title: Transgastric large-organ extraction: the initial human experience.

text: INTRODUCTION In laparoscopy, it often is the case that port sites are enlarged for specimen extraction. This leads to higher risk of trocar site complications, such as infection or incisional hernia. Natural orifice surgery (NOTES) is beneficial for minimizing these complications, and this is emphasized when the extracted specimen is of large volume. We have been using transgastric technique for appendectomy, cholecystectomy, and laparoscopic sleeve gastrectomy (LSG). Of these transgastric operations, we focus on the one with relatively large-organ extraction: LSG with transoral remnant extraction (TORE). We describe the details and feasibility of this procedure and compare the outcomes to conventional LSG. METHODS All patients undergoing LSG were considered candidates for TORE and were consented for this procedure if interested after an informed discussion. Eighteen LSGs with TORE (TORE group) and ten conventional LSGs (non-TORE group) were performed from August 2010 to March 2011. We retrospectively compared these two groups for the age, sex, preoperative body mass index, operating room time, hospital stay, excess weight loss (EWL), and trocar site complications. Laparoscopic sleeve gastrectomy with TORE consists of conventional LSG and transgastric retrieval of the resected stomach. The procedure exceeds exactly the same manner as conventional LSG until the initial stapling of the stomach. For TORE, the gastrectomy is initiated 5 cm proximal to the pylorus than usual LSG to save the space for the gastrotomy used for specimen retrieval. After the gastrectomy is completed, the full thickness of the distal most part of the staple line is incised open as wide as 2 cm by using electric cautery or ultrasonic dissector. A flexible upper endoscope, which has been in the stomach already as a bougie for gastrectomy, is then guided into the peritoneal cavity through the gastrotomy. The specimen is grasped endoscopically with a snare and extracted transorally. Following this, the gastrotomy is closed laparoscopically. The final shape of the gastric sleeve is identical to the one of conventional LSG. RESULTS There was no significant difference between the TORE and the non-TORE group for patients' profile, operating room time, hospital stay, and EWL. Neither group has experienced perioperative complications. All specimens were extracted readily and safely in the TORE group. Of the ten cases in the non-TORE group, four required extension of the trocar site. No trocar site complications were found in the TORE group, whereas the extended trocar site developed panniculitis in two cases of the non-TORE group; one required panniculectomy for refractory induration. CONCLUSIONS TORE can be safely and easily performed by surgeons with laparoscopic and endoscopic skill, and with commonly available instruments. While producing identical outcomes, our initial experience with the TORE technique demonstrates an advantage over traditional LSG, because it minimizes trocar site complications. Transgastric organ extraction is potentially applicable to other large-organ extractions in laparoscopic surgery without excessive risk or resources. Larger case volume and longer follow-up period is awaited.


ANNALS EXPRESS: Serological tests for Covid-19 antibodies: limitations must be recognised.


title: Stroke intervention for middle cerebral artery thrombus in a young patient with an ipsilateral Spetzler-Martin grade V arteriovenous malformation.

text: A patient (in their late 20s) was admitted with a right frontal stroke, left hemiparesis and hemianopsia, and a National Institutes of Health Stroke Scale (NIHSS) score of 11. CT perfusion imaging revealed an ischemic penumbra. A CT angiogram showed a Spetzler-Martin grade V arteriovenous malformation (AVM) in the right frontal lobe and a second, smaller AVM in the medial occipital region. Successful mechanical thrombectomy for middle cerebral artery thrombi improved flow from a Thrombolysis in Cerebral Infarction score of 0 to 2b. Following endovascular mechanical thrombectomy, the NIHSS dramatically improved from 11 to 2 and the patient was discharged home in 7 days. Evaluation 1 month after treatment disclosed a nearly complete recovery, with mild residual arm weakness (NIHSS 1). This case illustrates acute stroke intervention in the setting of an ipsilateral, large, high flow AVM in a young adult and is the first such reported case to our knowledge.


title: Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association.

text: BACKGROUND Kawasaki disease is an acute vasculitis of childhood that leads to coronary artery aneurysms in ≈25% of untreated cases. It has been reported worldwide and is the leading cause of acquired heart disease in children in developed countries. METHODS AND RESULTS To revise the previous American Heart Association guidelines, a multidisciplinary writing group of experts was convened to review and appraise available evidence and practice-based opinion, as well as to provide updated recommendations for diagnosis, treatment of the acute illness, and long-term management. Although the cause remains unknown, discussion sections highlight new insights into the epidemiology, genetics, pathogenesis, pathology, natural history, and long-term outcomes. Prompt diagnosis is essential, and an updated algorithm defines supplemental information to be used to assist the diagnosis when classic clinical criteria are incomplete. Although intravenous immune globulin is the mainstay of initial treatment, the role for additional primary therapy in selected patients is discussed. Approximately 10% to 20% of patients do not respond to initial intravenous immune globulin, and recommendations for additional therapies are provided. Careful initial management of evolving coronary artery abnormalities is essential, necessitating an increased frequency of assessments and escalation of thromboprophylaxis. Risk stratification for long-term management is based primarily on maximal coronary artery luminal dimensions, normalized as Z scores, and is calibrated to both past and current involvement. Patients with aneurysms require life-long and uninterrupted cardiology follow-up. CONCLUSIONS These recommendations provide updated and best evidence-based guidance to healthcare providers who diagnose and manage Kawasaki disease, but clinical decision making should be individualized to specific patient circumstances.


title: Health and wellness among incoming resident physicians: A multi-domain survey.

text: Introduction Burnout and depression are well-described in medical students and physicians and can lead to adverse personal and patient outcomes; however, their time course and risk factors remain understudied. Here, we measured multiple domains of mental and physical health and wellness and assessed gender differences among incoming physician trainees beginning residency at an academic medical center. Methods Using a cross-sectional study design, all incoming trainees (i.e. housestaff) at Johns Hopkins Hospital received a questionnaire assessing depression, burnout, sleep, exercise, and alcohol consumption, among other domains. Standardized instruments were utilized for questionnaire development. Tests of significance were two-tailed. Results 196 of 229 incoming housestaff (86%) completed the survey, and 49% were female. A history of depression was reported in 8%, and 5.4% met criteria for at least moderate depression by Patient Health Questionnaire (PHQ-9). Females were more likely to report a history of depression than males (13% vs. 3%, p=0.02) but had similar PHQ-9 scores. Four percent of participants reported feeling they were in the wrong profession. Goal and mean sleep were 7 and 6.7 hours/night, respectively. Forty-seven percent reported exercising once/week or not at all. While mean reported weekly alcohol consumption was three drinks, participants reported consuming ≥5 drinks in one sitting on average 1.6 times in the prior 6 months, and 4% used alcohol to sleep. Conclusions Incoming housestaff reported generally favorable mental and physical health at the beginning of residency training. However, exercise rates were low, and ill-suited alcohol consumption was noted, though infrequent. The few areas of possible improvement were largely similar between males and females. Wellness interventions might capitalize on the relatively high morale and health at the completion of medical school by helping to promote healthy habits, including regular exercise and avoidance of excess alcohol consumption, throughout future training and practice.


title: Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Tissue in Patients with Localized Prostate Cancer: A Prospective Phase 1 Clinical Trial.

text: BACKGROUND Magnetic resonance imaging-guided transurethral ultrasound ablation (MRI-TULSA) is a novel minimally invasive technology for ablating prostate tissue, potentially offering good disease control of localized cancer and low morbidity. OBJECTIVE To determine the clinical safety and feasibility of MRI-TULSA for whole-gland prostate ablation in a primary treatment setting of localized prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS A single-arm prospective phase 1 study was performed at three tertiary referral centers in Canada, Germany, and the United States. Thirty patients (median age: 69 yr; interquartile range [IQR]: 67-71 yr) with biopsy-proven low-risk (80%) and intermediate-risk (20%) PCa were treated and followed for 12 mo. INTERVENTION MRI-TULSA treatment was delivered with the therapeutic intent of conservative whole-gland ablation including 3-mm safety margins and 10% residual viable prostate expected around the capsule. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary end points were safety (adverse events) and feasibility (technical accuracy and precision of conformal thermal ablation). Exploratory outcomes included quality of life, prostate-specific antigen (PSA), and biopsy at 12 mo. RESULTS AND LIMITATIONS Median treatment time was 36min (IQR: 26-44) and prostate volume was 44ml (IQR: 38-48). Spatial control of thermal ablation was ±1.3mm on MRI thermometry. Common Terminology Criteria for Adverse Events included hematuria (43% grade [G] 1; 6.7% G2), urinary tract infections (33% G2), acute urinary retention (10% G1; 17% G2), and epididymitis (3.3% G3). There were no rectal injuries. Median pretreatment International Prostate Symptom Score 8 (IQR: 5-13) returned to 6 (IQR: 4-10) at 3 mo (mean change: -2; 95% confidence interval [CI], -4 to 1). Median pretreatment International Index of Erectile Function 13 (IQR: 6-28) recovered to 13 (IQR: 5-25) at 12 mo (mean change: -1; 95% CI, -5 to 3). Median PSA decreased 87% at 1 mo and was stable at 0.8 ng/ml (IQR: 0.6-1.1) to 12 mo. Positive biopsies showed 61% reduction in total cancer length, clinically significant disease in 9 of 29 patients (31%; 95% CI, 15-51), and any disease in 16 of 29 patients (55%; 95% CI, 36-74). CONCLUSIONS MRI-TULSA was feasible, safe, and technically precise for whole-gland prostate ablation in patients with localized PCa. Phase 1 data are sufficiently compelling to study MRI-TULSA further in a larger prospective trial with reduced safety margins. PATIENT SUMMARY We used magnetic resonance imaging-guided transurethral ultrasound to heat and ablate the prostate in men with prostate cancer. We showed that the treatment can be targeted within a narrow range (1mm) and has a well-tolerated side effect profile. A larger study is under way. TRIAL REGISTRATION NCT01686958, DRKS00005311.


title: A cross-species view on viruses.

text: We describe the creative ways that virologists are leveraging experimental cross-species infections to study the interactions between viruses and hosts. While viruses are usually well adapted to their hosts, cross-species approaches involve pairing viruses with species that they do not naturally infect. These cross-species infections pit viruses against animals, cell lines, or even single genes from foreign species. We highlight examples where cross-species infections have yielded insights into mechanisms of host innate immunity, viral countermeasures, and the evolutionary interplay between viruses and hosts.


Coronavirus Disease 2019: The Role of the Fibrinolytic System from Transmission to Organ Injury and Sequelae.


title: Skin temperature changes following sciatic nerve injury in rats.

text: In the clinical setting, skin temperature is both easily evaluated and useful in assessments of sympathetic dysfunction. The present study purposed to observe the serial skin temperature changes of both hindlimbs following several types of sciatic nerve injury (complete transection and ligation model [CTL], crush injury model [CRI], and chronic constriction injury model [CCI]) in Sprague-Dawley rats and, further, to delineate the possible mechanisms through various evaluation methods. The temperature differences between the intact and injured areas (ΔT) on the plantar surface and toes varied among the CTL, CRI, and CCI injury models during the acute stage (7 days post-injury). During the subacute to chronic stages (7-28 days post-injury), ΔT on the plantar area and toes of the CCI model were higher than those of the CTL and CRI models. The sciatic functional index was gradually restored in the CRI and CCI models, but was unchanged in the CTL model. The CTL model showed constant hypoesthesia; the CRI model, contrastingly, was restored to normal, and the CCI model showed gradual hyperesthesia until 28 days post-injury. The latency and amplitude of the compound muscle action potential (CMAP) in the involved plantar muscle was not found in the CTL group 4 weeks post-injury, but showed gradual restoration in the CRI and CCI models. Regression analysis revealed that the ΔT in the plantar area and toes were affected only by the CMAP amplitude in the involved plantar muscle; therefore, it can be said that the skin temperature on the injured area after sciatic nerve injury was influenced by the functional status of the involved muscle. Measurement of skin temperature can differentiate mild peripheral nerve injury from moderate-to-severe injuries, although its clinical significance might be limited.


title: Clinical Outcomes Following Recurrence of Intestinal Metaplasia After Successful Treatment of Barrett's Esophagus With Radiofrequency Ablation.

text: OBJECTIVES Radiofrequency ablation (RFA) is an effective treatment for Barrett's esophagus (BE). However, recurrence of BE after initially successful RFA is common, and outcomes following recurrence not well described. We report the outcomes associated with recurrence following initially successful RFA. METHODS We performed a retrospective cohort study of 306 patients treated with RFA for dysplastic BE. Complete eradication of intestinal metaplasia (CE-IM) was defined as complete histological and endoscopic remission of IM. Recurrence was defined as any presence of IM or dysplasia in the tubular esophagus or dysplasia in the gastric cardia subsequent to CE-IM. We examined rates and risk factors for recurrence, dysplastic recurrence, and invasive adenocarcinoma after CE-IM. We also describe the clinical course of patients following recurrence. RESULTS Of the 306 eligible patients undergoing RFA, 218 achieved CE-IM and also had subsequent surveillance endoscopy. Of these, 52 (24%) experienced recurrence of IM or Barrett's-associated neoplasia over 540.6 person-years (incidence rate 9.6%/year). Thirty (58%) of these achieved second CE-IM; 4 (1.8% of total, 7.7% of recurrences) ultimately progressed to invasive adenocarcinoma (incidence rate 0.65%/year). Longer Prague M was a strong risk factor for invasive adenocarcinoma (rate ratio of 1.34/cm). Most dysplastic recurrences were in the cardia, and the majority were not visible but detected on random biopsies. CONCLUSIONS Most patients with recurrent BE after initially successful RFA achieve second CE-IM; however, 1.8% progressed to invasive adenocarcinoma. Longer Prague M was predictive of invasive adenocarcinoma. Four-quadrant random biopsy of the cardia is advisable during surveillance endoscopy after CE-IM.


title: Clinical features, adenovirus types, and local production of inflammatory mediators in adenovirus infections.

text: BACKGROUND Adenovirus infection manifests in many ways, with respiratory and gastrointestinal symptoms predominating. METHODS We performed a retrospective chart review on children evaluated at our center who had a nasal wash culture positive for adenovirus. Archived nasal washes were retrieved. Polymerase chain reaction for 15 respiratory viruses was performed on these samples. Patients who were coinfected with another virus were excluded. Adenovirus typing was performed using polymerase chain reaction primers directed at the conserved hexon gene. Bead proteomics was used to measure concentrations of inflammatory mediators. RESULTS Seventy-eight patients were infected only with adenovirus. The clinical diagnosis was upper respiratory infection in 60%, pneumonia in 18%, febrile seizure in 8%, and bronchiolitis in 6%. Subgroup-C and B1 infections were most common. Seventy percent of patients with upper respiratory infection and all 5 patients with bronchiolitis had a subgroup-C infection; pneumonia was caused by subgroup-B1 and C viruses. Compared with asymptomatic control patients, adenovirus infected patients had higher nasal wash concentrations of interleukin (IL)-1alpha, IL-6, inducible protein-10, macrophage inflammatory protein-1alpha, tumor necrosis factor alpha, monokine induced by gamma interferon, and interferon-alpha (P < 0.05). In addition, we found that IL-8 and IL-1alpha (P < 0.05) were higher in the nasal washes obtained from hospitalized patients than in nonhospitalized patients. CONCLUSIONS Adenovirus infection causes an array of clinical disease and is associated with local production of several proinflammatory cytokines. The observation that nasal wash IL-8 and IL-1alpha concentrations were higher in patients requiring hospitalization suggests that these mediators contribute to disease severity.


title: Type 2 Endoleaks Post-EVAR: Current Evidence for Rupture Risk, Intervention and Outcomes of Treatment.

text: Type 2 endoleaks (EL2) are the most commonly encountered endoleaks following EVAR. Despite two decades of experience, there remains considerable variation in the management of EL2 with controversies ranging from if to treat, when to treat and how to treat. Here, we summarise the available evidence, describe the treatment techniques available and offer guidelines for management.


title: Management of Acute Myocardial Infarction During the COVID-19 Pandemic.

text: The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 (SARS-CoV2) has resulted in a new and lethal disease termed coronavirus disease 2019 (COVID-19). Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with COVID-19. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating a ST-elevation MI presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury and the prevalence of COVID-19 disease in the US population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on 1) the varied clinical presentations; 2) appropriate personal protection equipment (PPE) for health care workers; 3) role of the Emergency Department, Emergency Medical System and the Cardiac Catheterization Laboratory; and 4) Regional STEMI systems of care. During the COVID-19 pandemic, primary PCI remains the standard of care for STEMI patients at PCI capable hospitals when it can be provided in a timely fashion, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option. This article is protected by copyright. All rights reserved.


title: Symetis Acurate Transapical Aortic Valve: the initial experience with a second generation of transcatheter aortic valve replacement device.

text: BACKGROUND Transcatheter aortic valve replacement (TAVR) has proven to be a valuable alternative to conventional surgical aortic valve replacement in high risk and surgically in operable patients who suffer from severe symptomatic aortic stenosis. However, a significant number of complications, associated with both the learning curve and device specificity, have required attention and subsequent improvement. The Symetis transapical TAVR system is a self-positioning bioprosthesis composed of a non-coronary leaflet of surgical quality porcine tissue valve sewn into a self-expanding nitinol stent that iscovered with a PET-skirt. METHODS From June to September 2013 six patients have been operated on severe aortic stenosis using the new TAVR device. All patients have undergone critical assessment of a local Heart Team and have been disqualified from conventional AVR. Five were woman. Mean age was 82.3 ± 2.0 (mean LogEuroScore 23.9 ± 14.3). Four patients suffered from coronary artery disease - two had history of previous percutaneous coronary intervention with intracoronary stents, while the next two had history of coronary artery bypass grafting. Diabetes was frequent (n = 3) as well as chronic obstructive pulmonary disease (n = 4). Carotid artery disease was encountered in three patients similarly to atrial fibrillation. Mean left ventricular ejection fraction (LVEF) was 51.5 ± 11.8%, but one patient had suffered from low-flow-low-gradient aortic stenosis with LVEF of 29%. RESULTS The procedure was carried out successfully in all six cases. Two patients have received the valve sized L, three - M and one - S. Mean procedure time was 180 ± 19 min, mean cine 7.2 ± 1.2 min. Mean X-ray dose 930 ± 439 mGy, while mean volume of contrast given was 135 ± 61 mL. In all patients but one perivalvular leak (PVL) was not present. One patient had trace of PVL. Also, good LVEF was noted in all patients. Similar findings were obtained 30 days post procedure. No strokes, transient ischaemic attack or other cerebrovascular incidents were observed. CONCLUSIONS This brief clinical communication reports the first Polish experience with the second generation of TAVR device - the Symetis Acurate Transapical Aortic Valve. While it lacks large patient population and longer follow-up, it reveals that TAVR procedure can be performed safely, with minimal X-ray exposure time and contrast given and successfully - with almost nonexistent PVL and no cerebrovascular incidents or heart rhythm disturbances. Heart Team approach is vital, and transapical access should not be treated inferiorly, but rather as an equally appealing TAVR option.


Middle East Respiratory Syndrome.


Cesarean hysterectomy for abnormally invasive placenta: is urologists' participation in the surgery always necessary?


title: From compulsory to voluntary immunisation: Italy's National Vaccination Plan (2005-7) and the ethical and organisational challenges facing public health policy-makers across Europe.

text: Increasing geographical mobility and international travel augment the ease and speed by which infectious diseases can spread across large distances. It is therefore incumbent upon each state to ensure that immunisation programmes are effective and that herd immunity is achieved. Across Europe, a range of immunisation policies exist: compulsion, the offer of financial incentives to parents or healthcare professionals, social and professional pressure, or simply the dissemination of clear information and advice. Until recently, immunisation against particular communicable diseases was compulsory in Italy. The Italian National Vaccination Plan (NVP) (2005-7) paved the way for regions to suspend the sanctions associated with compulsory vaccinations for children when certain criteria are met--for example when immunisation coverage is high and when effective monitoring/surveillance systems are in place--and thus marked a milestone in the move from compulsory to voluntary immunisation. The forthcoming NVP for 2008-10 confirms the liberal approach to vaccination in Italy as it entrusts to the regions responsibility for the achievement and maintenance of herd immunity. This paper reviews the arguments for and against compulsory and voluntary immunisation in relation to the Italian NVP (2005-7) and in the context of the diverse immunisation policies that exist across Europe. It concludes with cautious support for the NVP and an associated shift from compulsory to voluntary immunisation in Italy, and draws similarities between issues concerning regional variation in immunisation policy in Italy and national variation in immunisation policy across Europe and beyond.


title: Modulatory mechanisms of enterocyte apoptosis by viral, bacterial and parasitic pathogens.

text: Enterocyte turnover along with proper epithelial barrier function are crucial aspects of mucosal defense. Apoptosis is a highly regulated type of programmed cell death that allows for the homeostatic turnover of the epithelial layer. Recent studies have suggested that microbial modulation of enterocyte apoptosis can result in increased epithelial permeability, leading to gastrointestinal pathophysiology. In this review, we highlight key mechanisms and pathways via which various viral, bacterial and parasitic pathogens are able to modulate enterocyte apoptosis. We also discuss how these alterations to enterocyte apoptosis can result in the activation of chronic gastrointestinal disorders, such as allergies, irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). The role of proteinase-activated receptors in the pathogenesis of modulated apoptosis-induced pathogenesis is also discussed. Newly discovered processes, through which host epithelial cells may have evolved, rescue mechanisms from microbe-induced apoptosis are discussed. Together, these mechanisms are key to our ever-increasing understanding of host-microbe interactions in the gut.


title: Temporal trends in early case-fatality rates in patients with intracerebral hemorrhage.

text: OBJECTIVE To assess whether temporal trends in very early (within 48 hours) case-fatality rates may differ from those occurring between 48 hours and 30 days in patients with spontaneous intracerebral hemorrhage (ICH). METHODS All cases of ICH that occurred in Dijon, France (151,000 inhabitants), were prospectively collected between 1985 and 2011, using a population-based registry. Time trends in 30-day case fatality were analyzed in 3 periods: 1985-1993, 1994-2002, and 2003-2011. Cox regression models were used to evaluate associations between time periods and case fatality within 48 hours and between 48 hours and 30 days, after adjustments for demographics, risk factors, severity, and ICH location. RESULTS A total of 531 ICH cases were recorded (mean age 72.9 ± 15.8, 52.7% women). Thirty-day case fatality gradually decreased with time from 40.9% in 1985-1993 to 33.5% 1994-2002 and to 29.6% in 2003-2011 (adjusted hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.47-1.07, p = 0.106, for 1994-2002, and adjusted HR 0.49, 95% CI 0.32-0.73, p < 0.001, for 2003-2011). Over the whole study period, 43.6% of 1-month deaths occurred within the first 48 hours following ICH onset. There was no temporal change in case fatality occurring within the first 48 hours but a decrease in deaths occurring between 48 hours and 30 days was observed with time (HR 0.53, 95% CI 0.31-0.90, p = 0.02, for 1994-2002, and HR 0.32, 95% CI 0.32-0.55, p < 0.01, for 2003-2011, compared with 1985-1993). CONCLUSION Although 30-day case fatality significantly decreased over the last 27 years, additional improvements in acute management of ICH are needed since very early case-fatality rates (within 48 hours) did not improve.


title: Effects of prolonged formalin fixation on the immunohistochemical detection of infectious agents in formalin-fixed, paraffin-embedded tissues.

text: Immunohistochemistry is commonly used to detect and characterize infectious agents in diagnostic pathology. The principal advantage of immunohistochemistry over other antigen detection techniques is the ability to identify antigen within the context of histologic lesions. Although epitope masking attributed to formalin fixation, especially prolonged fixation, has been considered a limiting factor in diagnostic immunohistochemistry, only a few studies have evaluated the immunohistochemical detection of infectious agents following prolonged formalin fixation. Therefore, the goal of this study was to evaluate the effects of prolonged formalin fixation on the immunohistochemical detection of 21 infectious agents. Tissue slices about 5 mm thick were fixed in 10% neutral-buffered formalin, processed, and paraffin embedded at day 1 or 2 and then at approximately weekly intervals. Three pathologists graded immunoreactivity according to a four-tier grading system: negative, weak, moderate, strong. Canine parvoviral immunoreactivity was markedly decreased following 2, 7, and 10 weeks of fixation in myocardium, small intestine, and spleen, respectively. Bovine respiratory syncytial virus immunoreactivity was markedly decreased following 7 weeks of fixation. Bartonella henselae had an abrupt loss of immunoreactivity following 9 weeks of fixation. Despite variation among time points, immunoreactivity remained moderate to strong throughout the study period for the other 18 antigens. These results suggest that prolonged formalin fixation of up to 7 weeks generally does not limit immunohistochemical detection of infectious agents. However, the effects of prolonged fixation depend on the targeted antigen and the selected antibody. The results of this study further validate the utility and reliability of immunohistochemistry in diagnostic pathology.


title: Toward translating near-infrared spectroscopy oxygen saturation data for the non-invasive prediction of spatial and temporal hemodynamics during exercise.

text: Image-based computational fluid dynamics (CFD) studies conducted at rest have shown that atherosclerotic plaque in the thoracic aorta (TA) correlates with adverse wall shear stress (WSS), but there is a paucity of such data under elevated flow conditions. We developed a pedaling exercise protocol to obtain phase contrast magnetic resonance imaging (PC-MRI) blood flow measurements in the TA and brachiocephalic arteries during three-tiered supine pedaling at 130, 150, and 170 % of resting heart rate (HR), and relate these measurements to non-invasive tissue oxygen saturation [Formula: see text] acquired by near-infrared spectroscopy (NIRS) while conducting the same protocol. Local quantification of WSS indices by CFD revealed low time-averaged WSS on the outer curvature of the ascending aorta and the inner curvature of the descending aorta (dAo) that progressively increased with exercise, but that remained low on the anterior surface of brachiocephalic arteries. High oscillatory WSS observed on the inner curvature of the aorta persisted during exercise as well. Results suggest locally continuous exposure to potentially deleterious indices of WSS despite benefits of exercise. Linear relationships between flow distributions and tissue oxygen extraction calculated from [Formula: see text] were found between the left common carotid versus cerebral tissue [Formula: see text] and the dAo versus leg tissue [Formula: see text]. A resulting six-step procedure is presented to use NIRS data as a surrogate for exercise PC-MRI when setting boundary conditions for future CFD studies of the TA under simulated exercise conditions. Relationships and ensemble-averaged PC-MRI inflow waveforms are provided in an online repository for this purpose.


Palliative Care Pandemic Support for Long-Term Care.


title: An overview of mobile applications (apps) to support the coronavirus disease-2019 response in India.

text: Background & objectives The potential benefits of mobile health (mHealth) initiatives to manage the coronavirus disease-2019 (COVID-19) pandemic have been explored. The Government of India, State governments, and healthcare organizations have developed various mobile apps for the containment of COVID-19. This study was aimed to systematically review COVID-19 related mobile apps and highlight gaps to inform the development of future mHealth initiatives. Methods Google Play and the Apple app stores were searched using the terms 'COVID-19', 'coronavirus', 'pandemic', and 'epidemic' in the first week of April 2020. A list of COVID-19-specific functions was compiled based on the review of the selected apps, the literature on epidemic surveillance, and national and international media reports. The World Health Organization guideline on Digital Health Interventions was used to classify the app functions under the categories of the general public, health workers, health system managers, and data services. Results The search yielded 346 potential COVID-19 apps, of which 50 met the inclusion criteria. Dissemination of untargeted COVID-19-related information on preventative strategies and monitoring the movements of quarantined individuals was the function of 27 (54%) and 19 (32%) apps, respectively. Eight (16%) apps had a contact tracing and hotspot identification function. Interpretation & conclusions Our study highlights the current emphasis on the development of self-testing, quarantine monitoring, and contact tracing apps. India's response to COVID-19 can be strengthened by developing comprehensive mHealth solutions for frontline healthcare workers, rapid response teams and public health authorities. Among this unprecedented global health emergency, the Governments must ensure the necessary but least intrusive measures for disease surveillance.


docid: pihhdinu

title: Severe acute respiratory syndrome coronavirus protein 6 is required for optimal replication.

text: Severe acute respiratory syndrome coronavirus (SARS-CoV) encodes several accessory proteins of unknown function. One of these proteins, protein 6 (p6), which is encoded by ORF6, enhances virus replication when introduced into a heterologous murine coronavirus (mouse hepatitis virus [MHV]) but is not essential for optimal SARS-CoV replication after infection at a relatively high multiplicity of infection (MOI). Here, we reconcile these apparently conflicting results by showing that p6 enhances SARS-CoV replication to nearly the same extent as when expressed in the context of MHV if cells are infected at a low MOI and accelerates disease in mice transgenic for the human SARS-CoV receptor.


title: Resilience or Resistance: A personal response to COVID-19.

text: Shortly after COVID-19 was declared a pandemic by the World Health Organization I sat in my office thinking about the future. The world was in lockdown but I refused to give up my expectations of the present and future, maintaining a Pollyannish outlook no matter what I read, heard or saw. This blithe optimism was facilitated by the fact I had just migrated, had not yet engaged fully with local mass and social media, and was out-of-synch with my former sources of information.


title: Natural and Artificial Intelligence in Neurosurgery: A Systematic Review.

text: BACKGROUND Machine learning (ML) is a domain of artificial intelligence that allows computer algorithms to learn from experience without being explicitly programmed. OBJECTIVE To summarize neurosurgical applications of ML where it has been compared to clinical expertise, here referred to as "natural intelligence." METHODS A systematic search was performed in the PubMed and Embase databases as of August 2016 to review all studies comparing the performance of various ML approaches with that of clinical experts in neurosurgical literature. RESULTS Twenty-three studies were identified that used ML algorithms for diagnosis, presurgical planning, or outcome prediction in neurosurgical patients. Compared to clinical experts, ML models demonstrated a median absolute improvement in accuracy and area under the receiver operating curve of 13% (interquartile range 4-21%) and 0.14 (interquartile range 0.07-0.21), respectively. In 29 (58%) of the 50 outcome measures for which a P-value was provided or calculated, ML models outperformed clinical experts (P < .05). In 18 of 50 (36%), no difference was seen between ML and expert performance (P > .05), while in 3 of 50 (6%) clinical experts outperformed ML models (P < .05). All 4 studies that compared clinicians assisted by ML models vs clinicians alone demonstrated a better performance in the first group. CONCLUSION We conclude that ML models have the potential to augment the decision-making capacity of clinicians in neurosurgical applications; however, significant hurdles remain associated with creating, validating, and deploying ML models in the clinical setting. Shifting from the preconceptions of a human-vs-machine to a human-and-machine paradigm could be essential to overcome these hurdles.


title: The Present and Future of Genomics in Adult Reconstructive Orthopaedic Surgery.

text: As of 2015, members of the "baby boomer generation" comprise 75 million people in the growing United States population. Many of these individuals will be facing the need for total hip or knee replacement. Currently, the age of onset of osteoarthritis continues to decrease and the need for total joint replacements continues to increase. In current practice, nearly all patients undergoing joint replacement receive similar preoperative, intraoperative, and postoperative management strategies. However, wide variability in outcomes and satisfaction with total joint replacement still remain. The key to understanding the cause for such varied outcomes may lie in our understanding of the genetic basis of degenerative joint disease. The future of "orthogenomic" research should be centered on clinical application focusing on early preoperative identification of at-risk patients. The goal is to establish twenty-first-century patient-specific strategies for optimizing results and expectations after adult reconstructive surgery.


title: A BMI-adjusted ultra-low-dose CT angiography protocol for the peripheral arteries-Image quality, diagnostic accuracy and radiation exposure.

text: OBJECTIVES To investigate radiation exposure, objective image quality, and the diagnostic accuracy of a BMI-adjusted ultra-low-dose CT angiography (CTA) protocol for the assessment of peripheral arterial disease (PAD), with digital subtraction angiography (DSA) as the standard of reference. METHODS In this prospective, IRB-approved study, 40 PAD patients (30 male, mean age 72 years) underwent CTA on a dual-source CT scanner at 80kV tube voltage. The reference amplitude for tube current modulation was personalized based on the body mass index (BMI) with 120 mAs for [BMI≤25] or 150 mAs for [2570%) was assessed by two readers independently and compared to subsequent DSA. Radiation exposure was assessed with the computed tomography dose index (CTDIvol) and the dosis-length product (DLP). Objective image quality was assessed via contrast- and signal-to-noise ratio (CNR and SNR) measurements. Radiation exposure and image quality were compared between the BMI groups and between the BMI-adjusted ultra-low-dose protocol and the low-dose institutional standard protocol (ISP). RESULTS The BMI-adjusted ultra-low-dose protocol reached high diagnostic accuracy values of 94% for Reader 1 and 93% for Reader 2. Moreover, in comparison to the ISP, it showed significantly (p<0.001) lower CTDIvol (1.97±0.55mGy vs. 4.18±0.62 mGy) and DLP (256±81mGy x cm vs. 544±83mGy x cm) but similar image quality (p=0.37 for CNR). Furthermore, image quality was similar between BMI groups (p=0.86 for CNR). CONCLUSIONS A CT protocol that incorporates low kV settings with a personalized (BMI-adjusted) reference amplitude for tube current modulation and iterative reconstruction enables very low radiation exposure CTA, while maintaining good image quality and high diagnostic accuracy in the assessment of PAD.


The emerging landscape of health communication in Asia: theoretical contributions, methodological questions, and applied collaborations.


title: Pancreatic and Intestinal Function Post Roux-en-Y Gastric Bypass Surgery for Obesity.

text: OBJECTIVES Despite the fact that the most effective treatment for morbid obesity today is gastric bypass surgery, some patients develop life-threatening nutritional complications associated with their weight loss. METHODS Here we examine the influence of the altered anatomy and digestive physiology on pancreatic secretion and fat absorption. Thirteen post Roux-en-Y gastric bypass (RYGB) patients who had lost >100 lbs in the first year following surgery and who gave variable histories of gastrointestinal (GI) dysfunction, were selected for study. Food-stimulated pancreatic enzyme secretion and GI hormone responses were measured during 2 h perfusions of the Roux limb with a standard polymeric liquid formula diet and polyethylene glycol marker, with collections of secretions from the common channel distal to the anastomosis and blood testing. Fat absorption was then measured during a 72 h balance study when a normal diet was given containing ~100 g fat/d. RESULTS Result showed that all patients had some fat malabsorption, but eight had coefficients of fat absorption <80%, indicative of steatorrhea. This was associated with significantly lower feed-stimulated secretion rates of trypsin, amylase, and lipase, and higher plasma peptide-YY concentrations compared with healthy controls. Five steatorrhea patients were subsequently treated with low quantities of pancreatic enzyme supplements for 3 months, and then retested. The supplements were well tolerated, and fat absorption improved in four of five patients accompanied by an increase in lipase secretion, but body weight increased in only three. Postprandial breath hydrogen concentrations were elevated with some improvement following enzyme supplementation suggesting persistent bacterial overgrowth and decreased colonic fermentation. CONCLUSIONS Our investigations revealed a wide spectrum of gastrointestinal abnormalities, including fat malabsorption, impaired food stimulated pancreatic secretion, ileal brake stimulation, and bacterial overgrowth, in patients following RYGB which could be attributed to the breakdown of the normally highly orchestrated digestive anatomy and physiology.


Minimally invasive treatment of a duodenal perforation associated with the EndoBarrier duodenal-jejunal bypass liner.


title: Whole transcriptome sequence data of 5-FU sensitive and 5-FU resistant tumors generated in a mouse model of de novo carcinogenesis.

text: We have performed whole transcriptome sequencing of 5-FU resistant and 5-FU sensitive tumors generated in a mouse model of de novo carcinogenesis that closely recapitulates tumor initiation, progression and maintenance in vivo. Tumors were generated using the DMBA/TPA model of chemically induced carcinogenesis [1], tumor-bearing mice were subsequently treated with 5-FU, and tumor growth as well as response to treatment was monitored by measuring tumor volume twice a week. Based on these measurements, we selected two 5-FU resistant and two 5-FU sensitive tumors and performed whole transcriptome sequencing and in order to identify differentially expressed transcripts between the two sets. Data obtained is deposited and available through NCBI SRA (reference number SRP155180 - https://www.ncbi.nlm.nih.gov/sra/?term=SRP155180).


title: Endoscopic totally extraperitoneal approach (TEA) technique for primary ventral hernia repair.

text: BACKGROUND Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space). METHODS Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall. RESULTS All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85-145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1-3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10-27 months). CONCLUSION In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.


title: The impact of flexible endoscopy in esophageal surgery.

text: Achalasia and Treatment of esophageal Adenocarcinoma are commonly associated to surgical resection. Newer technologies in interventional endoscopy gave way to a substantial paradigm shift in the management of these conditions. In the case of achalasia, endoscopic myotomy is rapidly displacing Heller's myotomy as the gold standard in many centers. Early stage neoplasia in Barrett's esophagus (BE) comprising high-grade dysplasia (HGD), intramucosal and, in some cases, submucosal carcinoma is now being treated without the need of esophagectomy. This review presents a summary of the most relevant endoscopic techniques for both achalasia and esophageal cancer. Endoscopic advances in diagnostic and therapeutic arenas allow for minimally invasive therapies and organ preservation in most settings of achalasia and early stage neoplasia of the esophagus provided that the clinical setting and physician's expertise are prepared for this approach.


title: Body ownership and the four-hand illusion.

text: Recent studies of the rubber hand illusion (RHI) have shown that the sense of body ownership is constrained by several factors and yet is still very flexible. However, exactly how flexible is our sense of body ownership? In this study, we address this issue by investigating the following question: is it possible that one may have the illusory experience of owning four hands? Under visual manipulation, the participant adopted the experimenter's first-person perspective (1PP) as if it was his/her own. Sitting face to face, the participant saw four hands-the experimenter's two hands from the adopted 1PP together with the subject's own two hands from the adopted third-person perspective (3PP). We found that: (1) the four-hand illusion did not occur in the passive four-hand condition. (2) In the active four-hand condition, the participants tapped their index fingers, imitated by the experimenter. When tactile stimulations were not provided, the key illusion was not induced, either. (3) Strikingly, once all four hands began to act with the same pattern and received synchronous tactile stimulations at the same time, many participants felt as if they had two more hands. These results show that the sense of body ownership is much more flexible than most researchers have suggested.


Successful treatment of patients severely ill with COVID-19.


title: [Rapid review of the use of community-wide surgical masks and acute respiratory infections].

text: OBJECTIVE To assess the effectiveness of using surgical masks in community settings to reduce the probability of infection by SARS-CoV-2 or other acute viral respiratory infection, compared to not using surgical masks. MATERIALS AND METHODS We followed the Cochrane rapid review methodology. The search strategy encompasses one academic database and pre-prints until April 1, 2020. Titles and abstracts were reviewed by one investigator. The full text review was divided among three researchers. The results were synthesized in a narrative way. RESULTS 713 manuscripts were identified, of which 21 met the inclusion criteria. Of six systematic reviews, four found no reduction in the probability of transmission. Experimental home studies found no differences in the probability of contagion associated with the use of mouth masks. Only one modeling study estimated a 20% reduction in the incidence of acute respiratory disease, assuming that 10 to 50% of the population use the surgical masks correctly. CONCLUSIONS The scientific evidence is inconclusive to recommend or discourage the use of surgical masks at the population level. Considering the potential negative effects, official recommendations should await for the results of natural experiments currently occurring in countries that have recommended the use of face masks at the population level.


Responding to the COVID-19 Pandemic: The Need for a Structurally Competent Health Care System.


First Isolation of Human Parechovirus Type 4 in Yamagata, Japan.


docid: touvakhf

title: Transarterial Balloon-assisted Onyx Embolization of Intracranial Arteriovenous Malformations Using a Dual-lumen Balloon Microcatheter: Two Case Reports.

text: The Onyx system has been well established in recent years as a very important material in the treatment of arteriovenous malformations (AVMs). When using the Onyx, it is essential to wait for the creation of a plug around the tip of the catheter, which enables the effective forward penetration of Onyx. Recent reports have shown that the introduction of a dimethyl sulfoxide compatible dual-lumen balloon microcatheter improves the efficiency of AVM embolization. We report our recent experience of two cases of intracranial AVM embolization using Onyx and the transarterial balloon-assisted technique. In both cases, the procedures were successfully performed and the nidus of the AVM was totally occluded in a relatively short time. This technique may enable immediate forward flow and penetration of Onyx without concern about reflux. It may also reduce the procedure time and increase the angiographic occlusion rate. Navigation of the dual-lumen balloon microcatheter nevertheless remains a challenge.


title: Evaluation of monkeypox disease progression by molecular imaging.

text: Infection of nonhuman primates (NHPs) with monkeypox virus (MPXV) is currently being developed as an animal model of variola infection in humans. We used positron emission tomography and computed tomography (PET/CT) to identify inflammatory patterns as predictors for the outcome of MPXV disease in NHPs. Two NHPs were sublethally inoculated by the intravenous (IV) or intrabronchial (IB) routes and imaged sequentially using fluorine-18 fluorodeoxyglucose ((18)FDG) uptake as a nonspecific marker of inflammation/immune activation. Inflammation was observed in the lungs of IB-infected NHPs, and bilobular involvement was associated with morbidity. Lymphadenopathy and immune activation in the axillary lymph nodes were evident in IV- and IB-infected NHPs. Interestingly, the surviving NHPs had significant (18)FDG uptake in the axillary lymph nodes at the time of MPXV challenge with no clinical signs of illness, suggesting an association between preexisting immune activation and survival. Molecular imaging identified patterns of inflammation/immune activation that may allow risk assessment of monkeypox disease.


title: Improved survival after an educational project on colon cancer management in the county of Stockholm--a population based cohort study.

text: INTRODUCTION Outcomes in rectal cancer have improved dramatically after the introduction of total mesorectal excision (TME). Recently, the TME concept has been transformed into that of complete mesocolic excision (CME) in an attempt to improve prognosis for patients with colon cancer. PATIENTS AND METHODS Multidisciplinary team (MDT) workshops including the CME concept were held annually between 2004 and 2008 at the Karolinska University Hospital. The workshops focused on preoperative staging, surgery and histopathology and included lectures and live surgery sessions. To compare survival before and after the "Stockholm Colon Cancer Project" all patients diagnosed with a right sided colon cancer between January 1, 2001 and December 31, 2003 (Group 1) and from January 1, 2006 until December 31, 2008 (Group 2) in Stockholm were identified from the Swedish ColoRectal Cancer Registry (SCRCR). RESULTS The proportion of patients having a tumour resection and the proportion having emergency surgery was higher in Group 1. There were more early tumours and more R0 resections in Group 2. Overall survival in all diagnosed patients and disease free survival after tumour resection was improved in the second time period. DISCUSSION Surgical teaching programmes may have an impact on the management and outcome in colon cancer. The exact impact from the "Stockholm Colon Cancer Project" cannot be established, however it is likely that it contributed to the improved survival.


title: Effect of target temperature management at 32-34 °C in cardiac arrest patients considering assessment by regional cerebral oxygen saturation: A multicenter retrospective cohort study.

text: AIM Target temperature management (TTM) is used in comatose post-cardiac arrest patients, but the recommended temperature range is wide. This study aimed to assess the effectiveness of TTM at 32-34 °C while considering the degree of cerebral injury and cerebral circulation, as assessed by regional cerebral oxygen saturation (rSO2). METHODS This is a secondary analysis of prospectively collected registry data from comatose patients who were transferred to 15 hospitals in Japan after out-of-hospital cardiac arrest (OHCA) from 2011 to 2013. The primary outcome was all-cause mortality at 90 days after OHCA, and the secondary outcome was favorable neurological outcomes as evaluated according to the Cerebral Performance Category. We monitored rSO2 noninvasively with near-infrared spectroscopy, which could assess cerebral perfusion and the balance of oxygen delivery and uptake. RESULTS We stratified 431 study patients into three groups according to rSO2 on hospital arrival: rSO2 ≤40% (n = 296), rSO2 41-60% (n = 67), and rSO2 ≥61% (n = 68). Propensity score analysis revealed that TTM at 32-34 °C decreased all-cause mortality in patients with rSO2 41-60% (average treatment effect on treated [ATT] by propensity score matching [PSM] -0.51, 95%CI -0.70 to -0.33; ATT by inverse probability of treatment weighting [IPW] -0.52, 95%CI -0.71 to -0.34), and increased favorable neurological outcomes in patients with rSO2 41-60% (ATT by PSM 0.50, 95%CI 0.32-0.68; ATT by IPW 0.52, 95%CI 0.35-0.69). CONCLUSION TTM at 32-34 °C effectively decreased all-cause mortality in comatose OHCA patients with rSO2 41-60% on hospital arrival in Japan.


title: Effect of long-term use of ankle-foot orthoses on tibialis anterior muscle electromyography in patients with sub-acute stroke: A randomized controlled trial.

text: OBJECTIVE To determine: (i) whether the use of ankle-foot orthoses over a period of 26 weeks affects tibialis anterior muscle activity; (ii) whether the timing of provision of ankle-foot orthoses (early or delayed) affects the results; (iii) whether the provision of ankle-foot orthoses affects tibialis anterior muscle activity within a single measurement. DESIGN Randomized controlled trial. SUBJECTS Unilateral hemiparetic subjects, a maximum of 6 weeks post-stroke. METHODS Subjects were assigned randomly to early (at inclusion; week 1) or delayed provision of ankle-foot orthoses (8 weeks later; week 9). Tibialis anterior electromyography was measured with and without ankle-foot orthoses, in study weeks 1, 9, 17 and 26. RESULTS A total of 26 subjects were analysed. In a single measurement, use of an ankle-foot orthosis significantly reduced the activity levels of the tibialis anterior muscle during the swing phase (p = 0.041) compared with walking without an ankle-foot or-thosis. During the 26-week follow-up, no changes were found in tibialis anterior muscle activity in the swing phase without an ankle-foot orthosis, both within-groups (p = 0.420 early; p = 0.282 delayed), and between-groups (p = 0.987). After 26 weeks, no differences were found in tibialis anterior muscle activity between both groups in the swing phase, with (p = 0.207) or without ankle-foot orthoses (p = 0.310). CONCLUSION Use of ankle-foot orthoses post-stroke reduced tibialis anterior muscle activity in the swing phase within 1 measurement; however, long-term use of ankle-foot orthoses for 26 weeks did not affect such activity. Early or delayed provision of ankle-foot orthoses did not affect the findings. The results indicate that there is no need to fear negative consequences on tibialis anterior-activity because of long-term AFO-use (early) after stroke.


title: Development and Validation of a Prognostic Model of Swallowing Recovery and Enteral Tube Feeding After Ischemic Stroke.

text: Importance Predicting the duration of poststroke dysphagia is important to guide therapeutic decisions. Guidelines recommend nasogastric tube (NGT) feeding if swallowing impairment persists for 7 days or longer and percutaneous endoscopic gastrostomy (PEG) placement if dysphagia does not recover within 30 days, but, to our knowledge, a systematic prediction method does not exist. Objective To develop and validate a prognostic model predicting swallowing recovery and the need for enteral tube feeding. Design, Setting, and Participants We enrolled participants with consecutive admissions for acute ischemic stroke and initially severe dysphagia in a prospective single-center derivation (2011-2014) and a multicenter validation (July 2015-March 2018) cohort study in 5 tertiary stroke referral centers in Switzerland. Exposures Severely impaired oral intake at admission (Functional Oral Intake Scale score <5). Main Outcomes and Measures Recovery of oral intake (primary end point, Functional Oral Intake Scale ≥5) or return to prestroke diet (secondary end point) measured 7 (indication for NGT feeding) and 30 (indication for PEG feeding) days after stroke. Results In total, 279 participants (131 women [47.0%]; median age, 77 years [interquartile range, 67-84 years]) were enrolled (153 [54.8%] in the derivation study; 126 [45.2%] in the validation cohort). Overall, 64% (95% CI, 59-71) participants failed to recover functional oral intake within 7 days and 30% (95% CI, 24-37) within 30 days. Prolonged swallowing recovery was independently associated with poor outcomes after stroke. The final prognostic model, the Predictive Swallowing Score, included 5 variables: age, stroke severity on admission, lesion location, initial risk of aspiration, and initial impairment of oral intake. Predictive Swallowing Score prediction estimates ranged from 5% (score, 0) to 96% (score, 10) for a persistent impairment of oral intake on day 7 and from 2% to 62% on day 30. Model performance in the validation cohort showed a discrimination (C statistic) of 0.84 (95% CI, 0.76-0.91; P < .001) for predicting the recovery of oral intake on day 7 and 0.77 (95% CI, 0.67-0.87; P < .001) on day 30, and a discrimination for a return to prestroke diet of 0.94 (day 7; 95% CI, 0.87-1.00; P < .001) and 0.71 (day 30; 95% CI, 0.61-0.82; P < .001). Calibration plots showed high agreement between the predicted and observed outcomes. Conclusions and Relevance The Predictive Swallowing Score, available as a smartphone application, is an easily applied prognostic instrument that reliably predicts swallowing recovery. It will support decision making for NGT or PEG insertion after ischemic stroke and is a step toward personalized medicine.


Endoscopic negative-pressure therapy for duodenal leakage using new open-pore film and polyurethane foam drains with the pull-through technique.


title: Understanding the financial impact of robotics in gynecologic surgery.

text: As surgical innovation and technological advancements evolve, the associated costs cannot be overlooked. Currently, the United States health care system is undergoing an attempted overhaul with technology such as robotics sitting front and center of the financial debate. As patient demand for less invasive surgical options increases and standards of practice change, patient outcomes must be carefully evaluated to justify the costs increase from traditional, often more invasive treatments. The collection of financial data is quite varied among hospital systems and so is the models used to determine the costs of robotics. Although limited thus far, various cost data have been ascertained in the areas of reproductive surgery, hysterectomy (both benign and oncologic), and pelvic reconstructive surgery.


title: Intraoperative burst suppression is associated with postoperative delirium following cardiac surgery: a prospective, observational study.

text: BACKGROUND Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with increased morbidity and mortality. We analysed whether perioperative bilateral BIS monitoring may detect abnormalities before the onset of POD in cardiac surgery patients. METHODS In a prospective observational study, 81 patients undergoing cardiac surgery were included. Bilateral Bispectral Index (BIS)-monitoring was applied during the pre-, intra- and postoperative period, and BIS, EEG Asymmetry (ASYM), and Burst Suppression Ratio (BSR) were recorded. POD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit, and patients were divided into a delirium and non-delirium group. RESULTS POD was detected in 26 patients (32%). A trend towards a lower ASYM was observed in the delirium group as compared to the non-delirium group on the preoperative day (ASYM = 48.2 ± 3.6% versus 50.0 ± 4.7%, mean ± sd, p = 0.087) as well as before induction of anaesthesia, with oral midazolam anxiolysis (median ASYM = 49.5%, IQR [47.4;51.5] versus 50.6%, IQR [49.1;54.2], p = 0.081). Delirious patients remained significantly (p = 0.018) longer in a burst suppression state intraoperatively (107 minutes, IQR [47;170] versus 44 minutes, IQR [11;120]) than non-delirious patients. Receiver operating analysis revealed burst suppression duration (area under the curve = 0.73, p = 0.001) and BSR (AUC = 0.68, p = 0.009) as predictors of POD. CONCLUSIONS Intraoperative assessment of BSR may identify patients at risk of POD and should be investigated in further studies. So far it remains unknown whether there is a causal relationship or rather an association between intraoperative burst suppression and the development of POD. TRIAL REGISTRATION clinicaltrials.gov NCT01048775.


title: Updated Estimates of Chronic Conditions Affecting Risk for Complications from Coronavirus Disease, United States.

text: We updated estimates of adults at risk for coronavirus disease complications on the basis of data for China by using recent US hospitalization data. This update to our previous publication substitutes obesity for cancer as an underlying condition and increases adults reporting any of the conditions from 45.4% to 56.0%.


title: Novel Coronavirus disease 2019 (COVID-19): new challenges and new responsibilities in developing countries.

text: Novel coronavirus disease 2019 (COVID-19) is caused by the SARS-CoV-2 virus, which belongs to the genus Coronaviridae with its high mutation rate. From the current perspective, we discuss the current status of COVID-19, new challenges, and potential interventions to control the pandemic in developing counties such as Pakistan.


title: Surgical Technique: Laparoscopic Gastric Sleeve Resection in Super-Obese Patients.

text: Laparoscopic gastric sleeve (LGS) resection in super-obese patients (BMI > 50 kg/m2) is a challenging procedure. We have developed a unique approach and technique for LGS with no buttress stapling and without oversewing. After 102 operations there have been no leaks and late complications.


title: [Interpretation of pathological changes for "Guidelines for the Diagnosis and Treatment of COVID-19 by the National Health Commission (Trial Version 7)"].

text: 国家卫生健康委员会发布《新型冠状病毒肺炎诊疗方案（试行第七版）》，首次将病理变化纳入其中。这些病理变化信息是基于当时所获得的有限病例病理观察（重庆和武汉共7例遗体穿刺、5例系统尸检）结果，经过多名病理专家和临床专家讨论总结并达成共识，是目前较为全面的新型冠状病毒感染疾病（COVID-19）病理变化的总结，是COVID-19诊疗方案的重要指导性指标。本文根据COVID-19病理学研究结果，结合严重急性呼吸综合征（SARS）的病理变化，对两种疾病的多器官病理变化进行了比较分析，发现COVID-19与SARS导致的机体病理变化大致相同，主要病变发生在肺、免疫系统（脾脏、淋巴结）及各器官的血管，但SARS肺、脾脏及各器官的血管病变严重且广泛，而COVID-19 Ⅱ型肺泡上皮细胞的增生不如SARS显著，肺内支气管内甚至肺泡腔内可见较多支气管栓，SARS则少见，这可能是通气和换气功能障碍的直接而重要的病理基础，关于COVID-19病理变化，由于掌握的材料有限，尚需将来积累更多的尸体解剖资料予以补充，目前相关的病理变化信息仅供参考。.


title: Prevalence of common mental disorders in widowhood: A systematic review and meta-analysis.

text: BACKGROUND Widowed people have a high risk of common mental disorders, however no summary estimates of the prevalences exist. The aim of this study was to conduct a systematic review and meta-analysis of the prevalence of common mental disorders in widowed people in the community. METHODS MEDLINE, Embase and PsycInfo were searched for papers reporting on prevalence of common mental disorders and widowhood. Eligible studies were included in random effects meta-analyses of the prevalence of depression and anxiety disorders. Subgroup analyses were performed on method of assessment of depression and age and sex. RESULTS The literature search identified 13,781 titles of which 42 were eligible for meta-analysis. The pooled prevalence of depression in studies using a screening scale was 40.6% (33.6%-47.6%) (n = 30). For studies using full diagnostic criteria the pooled prevalence of depression was 19.2% (13.4%-25.0%) (n = 12). Subgroup analyses of age (≥ or < 65) and sex did not show any differences regarding depression. Five studies reported the prevalence of anxiety disorders. The pooled prevalence estimate was 26.9% (8.1%-45.7%). LIMITATIONS The prevalence estimates in this study are summary estimates of prevalences from existing literature. Although the reporting bias assessment showed no evidence, there could be some reporting bias, as studies might only present results if there is a high prevalence. CONCLUSIONS Widowed people have a high prevalence of depression and anxiety disorders. The high prevalence of depression was independent of age and sex. The study identifies a population group at high risk needing special attention in clinical practice.


title: Carotid artery and lower cranial nerve exposure with increasing surgical complexity to the parapharyngeal space.

text: OBJECTIVES/HYPOTHESIS To investigate the extent of carotid artery exposure attained, including the identification of the external carotid branches and lower cranial nerves in five sequential external approaches to the parapharyngeal space, and to provide an anatomical algorithm. STUDY DESIGN Anatomical study. METHODS Six latex-injected adult cadaver heads were dissected in five consecutive approaches: transcervical approach with submandibular gland removal, posterior extension of the transcervical approach, transcervical approach with parotidectomy, parotidectomy with lateral mandibulotomy, and parotidectomy with mandibulectomy. The degree of carotid artery exposure attained, external carotid branches, and lower cranial nerves visualized was documented. RESULTS The transcervical approach exposed 1.5 cm (Standard Deviation (SD) 0.5) of internal carotid artery (ICA) and 1.25 cm (SD 0.25) of external carotid artery (ECA). The superior thyroid and facial arteries and cranial nerve XII and XI were identified. The posterior extension exposed 2.9 cm (SD 0.7) of ICA and 2.7 cm (SD 1.0) of ECA. Occipital and ascending pharyngeal arteries were visualized. The transparotid approach exposed 4.0 cm (SD 1.1) of ICA and 3.98 cm (SD 1.8) of ECA. Lateral mandibulotomy exposed the internal maxillary artery, cranial nerve X, the sympathetic trunk, and 4.6 cm (SD 2.4) of ICA. Mandibulectomy allowed for complete ECA exposure, cranial nerve IX, lingual nerve, and 6.9 cm (SD 1.3) of ICA. CONCLUSION Approaches for the parapharyngeal space must be based on anatomic and biological patient factors. This study provides a guide for the skull base surgeon for an extended approach based on the desired anatomic exposure. LEVEL OF EVIDENCE N/A. Laryngoscope, 127:585-591, 2017.


Alarm at the Gate-Health and Social Inequalities are Comorbid Conditions of HIV and COVID-19.


title: Implementation of HIV care in Western Kenya during corona virus disease 2019 response.

text: : To ensure the continuity of high-quality HIV care in Kisumu County, Kenya during the corona virus disease 2019 pandemic, the Ministry of Health implemented a strategy to promote physical distancing and corona virus disease 2019 case detection. A total of 23 262 (84.2%) of the 27 641 patients eligible for early refill received an extra 3-month supply of antiretrovirals. Across 60 Ministry of Health clinics, average attendance decreased from 1298 to 640 patients per day postintervention, representing a 50.7% reduction.


title: Therapeutic strategies in an outbreak scenario to treat the novel coronavirus originating in Wuhan, China [version 1;peer review: awaiting peer review]

text: A novel coronavirus (2019-nCoV) originating in Wuhan, China presents a potential respiratory viral pandemic to the world population Current efforts are focused on containment and quarantine of infected individuals Ultimately, the outbreak could be controlled with a protective vaccine to prevent 2019-nCoV infection While vaccine research should be pursued intensely, there exists today no therapy to treat 2019-nCoV upon infection, despite an urgent need to find options to help these patients and preclude potential death Herein, I review the potential options to treat 2019-nCoV in patients, with an emphasis on the necessity for speed and timeliness in developing new and effective therapies in this outbreak I consider the options of drug repurposing, developing neutralizing monoclonal antibody therapy, and an oligonucleotide strategy targeting the viral RNA genome, emphasizing the promise and pitfalls of these approaches Finally, I advocate for the fastest strategy to develop a treatment now, which could be resistant to any mutations the virus may have in the future The proposal is a biologic that blocks 2019-nCoV entry using a soluble version of the viral receptor, angiotensin-converting enzyme 2 (ACE2), fused to an immunoglobulin Fc domain, providing a neutralizing antibody with maximal breath to avoid any viral escape, while also helping to recruit the immune system to build lasting immunity The sequence of the ACE2-Fc protein is provided to investigators, allowing its possible use in recombinant protein expression systems to start producing drug today to treat patients under compassionate use, while formal clinical trials are later undertaken Such a treatment could help infected patients before a protective vaccine is developed and widely available in the coming months to year(s)


title: Comprehensive evaluation of manikin-based airway training with second generation supraglottic airway devices.

text: Background Supraglottic airway devices (SADs) are an essential second line tool during difficult airway management after failed tracheal intubation. Particularly for such challenging situations the handling of an SAD requires sufficient training. We hypothesized that the feasibility of manikin-based airway management with second generation SADs depends on the type of manikin. Methods Two airway manikins (TruCorp AirSim® and Laerdal Resusci Anne® Airway Trainer™) were evaluated by 80 experienced anesthesia providers using 5 different second generation SADs (LMA® Supreme™ [LMA], Ambu® AuraGain™, i-gel®, KOO™-SGA and LTS-D™). The primary outcome of the study was feasibility of ventilation measured by assessment of the manikins' lung distention. As secondary outcome measures, oropharyngeal leakage pressure (OLP), ease of gastric tube insertion the insertion time, position and subjective assessments were evaluated. Results Ventilation was feasible with all combinations of SAD and manikin. By contrast, an OLP exceeding 10 cm H2O could be reached with most of the SADs in the TruCorp but with the LTS-D only in the Laerdal manikin. Gastric tube insertion was successful in above 90% in the Laerdal vs 87% in the TruCorp manikin (P<0.009). Insertion times differed significantly between manikins. The SAD positions were better in the Laerdal manikin for LMA, Ambu, i-gel and LTS-D. Participant's assessments were superior in the Laerdal manikin for LMA, Ambu, i-gel and KOO-SGA. Conclusions Ventilation is possible with all combinations. However, manikins are variable in their ability to adequately represent additional functions of second generation SADs. In order to achieve the best performance during training, the airway manikin should be chosen depending on the SAD in question.


China coronavirus: Six questions scientists are asking.


title: Detection of coronaviruses in children with acute gastroenteritis in Maddina, Saudi Arabia.

text: BACKGROUND The role of coronaviruses in paediatric gastro-enteritis is not well defined. We investigated the detection rate and epidemiological features of infection with coronavirus in children receiving hospital care for acute gastro-enteritis in Maddina, Saudi Arabia. METHODS Stool specimens were collected from children less than 5 years of age who were either hospitalised in Maddina or given oral rehydration therapy as outpatients between April 2004 and April 2005. Coronaviruses were detected by electron microscopy. RESULTS Coronaviruses were detected in 63 (6%) of 984 children with acute gastro-enteritis and were more commonly detected in outpatients (47/423, 11%) than in inpatients (16/561, 3%). The median age (range) of children with coronavirus infection was 42 months (10-60). Coronaviruses were detected throughout the year with the highest detection rate at the end of the winter season. CONCLUSIONS Coronaviruses were commonly identified in children with diarrhoea in Saudi Arabia. Their role in paediatric gastro-enteritis warrants further evaluation.


title: Minimally invasive endovascular stent-electrode array for high-fidelity, chronic recordings of cortical neural activity.

text: High-fidelity intracranial electrode arrays for recording and stimulating brain activity have facilitated major advances in the treatment of neurological conditions over the past decade. Traditional arrays require direct implantation into the brain via open craniotomy, which can lead to inflammatory tissue responses, necessitating development of minimally invasive approaches that avoid brain trauma. Here we demonstrate the feasibility of chronically recording brain activity from within a vein using a passive stent-electrode recording array (stentrode). We achieved implantation into a superficial cortical vein overlying the motor cortex via catheter angiography and demonstrate neural recordings in freely moving sheep for up to 190 d. Spectral content and bandwidth of vascular electrocorticography were comparable to those of recordings from epidural surface arrays. Venous internal lumen patency was maintained for the duration of implantation. Stentrodes may have wide ranging applications as a neural interface for treatment of a range of neurological conditions.


title: Anxiety and depression are more prevalent in patients with graves' disease than in patients with nodular goitre.

text: BACKGROUND AND OBJECTIVE Graves' disease has been associated with an increased psychiatric morbidity. It is unclarified whether this relates to Graves' disease or chronic disease per se. The aim of our study was to estimate the prevalence of anxiety and depression symptoms in patients with Graves' disease compared to patients with another chronic thyroid disease, nodular goitre, and to investigate determinants of anxiety and depression in Graves' disease. METHODS 157 cross-sectionally sampled patients with Graves' disease, 17 newly diagnosed, 140 treated, and 251 controls with nodular goitre completed the Hospital Anxiety and Depression Scale (HADS). The differences in the mean HADS scores between the groups were analysed using multiple linear regression, controlling for socio-demographic variables. HADS scores were also analysed dichotomized: a score >10 indicating probable 'anxiety'/probable 'depression'. Determinants of anxiety and depression symptoms in Graves' disease were examined using multiple linear regression. RESULTS In Graves' disease levels of anxiety (p = 0.008) and depression (p = 0.014) were significantly higher than in controls. The prevalence of depression was 10% in Graves' disease versus 4% in nodular goitre (p = 0.038), anxiety was 18 versus 13% (p = 0.131). Symptoms of anxiety (p = 0.04) and depression (p = 0.01) increased with comorbidity. Anxiety symptoms increased with duration of Graves' disease (p = 0.04). Neither thyroid function nor autoantibody levels were associated with anxiety and depression symptoms. CONCLUSIONS Anxiety and depression symptoms were more severe in Graves' disease than in nodular goitre. Symptoms were positively correlated to comorbidity and duration of Graves' disease but neither to thyroid function nor thyroid autoimmunity.


title: Infection prophylaxis and management of viral infection.

text: Viral infections are associated with significant morbidity and mortality in lung transplant recipients. Importantly, several viral infections have been associated with the development of chronic lung allograft dysfunction (CLAD). Community-acquired respiratory viruses (CARV) such as influenza and respiratory syncytial virus (RSV), are frequently associated with acute and chronic rejection. Cytomegalovirus (CMV) remains a significant burden in regards to morbidity and mortality in lung transplant recipients. Epstein-Barr virus (EBV) is mostly involved with the development of post-transplant lymphoproliferative disorder (PTLD), a lymphoid proliferation that occurs in the setting of immunosuppression. On the other hand, the development of direct acting antivirals for hepatitis C virus (HCV) is changing the use of HCV-positive organs in transplantation. In this article we will focus on reviewing common viral infections that have a significant impact on lung transplant recipients looking at epidemiology, prevention and potential treatment.


title: Self-monitoring of blood pressure in patients with hypertension related multi-morbidity: Systematic review and individual patient data meta-analysis.

text: BACKGROUND Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity. METHODS A systematic review was conducted of articles published in Medline, Embase and the Cochrane Library up to January 2018. Randomised controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorised by whether they examined a low/high intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12-months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis. RESULTS A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (-3.12 mmHg, [95%CI -4.78, -1.46 mmHg]; p value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (p<0.001 for all outcomes), and possibly stroke (p<0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes or chronic kidney disease. CONCLUSIONS Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high intensity co-interventions.


title: Massive traumatic abdominal hernia repair with biologic mesh.

text: Traumatic abdominal wall hernias (TAWHs) are rare. They can arise from either high or low impact trauma and can be associated with significant associated injury. We present the case of a 27-year-old male involved in a high-impact road traffic accident resulting in a TAWH. He sustained significant disruption to the abdominal wall and sustained injuries to the thoracic cage. Operative management was undertaken with a porcine dermal collagen mesh, using a bridge technique.


title: [Virus and Atypical Pathogens Detected in Community-Acquired Lower Respiratory Tract Infection in Infants and Children of Sfax Region, Tunisia].

text: Little is known about viral and atypical bacteria pathogen spectra of community-acquired lower respiratory tract infection in children in Tunisia. Thus, a prospective study was carried out between January 2009 and March 2010 in Sfax. Nasopharyngeal aspirates collected from 368 patients (78 with pneumonia and 290 with acute bronchiolitis) were analyzed by indirect immunofluorescence assay and PCR to detect influenza viruses, parainfluenza viruses, respiratory syncytial virus (RSV), human metapneumovirus, human rhinovirus, human enterovirus, adenovirus, coronavirus, Mycoplasma pneumonia (Mpn) and Chlamydia pneumonia (Cpn). One or more etiology was documented in 319 cases (86.7%). The most detected viruses were RSV (42.7%), rhinovirus (32.9%) and adenovirus (28.5%). Co-detection of two or three pathogens was found in 40% of positive samples. This study highlights the importance of respiratory viruses in lower respiratory tract infection in children of Sfax region as well as the high rate of co-detection of multiple viruses, resulting in challenges in clinical interpretation.


Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic.


title: Paediatric magnetic resonance enteroclysis under general anaesthesia - initial experience.

text: MR enterography is the accepted imaging reference standard for small bowel assessment in inflammatory bowel disease. There is an increasing cohort of children with inflammatory bowel disease presenting at an early age (<5 years) with severe disease. Younger children present a technical challenge for enterography because of the need for sedation/general anaesthesia to allow image optimisation and the need for oral contrast to allow adequate luminal assessment. Through our experiences, MR enteroclysis under general anaesthesia has proven to be a successful imaging technique for the work-up of these patients. In this paper, we present our institutional practice for performing MR enteroclysis under general anaesthesia.


title: The evolving role of infectomics in drug discovery.

text: Signatures of infectomes, which are encoded by both host and microbial genomes, and mirror the interplay between pathogens and their hosts, provide invaluable knowledge in the search for novel antimicrobial drugs. Infectomics is the study of infectomes by using systems biology and high-throughput omic approaches. There are three types of infectomic approaches that can be used for drug discovery: ecological infectomics, immunoinfectomics and chemical infectomics. Ecological infectomics, which is the ecological study of infectomes, explores symbiotic solutions to microbial infections. Research on drug discovery using infectomic signatures and immunomic approaches falls within the field of immunoinfectomics. Advances in chemical infectomics will lead to the development of a new generation of chemical drugs for therapeutics for microbial infections.


title: Tensile strength testing for resorbable mesh fixation systems in laparoscopic ventral hernia repair.

text: BACKGROUND In an attempt to improve patient outcome and quality of life after laparoscopic ventral hernia repair, resorbable fixation devices have been developed to allow adequate mesh fixation while minimizing accompanying side-effects as tack erosion and adhesion formation. MATERIALS AND METHODS In experimental set-up, 24 pigs were treated by laparoscopic mesh placement. Two different meshes (PP/ORC and PP/ePTFE) and four fixation devices were evaluated: a 6.4 mm poly(D,L: )-lactide pushpin (tack I), a 6.8 mm poly(D,L: )-lactide with blunt tip (tack II), a 4.1 mm poly(glycolide-co-L-lactide) (tack III) and one titanium tack (control tack). A first group of animals (n = 12) was euthanized after 2 weeks survival and a second group (n = 12) after 6 months. At euthanasia, a relaparoscopy was performed to assess adhesion formation followed by laparotomy with excision of the entire abdominal wall. Tensile strength of the individual fixation systems was tested with the use of a tensiometer by measuring the force to pull the tack out of the mesh. Additionally, the foreign body reaction to the fixation systems was evaluated histologically as was their potential degradation. RESULTS At 2 weeks the tensile strength was significantly higher for the control tack (31.98 N/cm²) compared to the resorbable devices. Except for tack II, the tensile strength was higher when the devices were fixed in a PP/ePTFE mesh compared to the PP/ORC mesh. After 6 months only tack III was completely resorbed, while tack I (9.292 N/cm²) had the lowest tensile strength. At this time-point similar tensile strength was observed for both tack II (29.56 N/cm²) and the control tack (27.77 N/cm²). Adhesions seem to be more depending on the type of mesh, in favor of PP/ePTFE. CONCLUSION At long term, the 4.1 mm poly(glycolide-co-L-lactide) tack was the only tack completely resorbed while the 6.8 mm poly(D,L: )-lactide tack with blunt tip reached equal strengths to the permanent tack.


title: Comparison of results after anterior cruciate ligament reconstruction using a four-strand single semitendinosus or a semitendinosus and gracilis tendon.

text: PURPOSES To compare the clinical and functional results of anterior cruciate ligament (ACL) reconstruction using an autologous four-strand single semitendinosus (ST) tendon or a ST and gracilis tendon. It was hypothesized that successful ACL reconstruction using a single ST tendon without the gracilis tendon could provide comparable knee stability and reduce donor site morbidity. METHODS This study evaluated 144 cases of single-bundle ACL reconstruction using an autologous hamstring tendon. The ST group included 85 cases of reconstruction using a single ST tendon, and the ST/G group included 59 cases of reconstruction using a ST tendon and a gracilis tendon. An extracortical suspension device and a suture tied around a screw post with an additional bioabsorbable screw were used to fix the femoral and tibial tunnels, respectively. Clinical evaluations involved the Lachman, pivot-shift, and one-leg hop tests; an isokinetic test; a KT-2000 arthrometer; an assessment of return to pre-injury activities; and Lysholm, Tegner activity, and International Knee Documentation Committee (IKDC) subjective scores. RESULTS No significant differences were found between the ST and ST/G groups with respect to the Lysholm, Tegner activity, and subjective IKDC scores; the Lachman, pivot-shift, and one-leg hop tests; KT-2000 arthrometer side-to-side differences; or return to pre-injury activities. However, mean peak torque deficit, as determined using the isokinetic test during flexion at 60°/s, was significantly lower in the ST group than in the ST/G group (p = 0.047). CONCLUSION This study showed good results for ACL reconstruction using a single ST tendon without deterioration of stability. This provides the evidence that ACL reconstruction using a single ST tendon without the gracilis tendon decreases donor site morbidity without compromising joint stability. LEVEL OF EVIDENCE IV.


title: Accuracy of multidetector CT in detecting anastomotic leaks following stapled left-sided colonic anastomosis.

text: AIMS To assess accuracy of multidetector computed tomography (MDCT) and individual radiological signs in the diagnosis of anastomotic leaks. MATERIALS AND METHODS Patients undergoing anterior resection with a stapled anastomosis over a 2 year period were identified. Electronic and clinical records of these patients were reviewed. Unenhanced and/or enhanced MDCT was performed with intravenous and/or per-rectal contrast medium and read by a radiologist blinded to the patients' clinical details to determine the sensitivity and specificity of specific findings at MDCT for identifying leaks. RESULTS Seventeen percent (30/170) of the anterior resections were suspected to have an anastomotic leak. Ninety-three percent (28/30) of patients underwent MDCT. Seven point six percent (11+2/170) had a confirmed leak. Two patients underwent surgery without MDCT. A leak was confirmed by MDCT in 91% (10/11) of patients. The sensitivity, specificity, and positive and negative predictive values of MDCT in diagnosing a leak was 0.91, 1, 1, and 0.95, respectively. The sensitivity of peri-anastomotic air, peri-anastomotic collection, extravasation of rectal contrast medium, and staple line integrity was 0.81, 0.63, 0.54, and 0.72, respectively. Use of rectal contrast medium (8/11 cases) increased the subjective ease of diagnosis and was the only sign in one patient. CONCLUSIONS Presence of peri-anastomotic air is a reliable marker of anastomotic leaks at MDCT. Leakage of rectal contrast medium is highly accurate and increases confidence of diagnosis. The appearance of the staple line itself is not accurate in assessing anastomotic integrity.


title: A novel imaging technique for better detecting new lesions in multiple sclerosis.

text: We developed a tool that performs longitudinal subtraction of 3D double inversion recovery (DIR) images in follow-up magnetic resonance (MR) examinations of patients with multiple sclerosis. As DIR sequences show a high lesion-to-parenchyma contrast, we hypothesized that such a tool might lead to increased sensitivity for new lesions as well as to speeding up the routine clinical work-up of follow-up MR imaging in multiple sclerosis by directly visualizing new lesions. DIR subtraction images of serial MR examinations were calculated in 106 patients with multiple sclerosis. Existence of new lesions was assessed in three different ways: by standard visual comparison, by FLAIR, and by DIR subtraction maps. A reference standard, to which the single modalities were compared, was defined by combining all information from all readouts and all readers. The presence and number of new lesions were determined and the time needed for analysis measured. Accuracy of detecting overall existence of new lesions using DIR subtraction maps was significantly higher than using visual comparison (96 vs. 86%, p = 0.013) or FLAIR subtraction maps (p < 0.001), with increased sensitivity and higher negative predictive value. Significantly more new lesions were detected when using DIR subtraction maps (p < 0.001). Analyzing subtraction maps took less than a third of the time needed for the standard visual comparison (p = 0.007). Thus, DIR subtraction maps improve the detection of new lesions in a clinical setting both in terms of accuracy and in terms of speed.


Protecting older adults during social distancing.


title: Increased mucosal CD4+ T cell activation in rhesus macaques following vaccination with an adenoviral vector.

text: UNLABELLED The possibility that vaccination with adenovirus (AdV) vectors increased mucosal T cell activation remains a central hypothesis to explain the potential enhancement of HIV acquisition within the Step trial. Modeling this within rhesus macaques is complicated because human adenoviruses, including human adenovirus type 5 (HAdV-5), are not endogenous to macaques. Here, we tested whether vaccination with a rhesus macaque-derived adenoviral vector (simian adenovirus 7 [SAdV-7]) enhances mucosal T cell activation within rhesus macaques. Following intramuscular SAdV-7 vaccination, we observed a pronounced increase in SAdV-7-specific CD4(+) T cell responses in peripheral blood and, more dramatically, in rectal mucosa tissue. Vaccination also induced a significant increase in the frequency of activated memory CD4(+) T cells in SAdV-7- and HAdV-5-vaccinated animals in the rectal mucosa but not in peripheral blood. These fluctuations within the rectal mucosa were also associated with a pronounced decrease in the relative frequency of naive resting CD4(+) T cells. Together, these results indicate that peripheral vaccination with an AdV vector can increase the activation of mucosal CD4(+) T cells, potentially providing an experimental model to further evaluate the role of host-vector interactions in increased HIV acquisition after AdV vector vaccination. IMPORTANCE The possibility that vaccination with a human adenovirus 5 vector increased mucosal T cell activation remains a central hypothesis to explain the potential enhancement of human immunodeficiency virus (HIV) acquisition within the Step trial. In this study, we tested whether vaccination with a rhesus macaque-derived adenoviral vector in rhesus macaques enhances mucosal CD4(+) T cell activation, the main cell target of simian immunodeficiency virus (SIV)/HIV. The results showed that vaccination with an adenoviral vector indeed increases activation of mucosal CD4(+) T cells and potentially increases susceptibility to SIV infection.


How GPs can contribute to the challenge of covid-19.


title: ACE2 Expression is Increased in the Lungs of Patients with Comorbidities Associated with Severe COVID-19.

text: PATIENTS who died from COVID-19 often had comorbidities, such as hypertension, diabetes, and chronic obstructive lung disease. Although angiotensin-converting enzyme 2 (ACE2) is crucial for SARS-CoV2 to bind and enter host cells, no study has systematically assessed the ACE2 expression in the lungs of patients with these diseases. Here, we analyzed over 700 lung transcriptome samples of patients with comorbidities associated with severe COVID-19 and found that ACE2 was highly expressed in these patients, compared to control individuals. This finding suggests that patients with such comorbidities may have higher chances of developing severe COVID-19. Correlation and network analyses revealed many potential regulators of ACE2 in the human lung, including genes related to histone modifications, such as HAT1, HDAC2, and KDM5B. Our systems biology approach offers a possible explanation for increase of COVID-19 severity in patients with certain comorbidities.


Rapid Publication, Knowledge Sharing, and Our Responsibility During the COVID-19 Pandemic.


title: Comparison of a Novel Cadaver Model (Fix for Life) With the Formalin-Fixed Cadaver and Manikin Model for Suitability and Realism in Airway Management Training.

text: BACKGROUND Manikins are widely used in airway management training; however, simulation of realism and interpatient variability remains a challenge. We investigated whether cadavers embalmed with the novel Fix for Life (F4L) embalmment method are a suitable and realistic model for teaching 3 basic airway skills: facemask ventilation, tracheal intubation, and laryngeal mask insertion compared to a manikin (SimMan 3G) and formalin-fixed cadavers. METHODS Thirty anesthesiologists and experienced residents ("operators") were instructed to perform the 3 airway techniques in 10 F4L, 10 formalin-fixed cadavers, and 1 manikin. The order of the model type was randomized per operator. Primary outcomes were the operators' ranking of each model type as a teaching model (total rank), ranking of the model types per technique, and an operator's average verbal rating score for suitability and realism of learning the technique on the model. Secondary outcomes were the percentages of successfully performed procedures per technique and per model (success rates in completing the respective airway maneuvers). For each of the airway techniques, the Friedman analysis of variance was used to compare the 3 models on mean operator ranking and mean verbal rating scores. RESULTS Twenty-seven of 30 operators (90%) performed all airway techniques on all of the available models, whereas 3 operators performed the majority but not all of the airway maneuvers on all models for logistical reasons. The total number of attempts for each technique was 30 on the manikin, 292 in the F4L, and 282 on the formalin-fixed cadavers. The operators' median total ranking of each model type as a teaching model was 1 for F4L, 2 for the manikin and, 3 for the formalin-fixed cadavers (P < .001). F4L was considered the best model for mask ventilation (P = .029) and had a higher mean verbal rating score for realism in laryngeal mask airway insertion (P = .043). The F4L and manikin did not differ significantly in other scores for suitability and realism. The formalin-fixed cadaver was ranked last and received lowest scores in all procedures (all P < .001). Success rates of the procedures were highest in the manikin. CONCLUSIONS F4L cadavers were ranked highest for mask ventilation and were considered the most realistic model for training laryngeal mask insertion. Formalin-fixed cadavers are inappropriate for airway management training.