title: Gastric wall thickness and stapling in laparoscopic sleeve gastrectomy - a literature review.

text: Despite the growing experience of bariatric surgeons in performing laparoscopic sleeve gastrectomy, the number of complications involving staple line leaks remains constant. Hence a solution to avoid such complications is still sought. A defect of the staple line may be the consequence of an inappropriate choice of staple size in relation to gastric wall thickness. Due to the variable nature of gastric wall thickness, the choice of proper staple height is not obvious. In the few studies in which gastric wall thickness was measured, it was observed to decrease gradually from the antrum to the fundus. However, the authors are divided on the issue of whether gender and body mass index influence gastric wall thickness. The question whether there are other perioperative factors that would allow gastric wall thickness to be predicted remains unanswered.


title: The effect of increasing operator experience on procedure-related characteristics in patients undergoing carotid artery stenting.

text: Objectives To evaluate the efficacy and safety of carotid artery stenting for the treatment of severe carotid artery disease in our department and to investigate the effect of increasing operator experience on perioperative and procedure-related characteristics. Methods From January 2007 to February 2015 200 patients underwent 207 endovascular procedures for carotid artery stenosis. Of all, 113 arteries (56.5%) were symptomatic. Significant changes across time were calculated with the use of Change Point analysis using bootstrap and mean squared error estimates. Results The technical success was 98.6% (204/207 cases). Thirty-day neurological events included stroke in four patients (2%) and transient ischemic attack in two (1%). None of the patients died during the first 30 days. The most significant change of radiation duration occurred after the 33rd patient with a decrease from 25.31 min to 12.31 min, while for the total operative time that change occurred between the 31st and 33rd patient where mean operation time decreased from 88.89 min to 49.22 min. The most significant change of contrast media used occurred at the 40th patient with a decrease from 91.58 ml to 62 ml. During a mean follow-up period of 42 ± 20.02 months none of the patients experienced any cerebrovascular event. There was one case of significant recurrent stenosis, which was successfully treated by endovascular means. Conclusions Endovascular treatment of carotid artery stenosis performed in a single center with the use of a cerebral protection device seems to consist a safe therapeutic choice with acceptable results, within the referenced benchmarks proposed in the latest guidelines. Certain perioperative parameters such as the amount of contrast media used, the fluoroscopy and operation time, seem to decline overtime indicating increasing operator's experience. A number of performed cases above 40 was related to the significant decrease of those parameters and may represent the learning curve of the procedure.


title: Novel genetically encoded biosensors using firefly luciferase.

text: Genetically encoded biosensors have proven valuable for real-time monitoring of intracellular phenomena, particularly FRET-based sensors incorporating variants of green fluorescent protein. To increase detection sensitivity and response dynamics, we genetically engineered firefly luciferase to detect specific intermolecular interactions through modulation of its luminescence activity. This concept has been applied in covalent, noncovalent, and allosteric design configurations. The covalent design gives sensitive detection of protease activity through a cleavage-dependent increase in luminescence. The noncovalent and allosteric designs allow reversible detection of the small molecules rapamycin and cAMP, respectively. These sensors allow detection of molecular processes within living cells following addition of the luciferin substrate to the growth medium. For example, the cAMP sensor allows monitoring of intracellular signal transduction associated with G-protein coupled receptor function. These and other luminescent biosensors will be useful for the sensitive detection of cellular physiology in research and drug discovery.


Return to play after COVID-19: a sport cardiologist's view.


title: Borrelia crocidurae infection in acutely febrile patients, Senegal.

text: As malaria cases in Africa decline, other causes of acute febrile illness are being explored. To determine incidence of Borrelia crocidurae infection during June 2010-October 2011, we collected 1,566 blood specimens from febrile patients in Senegal. Incidence was high (7.3%). New treatment strategies, possibly doxycycline, might be indicated for febrile patients.


Tocilizumab for Hemophagocytic Syndrome in a Kidney Transplant Recipient With COVID-19.


Myocarditis as an immune-related adverse event with ipilimumab/nivolumab combination therapy for metastatic melanoma.


title: Prospective Biomarker Screening for Diagnosis of Invasive Aspergillosis in High-Risk Pediatric Patients.

text: Combined biomarker screening is increasingly used to diagnose invasive aspergillosis (IA) in high-risk patients. In adults, the combination of galactomannan (GM) and fungal DNA detection has proven to be beneficial in the diagnosis of IA. Data in purely pediatric cohorts are scarce. Here, we monitored 39 children shortly before and after allogeneic stem cell transplantation twice weekly by use of a commercial GM enzyme-linked immunosorbent assay (ELISA) and a PCR assay based on amplification of the pan-Aspergillus ITS1/5.8S ribosomal operon. In addition, clinical data were recorded and classification of IA was performed according to the European Organization for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria. Among the 39 high-risk children, we identified 4 patients (10.3%) with probable and 2 (5.1%) with possible IA. All patients with probable IA were repeatedly positive for both tests (means of 9.5 and 6.8 positive GM and PCR samples, respectively), whereas both possible IA cases were detected by PCR. The sensitivity and specificity were, respectively, 67% and 89% for GM and 100% and 63% for PCR. Positive and negative predictive values were, respectively, 50% and 100% for GM and 27% and 100% for PCR. For the combined testing approach, both values were 100%. The number of positive samples seemed to be lower in patients undergoing antifungal therapy. Sporadically positive tests occurred in 12% (GM) and 42% (PCR) of unclassified patients. In summary, our data show that combined monitoring for GM and fungal DNA also results in a high diagnostic accuracy in pediatric patients. Future studies have to determine whether combined testing is suitable for early detection of subclinical disease and how antifungal prophylaxis impacts assay performance.


title: Does depth of anesthesia monitoring improve postoperative outcomes?

text: PURPOSE OF REVIEW Devices using the electroencephalogram to estimate anesthetic depth have been available since 1996. Despite the use of these monitors for over a decade, there is little agreement among clinicians about the need for or value of depth of anesthesia monitoring. Since the majority of the studies evaluating the impact of depth of anesthesia monitoring on postoperative outcomes have utilized the bispectral index (BIS Covidian), this manuscript will focus on studies with this device. This review will evaluate the evidence that BIS monitoring can improve long-term outcomes. RECENT FINDINGS BIS-guided anesthesia can reduce the incidence of awareness with recall in high-risk patients, but a recent study found that anesthetic management directed by an end-tidal anesthetic-agent concentration protocol is equally effective, and probably less expensive. Deep anesthesia (BIS < 45) during the intraoperative period is associated with increased postoperative mortality, but this relationship may be an epiphenomenon rather than causal. SUMMARY There is growing concern that anesthetic management and even specific anesthetic agents may worsen outcomes in high-risk patients. There is, however, no conclusive evidence that depth of anesthesia monitors can improve outcomes and no evidenced-based reasons for anesthesia providers to change their current practice.


title: Characteristics of ischemic brain lesions after stenting or endarterectomy for symptomatic carotid artery stenosis: results from the international carotid stenting study-magnetic resonance imaging substudy.

text: BACKGROUND AND PURPOSE In a substudy of the International Carotid Stenting Study (ICSS), more patients had new ischemic brain lesions on diffusion-weighted magnetic resonance imaging (MRI) after stenting (CAS) than after endarterectomy (CEA). In the present analysis, we compared characteristics of diffusion-weighted MRI lesions. METHODS Number, individual and total volumes, and location of new diffusion-weighted MRI lesions were compared in patients with symptomatic carotid stenosis randomized to CAS (n=124) or CEA (n=107) in the ICSS-MRI substudy. RESULTS CAS patients had higher lesion numbers than CEA patients (1 lesion, 15% vs 8%; 2-5 lesions, 19% vs 5%; >5 lesions, 16% vs 4%). The overall risk ratio for the expected lesion count with CAS versus CEA was 8.8 (95% confidence interval, 4.4-17.5; P<0.0001) and significantly increased among patients with lower blood pressure at randomization, diabetes mellitus, stroke as the qualifying event, left-side stenosis, and if patients were treated at centers routinely using filter-type protection devices during CAS. Individual lesions were smaller in the CAS group than in the CEA group (P<0.0001). Total lesion volume per patient did not differ significantly. Lesions in the CAS group were more likely to occur in cortical areas and subjacent white matter supplied by leptomeningeal arteries than lesions in the CEA group (odds ratio, 4.2; 95% confidence interval, 1.7-10.2; P=0.002). CONCLUSIONS Compared with patients undergoing CEA, patients treated with CAS had higher numbers of periprocedural ischemic brain lesions, and lesions were smaller and more likely to occur in cortical areas and subjacent white matter. These findings may reflect differences in underlying mechanisms of cerebral ischemia.


docid: dgyuwheh

title: Survival, Neurologic Injury, and Kidney Function after Surgery for Acute Type A Aortic Dissection.

text: BACKGROUND To analyze survival, neurologic injury, and kidney function after acute type A aortic dissection. METHODS A total of 445 patients undergoing surgery for acute type A aortic dissection were analyzed. Evaluation according to risk factors for mortality, neurologic injury, and kidney function was performed. RESULTS Overall 1-, 5-, and 10-year survival rates were 82.8 ± 1.8%, 73.6 ± 2.4%, and 59.3 ± 3.9, respectively. Independent preoperative risk factors for mortality were preexisting renal impairment (p = 0.001), reduced left ventricular ejection fraction (p < 0.001), and age (p < 0.001). Perioperative risk factors were prolonged cross-clamp (p < 0.001) and cerebral perfusion time (p = 0.001). Risk factors for renal failure were preexisting renal impairment (p < 0.001), prolonged cross-clamp time (p < 0.001), cerebral perfusion time (p < 0.001), and age (p = 0.022). Risk factors for neurologic injury were cross-clamp time (p = 0.038), cerebral perfusion time (p = 0.007), and age (p = 0.045). CONCLUSION In addition to classic risk factors, survival after type A aortic dissection is affected by preexisting renal impairment. Preexisting renal impairment is predictive of postoperative renal failure. Therefore treatment and prevention strategies for renal failure during the acute and long-term course after acute type A aortic dissection are warranted.


title: A model to demonstrate that endotension is a nonvisualized type I endoleak.

text: OBJECTIVE Unexplained aneurysm growth despite multimodality imaging after endovascular aneurysm repair is often attributed to endotension. We tested a hypothesis that endotension may be from a type Ia endoleak pressurizing the aneurysm sac, without net forward flow, not visualized on standard angiographic imaging. METHODS A patient-specific aortic aneurysm phantom was constructed of polyvinyl alcohol using three-dimensional molding techniques. A bifurcated stent graft was implanted, and the phantom was connected to a hemodynamic simulator for testing. Type Ia endoleaks were created using 7F catheters. Three scenarios were studied: complete exclusion (no endoleak), inflow with no sac outflow, and inflow with sac outflow. Imaging with digital subtraction angiography was performed at 48 kVp at 5 frames/s, followed by delayed imaging at 1 frame/min for 30 minutes. RESULTS With no endoleak, the systemic pressure averaged 113 mm Hg and aneurysm sac pressure averaged 101 mm Hg. With an endoleak present without outflow, the systemic pressure averaged 116 mm Hg, the aneurysm sac pressure averaged 120 mm Hg, and endoleak flow was bidirectional with no net forward flow. With endoleak present with aneurysm sac outflow, the systemic pressure averaged 119 mm Hg, aneurysm sac pressure averaged 105.5 mm Hg, and net endoleak flow into the aneurysm sac was 21 mL/min across the endoleak channel. With digital subtraction imaging, the endoleak with no outflow was noted after >9 minutes of delayed imaging. CONCLUSIONS In our model, the creation of a type Ia endoleak in the absence of sac outflow resulted in a mean pressure higher than the systemic mean pressure with zero net flow into the aneurysm sac. Consequently, the endoleak could only be visualized with markedly delayed imaging and not with standard contrast digital subtraction angiography like that used in clinical practice. Our findings suggest that endotension may in fact be the result of undetected endoleaks secondary to the limitations of present iodinated contrast imaging modalities.


title: The impact of visceral obesity on surgical outcomes of laparoscopic surgery for colon cancer.

text: PURPOSE Although obesity is considered as a risk factor for postoperative morbidity in abdominal surgery, its effect on the outcomes of laparoscopic-assisted colectomy (LAC) is still unclear. The technical difficulty and risk factor for postoperative complication in LAC are thought to be influenced by visceral obesity. The aim of this prospective study was to evaluate the impact of visceral fat on the surgical outcomes of LAC. METHODS Between April 2005 and December 2010, consecutive patients with preoperatively diagnosed colon cancer, excluding medium and low rectal cancer, who underwent LAC, were enrolled. Their visceral fat area (VFA) and body mass index (BMI) were prospectively collected. The VFA was assessed by Fat Scan software. The patients were classified into two groups as follows: VFA nonobese with VFA <100 cm(2) (VNO) and VFA obese with VFA ≧100 cm(2) (VO). The predictive factors for surgical complications of LAC were evaluated by univariate and logistic regression analyses. RESULTS A total of 338 consecutive patients were enrolled in this study. Of the 338 patients, 194 (57.4 %) and 138 (42.6 %) were classified into the VNO and VO groups, respectively. Logistic regression analysis showed that high BMI (≧25 kg/m(2)) and VO independently predicted the incidence of overall postoperative complications (p = 0.040 and 0.007, respectively). VO was more highly related to the incidence of overall postoperative complications, anastomotic leakage (p = 0.021), and surgical site infection (SSI) (p = 0.013) than high BMI. CONCLUSIONS VFA is a more useful parameter than BMI in predicting surgical outcomes after LAC.


title: Licorice beta-amyrin 11-oxidase, a cytochrome P450 with a key role in the biosynthesis of the triterpene sweetener glycyrrhizin.

text: Glycyrrhizin, a major bioactive compound derived from the underground parts of Glycyrrhiza (licorice) plants, is a triterpene saponin that possesses a wide range of pharmacological properties and is used worldwide as a natural sweetener. Because of its economic value, the biosynthesis of glycyrrhizin has received considerable attention. Glycyrrhizin is most likely derived from the triterpene beta-amyrin, an initial product of the cyclization of 2,3-oxidosqualene. The subsequent steps in glycyrrhizin biosynthesis are believed to involve a series of oxidative reactions at the C-11 and C-30 positions, followed by glycosyl transfers to the C-3 hydroxyl group; however, no genes encoding relevant oxidases or glycosyltransferases have been identified. Here we report the successful identification of CYP88D6, a cytochrome P450 monooxygenase (P450) gene, as a glycyrrhizin-biosynthetic gene, by transcript profiling-based selection from a collection of licorice expressed sequence tags (ESTs). CYP88D6 was characterized by in vitro enzymatic activity assays and shown to catalyze the sequential two-step oxidation of beta-amyrin at C-11 to produce 11-oxo-beta-amyrin, a possible biosynthetic intermediate between beta-amyrin and glycyrrhizin. CYP88D6 coexpressed with beta-amyrin synthase in yeast also catalyzed in vivo oxidation of beta-amyrin to 11-oxo-beta-amyrin. CYP88D6 expression was detected in the roots and stolons by RT-PCR; however, no amplification was observed in the leaves or stems, which is consistent with the accumulation pattern of glycyrrhizin in planta. These results suggest a role for CYP88D6 as a beta-amyrin 11-oxidase in the glycyrrhizin pathway.


title: Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis.

text: OBJECTIVE We explore the impact of discharge disposition (independent rehabilitation facility (IRF) vs skilled nursing facility (SNF)) on 90 day outcomes in persons with stroke who received acute endovascular treatment. METHODS Using a database from a single primary care stroke center, discharge disposition, National Institutes of Health Stroke Scale (NIHSS), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-Arterial Therapy 2 (HIAT-2), and Acute Physiology and Chronic Health Evaluation (APACHE II) scores, and successful reperfusion were obtained. Univariate analysis was performed to assess predictors of good clinical outcome, as defined by 90 day modified Rankin Scale (mRS) scores ≤2. A binary logistic regression model was used to determine the impact of placement to an IRF versus an SNF on clinical outcomes. RESULTS 147 subjects were included in the analysis with a mean age of 63±14 years and median NIHSS of 18 (IQR 14-21). Final infarct volumes, and modified APACHE II, THRIVE, and HIAT-2 scores were similar between those discharged to an IRF and those discharged to an SNF.However, their 90 day outcomes were significantly different, with far fewer patients at SNFs achieving good clinical outcomes (25% vs 46%; p=0.023). Disposition to SNF was significantly associated with a lower probability of achieving an mRS score of 0-2 at 90 days (OR = 0.337 (95% CI 0.12 to 0.94); p<0.04). CONCLUSIONS Subjects discharged to SNFs and IRFs after thrombectomy have similar medical and neurological severity at admission and similar final infarct volumes at discharge. Despite these similarities, patients discharged to an SNF had a significantly lower probability of achieving a good neurological outcome. These results have implications for future acute stroke trial design.


title: PET/MRI of Hepatic 90Y Microsphere Deposition Determines Individual Tumor Response.

text: PURPOSE The purpose of our study is to determine if there is a relationship between dose deposition measured by PET/MRI and individual lesion response to yttrium-90 ((90)Y) microsphere radioembolization. MATERIALS AND METHODS 26 patients undergoing lobar treatment with (90)Y microspheres underwent PET/MRI within 66 h of treatment and had follow-up imaging available. Adequate visualization of tumor was available in 24 patients, and contours were drawn on simultaneously acquired PET/MRI data. Dose volume histograms (DVHs) were extracted from dose maps, which were generated using a voxelized dose kernel. Similar contours to capture dimensional and volumetric change of tumors were drawn on follow-up imaging. Response was analyzed using both RECIST and volumetric RECIST (vRECIST) criteria. RESULTS A total of 8 hepatocellular carcinoma (HCC), 4 neuroendocrine tumor (NET), 9 colorectal metastases (CRC) patients, and 3 patients with other metastatic disease met inclusion criteria. Average dose was useful in predicting response between responders and non-responders for all lesion types and for CRC lesions alone using both response criteria (p < 0.05). D70 (minimum dose to 70 % of volume) was also useful in predicting response when using vRECIST. No significant trend was seen in the other tumor types. For CRC lesions, an average dose of 29.8 Gy offered 76.9 % sensitivity and 75.9 % specificity for response. CONCLUSIONS PET/MRI of (90)Y microsphere distribution showed significantly higher DVH values for responders than non-responders in patients with CRC. DVH analysis of (90)Y microsphere distribution following treatment may be an important predictor of response and could be used to guide future adaptive therapy trials.


title: Undiagnosed respiratory viruses in children.

text: OBJECTIVE An estimated 12 to 32 million upper respiratory infections occur in young children each year. In addition, 20% to 53% of infants will have > or = 1 episode of lower respiratory infection in the first year of life. The current methods of diagnosing respiratory viruses are limited in scope and sensitivity. Polymerase chain reaction is a more sensitive method than antigen detection and is often used for newly discovered viruses. Using polymerase chain reaction, we sought to diagnose adenoviruses, human bocavirus, and human metapneumovirus at our children's hospital. METHODS Nasal-swab specimens submitted for antigen detection of respiratory viruses were collected and processed by using polymerase chain reaction to detect adenoviruses, human bocavirus, and human metapneumovirus. Inpatient and emergency department records were reviewed for clinical and demographic data. RESULTS Approximately 1500 specimens were collected over 21 months; they contained adenoviruses, human bocavirus, and human metapneumovirus in 5.9%, 5.6%, and 5.2% of children, respectively. Using polymerase chain reaction and antigen detection, a viral agent was identified in as many as 62% of the specimens. Lower respiratory tract disease was present most frequently in patients infected with human metapneumovirus (63%) and least frequently in those infected with adenoviruses (45%). We detected adenoviruses by polymerase chain reaction in 59 patients for whom the antigen-detection test results were negative. A paroxysmal cough led to clinical suspicion of Bordetella pertussis infection in 19% of patients infected with human bocavirus. CONCLUSIONS Adenoviruses, human bocavirus, and human metapneumovirus were each present in approximately 5% of specimens submitted for respiratory virus rapid testing. The lower respiratory tract was more commonly affected in patients with human bocavirus and human metapneumovirus infections. Adenovirus was often undiagnosed by antigen detection. Other findings included the presence of a pertussis-like illness associated with human bocavirus.


title: Rigorous surveillance is necessary for high confidence in end-of-outbreak declarations for Ebola and other infectious diseases.

text: The World Health Organization considers an Ebola outbreak to have ended once 42 days have passed since the last possible exposure to a confirmed case. Benefits of a quick end-of-outbreak declaration, such as reductions in trade/travel restrictions, must be balanced against the chance of flare-ups from undetected residual cases. We show how epidemiological modelling can be used to estimate the surveillance level required for decision-makers to be confident that an outbreak is over. Results from a simple model characterizing an Ebola outbreak suggest that a surveillance sensitivity (i.e. case reporting percentage) of 79% is necessary for 95% confidence that an outbreak is over after 42 days without symptomatic cases. With weaker surveillance, unrecognized transmission may still occur: if the surveillance sensitivity is only 40%, then 62 days must be waited for 95% certainty. By quantifying the certainty in end-of-outbreak declarations, public health decision-makers can plan and communicate more effectively. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'. This issue is linked with the earlier theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'.


title: The impact of COVID-19 on dental education in North America-Where do we go next?

text: During the COVID-19 pandemic, the dental education community faced unprecedented challenges. In this commentary, we share the perspectives of faculty clinicians, residents and students in academic dental institutions in the United States and Canada. We discuss COVID-19's impact on various aspects of academic dentistry including patient care, education, research and raise key concerns regarding the future of dental education post-pandemic.


title: Participants' accrual and delivery of HIV prevention interventions among men who have sex with men in sub-Saharan Africa: a systematic review.

text: BACKGROUND Across sub-Saharan Africa (SSA), HIV disproportionately affects men-who-have-sex-with-men (MSM) compared with other men of the same age group in the general population. Access to HIV services remains low among this group although several effective interventions have been documented. It is therefore important to identify what has worked well to increase the reach of HIV services among MSM. METHODS We searched MEDLINE, POPLINE and the Web of Science databases to collect published articles reporting HIV interventions among MSM across sub-Saharan Africa. Covidence was used to review the articles. The review protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO) - CRD42017060808. RESULTS The search identified 2627 citations, and following removal of duplicates and inclusion and exclusion criteria, only 15 papers were eligible for inclusion in the review. The articles reported various accrual strategies, namely: respondent driven sampling, known peers identified through hotspot or baseline surveys, engagement with existing community-based organizations, and through peer educators contacting MSM in virtual sites. Some programs, however, combined some of these accrual strategies. Peer-led outreach services were indicated to reach and deliver services to more MSM. A combination of peer outreach and mobile clinics increased uptake of health information and services. Health facilities, especially MSM-friendly facilities attract access and use of services by MSM and retention into care. CONCLUSIONS There are various strategies for accrual and delivering services to MSM across SSA. However, each of these strategies have specific strengths and weaknesses necessitating combinations of interventions and integration of the specific context to inform implementation. If the best of intervention content and implementation are used to inform these services, sufficient coverage and impact of HIV prevention and treatment programs for MSM across SSA can be optimized.


title: Fine needle diathermy occlusion of corneal vessels.

text: AIMS To evaluate the efficacy of fine needle diathermy (FND) occlusion of corneal vessels in relation to defined clinical indications. METHODS A retrospective, consecutive case series including all patients treated by FND for occlusion of corneal vessels between 2004 and 2012. Indications were lipid keratopathy, preparation for keratoplasty to reduce risk of rejection and treatment of recalcitrant corneal graft rejection associated with stromal vessels. Our outcome measures were occlusion of corneal vessels with reduced corneal vascularisation, reduction in amount of lipid deposition, and reduction of graft rejection episodes. RESULTS FND effectively reduced lipid deposition associated with the treated vessels in 14 out of 17 eyes (82.3%). When used to reduce corneal vascularisation before keratoplasty and to reduce intraoperative bleeding, the 1-year survival of the high-risk grafts was (84.6%). FND prevented further rejection episodes in 3 out of 4 corneal grafts. Fourteen eyes required retreatment (2-5 times) of which 9 had lipid keratopathy and 5 were in preparation for corneal grafting. CONCLUSIONS FND is effective in occluding established corneal vessels. Corneal microperforation is a potentially serious adverse event, but other adverse events, such as striae, whitening and intracorneal haemorrhages are reversible. It should be considered for established corneal vessels, and can be combined with antivascular endothelial growth factors.


title: Injectable collagen for the treatment of fecal incontinence: long-term results.

text: BACKGROUND Fecal incontinence is a distressing condition that is difficult to treat. Injection of bulking agents has been used to treat passive fecal incontinence. However, no long-term results are available. OBJECTIVE The aim of this study was to assess the long-term clinical effectiveness of intra-anal injection of collagen for passive fecal incontinence. DESIGN This research is a retrospective cohort study from a prospectively collected database SETTING This investigation took place in a high-volume tertiary colorectal department. PATIENTS All patients who underwent intra-anal injection of collagen for passive fecal incontinence with internal sphincter dysfunction between January 2006 and December 2009 were included in the study. Data including demographic details, preoperative anorectal physiology, and outcome measures were collected prospectively and maintained in a database MAIN OUTCOME MEASURES The primary outcomes measured were the Cleveland Clinic Florida incontinence score and the responses to a subjective patient satisfaction questionnaire before the procedure and at subsequent follow-up visits. Data were analyzed by using SPSS v19.0. RESULTS One hundred patients (70 female; mean age, 61 years (range, 36-82)) were followed up for a minimum duration of 36 months. Fifty-six patients (56%) had an improvement in fecal incontinence score from a mean of 14 (range, 9-18) to a mean of 8 (range, 5-14). A total of 68% reported subjective improvement in symptoms. Thirty-eight patients (38%) required a repeat injection of collagen, and a further 15 patients required a third injection. The median interval between the first and final injection was 12 months (range, 4-16 months). Age was the only independent predictor of successful outcome (p = 0.032). There was no morbidity. LIMITATIONS This study was limited by its nonrandomized retrospective design. CONCLUSIONS Injection of collagen into the internal anal sphincter is simple, safe, and effective in patients with passive fecal incontinence, although repeat injections are necessary in approximately half of the patients.


A transatlantic review of the NHS at 60.


title: Effect of Ischemia Duration and Door-to-Balloon Time on Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction: An Analysis From HORIZONS-AMI Trial (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction).

text: OBJECTIVES This study sought to investigate the effect of treatment delay on microvascular reperfusion in ST-segment elevation myocardial infarction (STEMI) patients from the large, multicenter, prospective HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. BACKGROUND Despite restoration of epicardial blood flow during primary percutaneous coronary intervention (PCI), one-third of patients do not obtain myocardial perfusion due to impairment in the microvascular circulation. METHODS We examined the effect of symptom onset-to-balloon time (SBT) and door-to-balloon time (DBT) on myocardial reperfusion during primary PCI in STEMI, utilizing resolution of ST-segment elevation (STR) and the myocardial blush grade (MBG). The primary analysis was the relationships between SBT ≤2, >2 to 4, and >4 h and DBT ≤1, >1 to 1.5, >1.5 to 2, and >2 h with MBG and STR. Clinical risk was assessed using a modified version of the Thrombolysis In Myocardial Infarction risk score for STEMI. RESULTS In 2,056 patients, absent microvascular perfusion (MBG 0/1) and STR (STR <30%) after primary PCI was significantly more common in patients with longer SBT, in patients with both low and high clinical risk profiles. By multivariable analysis, SBT (p < 0.0001), anterior infarction (p < 0.0001), reference vessel diameter (p = 0.005), lesion minimum lumen diameter (p < 0.0001), hyperlipidemia (p = 0.03), and current smoking (p = 0.001) were independent predictors of MBG 0/1, whereas SBT (p = 0.007), anterior infarction (p < 0.0001), and history of renal insufficiency (p = 0.0002) were independent predictors of absent STR. DBT (p < 0.0001) was an independent predictor of MBG 0/1. MBG 0/1 and STR<30% identified patients with increased 3-year mortality. CONCLUSIONS The present study suggests that delay in mechanical reperfusion therapy during STEMI is associated with greater injury to the microcirculation.


title: Retroperitoneal laparoscopic nephroureterectomy with distal and intramural ureter resection for a tuberculous non - functional kidney.

text: OBJECTIVE To evaluate the safety and feasibility of total retroperitoneal laparoscopic nephroureterectomy with urinary-bladder junction resection for a tuberculous non-functional kidney. MATERIALS AND METHODS A total of 27 individuals diagnosed with unilateral non-functional kidney secondary to tuberculosis were treated between June 2011 and June 2015. All patients had normal renal function on the contralateral side and underwent the standard four-drug anti-tuberculosis treatment for at least four weeks before surgery. Total retroperitoneal laparoscopic nephroureterectomy was performed in all patients, and the urinary-bladder junction of distal ureter was managed using different auto-suture techniques. RESULTS Nineteen male and 8 female patients with an average age of 47.3 years (range, 36-64 years) underwent surgery. All the operations were successfully performed without conversion. The median operative time was 109.3 min (range, 75-138 min), the median blood loss was 157.5 mL (range, 70-250 mL), and the median hospitalization time was 3.7 days (range, 3-6 days). No serious perioperative complications occurred. Anti-tuberculosis chemotherapy was prescribed to all patients, with the entire course of treatment lasting six months. No recurrence of tuberculosis of the bladder or the contralateral kidney was observed during the median follow-up period of 26.7 months (range, 6-54 months). CONCLUSION Retroperitoneal laparoscopic nephroureterectomy with urinary-bladder junction resection is a safe and feasible approach for the treatment of tuberculous non-functional kidneys.


docid: azjhiivv

title: Salicylic acid-based poly(anhydride-ester) nerve guidance conduits: Impact of localized drug release on nerve regeneration.

text: Nerve guidance conduits (NGCs) can serve as physical scaffolds aligning and supporting regenerating cells while preventing scar tissue formation that often interferes with the regeneration process. Numerous studies have focused on functionalizing NGCs with neurotrophic factors, for example, to support nerve regeneration over longer gaps, but few directly incorporate therapeutic agents. Herein, we fabricated NGCs from a polyanhydride comprised of salicylic acid (SA), a nonsteroidal anti-inflammatory drug, then performed in vitro and in vivo assays. In vitro studies included cytotoxicity, anti-inflammatory response, and NGC porosity measurements. To prepare for implantation, type I collagen hydrogels were used as NGC luminal fillers to further enhance the axonal regeneration process. For the in vivo studies, SA-NGCs were implanted in femoral nerves of mice for 16 weeks and evaluated for functional recovery. The SA-based NGCs functioned as both a drug delivery vehicle capable of reducing inflammation and scar tissue formation because of SA release as well as a tissue scaffold that promotes peripheral nerve regeneration and functional recovery.


title: Instructional design in the development of an online course on Basic Life Support.

text: OBJECTIVE To develop and evaluate an online course on Basic Life Support. METHOD Technological production research of online course guided by the ADDIE (Analysis, Design, Development, Implementation, Evaluation) instructional design model based on Andragogy and the Meaningful Learning Theory. The online course was constructed in the platform Moodle, previously assessed by a group of experts, and then presented to the students of the Nursing School of the University of São Paulo, who assessed it at the end of the course. RESULTS The course was evaluated by the experts and obtained a mean score of 0.92 (SD 0.15), considered as good quality (between 0.90-0.94), and by the students, with a mean score of 0.95 (SD 0.03), considered as high quality (0.95-1.00). CONCLUSION The instructional design used was found to be appropriate to the development of the online course. As an active educational strategy, it contributed to the learning on Basic Life Support during cardiac arrest-related procedures in adults. In view of the need for technological innovations in education and systematization of care in cardiopulmonary resuscitation, the online course allows the establishment of continuous improvement processes in the quality of resuscitation in the care provided by students and professionals.


title: Simple tests for rapid detection of canine parvovirus antigen and canine parvovirus-specific antibodies.

text: Canine parvovirus (CPV) is the number one viral cause of enteritis, morbidity, and mortality in 8-week-old young puppies. We have developed twin assays (slide agglutination test [SAT] for CPV antigen and slide inhibition test [SIT] for CPV antibody) that are sensitive, specific, cost-effective, generic for all genotypes of CPV, and provide instant results for CPV antigen detection in feces and antibody quantification in serum. We found these assays to be useful for routine applications in kennels with large numbers of puppies at risk. The results of these assays are available in 1 min and do not require any special instrumentation. SAT-SIT technology will find applications in rapid screening of samples for other hemagglutinating emerging viruses of animals and humans (influenza virus and severe acute respiratory syndrome coronavirus).


title: Effects of age on effect-site concentration of remifentanil for suppressing anesthetic emergence cough in male patients undergoing laparoscopic cholecystectomy.

text: Background Remifentanil infusion during emergence lowers cough. Effect-site concentration (Ce) of remifentanil using target-controlled infusion (TCI) has been evaluated in previous studies. Recent studies revealed the existence of sex-related differences in remifentanil Ce in young and elderly patients. Thus, there was the need to re-evaluate the effect of age in single sex. We investigated the remifentanil Ce for suppressing emergence cough in young and elderly male patients and evaluated the age-related differences. Patients and methods In total, 25 young (ages between 20 and 50 years) and 24 elderly (ages between 65 and 75 years) male patients undergoing laparoscopic cholecystectomy were enrolled. Anesthesia was implemented with remifentanil using TCI and sevoflurane. The remifentanil Ce for suppressing emergence cough was estimated for each group using Dixon's up-and-down method and isotonic regression method with a bootstrapping approach. Results The remifentanil Ce for suppressing emergence cough in 50% (EC50) and 95% (EC95) of the patients was comparable between the young and elderly patients. Isotonic regression demonstrated that the EC50 (83% confidence interval [CI]) of remifentanil was 2.56 (2.39-2.75) ng/mL in the young patients and 2.15 (1.92-2.5) ng/mL in the elderly patients. The EC95 (95% CI) of remifentanil was 3.33 (2.94-3.46) ng/mL in the young patients and 3.41 (3.18-3.48) ng/mL in the elderly patients. Dixon's up-and-down method also demonstrated that the EC50 was comparable between the two groups (2.69±0.32 ng/mL vs 2.39±0.38 ng/mL, P=0.132). Conclusion The remifentanil Ce for suppressing emergence cough following extubation during general anesthesia was comparable between young and elderly male patients. It indicates that age-related differences in remifentanil requirement for suppressing emergence cough did not exist in male sex.


title: [What are the highlights of "Diagnosis and treatment of Disease 2019 novel coronavirus infection suitable for Military support Hubei medical team"].

text: Thousands of medical workers in the Military support Hubei medical team are exerting themselves in many hospitals in Hubei Province. They are diligent in treating patients, at the same time, they constantly summarize experience and combine the characteristics of military hospitals. According to " the Diagnosis and Treatment of New Coronavirus Pneumonia "(6th edition) of the National Health Commission of the People's Republic of China, a new guideline for the diagnosis and treatment of 2019 novel coronavirus infection suitable for the military (first trial version) was established. Some unique opinions and suggestions are put forward in terms of disease name, diagnosis criteria, antiviral treatment, glucocorticoid application, etc. This article will make a proper interpretation in order to understand the guideline better and help guide the diagnosis and treatment of diseases.


docid: ntvwiljr

title: Differential virological and immunological outcome of severe acute respiratory syndrome coronavirus infection in susceptible and resistant transgenic mice expressing human angiotensin-converting enzyme 2.

text: We previously reported that transgenic (Tg) mice expressing human angiotensin-converting enzyme 2 (hACE2), the receptor for severe acute respiratory syndrome coronavirus (SARS-CoV), were highly susceptible to SARS-CoV infection, which resulted in the development of disease of various severity and even death in some lineages. In this study, we further characterized and compared the pathogeneses of SARS-CoV infection in two of the most stable Tg lineages, AC70 and AC22, representing those susceptible and resistant to the lethal SARS-CoV infection, respectively. The kinetics of virus replication and the inflammatory responses within the lungs and brains, as well as the clinical and pathological outcomes, were assessed in each lineage. In addition, we generated information on lymphocyte subsets and mitogen-mediated proliferation of splenocytes. We found that while both lineages were permissive to SARS-CoV infection, causing elevated secretion of many inflammatory mediators within the lungs and brains, viral infection appeared to be more intense in AC70 than in AC22 mice, especially in the brain. Moreover, such infection was accompanied by a more profound immune suppression in the former, as evidenced by the extensive loss of T cells, compromised responses to concanavalin A stimulation, and absence of inflammatory infiltrates within the brain. We also found that CD8(+) T cells were partially effective in attenuating the pathogenesis of SARS-CoV infection in lethality-resistant AC22 mice. Collectively, our data revealed a more intense viral infection and immunosuppression in AC70 mice than in AC22 mice, thereby providing us with an immunopathogenic basis for the fatal outcome of SARS-CoV infection in the AC70 mice.


title: Neuropathology of italian cats in feline spongiform encephalopathy surveillance.

text: Feline spongiform encephalopathy (FSE) is a transmissible spongiform encephalopathy associated with the consumption of feedstuffs contaminated with tissue from bovine spongiform encephalopathy-affected cattle and characterized by the accumulation in the central nervous system of an abnormal isoform of the prion protein (PrP(sc)). Clinically, it presents as a progressive fatal neurologic syndrome that is not easily distinguished from other feline neurologic conditions. Most cases of FSE have been reported in England, where it was first detected in 1990, but a few cases have been reported from other European countries. To identify possible cases of FSE in Italy, the Italian Ministry of Health funded a 2-year surveillance project during which the brains from 110 domestic cats with neurologic signs were evaluated histologically for spongiform encephalopathy and immunohistochemically to detect PrP(sc). Although no cases of FSE were found, the study proved useful in monitoring the Italian cat population for other neurologic diseases: neoplasia (21.8%), toxic-metabolic encephalopathy (18.2%), granulomatous encephalitis (15.5%), suppurative encephalitis (4.6%), trauma (3.6%), circulatory disorders (3.6%), degeneration (2.7%), nonsuppurative encephalitis (2.7%), and neuromuscular diseases (1.8%). No histologic lesions were found in 20% of the brains, and samples from 5.5% of the cats were rejected as unsuitable.


title: Mechanical thrombectomy in acute ischaemic stroke: a review of the different techniques.

text: Endovascular mechanical thrombectomy (MT) is reserved for acute ischaemic stroke secondary to large vessel occlusion. The various MT techniques employed in the treatment of hyperacute strokes are constantly evolving with new devices and improvisation of existing technology (Wahlgren, et al 2016). In this review, we describe a variety of MT techniques gained from our experience of performing over 350 procedures in 7 years of providing a 24/7 service within the national framework of a hyperacute stroke centre. We outline a number of endovascular techniques, procedure limitations, and potential complications.


title: [Application and thinking of health standards related to medical care and health information etc. in prevention and control of COVID-19].

text: Objective: To compare the technical elements of health standards for nosocomial infection control, health protection, health information, and health emergency and biosafety in the context of the prevention and control of COVID-19, and provide support for the further optimization of the epidemic prevention and control guidelines. Methods: Above mentioned health standards used in COVID-19 prevention and control were collected for a systematic comparison with "Guidelines for Prevention and Control of COVID-19 in Medical Institutions" (the 1st Edition) from the perspective of technical elements. Results: The application scope and technical elements of the current health standards basically meet the needs for the prevention and control of COVID-19 epidemic. Conclusions: The implementation of the current health standards can provide strong technical support for the prevention and control of COVID-19 epidemic. The experience obtained in the epidemic prevention and control can also contribute to the further revision and improvement of the health standards.


title: Comparison of sevoflurane and desflurane on effect-site concentration of remifentanil for preventing anesthetic emergence cough in elderly female patients undergoing laparoscopic cholecystectomy.

text: Purpose Among inhalational anesthetics, desflurane is widely believed to provoke upper airway irritation including coughing and laryngospasm. Remifentanil has been generally used to prevent cough due to its unique pharmacodynamics. However, there was no study that compared optimal remifentanil effect-site concentration (Ce) to prevent emergence cough according to the type of inhalational agent in elderly female patients. Thus, we investigated the Ce of remifentanil for preventing cough during emergence from sevoflurane and desflurane anesthesia in elderly female patients. Methods Forty-three female patients between 60 and 75 years of age undergoing laparoscopic cholecystectomy were randomly allocated to sevoflurane group (n=22) or desflurane group (n=21). The optimal remifentanil Ce using target-controlled infusion for 50% of patients (EC50) and 95% of patients (EC95) was assessed by Dixon's up-and-down method or isotonic regression method with a bootstrapping approach. Results By Dixon's up-and-down method, the EC50 of remifentanil in sevoflurane group (2.08±0.47 ng/mL) was comparable with that in desflurane group (2.25±0.40 ng/mL) (P=0.385). The EC50 (83% CIs) and EC95 (95% CIs) by isotonic regression also did not show significant difference between two groups [2.06 (1.45-2.23) and 2.46 (2.35-2.48) ng/mL in sevoflurane group and 2.14 (1.45-2.56) and 2.88 (2.47-2.98) ng/mL in desflurane group, respectively]. Conclusion There was no difference in the remifentanil Ce to prevent emergence cough between sevoflurane and desflurane anesthesia. Therefore, the clinicians may not need to adjust the remifentanil Ce to prevent emergence cough according to inhalational agents in elderly female patients.


title: Anti-Ebola Virus Antibody Levels in Convalescent Plasma and Viral Load After Plasma Infusion in Patients With Ebola Virus Disease.

text: Background Ebola virus (EBOV) neutralizing antibody in plasma may reduce viral load following administration of plasma to patients with Ebola virus disease (EVD), but measurement of these antibodies is complex. Methods Anti-EBOV antibody was measured by 2 neutralization and 2 enzyme-linked immunosorbent assays (ELISAs) in convalescent plasma (ECP) from 100 EVD survivor donors in Liberia. Viral load was assessed repetitively in patients with EVD participating in a clinical trial of enhanced standard of care plus ECP. Results All 4 anti-EBOV assays were highly concordant for detection of EBOV antibody. Antibodies were not detected in plasma specimens obtained from 15 of 100 donors, including 7 with documented EBOV-positive reverse-transcription polymerase chain reaction during EVD. Viral load was reduced following each dose in the 2 clinical trial participants who received ECP with higher antibody levels but not in the 2 who received ECP with lower antibody levels. Conclusions Recovery from EVD can occur with absence of detectable anti-EBOV antibody several months after disease onset. ELISAs may be useful to select ECP donors or identify ECP units that contain neutralizing antibody. ECP with higher anti-EBOV antibody levels may have greater effect on EBOV load-an observation that requires further investigation. Clinical Trials Registration NCT02333578.


title: Continuous evolution of avian infectious bronchitis virus resulting in different variants co-circulating in Southern China.

text: Sixty field strains of avian infectious bronchitis virus (IBV) were isolated from chicken flocks in different regions of Guangxi from 1985 to 2012. Phylogenetic analysis of S1 subunit glycoprotein genes revealed that field isolates from 2009-2011 mostly belonged to the LX4 type, while those from 1985-2008 belonged to the HN08 type, and a few others belonged to the 4/91 type, the TW type and the Mass type. In addition, it is noteworthy that no obvious regional differences were found among these 60 strains isolated from six regions in Guangxi, while there was a high degree of sequence identity among the isolates in the same period of time.


docid: bccbrwdq

title: Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review.

text: AIM To perform a systematic review to answer 'In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?' METHODS The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369) RESULTS: We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68-12.48) and survival to 30 days (OR 2.14, 95% CI 0.73-6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74-2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46-2.34). CONCLUSIONS Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.


title: EUS-guided ethanol ablation therapy for gastric stromal tumors.

text: EUS-guided fine-needle ethanol injection (FNI) therapy of some types of cystic and solid tumors has been documented. However, reported cases to date of gastrointestinal-stromal tumors (GIST) treated with this technique are scarce. Ethanol ablation is an alternative treatment with a low rate of adverse events in selected cases.


title: Severe acute respiratory syndrome coronaviruses with mutations in the E protein are attenuated and promising vaccine candidates.

text: UNLABELLED Severe acute respiratory syndrome coronavirus (SARS-CoV) causes a respiratory disease with a mortality rate of 10%. A mouse-adapted SARS-CoV (SARS-CoV-MA15) lacking the envelope (E) protein (rSARS-CoV-MA15-ΔE) is attenuated in vivo. To identify E protein regions and host responses that contribute to rSARS-CoV-MA15-ΔE attenuation, several mutants (rSARS-CoV-MA15-E*) containing point mutations or deletions in the amino-terminal or the carboxy-terminal regions of the E protein were generated. Amino acid substitutions in the amino terminus, or deletion of regions in the internal carboxy-terminal region of E protein, led to virus attenuation. Attenuated viruses induced minimal lung injury, diminished limited neutrophil influx, and increased CD4(+) and CD8(+) T cell counts in the lungs of BALB/c mice, compared to mice infected with the wild-type virus. To analyze the host responses leading to rSARS-CoV-MA15-E* attenuation, differences in gene expression elicited by the native and mutant viruses in the lungs of infected mice were determined. Expression levels of a large number of proinflammatory cytokines associated with lung injury were reduced in the lungs of rSARS-CoV-MA15-E*-infected mice, whereas the levels of anti-inflammatory cytokines were increased, both at the mRNA and protein levels. These results suggested that the reduction in lung inflammation together with a more robust antiviral T cell response contributed to rSARS-CoV-MA15-E* attenuation. The attenuated viruses completely protected mice against challenge with the lethal parental virus, indicating that these viruses are promising vaccine candidates. IMPORTANCE Human coronaviruses are important zoonotic pathogens. SARS-CoV caused a worldwide epidemic infecting more than 8,000 people with a mortality of around 10%. Therefore, understanding the virulence mechanisms of this pathogen and developing efficacious vaccines are of high importance to prevent epidemics from this and other human coronaviruses. Previously, we demonstrated that a SARS-CoV lacking the E protein was attenuated in vivo. Here, we show that small deletions and modifications within the E protein led to virus attenuation, manifested by minimal lung injury, limited neutrophil influx to the lungs, reduced expression of proinflammatory cytokines, increased anti-inflammatory cytokine levels, and enhanced CD4(+) and CD8(+) T cell counts in vivo, suggesting that these phenomena contribute to virus attenuation. The attenuated mutants fully protected mice from challenge with virulent virus. These studies show that mutations in the E protein are not well tolerated and indicate that this protein is an excellent target for vaccine development.


title: COVID-19 Return to Work Guidance and Recommendations for Vestibular Clinicians.

text: As states begin issuing progressive deconfinement guidelines, hospitals and institutions are starting to reopen for elective procedures and consultations. Vestibular clinicians are opening their practices to evaluate, test or treat patients with dizziness and balance problems. The following document, requested by the American Balance Society, collates the current information about the virus, including transmission from asymptomatic carriers, decontamination and other safety protocols, and provides a return to work guidance for clinicians caring for this population of patients, promoting provider, patient and staff safety.


title: The influence of norepinephrine and phenylephrine on cerebral perfusion and oxygenation during propofol-remifentanil and propofol-remifentanil-dexmedetomidine anaesthesia in piglets.

text: BACKGROUND Vasopressors are frequently used to increase blood pressure in order to ensure sufficient cerebral perfusion and oxygenation (CPO) during hypotensive periods in anaesthetized patients. Efficacy depends both on the vasopressor and anaesthetic protocol used. Propofol-remifentanil total intravenous anaesthesia (TIVA) is common in human anaesthesia, and dexmedetomidine is increasingly used as adjuvant to facilitate better haemodynamic stability and analgesia. Little is known of its interaction with vasopressors and subsequent effects on CPO. This study investigates the CPO response to infusions of norepinephrine and phenylephrine in piglets during propofol-remifentanil and propofol-remifentanil-dexmedetomidine anaesthesia. Sixteen healthy female piglets (25-34 kg) were randomly allocated into a two-arm parallel group design with either normal blood pressure (NBP) or induced low blood pressure (LBP). Anaesthesia was induced with propofol without premedication and maintained with propofol-remifentanil TIVA, and finally supplemented with continuous infusion of dexmedetomidine. Norepinephrine and phenylephrine were infused in consecutive intervention periods before and after addition of dexmedetomidine. Cerebral perfusion measured by laser speckle contrast imaging was related to cerebral oxygenation as measured by an intracerebral Licox probe (partial pressure of oxygen) and transcranial near infrared spectroscopy technology (NIRS) (cerebral oxygen saturation). RESULTS During propofol-remifentanil anaesthesia, increases in blood pressure by norepinephrine and phenylephrine did not change cerebral perfusion significantly, but cerebral partial pressure of oxygen (Licox) increased following vasopressors in both groups and increases following norepinephrine were significant (NBP: P = 0.04, LBP: P = 0.02). In contrast, cerebral oxygen saturation (NIRS) fell significantly in NBP following phenylephrine (P = 0.003), and following both norepinephrine (P = 0.02) and phenylephrine (P = 0.002) in LBP. Blood pressure increase by both norepinephrine and phenylephrine during propofol-remifentanil-dexmedetomidine anaesthesia was not followed by significant changes in cerebral perfusion. Licox measures increased significantly following both vasopressors in both groups, whereas the decreases in NIRS measures were only significant in the NBP group. CONCLUSIONS Cerebral partial pressure of oxygen measured by Licox increased significantly in concert with the vasopressor induced increases in blood pressure in healthy piglets with both normal and low blood pressure. Cerebral oxygenation assessed by intracerebral Licox and transcranial NIRS showed opposing results to vasopressor infusions.


title: The triple variable index combines information generated over time from common monitoring variables to identify patients expressing distinct patterns of intraoperative physiology.

text: BACKGROUND Mean arterial pressure (MAP), bispectral index (BIS), and minimum alveolar concentration (MAC) represent valuable, yet dynamic intraoperative monitoring variables. They provide information related to poor outcomes when considered together, however their collective behavior across time has not been characterized. METHODS We have developed the Triple Variable Index (TVI), a composite variable representing the sum of z-scores from MAP, BIS, and MAC values that occur together during surgery. We generated a TVI expression profile, defined as the sequential TVI values expressed across time, for each surgery where concurrent MAP, BIS, and MAC monitoring occurred in an adult patient (≥18 years) at the University of Pittsburgh Medical Center between January and July 2014 (n = 5296). Patterns of TVI expression were identified using k-means clustering and compared across numerous patient, procedure, and outcome characteristics. TVI and the triple low state were compared as prediction models for 30-day postoperative mortality. RESULTS The median frequency MAP, BIS, and MAC were recorded was one measurement every 3, 5, and 5 min. Three expression patterns were identified: elevated, mixed, and depressed. The elevated pattern displayed the highest average MAP, BIS, and MAC values (86.5 mmHg, 45.3, and 0.98, respectively), while the depressed pattern displayed the lowest values (76.6 mmHg, 38.0, 0.66). Patterns (elevated, mixed, depressed) were distinct across the following characteristics: average patient age (52, 53, 54 years), American Society of Anesthesiologists Physical Status 4 (6.7, 16.1, 27.3%) and 5 (0.1, 0.6, 1.6%) categories, cardiac (2.2, 6.5, 16.1%) and emergent (5.8, 10.5, 12.8%) surgery, cardiopulmonary bypass use (0.3, 2.6, 9.8%), intraoperative medication administration including etomidate (3.0, 7.3, 12.6%), hydromorphone (47.6, 26.3, 25.2%), ketamine (11.2, 4.6, 3.0%), dexmedetomidine (18.4, 16.6, 13.6%), phenylephrine (74.0, 74.8, 83.0), epinephrine (2.0, 6.0, 18.0%), norepinephrine (2.4, 7.5, 21.2%), vasopressin (3.4, 7.6, 21.0%), succinylcholine (74.0, 69.0, 61.9%), intraoperative hypotension (28.8, 33.0, 52.3%) and the triple low state (9.4, 30.3, 80.0%) exposure, and 30-day postoperative mortality (0.8, 2.7, 5.6%). TVI was a better predictor of patients that died or survived in the 30 days following surgery compared to cumulative triple low state exposure (AUC 0.68 versus 0.62, p < 0.05). CONCLUSIONS Surgeries that share similar patterns of TVI expression display distinct patient, procedure, and outcome characteristics.


title: Laparoscopic management for carcinoid metastasis to the spleen.

text: We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung carcinoid tumour. They were found to have a 4.7 cm splenic lesion on CT with a probable left acetabular metastasis demonstrated on Gallium PET scan. The patient underwent laparoscopic splenectomy for debulking treatment of the splenic lesion that was confirmed to be a splenic metastasis of the resected carcinoid lung tumour. Following an uncomplicated recovery, the patient was discharged on the second postoperative day. On discharge, she received adjuvant therapy with Lutetium 177 DOTATATE. This is the first report of a carcinoid splenic metastasis successfully treated with laparoscopic splenectomy.


title: Current best evidence recommendations on measurement and interpretation of physical function in patients with chronic kidney disease.

text: Chronic kidney disease (CKD) is becoming a serious health problem throughout the world and is one of the most potent known risk factors for cardiovascular disease. Deterioration of physical function is accelerated in patients with CKD to levels that significantly impact on clinically and patient-important outcomes such as morbidity, employment, quality of life and, ultimately, survival. However, meaningful interpretation of the existing physical function-related literature in adult patients with CKD is hindered, possibly due to inconsistent choice of methodology, assessment tools and reporting of data. The current comprehensive review of the literature aims to provide the theoretical rationale and framework for physical function assessment and to identify the prevailing approaches to (i) the characterization (classification and terminology), (ii) interpretation, and (iii) reporting of physical function assessment in people with CKD. Comprehensive assessment of physical function can provide important information about the presence of 'physiological impairment' at a body systems level (exercise tolerance under well controlled, laboratory-based procedures), 'functional limitations' (physical performance during tasks imitating usual daily, personal or occupational tasks) and 'functional disability' (via self-reported physical functioning in the context of a socio-cultural environment). The selection of physical function assessment tools should be guided by the primary purpose of the assessment (e.g. research or routine clinical monitoring), by the overall scientific 'soundness' of the chosen tool (e.g. validity, utility, reproducibility, responsiveness characteristics) and by operational factors (e.g. patient collaboration, cost, personnel expertise). Recommendations for tests, methods and protocols are therefore presented, for the assessment of cardiorespiratory and muscular fitness, physical performance and self-reported physical functioning. These recommendations are based on synthesis of available information as derived from controlled exercise training interventions in adult patients with CKD. Special considerations for physical function assessment and suggestions for future research are also addressed. Such an information synthesis might promote greater standardization of the physical function assessment of patients with CKD in routine clinical care or research settings. This would potentially lead to generation of adequate scientific decision-making criteria to help researchers and healthcare providers in selecting the most appropriate measures according to the physical function areas assessed, and to accurately and meaningfully characterize and compare patients' responses to therapeutic interventions.


title: Isolation and characterization of current human coronavirus strains in primary human epithelial cell cultures reveal differences in target cell tropism.

text: The human airway epithelium (HAE) represents the entry port of many human respiratory viruses, including human coronaviruses (HCoVs). Nowadays, four HCoVs, HCoV-229E, HCoV-OC43, HCoV-HKU1, and HCoV-NL63, are known to be circulating worldwide, causing upper and lower respiratory tract infections in nonhospitalized and hospitalized children. Studies of the fundamental aspects of these HCoV infections at the primary entry port, such as cell tropism, are seriously hampered by the lack of a universal culture system or suitable animal models. To expand the knowledge on fundamental virus-host interactions for all four HCoVs at the site of primary infection, we used pseudostratified HAE cell cultures to isolate and characterize representative clinical HCoV strains directly from nasopharyngeal material. Ten contemporary isolates were obtained, representing HCoV-229E (n = 1), HCoV-NL63 (n = 1), HCoV-HKU1 (n = 4), and HCoV-OC43 (n = 4). For each strain, we analyzed the replication kinetics and progeny virus release on HAE cell cultures derived from different donors. Surprisingly, by visualizing HCoV infection by confocal microscopy, we observed that HCoV-229E employs a target cell tropism for nonciliated cells, whereas HCoV-OC43, HCoV-HKU1, and HCoV-NL63 all infect ciliated cells. Collectively, the data demonstrate that HAE cell cultures, which morphologically and functionally resemble human airways in vivo, represent a robust universal culture system for isolating and comparing all contemporary HCoV strains.


title: Measurement of peritoneal fluid urea nitrogen and creatinine levels is useful to detect iatrogenic urinary tract leakage in colorectal surgery.

text: BACKGROUND Increased peritoneal drainage after colorectal surgery is a common problem. Measurement of peritoneal fluid urea nitrogen (UN) and creatinine (Cr) is a diagnostic tool to detect the urinary tract leakage (UTL). We evaluated its application in colorectal surgery. METHODS We conducted a retrospective chart review study. We enrolled patients with iatrogenic UTL, and measured their UN and Cr levels in peritoneal fluid and compared them with those in blood and urine. Meanwhile, we assigned patients without UTL to a control group and compared clinical parameters of both groups. RESULTS Twenty-three patients with iatrogenic UTL were recruited. The overall incidence was 0.5%. UN level in peritoneal fluid (322 ± 56 mg/dL) was significantly higher than that in blood (18.7 ± 4.0 mg/dL, p < 0.001); Cr level in peritoneal fluid (69.7 ± 14.3 mg/dL) was also significantly higher than that in blood (1.5 ± 0.5 mg/dL, p < 0.001). UN level in peritoneal fluid was significantly higher in the iatrogenic UTL group than in the control group (322 mL/dL vs. 9.3 mL/dL, p < 0.001); Cr level in peritoneal fluid was also significantly higher (69.7 mg/dL vs. 0.98 mg/dL, p < 0.001). CONCLUSION When increased peritoneal drainage is found postoperatively in colorectal surgery, measurement of UN and Cr levels in peritoneal fluid can be a useful diagnostic tool to determine intraperitoneal iatrogenic UTL.


title: Prevention and management of COVID-19 among patients with diabetes: an appraisal of the literature

text: The coronavirus disease 2019 (COVID-19) pandemic has emerged as one of the greatest challenges faced by humankind in the recent past. People with diabetes and related comorbidities are at increased risk of its complications and of COVID-19-related death. Older age, multi-morbidity, hyperglycaemia, cardiac injury and severe inflammatory response are predictors of poor outcome. The complex interplay between COVID-19, diabetes and the effects of related therapies is being explored. Most patients experience a mild illness with COVID-19, while people with diabetes are at increased risk of severe disease. Optimising glycaemic control and adopting measures to prevent disease spread are critical aspects. The management of mild disease is supportive, while very many immunomodulatory and antiviral therapies are being investigated for the treatment of severe disease. Several of these agents have specific considerations for use in people with diabetes. Since mass population lockdowns are considered a key step in controlling disease spread, it follows that, in addition to the direct vulnerability to severe COVID-19, people with diabetes can be affected by limited access to healthcare, insulin, other medications and blood glucose monitoring equipment. Measures to prevent disease spread at the individual and community level are the key to mitigating the rapidly escalating pandemic, while agents for chemoprophylaxis and vaccines are being explored. People with diabetes should be recognised as a vulnerable group for complicated disease and are at risk during times of disturbed social systems. Strategies are needed to safeguard the health of patients with diabetes during the pandemic. This review summarises the current knowledge and perceived challenges for prevention and management of COVID-19 in people with diabetes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s00125-020-05164-x) contains peer-reviewed but unedited supplementary material including a slideset of the figures for download, which is available to authorised users.


title: Prospective study on serum metal levels in patients with metal-on-metal lumbar disc arthroplasty.

text: PURPOSE Metal-on-metal total disc replacement is a recent alternative treatment for degenerative disc disease. Wear and corrosion of these implants can lead to local and systemic transport of metal debris. This prospective longitudinal study examined the serum chromium and cobalt levels in 24 patients with cobalt-chromium alloy metal-on-metal lumbar disc replacements. METHODS Serum was assayed for chromium (Cr) and cobalt (Co) using high-resolution inductively-coupled plasma-mass spectrometry. Detection limits were 0.015 ng/mL for Cr and 0.04 ng/mL for Co. RESULTS Median serum Co levels at pre-op, 3, 6, 12, 24, and 36-months post-op were 0.10, 1.03, 0.96, 0.98, 0.67, and 0.52 ng/mL, respectively. Median serum Cr levels were 0.06, 0.49, 0.65, 0.43, 0.52, and 0.50 ng/mL, respectively. CONCLUSION In general, these results indicated that serum Co and Cr levels are elevated at all postoperative time points and are of the same order of magnitude as those observed in well-functioning metal-on-metal surface replacements of the hip and in metal-on-metal total hip replacements at similar postoperative time points.


title: Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.

text: BACKGROUND Lobectomy using video-assisted thoracoscopic surgery (VATS) still is a controversial operation despite its many observed benefits. The controversy may be due to difficulties performing the procedure. This study addresses a standardized anterior approach facilitating the operation. METHODS This report describes 156 VATS lobectomies performed with a uniform anterior three-port technique. The surgeon and the assistant stand on the abdominal side of the patient, and the setup is independent of the lobe to be resected. RESULTS From 2005 to 2007, 156 VATS lobectomies and 13 conversions (7.7%) were performed with an anterior three-port technique. No mortality occurred among the VATS lobectomies during a 30-day period. The major comorbidity rate was 78%. The comorbidities included former thoracic surgery (9%) or a history of another cancer (22%), indicating potentially difficult surgery and a nonselected population. The majority (92%) of the patients had lung cancer. The major postoperative problem was air leakage, which usually prolongs the tube time and the in-hospital stay, but a "no-touch fissure" technique significantly reduced the median tube time to 4 days and the postoperative hospital stay to 5 days. CONCLUSIONS This study shows that VATS lobectomies can be performed using a standardized anterior approach with low rates of conversion and morbidity. A "no-touch fissure" technique lowers the postoperative tube time, the in-hospital stay, and the number of patients with prolonged air leakage. A uniform anterior approach facilitates VATS lobectomy and makes this advanced procedure more easily adaptable by many surgeons familiar with an open anterior approach. The findings show that VATS lobectomy can be performed safely for a large proportion of lung cancer patients.


title: Sirt3 Mediates the Inhibitory Effect of Adjudin on Astrocyte Activation and Glial Scar Formation following Ischemic Stroke.

text: In response to stroke-induced injury, astrocytes can be activated and form a scar. Inflammation is an essential component for glial scar formation. Previous study has shown that adjudin, a potential Sirt3 activator, could attenuate lipopolysaccharide (LPS)- and stroke-induced neuroinflammation. To investigate the potential inhibitory effect and mechanism of adjudin on astrocyte activation, we used a transient middle cerebral artery occlusion (tMCAO) model with or without adjudin treatment in wild type (WT) and Sirt3 knockout (KO) mice and performed a wound healing experiment in vitro. Both our in vivo and in vitro results showed that adjudin reduced astrocyte activation by upregulating Sirt3 expression. In addition, adjudin treatment after stroke promoted functional and neurovascular recovery accompanied with the decreased area of glial scar in WT mice, which was blunted by Sirt3 deficiency. Furthermore, adjudin could increase Foxo3a and inhibit Notch1 signaling pathway via Sirt3. Both the suppression of Foxo3a and overexpression of N1ICD could alleviate the inhibitory effect of adjudin in vitro indicating that Sirt3-Foxo3a and Sirt3-Notch1 signaling pathways were involved in the inhibitory effect of adjudin in wound healing experiment.


title: Meeting report: Emerging respiratory viral infections and nonhuman primate case reports.

text: A workshop on Emerging Respiratory Viral Infections and Spontaneous Diseases in nonhuman primates was sponsored by the concurrent Annual Meetings of the American College of Veterinary Pathologists and the American Society for Veterinary Clinical Pathology, held December 1-5, 2012, in Seattle, Washington. The session had platform presentations from Drs Karen Terio, Thijs Kuiken, Guy Boivin, and Robert Palermo that focused on naturally occurring influenza, human respiratory syncytial virus, and metapneumovirus in wild and zoo-housed great apes; the molecular biology and pathology of these viral respiratory diseases in nonhuman primate (NHP) models; and the therapeutic and vaccine approaches to prevention and control of these emerging respiratory viral infections. These formal presentations were followed by presentations of 14 unique case studies of rare or newly observed spontaneous lesions in NHPs (see online files for access to digital whole-slide images corresponding to each case report at http://scanscope.com/ACVP%20Slide%20Seminars/2012/Primate%20Pathology/view.apml). The session was attended by meeting participants that included students, pathology trainees, and experienced pathologists from academia and industry with an interest in respiratory and spontaneous diseases of NHPs.


title: Procedural and indwelling complications with inferior vena cava filters: frequency, etiology, and management.

text: Inferior vena cava (IVC) filters are commonly used in select high-risk patients for the prevention of pulmonary embolism. Potentially serious complications can arise from the use of IVC filters, including thrombosis of the filter itself and filter fragment embolization. This article discusses the utility of IVC filters and reviews the management of two cases of filter-related complications.


title: CT coronary angiography in atrial fibrillation: a comparison of radiation dose and diagnostic confidence with retrospective gating vs prospective gating with systolic acquisition.

text: OBJECTIVE To compare unmodulated, retrospective electrocardiographic (ECG) gating to prospective ECG gating with systolic acquisition for CT coronary angiography (CTCA) in patients with atrial fibrillation (AF), considering the radiation dose and the diagnostic confidence achieved with each technique. METHODS A retrospective service evaluation was conducted before and after prospective gating with systolic acquisition replaced retrospectively gated imaging for patients with AF undergoing CTCA at our institution. 25 consecutive patients were examined in each group. The scan parameters and radiation dose information had been collected in a prospective fashion. The image sets were read by blinded, expert readers who rated their diagnostic confidence using a 5-point Likert scale. RESULTS The radiation dose received by patients was significantly greater in the retrospectively gated group than those being scanned using prospective gating (21 vs 5.9 mSv, p < 0.01). The prospective gating technique was also associated with greater diagnostic confidence (mean, per-patient score 3.09 vs 3.78, p = 0.02). CONCLUSION Prospective gating with systolic acquisition appears to improve diagnostic confidence at a significantly reduced radiation dose compared with retrospective gating in patients with AF. ADVANCES IN KNOWLEDGE The use of prospective gating with systolic triggering significantly reduces the radiation exposure to patients in AF undergoing CTCA. The same protocol also appears to improve diagnostic confidence.


Outpatient Treatment at Home for Medicare Beneficiaries During and After the COVID-19 Pandemic.


title: Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis.

text: BACKGROUND Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis. STUDY DESIGN Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed. RESULTS Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop. CONCLUSIONS Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.


title: COVID-19: is fibrosis the killer?

text: COVID-19 is a respiratory disease A recent report in Lancet examined, retrospectively, 137 patients with COVD-19 Patients that died had elevated IL-6 levels and acute respiratory distress syndrome These data have obvious implications for how to control mortality in COVID-19


title: Adenoid Cystic Carcinoma of Bartholin's Gland: What Is the Best Approach?

text: Background and summary: Among all vulvar cancers, primary adenoid cystic carcinoma (ACC) of Bartholin's gland is a very rare tumor characterized by a slow growth, a high local aggressiveness, and a remarkable recurrence rate. Due to its rarity, treatment remains a challenge for oncologists and gynecological surgeons. Key message: The present paper reports clinical, radiological, and histological features of ACC of Bartholin's gland and reviews the literature data on the treatment options with a particular focus on the potential role of particle radiation therapy.


title: SILS sigmoidectomy versus multiport laparoscopic sigmoidectomy for diverticulitis.

text: BACKGROUND AND OBJECTIVES In this single-institution study, we aimed to compare the safety, feasibility, and outcomes of single-incision laparoscopic sigmoidectomy (SILSS) with multiport laparoscopic sigmoidectomy (MLS) for recurrent diverticulitis. METHODS Between October 2011 and February 2013, 60 sigmoidectomies were performed by the same surgeon. Forty patients had a MLS and 20 patients had a SILSS. Outcomes were compared. RESULTS Patient characteristics were similar. There was no difference in morbidity, mortality or readmission rates. The mean operative time was longer in the SILSS group (P=.0012). In a larger proportion of patients from the SILSS group, 2 linear staplers were needed for transection at the rectum (P=.006). The total cost of disposable items was higher in the SILSS group (P<.0001). No additional ports were placed in the SILSS group. Return to bowel function or return to oral intake was faster in the SILSS group (P=.0446 and P=.0137, respectively). Maximum pain scores on postoperative days 1 and 2 were significantly less for the SILSS group (P=.0014 and P=.047, respectively). Hospital stay was borderline statistically shorter in the SILSS group (P=.0053). SILSS was also associated with better cosmesis (P<.0011). CONCLUSION SILSS is feasible and safe and is associated with earlier recovery of bowel function, a significant reduction in postoperative pain, and better cosmesis.


title: Parental manual ventilation in resource-limited settings: an ethical controversy.

text: Lower respiratory tract infections are a leading cause of paediatric morbidity and mortality worldwide. Children in low-income countries are disproportionately affected. This is in large part due to limitations in healthcare resources and medical technologies. Mechanical ventilation can be a life-saving therapy for many children with acute respiratory failure. The scarcity of functioning ventilators in low-income countries results in countless preventable deaths. Some hospitals have attempted to adapt to this scarcity by using hand-bag ventilation, as either a bridge to a mechanical ventilator, or until clinical improvement occurs rendering mechanical ventilation no longer necessary. In instances of hand-bag ventilation, an endotracheal tube is first placed. Family members are then asked to play the role of a ventilator, manually compressing a bag repeatedly to inflate the child's lungs. This approach is fraught with numerous ethical challenges. A careful examination of the data and a nuanced approach to the ethical considerations are imperative. Ethical arguments in support of and in opposition to allowing parental hand-bag ventilation are explored, including the best interests of the child, the child's right to an open future, beneficence and parental protection, legitimising substandard care, and finally, contextual concerns. An algorithmic, potentially ethically permissible approach to parental participation in manual ventilation is proposed.


title: [Exploration of omics mechanism and drug prediction of coronavirus-induced heart failure based on clinical bioinformatics].

text: Objective: Present study investigated the mechanism of heart failure associated with coronavirus infection and predicted potential effective therapeutic drugs against heart failure associated with coronavirus infection. Methods: Coronavirus and heart failure were searched in the Gene Expression Omnibus (GEO) and omics data were selected to meet experimental requirements. Differentially expressed genes were analyzed using the Limma package in R language to screen for differentially expressed genes. The two sets of differential genes were introduced into the R language cluster Profiler package for gene ontology (GO) and Kyoto gene and genome encyclopedia (KEGG) pathway enrichment analysis. Two sets of intersections were taken. A protein interaction network was constructed for all differentially expressed genes using STRING database and core genes were screened. Finally, the apparently accurate treatment prediction platform (EpiMed) independently developed by the team was used to predict the therapeutic drug. Results: The GSE59185 coronavirus data set was searched and screened in the GEO database, and divided into wt group, ΔE group, Δ3 group, Δ5 group according to different subtypes, and compared with control group. After the difference analysis, 191 up-regulated genes and 18 down-regulated genes were defined. The GEO126062 heart failure data set was retrieved and screened from the GEO database. A total of 495 differentially expressed genes were screened, of which 165 were up-regulated and 330 were down-regulated. Correlation analysis of differentially expressed genes between coronavirus and heart failure was performed. After cross processing, there were 20 GO entries, which were mainly enriched in virus response, virus defense response, type Ⅰ interferon response, γ interferon regulation, innate immune response regulation, negative regulation of virus life cycle, replication regulation of viral genome, etc . There are 5 KEGG pathways, mainly interacting with tumor necrosis factor signaling pathway, IL-17 signaling pathway, cytokine and receptor interaction, Toll-like receptor signaling pathway, human giant cells viral infection related. All differentially expressed genes were introduced into the SREING online analysis website for protein interaction network analysis, and core genes such as signal transducer and activator of transcription 3, IL-10, IL17, TNF, interferon regulatory factor 9, 2'-5'-oligoadenylate synthetase 1, mitogen-activated protein kinase 3, radical s-adenosyl methionine domain containing 2, c-x-c motif chemokine ligand 10, caspase 3 and other genes were screened. The drugs predicted by EpiMed's apparent precision treatment prediction platform for disease-drug association analysis are mainly TNF-α inhibitors, resveratrol, ritonavir, paeony, retinoic acid, forsythia, and houttuynia cordata. Conclusions: The abnormal activation of multiple inflammatory pathways may be the cause of heart failure in patients after coronavirus infection. Resveratrol, ritonavir, retinoic acid, amaranth, forsythia, houttuynia may have therapeutic effects. Future basic and clinical research is warranted to validate present results and hypothesis.


The EU and the social determinants of health in a post-COVID world.


title: Effect of Tri-Staple Technology and Slow Firing on Secure Stapling Using an Endoscopic Linear Stapler.

text: AIM To evaluate the effect of Tri-staple technology and slow firing using the Endo-GIA endoscopic linear stapler. METHODS The cardiac and pyloric portions of porcine stomachs were divided using the endoscopic linear stapler with different reload types. A total of 8 min of waiting time was employed during firing in the slow-firing group and no waiting time was employed in the normal-firing group. The shape of the staples was then evaluated. The length of the staple line and serosal laceration was also determined. RESULTS There was a moderate negative correlation between tissue thickness and secure staple formation. Tri-staple reloads (purple, black) offered more secure staple formation compared with Universal green reload. Although slow firing enhanced secure staple formation, its effect was greater when using green reload, compared with Tri-staple reloads. Significantly shorter staple line length and longer serosal laceration was observed in the thick tissue. Although the cartridge type did not influence lengths of the staple line or serosal laceration, both were better in the slow-firing group. CONCLUSIONS Tri-staple reloads offered more secure staple formation compared with the Universal reload. Although slow firing improved staple line shortening and serosal laceration, its effect on secure stapling was relatively small when using Tri-staple reloads.


title: The partial underlay preperitoneal with panniculectomy repair for incisional abdominal hernia in the morbidly obese.

text: BACKGROUND Because of high frequency, high morbidity, and difficulty of repair, incisional hernias in obese patients represent a particularly vexing and common problem for surgeons. The objective of this study was to describe a highly selective technique for incisional hernia repair with panniculectomy in the morbidly obese. We also describe perioperative characteristics and preliminary outcomes for a limited series of patients who underwent this procedure. METHODS We performed a preperitoneal partial mesh underlay with a panniculectomy (PUPP) on 10 patients with incisional hernias and a body mass index (BMI)>40 kg/m(2). The hernia repair was performed by a general surgery team, and the panniculectomy was performed by a plastic surgery team. We retrospectively analyzed perioperative variables for each patient. Phone interviews were conducted to obtain follow-up. RESULTS Mean patient age was 53 years (range 32-75 yr) with mean BMI of 46 kg/m(2) (range 41-60 kg/m(2)). Patients had a history of 3.4 average prior abdominal operations, and a median of 3 prior hernia repairs. The average operative time was 371 minutes with a mean estimated blood loss of 162 ccs. Three patients experienced a minor wound complication. There were no major wound complications, and the 30-day mortality rate was zero. At a median and average follow-up time of 805 and 345 days, respectively, one patient developed a hernia recurrence. Patients were satisfied with their appearance and the hernia repair, with mean satisfaction scores of 4.3 and 4.9 out of 5 (very satisfied), respectively. CONCLUSION The PUPP hernia repair is a viable option for incisional herniorrhaphy and concurrent panniculectomy in the morbidly obese.


title: Use of pressure mapping for quantitative analysis of pressure points induced by external coaptation of the distal portion of the pelvic limb of dogs.

text: OBJECTIVE To quantitatively measure the amount of pressure induced at the calcaneus and cranial tibial surface of dogs by use of 2 cast configurations. ANIMALS 13 client- or student-owned dogs. PROCEDURES Pressure sensors were placed over the calcaneus and cranial tibial surface. Dogs then were fitted with a fiberglass cast on a pelvic limb extending from the digits to the stifle joint (tall cast). Pressure induced over the calcaneus and proximal edge of the cast at the level of the cranial tibial surface was simultaneously recorded during ambulation. Subsequently, the cast was shortened to end immediately proximal to the calcaneus (short cast), and data acquisition was repeated. Pressure at the level of the calcaneus and cranial tibial surface for both cast configurations was compared by use of paired t tests. RESULTS The short cast created significantly greater peak pressure at the level of the calcaneus (mean ± SD, 0.2 ± 0.07 MPa), compared with peak pressure created by the tall cast (0.1 ± 0.06 MPa). Mean pressure at the proximal cranial edge of the cast was significantly greater for the short cast (0.2 ± 0.06 MPa) than for the tall cast (0.04 ± 0.03 MPa). CONCLUSIONS AND CLINICAL RELEVANCE A cast extended to the level of the proximal portion of the tibia caused less pressure at the level of the calcaneus and the proximal cranial edge of the cast. Reducing the amount of pressure at these locations may minimize the potential for pressure sores and other soft tissue injuries.


title: Laparoscopic treatment of incisional and primary ventral hernia in morbidly obese patients with a BMI over 35.

text: INTRODUCTION Incisional and ventral hernias are common surgical indications. Their management is associated with significant complications and recurrences in open surgery (15-25%). Since laparoscopy has become a standard in bariatric surgery, there has been a natural trend to treat obese patients with parietal wall defects laparoscopically. The aim of our study was to evaluate the feasibility and the results of the laparoscopic management of parietal wall defects in patients with a BMI >35. MATERIALS AND METHODS A series of 79 patients were included. Data were acquired prospectively and analyzed retrospectively. The surgical procedure was standardized: 3 ports, mesh type (Parietex™ Composite mesh, Covidien, France), fixation with non-absorbable transfascial sutures, and tackers. Complications were evaluated. RESULTS Out of 79 patients (29 men, 50 women), 43 had umbilical and 36 had ventral hernias. Mean age was 52.4 years, and mean BMI was 40.83 kg/m(2). Mean postoperative hospital stay was 2 days. Postoperative pain evaluated by visual analog scale was 2.86. No intraoperative complications or deaths occurred. Seven postoperative complications occurred (8.86%): two parietal wall hematomas treated by radiological embolization, two significant cases of postoperative pain, one postoperative obstruction, one spontaneously resolved respiratory failure, and one early (day 1) parietal wall defect with immediate reoperation. Postoperative seroma rate was 26.58% (21 patients, all of whom were treated conservatively). Postoperative follow-up was 18.10 months (1-84 months), and recurrence rate was 3.8% (3 patients). DISCUSSION This study confirms the feasibility and safety of the laparoscopic approach for ventral hernias in morbidly obese patients. Recurrence rates (3.8%) appeared lower than the ones observed in the literature (15-25%). Postoperative hemorrhage and port-site hernia are specific complications of this approach. Postoperative hospital stay is low (2 days) as compared to open surgery. Laparoscopic management of parietal wall defects should be considered a standard option in morbidly obese patients.