPD. DESIGN A pilot, time-series study. SETTING Neonatal intensive care unit. PATIENTS Infants with severe BPD who required MV. INTERVENTIONS MV with helium-oxygen and air-oxygen mixtures. MAIN OUTCOME MEASURES Respiratory parameters, acid-base balance, oxygenation and vital signs were recorded at five time points: initially during MV with air-oxygen, after 15 and 60 min of helium-oxygen MV, and 15 and 60 min after return to air-oxygen MV. RESULTS 15 infants with BPD were enrolled. Helium-oxygen MV was well tolerated and was associated with a statistically significant increase in tidal volume, dynamic compliance and peak expiratory flow rate. An improvement in oxygenation and a decrease in fraction of inspired oxygen was also observed. During helium-oxygen MV there was a significant decrease in the oxygenation index and alveolar-arterial oxygen tension difference. The PaO2/fraction of inspired oxygen (FiO2) ratio increased significantly during helium-oxygen ventilation. A decrease in PaCO2 and an increase in pH were also observed during helium-oxygen administration, however this was not statistically significant. After ventilation with helium-oxygen was discontinued, the infants' respiratory function and oxygenation deteriorated and supplemental oxygen requirements increased accordingly. CONCLUSIONS Helium-oxygen MV is safe and resulted in improvement of respiratory function and oxygenation in infants with severe BPD requiring MV.


title: Laparoscopic Sleeve Gastrectomy Versus Banded Roux-en-Y Gastric Bypass for Diabetes and Obesity: a Prospective Randomised Double-Blind Trial.

text: BACKGROUND There are very few randomised, blinded trials comparing laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB) in achieving remission of type 2 diabetes (T2D), particularly silastic ring (SR)-LRYGB. We compared the effectiveness of (LSG) versus SR-LRYGB among patients with T2D and morbid obesity. METHODS Prospective, randomised, parallel, 2-arm, blinded clinical trial conducted in a single Auckland (New Zealand) centre. Eligible patients aged 20-55 years, T2D of at least 6 months duration and BMI 35-65 kg/m2 were randomised 1:1 to LSG (n = 58) or SR-LRYGB (n = 56) using random number codes disclosed after anaesthesia induction. Primary outcome was T2D remission defined by different HbA1c thresholds at 1 year. Secondary outcomes included weight loss, quality of life, anxiety and depressive symptoms, post-operative complications and mortality. RESULTS Mean ± standard deviation (SD) pre-operative BMI was 42.5 ± 6.2 kg/m2, HbA1c 63 ± 16 mmol/mol (30% insulin-treated, 28% had diabetes duration over 10 years). Proportions achieving HbA1c ≤ 38 mmol/mol, < 42 mmol/mol, < 48 mmol/mol and < 53 mmol/mol without diabetes medication at 1 year in SR-LRYGB vs LSG were 38 vs 43% (p = 0.56), 52 vs 49% (p = 0.85), 75 vs 72% (p = 0.83) and 80 vs 77% (p = 0.82), respectively. Mean ± SD % total weight loss at 1 year was greater after SR-LRYGB than LSG: 32.2 ± 7.7 vs 27.1 ± 7.5%, respectively (p < 0.001). Gastrointestinal complications were more frequent after SR-LRYGB (including 3 ulcers, 1 anastomotic leak, 1 abdominal bleeding). Quality of life and depression symptoms improved significantly in both groups. CONCLUSION Despite significantly greater weight loss after SR-LRYGB, there was similar T2D remission and psychosocial improvement after LSG and SR-LRYGB at 1 year. TRIAL REGISTRATION Prospectively registered at Australia and New Zealand Clinical Trials Register (ACTRN 12611000751976) and retrospectively registered at Clinical Trials (NCT1486680).


title: Elevated Amygdala Activity in Young Adults With Familial Risk for Depression: A Potential Marker of Low Resilience.

text: BACKGROUND Amygdala overactivity has been frequently observed in patients with depression, as well as in nondepressed relatives of patients with depression. A remaining unanswered question is whether elevated amygdala activity in those with familial risk for depression is related to the presence of subthreshold symptoms or to a trait-level vulnerability for illness. METHODS To examine this question, functional magnetic resonance imaging data were collected in nondepressed young adults with (family history [FH+]) (n = 27) or without (FH-) (n = 45) a first-degree relative with a history of depression while they viewed images of "looming" or withdrawing stimuli (faces and cars) that varied in salience by virtue of their apparent proximity to the subject. Activation of the amygdala and 2 other regions known to exhibit responses to looming stimuli, the dorsal intraparietal sulcus (DIPS) and ventral premotor cortex (PMv), were measured, as well as levels of resilience, anxiety, and psychotic and depressive symptoms. RESULTS Compared with the FH- group, the FH+ group exhibited significantly greater responses of the amygdala, but not the dorsal intraparietal sulcus or ventral premotor cortex, to looming face stimuli. Moreover, amygdala responses in the FH+ group were negatively correlated with levels of resilience and unrelated to levels of subthreshold symptoms of psychopathology. CONCLUSIONS These findings indicate that elevated amygdala activity in nondepressed young adults with a familial history of depression is more closely linked to poor resilience than to current symptom state.


title: Cost analysis of intubation-related tracheal injury using a national database.

text: OBJECTIVE To perform risk analysis of tracheal injuries caused by endotracheal intubation (ETI) and to estimate the financial impact of these sequelae. STUDY DESIGN Cost analysis using a national database. SETTINGS The Agency for Healthcare Research and Quality (AHRQ) 2006 National Inpatient Sample. SUBJECTS AND METHODS We identified clinical manifestations and treatments of complications associated with endotracheal tubes and codified them into International Classification of Disease-ninth revision diagnosis and procedure codes, intentionally excluding alternative etiologies of tracheal injury. Using the AHRQ 2006 National Inpatient Sample, we then compared patients with tracheal injury coded during the medical or surgical stay for length of stay (LOS) and mean hospital cost with diagnosis-related group (DRG)-matched controls; we also examined readmissions treating tracheal injury. RESULTS Tracheal injury presents as tracheal stenosis, tracheomalacia, tracheoesophageal fistula, laryngotracheal ulceration, and vocal cord paralysis. A total of 3232 discharge records met criteria for tracheal injury from ETI within the index hospital stay. Average LOS for patients with tracheal injury (6.3 days; 95% confidence interval [CI] 6.0-6.3) exceeded LOS in the uncomplicated sample (5.2 days; CI 5.1-5.3) by 1.1 days. The average hospital cost was $1888 higher with tracheal injury ($10,375 [CI $9762-$10,988] vs $8487 [CI $8266-$8669]). LOS for procedures treating prior tracheal injury averaged 4.7 days and cost an average of $11,025 per discharge. CONCLUSION Tracheal injury from ETI is associated with a significant increase in healthcare costs that accrue both during the index admission and during subsequent hospitalizations required to treat the injury.


title: Rabies encephalitis and extra-neural manifestations in a patient bitten by a domestic cat.

text: Rabies encephalitis is a fatal zoonotic viral disease transmitted to humans either by domestic animals like dogs and cats or by wild animals like bats, skunks and raccoons. We present the case of a 25-year-old woman admitted due to behavioral disorders, generalized paresthesiasand acute respiratory deterioration compatible with a respiratory distress syndrome (ARDS) requiring orotracheal intubation, mechanical ventilation and empirical initiation of antibiotic and antiviral therapy. Chest tomography showed pneumomediastinum and changes suggestive of pulmonary infection. In the presence of neurological symptoms, a central nervous system (CNS) infection was suspected and the cerebrospinal fluid showed no pleocytosis, hiperproteinorrachy without glucose consumption; cranial CT scan was normal. During hospitalization, the family reported that the patient was bitten by a cat 30-day prior to the onset of rabies-like symptoms, and the animal was sacrificed. The patient had an unfavorable clinical evolution, with electroencephalographic activity dissociation evidenced by video telemetry. The zoonotic exposure led to the suspected diagnosis of rabies infection. The patient died and the suspected diagnosis was confirmed by histopathology, with presence of Negri bodies on cerebellum Purkinje cells and a positive immunofluorescence test for rabies virus. Both, initial extra-neural manifestations and late reporting of rabies exposure led to delayed diagnosis.


title: Variability and limitations in home-based exercise program descriptions in oncology: a scoping review.

text: BACKGROUND The literature reflects considerable heterogeneity in what constitutes home-based exercise interventions. The variability for where and what "home-based" exercise can represent challenges interpretation of findings and appropriate advocacy, referral, or development of these models of care. Therefore, the objective of this review was to provide a comprehensive summary of how home-based exercise is defined and reported in the literature and summarize the range of supportive elements utilized in home-based exercise trials. METHODS We followed methodology for scoping reviews. Relevant research databases were searched from inception to March 2019. Two reviewers independently screened articles to determine eligibility and extracted terminology used to describe home-based exercise and intervention details for intervention delivery. RESULTS Of the 9432 records identified, 229 articles met inclusion criteria. Across the literature, exercise interventions were described as home-based if they were completed at-home, outdoors in the neighbourhood, and in community facilities; or in self-selected environments; or if they were unsupervised. Supportive elements for home-based models ranged with respect to the amount of supervision and resources utilized, including the provision of print materials, exercise equipment, telephone support, home visits, and technology. CONCLUSIONS This review provides a comprehensive summary of strategies previously utilized to deliver home-based exercise interventions in oncology, along with the various definitions of the home-based environment for exercise reported by researchers. Specific recommendations to improve the prescription and reporting of home-based exercise interventions are provided in order to facilitate the delivery, evaluation, and translation of findings into clinical practice.


title: Co-expression of hepatitis C virus polytope-HBsAg and p19-silencing suppressor protein in tobacco leaves.

text: CONTEXT Plants transformed by virus-based vectors have emerged as promising tools to rapidly express large amounts and inexpensive antigens in transient condition. OBJECTIVE We studied the possibility of transient-expression of an HBsAg-fused polytopic construct (HCVpc) [containing H-2d and HLA-A2-restricted CD8+CTL-epitopic peptides of C (Core; aa 132-142), E6 (Envelope2; aa 614-622), N (NS3; aa 1406-1415), and E4 (Envelope2; aa 405-414) in tandem of CE6NE4] in tobacco (Nicotiana tabacum) leaves for the development of a plant-based HCV vaccine. MATERIALS AND METHODS A codon-optimized gene encoding the Kozak sequence, hexahistidine (6×His)-tag peptide, and HCVpc in tandem was designed, chemically synthesized, fused to HBsAg gene, and inserted into Potato virus X (PVX-GW) vector under the control of duplicated PVX coat protein promoter (CPP). The resulted recombinant plasmids (after confirmation by restriction and sequencing analyses) were transferred into Agrobacterium tumefaciens strain GV3101 and vacuum infiltrated into tobacco leaves. The effect of gene-silencing suppressor, p19 protein from tomato bushy stunt virus, on the expression yield of HCVpc-HBsAg was also evaluated by co-infiltration of a p19 expression vector. RESULTS Codon-optimized gene increased adaptation index (CAI) value (from 0.61 to 0.92) in tobacco. The expression of the HCVpc-HBsAg was confirmed by western blot and HBsAg-based detection ELISA on total extractable proteins of tobacco leaves. The expression level of the fusion protein was significantly higher in p19 co-agroinfiltrated plants. DISCUSSION AND CONCLUSION The results indicated the possibility of expression of HCVpc-HBsAg constructs with proper protein conformations in tobacco for final application as a plant-derived HCV vaccine.


title: Relative health performance in BRICS over the past 20 years: the winners and losers.

text: OBJECTIVE To determine whether the health performance of Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--has kept in step with their economic development. METHODS Reductions in age- and sex-specific mortality seen in each BRICS country between 1990 and 2011 were measured. These results were compared with those of the best-performing countries in the world and the best-performing countries with similar income levels. We estimated each country's progress in reducing mortality and compared changes in that country's mortality rates against other countries with similar mean incomes to examine changes in avoidable mortality. FINDINGS The relative health performance of the five study countries differed markedly over the study period. Brazil demonstrated fairly even improvement in relative health performance across the different age and sex subgroups that we assessed. India's improvement was more modest and more varied across the subgroups. South Africa and the Russian Federation exhibited large declines in health performance as well as large sex-specific inequalities in health. Although China's levels of avoidable mortality decreased in absolute terms, the level of improvement appeared low in the context of China's economic growth. CONCLUSION When evaluating a country's health performance in terms of avoidable mortality, it is useful to compare that performance against the performance of other countries. Such comparison allows any country-specific improvements to be distinguished from general global improvements.