title: Proliferative and nonproliferative lesions of the rat and mouse hepatobiliary system.

text: The INHAND Project (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions in Rats and Mice) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP) and North America (STP) to develop an internationally-accepted nomenclature for proliferative and non-proliferative lesions in laboratory animals. The purpose of this publication is to provide a standardized nomenclature and differential diagnosis for classifying microscopic lesions observed in the hepatobiliary system of laboratory rats and mice, with color microphotographs illustrating examples of some lesions. The standardized nomenclature presented in this document is also available for society members electronically on the internet (http://goreni.org). Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous and aging lesions as well as lesions induced by exposure to test materials. A widely accepted and utilized international harmonization of nomenclature for lesions of the hepatobiliary system in laboratory animals will decrease confusion among regulatory and scientific research organizations in different countries and provide a common language to increase and enrich international exchanges of information among toxicologists and pathologists.


title: Intrathoracic Pressure Regulation Augments Stroke Volume and Ventricular Function in Human Hemorrhage.

text: Obtaining intravenous (i.v.) access for fluid administration is a critical step in treating hemorrhage. However, expertise, supplies, and personnel to accomplish this task can be delayed or even absent in austere environments. An alternative approach that can "buy time" and improve circulation when i.v. fluids are absent is needed. Preclinical studies show that intrathoracic pressure regulation (ITPR) can increase perfusion in hypovolemia in the absence of i.v. fluid. We compared ITPR with placebo in humans undergoing a 15% hemorrhage under general anesthesia. Paired healthy volunteers (n = 7, aged 21 - 35 years) received either ITPR or placebo on different study days. Institutional review board informed consent was obtained. Subjects were anesthetized using propofol, intubated, and mechanically ventilated and hemorrhaged (10 mL/kg). Twenty minutes after hemorrhage, ITPR (-12 cm H2O vacuum) or placebo (device but no vacuum) was administered for another 60 min. Intravenous fluid was administered when systolic blood pressure was less than 85 mmHg. Hemodynamics, cardiac function by echocardiography, and volumetric data were compared. Data were expressed in Δmean ± SEM before and after ITPR/placebo intervention. There were no differences in mean arterial pressure (ITPR, 2.1 ± 3 mmHg; placebo, -0.7 ± 3 mmHg) or fluid infused (ITPR, 17.4 ± 4 mL/kg; placebo, 18.6 ± 5 mL/kg). Urinary output and plasma volume also were not significantly different. Intrathoracic pressure regulation augmented stroke volume (ITPR, 22 ± 5 mL, placebo, 6 ± 4 mL; P < 0.05), ejection fraction (ITPR, 4% ± 1%; placebo, 0% ± 1%), and diastolic function (ΔE/e') (ITPR, -0.8 ± 0.4 vs. placebo, +0.81 ± 0.6; P < 0.05). Intrathoracic pressure regulation did not improve mean arterial pressure in healthy volunteers aged 21 to 35 years. However, ITPR augmented stroke volume, which could be caused by improved ventricular function.


title: Traditional and Complementary Medicine Use Among Indigenous Cancer Patients in Australia, Canada, New Zealand, and the United States: A Systematic Review.

text: BACKGROUND Cancer 'patients' are increasingly using traditional indigenous and complementary medicines (T&CM) alongside conventional medical treatments to both cure and cope with their cancer diagnoses. To date T&CM use among Indigenous cancer patients from Australia, Canada, New Zealand, and the United States has not been systematically reviewed. METHODS We systematically searched bibliographic databases to identify original research published between January 2000 and October 2017 regarding T&CM use by Indigenous cancer patients in Australia, Canada, New Zealand, and the United States. Data from records meeting eligibility criteria were extracted and appraised for quality by 2 independent reviewers. RESULTS Twenty-one journal articles from 18 studies across all 4 countries met our inclusion criteria. T&CM use ranged from 19% to 57.7% (differing across countries). T&CM was mostly used concurrently with conventional cancer treatments to meet their spiritual, emotional, social, and cultural needs; however, bush, traditional, and herbal medicines were used in a minority of cases as an alternative. CONCLUSIONS Our findings highlight the importance of T&CM use to Indigenous cancer patients across these 4 countries; we identified multiple perceived spiritual, emotional and cultural benefits to its use. The patient's perception of their health professional's attitudes toward T&CM in some cases hindered or encouraged the patient's disclosure. Additional research is required to further explore the use and disclosure of T&CM among Indigenous cancer patients to help inform and ensure effective, safe, coordinated care for Indigenous cancer patients that relies on shared open decision making and communication across patients, communities, and providers.


title: Immunopathological basis of lymphocytic choriomeningitis virus-induced chorioretinitis and keratitis.

text: The infection of humans with the rodent-borne lymphocytic choriomeningitis virus (LCMV) can lead to central nervous system disease in adults or severe neurological disease with hydrocephalus and chorioretinitis in children infected congenitally. Although LCMV-induced meningitis and encephalitis have been studied extensively, the immunopathological mechanisms underlying LCMV infection-associated ocular disease remain elusive. We report here that the intraocular administration of the neurotropic LCMV strain Armstrong (Arm) elicited pronounced chorioretinitis and keratitis and that infection with the more viscerotropic strains WE and Docile precipitated less severe immunopathological ocular disease. Time course analyses revealed that LCMV Arm infection of the uvea and neuroretina led to monophasic chorioretinitis which peaked between days 7 and 12 after infection. Analyses of T-cell-deficient mouse strains showed that LCMV-mediated ocular disease was strictly dependent on the presence of virus-specific CD8(+) T cells and that the contribution of CD4(+) T cells was negligible. Whereas the topical application of immunosuppressive agents did not prevent the development of chorioretinitis, passive immunization with hyperimmune sera partially prevented retinal and corneal damage. Likewise, mice displaying preexisting LCMV-specific T-cell responses were protected against LCMV-induced ocular disease. Thus, antibody- and/or T-cell-based vaccination protocols could be employed as preventive strategies against LCMV-mediated chorioretinitis.


title: Visual Occlusion During Minimally Invasive Surgery: A Contemporary Review of Methods to Reduce Laparoscopic and Robotic Lens Fogging and Other Sources of Optical Loss.

text: BACKGROUND Maintenance of optimal vision during minimally invasive surgery is crucial to maintaining operative awareness, efficiency, and safety. Hampered vision is commonly caused by laparoscopic lens fogging (LLF), which has prompted the development of various antifogging fluids and warming devices. However, limited comparative evidence exists in contemporary literature. Despite technologic advancements there remains no consensus as to superior methods to prevent LLF or restore visual acuity once LLF has occurred. We performed a review of literature to present the current body of evidence supporting the use of numerous techniques. METHODS A standardized Preferred Reporting Items for Systematic Reviews and Meta-Analysis review was performed, and PubMed, Embase, Web of Science, and Google Scholar were searched. Articles pertaining to mechanisms and prevention of LLF were reviewed. We applied no limit to year of publication or publication type and all articles encountered were included in final review. Limited original research and heterogenous outcome measures precluded meta-analytical assessment. RESULTS Vision loss has a multitude of causes and although scientific theory can be applied to in vivo environments, no authors have completely characterized this complex problem. No method to prevent or correct LLF was identified as superior to others and comparative evidence is minimal. Robotic LLF was poorly investigated and aside from a single analysis has not been directly compared to standard laparoscopic fogging in any capacity. CONCLUSIONS Obscured vision during surgery is hazardous and typically caused by LLF. The etiology of LLF despite application of scientific theory is yet to be definitively proven in the in vivo environment. Common methods of prevention of LLF or restoration of vision due to LLF have little evidence-based data to support their use. A multiarm comparative in vivo analysis is required to formally assess these commonly used techniques in both standard and robotic laparoscopes.


Gates launches $1bn vaccine initiative to target emerging infectious diseases.


title: Characterization of brain blood flow and the amplitude of low-frequency fluctuations in major depressive disorder: A multimodal meta-analysis.

text: BACKGROUND In healthy subjects, there is an association between amplitude of low-frequency fluctuations (ALFF) and regional cerebral blood flow (rCBF). To date, no published meta-analysis has investigated changes in the regional ALFF in medication-free depressed patients. METHODS In this study, we aimed to explore whether resting-state rCBF and ALFF changes co-occur in the depressed brain without the potential confound of medication. Using signed differential mapping (SDM), we conducted two meta-analyses, one of rCBF studies and one of ALFF studies, involving medication-free patients with major depressive disorder (MDD). In addition, we conducted a multimodal meta-analysis to identify brain regions that showed abnormalities in both rCBF and ALFF. RESULTS A total of 16 studies were included in this series. We identified abnormalities in resting-state rCBF and ALFF in the left insula in medication-free MDD patients compared with healthy controls (HC). In addition, we observed altered resting-state rCBF in the limbic-subcortical-cortical circuit and altered ALFF in the default mode network (DMN) and some motor-related brain regions. LIMITATIONS The analysis techniques, patient characteristics and clinical variables of the included studies were heterogeneous. CONCLUSIONS The conjoint alterations in ALFF and rCBF in the left insula may represent core neuropathological changes in medication-free patients with MDD and merit further studying.


title: [Late occurrence of pulmonary embolsim in SARS-CoV-2 pneumonia: a case series].

text: Several studies suggested that the acute phase of SARS-CoV-2 infection may be associated with a hypercoagulable state and increased risk for venous thromboembolism but the incidence of thrombotic complications in the late phase of the disease is currently unknown. The present article describes three cases of patients with SARS-CoV-2 pneumonia and late occurrence of pulmonary embolism. Case 1: a 57-year-old man diagnosed with pulmonary embolism and type B aortic dissection after 12 days from SARS-CoV-2 pneumonia. Laboratory panel at the time of pulmonary embolism showed no signs of ongoing inflammation but only an elevated D-dimer. Case 2: a 76-year-old man with a diagnosis of SARS-CoV-2 pneumonia followed by pulmonary embolism 20 days later, high-resolution computed tomography on that time showed a partial resolution of crazy paving consolidation. Case 3: a 77-year-old man with SARS-CoV-2 pneumonia who developed a venous thromboembolic event despite thromboprophylaxis with low molecular weight heparin. Also in this patients no markers of inflammation were present at the time of complication.The present cases raise the possibility that in SARS-CoV-2 infection the hypercoagulable state may persist over the active inflammation phase and cytokine storm. These findings suggest a role for medium-long term therapeutic anticoagulation started at the time of SARS-CoV-2 pneumonia diagnosis.


COVID-19: A UK Children's Hospital Experience.


title: Monitoring of cerebral blood flow autoregulation in adults undergoing sevoflurane anesthesia: a prospective cohort study of two age groups.

text: Autoregulation of blood flow is a key feature of the human cerebral vascular system to assure adequate oxygenation and metabolism of the brain under changing physiological conditions. The impact of advanced age and anesthesia on cerebral autoregulation remains unclear. The primary objective of this study was to determine the effect of sevoflurane anesthesia on cerebral autoregulation in two different age groups. This is a follow-up analysis of data acquired in a prospective observational cohort study. One hundred thirty-three patients aged 18-40 and ≥65 years scheduled for major noncardiac surgery under general anesthesia were included. Cerebral autoregulation indices, limits, and ranges were compared in young and elderly patient groups. Forty-nine patients (37 %) aged 18-40 years and 84 patients (63 %) aged ≥65 years were included in the study. Age-adjusted minimum alveolar concentrations of sevoflurane were 0.89 ± 0.07 in young and 0.99 ± 0.14 in older subjects (P < 0.001). Effective autoregulation was found in a blood pressure range of 13.8 ± 9.8 mmHg in young and 10.2 ± 8.6 mmHg in older patients (P = 0.079). The lower limit of autoregulation was 66 ± 12 mmHg and 73 ± 14 mmHg in young and older patients, respectively (P = 0.075). The association between sevoflurane concentrations and autoregulatory capacity was similar in both age groups. Our data suggests that the autoregulatory plateau is shortened in both young and older patients under sevoflurane anesthesia with approximately 1 MAC. Lower and upper limits of cerebral blood flow autoregulation, as well as the autoregulatory range, are not influenced by the age of anesthetized patients. Trial registration ClinicalTrials.gov (NCT00512200).


title: Human Factors Considerations in Using Personal Protective Equipment in the COVID-19 Pandemic Context: A Bi-national Survey Study.

text: BACKGROUND Full personal protective equipment (level 1 PPE) is used in various domains and contexts. Prior research has shown positive influences of such equipment on performance, comfort, and contamination levels. The COVID-19 pandemic forced a pervasive requirement of PPE, with little preparation, rushed deployment, inadequate time for training, and massive use by personnel who are inexperienced or not qualified in its effective use. OBJECTIVE This study aimed to examine the key human factors: physical and ergonomic, perceptual and cognitive, that influence the use of level 1 PPE when attending to suspected or confirmed COVID-19 patients. METHODS The research approach consisted of a short survey disseminated to healthcare professionals in two countries, Israel and Portugal, with similar demographics and healthcare systems. The survey included 10 items with a 5-point Likert Scale, regarding the key human factors involved in level 1 PPE, as identified in prior research. RESULTS A total of 722 respondents from Israel and 301 respondents from Portugal were included in the analysis. All the respondents reported using level 1 PPE with COVID-19 patients in the range of several hours daily to several hours weekly. Cronbach's alpha was .73 for Israel, and .75 for Portugal. Responses showed high levels of difficulty, with medians of 4 for items related to discomfort, hearing and seeing, and doffing. A factor analysis showed a set of strongly related variables consisting of hearing, understanding speech, and understanding the situation. This suggests that degradation in communication was strongly associated with degradation in situational awareness. A subsequent mediation analysis showed a direct effect of PPE discomfort on situational awareness (P<.01); this was also influenced (mediated) by difficulties in communicating, namely in hearing and understanding speech. CONCLUSIONS In 2020, the Covid-19 pandemic is paving the way for updating PPE design. The use of already deployed technology affords ample opportunities to improve, adapt, and overcome caveats. The findings here suggest that the use of level 1 PPE with COVID-19 patients has perceptual and cognitive effects, in addition to physical and ergonomic influences. Efforts should be taken to mitigate harmful effects of such influences, both regarding the performance of medical actions and the risk of contamination to healthcare workers. Such efforts involve the design of PPE; the introduction of technologies to enhance vision, hearing, and communicating during use of PPE; and training staff in using the equipment, and in effective communication and teamwork protocols. CLINICALTRIAL


Loss of integrity of a reinforced endotracheal tube by patient bite.


title: A practical method of using the anatomical space of the vesicouterine ligament for laparoscopic radical hysterectomy: a retrospective cohort study.

text: OBJECTIVE To investigate the practicality of a new method using anatomical spaces for performing standard laparoscopic radical hysterectomy (LRH) without ureteral injury in patients with cervical cancer. METHODS Clinicopathological characteristics and perioperative complications were retrospectively analysed in 440 patients with stages IB1 to IIB cervical cancer. The patients were assigned to two of the following groups: LRH by our method of using anatomical landmarks (anatomical space group, n = 217) and the traditional method (traditional group, n = 223). RESULTS The mean operative duration and time of vesicouterine ligament (VUL) dissection were significantly shorter (173.87 ± 30.39 vs. 210.83 ± 44.55 minutes; 32.75 ± 7.23 vs. 43.48 ± 11.22 minutes), and blood loss was less in the anatomical space group compared with the traditional group. The rate of the intraoperative complication of ureteral injury was also significantly lower in the anatomical space group compared with the traditional group (0 vs. 5). CONCLUSIONS LRH by the anatomical method, using the axillary space and other potential spaces as anatomical landmarks, results in less blood loss and reduced ureteral injury compared with the traditional method. This method is safe and practical for separating the ureter from the VUL in patients with cervical cancer.


title: Association of Menopausal Age with Unruptured Intracranial Aneurysm Morphology.

text: Background The prevalence of unruptured intracranial aneurysms (UIAs) increases rapidly in aging women compared with younger women. The impact of menopausal age on UIAs and treatment outcomes with endovascular therapy has not been well studied. We hypothesized that premenopausal age may have a protective effect on presentation size and treatment outcomes. Objective To evaluate the association of menopause with UIA size and outcome with endovascular therapy. Methods Retrospective analysis of consecutive female patients with UIAs treated with endovascular therapy at our academic tertiary care center. UIA characteristics, complications, and outcomes were recorded and compared. Results 117 patients were included: 23 patients in the premenopausal age (PRM) group and 94 in the postmenopausal age (POM) group. 93.6% of all aneurysms in the PRM group were in the internal carotid artery (ICA) segments (p < 0.05). Hence only ICA segment aneurysms were further studied. A total of 21 patients in the PRM group and 60 in the POM group were found to have ICA segment aneurysms. Baseline characteristics were similar between the 2 groups. The mean size of the aneurysms in the PRM group was 8.6 ± 3.9 versus 10.8 ± 5.6 mm in the POM group (p = 0.055). There was a trend to higher aneurysm neck size seen in the POM group (4.7 ± 2.5 vs. 3.7 ± 1.7 mm; p = 0.07). The number of aneurysm lobes was higher in the PRM group (1.23 ± 0.54 vs. 1.07 ± 0.31; p = 0.18). In multivariate analysis, the PRM group had a significantly higher number of UIA lobes. Complications and endovascular therapy outcomes were similar between the 2 groups. Conclusions A trend to increased UIA maximal diameter and neck size was seen in the POM group compared to the PRM group. The PRM group had a significantly higher number of UIA lobes. Larger prospective trials are needed to confirm these findings.


title: Is there any benefit to incorporating a laparoscopic procedure into minimally invasive esophagectomy? The impact on perioperative results in patients with esophageal cancer.

text: BACKGROUND The benefit of using the laparoscopic approach in minimally invasive esophagectomy (MIE) has not been established. We therefore compared the outcome of esophagectomy for patients with esophageal cancer performed with open surgery, video-assisted thoracic surgery (VATS)/laparotomy (hybrid MIE), and VATS/ laparoscopy (total MIE). METHODS Patients with esophageal cancer undergoing tri-incisional esophagectomy with three different approaches between 2005 and 2009 were analyzed from a prospective database. RESULTS Three groups of patients underwent esophagectomy by open surgery (n = 64), hybrid MIE (n = 44), and total MIE (n = 30). The total MIE group had significantly longer operative times but had shorter postoperative ventilator usage times postoperative hospital stay, and they began jejunostomy feeding sooner (P < 0.05, compared with the other groups). There was a significant trend toward a decrease in postoperative pulmonary complications and anastomotic leakage in parallel to the proportion of minimally invasive procedures for esophagectomy (P < 0.05 for the trend test), with a significant difference between the open surgery and total MIE groups (30% vs. 6.7%, and 28% vs. 6.7%, respectively; P < 0.05). CONCLUSIONS Use of a laparoscopic procedure in MIE for patients with esophageal cancer might provide benefit by facilitating postoperative recovery and reducing the rates of post-esophagectomy pulmonary complications and anastomotic leakage.


title: Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery.

text: BACKGROUND Chyle leak is a well known but poorly characterized complication after pancreatic surgery. Available data on incidence, risk factors and clinical significance of chyle leak are highly heterogeneous. METHODS For this cohort study all patients who underwent pancreatic surgery between January 2008 and December 2012 were identified from a prospective database. Chyle leak was defined as any drainage output with triglyceride content of 110 mg/dl or more. Risk factors for chyle leak were assessed by univariable and multivariable analyses. The clinical relevance of chyle leak was evaluated using hospital stay and resolution by 14 days for short-term outcome and overall survival for long-term outcome. RESULTS Chyle leak developed in 346 (10·4 per cent) of 3324 patients. Pre-existing diabetes, resection for malignancy, distal pancreatectomy, duration of surgery 180 min or longer, and concomitant pancreatic fistula or abscess were independent risk factors for chyle leak. Both isolated chyle leak and coincidental chyle leak (with other intra-abdominal complications) were associated with prolonged hospital stay. Some 178 (87·7 per cent) of 203 isolated chyle leaks and 90 (70·3 per cent) of 128 coincidental chyle leaks resolved with conservative management within 14 days. Initial and maximum drainage volumes were associated with duration of hospital stay and success of therapy by 14 days. Impact on survival was restricted to chyle leaks that persisted at 14 days in patients with cancer undergoing palliative surgery. CONCLUSION Chyle leak is a relevant complication, with an incidence of more than 10 per cent after pancreatic surgery, and has a major impact on hospital stay. Drainage volume is associated with hospital stay and success of therapy.


title: Prevention of lung cancer recurrence using cisplatin-loaded superhydrophobic nanofiber meshes.

text: For early stage lung cancer patients, local cancer recurrence after surgical resection is a significant concern and stems from microscopic disease left behind after surgery. Here we apply a local drug delivery strategy to combat local lung cancer recurrence after resection using non-woven, biodegradable nanofiber meshes loaded with cisplatin. The meshes are fabricated using a scalable electrospinning process from two biocompatible polymers--polycaprolactone and poly(glycerol monostearate-co-caprolactone)--to afford favorable mechanical properties for use in a dynamic tissue such as the lung. Owing to their rough nanostructure and hydrophobic polymer composition, these meshes exhibit superhydrophobicity, and it is this non-wetting nature that sustains the release of cisplatin in a linear fashion over ∼90 days, with anti-cancer efficacy demonstrated using an in vitro Lewis Lung carcinoma (LLC) cell assay. The in vivo evaluation of cisplatin-loaded superhydrophobic meshes in the prevention of local cancer recurrence in a murine model of LLC surgical resection demonstrated a statistically significant increase (p = 0.0006) in median recurrence-free survival to >23 days, compared to standard intraperitoneal cisplatin therapy of equivalent dose. These results emphasize the importance of supplementing cytoreductive surgery with local drug delivery strategies to improve prognosis for lung cancer patients undergoing tumor resection.


Human factors analysis of a near-miss event: oxygen supply failure during cardiopulmonary bypass.


title: Impact of proton pump inhibitors and dual antiplatelet therapy cessation on outcomes following percutaneous coronary intervention: Results From the PARIS Registry.

text: BACKGROUND Proton pump inhibitors (PPI) may decrease the availability of clopidogrel by competitive antagonism, leading to a potential increase in ischemic events. METHODS We evaluated patients from the all-comer PARIS registry treated with dual antiplatelet therapy (DAPT) with aspirin and clopidogrel following coronary stenting for outcomes stratified by PPI use. Two-year major adverse cardiovascular events (MACE), composite of cardiac death, myocardial infarction, definite or probable stent thrombosis or target lesion revascularization (TLR), and net adverse cardiac events (NACE), composite of MACE or Bleeding Academic Research consortium (BARC) type 3 or 5 bleeding were assessed. We also explored associations between PPI use and patterns of 2-year DAPT cessation. RESULTS The cohort comprised 4635 patients (23% PPI users) with mean age 64.4 ±11.4 years. Two year adjusted risk of MACE (HR: 1.27, 95% CI: 1.04-1.55), NACE (HR: 1.21, 95% CI: 1.01-1.44) and TLR (HR: 1.33, 95% CI: 1.04-1.71) were significantly higher in PPI users vs. non-users, without a difference in bleeding. Although the incidence of 2-year DAPT discontinuation and interruption was similar, DAPT disruption was significantly lower among PPI users vs. non-users (10.0% vs. 14.7%, P <0.0001). Compared to non-PPI users on continued DAPT, disruption was associated with higher MACE in both PPI users (HR: 2.34, 95% CI: 1.38-3.97) and non-users (HR: 1.41, 95% CI: 1.02-1.94) but greater BARC 3,5 bleeding only in non-PPI users (HR: 2.06, 95% CI: 1.21-3.51). CONCLUSIONS In clopidogrel treated PCI patients, the 2-year adjusted risk of MACE and NACE was significantly higher in PPI users driven by higher TLR compared to non-PPI users, without a difference in bleeding. PPI use was associated with lower incidence of DAPT disruption without an increase in disruption related bleeding compared to non-PPI users on DAPT. © 2016 Wiley Periodicals, Inc.


title: Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak perceptions of risk and stress evaluation in nurses.

text: INTRODUCTION Saudi Arabia was affected by an outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV). We aimed to determine the perception of risk and level of stress among nurses. METHODOLOGY A questionnaire survey was administered to determine the perceptions of risk of MERS-CoV infection. RESULTS The majority of the participants were females (332; 86.0%), and there were 54 (14.0%) males. Of the 386 respondents, nurses constituted the majority of the respondents (293; 75.9%), and there were 34 doctors (8.8%). The percentage of exposure was found to be greater in those who were working in the intensive care unit (ICU) (89; 23%). There was a significant difference in the worry and fear scale of contracting the MERS-CoV infection between participants who worked in isolation areas, ICUs, and emergency rooms (mean: 3.01±1.1) compared to participants who worked in areas that are less likely to admit and have MERS-CoV suspected or positive cases (mean: 2.77±1.1; p = 0.031. Females were significantly more worried and fearful of contracting the virus compared to males (mean: 2.92±1.1 versus 2.61±1.0, respectively; p = 0.045). CONCLUSIONS MERS-CoV caused a relatively significant level of distress among nurses. There was a difference in the worry and fear scale of contracting the MERS-CoV infection between participants who worked in areas likely to admit and have MERS-CoV suspected or positive cases. After the campaign, the level of confidence got higher and the participants were more adherent to the infection control precautions.


Position statement of the Royal Spanish Football Federation for the resumption of football activities after the COVID-19 pandemic (June 2020).


Letter to the Editor: CoVid-19 and Type 1 Diabetes: every cloud has a silver lining. Searching the reason of a lower aggressiveness of the CoronaVirus disease in Type 1 Diabetes.


Risk of stent thrombosis with bioresorbable vascular scaffolds - Authors' reply.


title: Single incision laparoscopic total abdominal colectomy with ileorectal anastomosis for synchronous colon cancer.

text: Single incision laparoscopy is currently performed mostly for basic laparoscopic procedures involving single abdominal quadrants. The aim of this case report is to show that single incision laparoscopic techniques can be utilized for complex abdominal laparoscopic procedures with a large target organ and a working space involving all quadrants of the abdominal cavity. A single incision laparoscopic total abdominal colectomy with an ileorectal anastomosis and intraoperative CO(2) colonoscopy was performed for a patient with synchronous adenocarcinoma of the cecum and the sigmoid colon. The patient was discharged home on postoperative day 4 and had no immediate postoperative complications. Single incision laparoscopy is feasible for complex colorectal procedures. Some of the techniques used may be adapted further to achieve colonic resection via a natural orifice in the future.


docid: elglyass

title: Thromboprophylaxis in COVID-19: Anti-FXa - The Missing Factor?


title: Supporting health care workers during the COVID-19 pandemic: Mental health support initiatives and lessons learned from an academic medical center.

text: The unprecedented COVID-19 pandemic has put a great strain on the physical and mental health of health care workers across the globe. This commentary provides an overview of mental health initiatives implemented at an academic medical center to support health care workers during this challenging time and highlights lessons learned. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Robot-assisted radical cystectomy and intracorporeal urinary diversion - safe and reproducible?

text: INTRODUCTION Robot-assisted radical cystectomy (RARC) plus intracorporeal urinary diversion is feasible. Few centers worldwide demonstrated comparable functional and oncologic outcomes. We reported a large series of RARC and intracorporeal diversion to assess its feasibility and reproducibility. MATERIAL AND METHODS We identified 101 RARCs in 82 men and 19 women (mean age 68.3 years) from October 2009 to October 2014. The patients underwent RARC and pelvic lymphadenectomy followed by intracorporeal urinary diversion (ileal conduit/ neobladder). Out of the 101 patients, 28 (27.7%) received intracorporeal ileal conduits and 73 (72.3%) intracorporeal neobladders. Studer pouch was performed in all the patients who underwent intracorporeal neobladder formation. Perioperative, functional and oncologic results including CSS and OS are reported. RESULTS Mean operative time was 402.3 minutes (205-690) and blood loss was 345.3 ml (50-1000). The mean hospital stay was 17.1 days (5-62). All the surgeries were completed with no open conversion. Minor complications (Grade I and II) were reported in 27.7% of patients while major complications (grade III and above) were reported in 36.6% of patients. The mean nodal yield was 20.6 (0-46). Positive ureteric margins were found in 8.9% of patients. The average follow-up was 27.5 months (1-52). Daytime continence could be achieved in 89.2% of patients who underwent intracorporeal neobladder. The 3-year cancer specific survival (CSS) and overall survival (OS) was 80.2% and 69.8% respectively. CONCLUSIONS RARC with intracorporeal diversion is safe and reproducible in 'non-pioneer' tertiary centers with robotic expertise having acceptable operative time and complications as well as comparable functional and oncologic outcomes.


title: Coronavirus disease 2019: a bibliometric analysis and review.

text: OBJECTIVE On December 8, 2019, many cases of pneumonia with unknown etiology were first reported in Wuhan, China, subsequently identified as a novel coronavirus infection aroused worldwide concern. As the outbreak is ongoing, more and more researchers focused interest on the COVID-19. Therefore, we retrospectively analyzed the publications about COVID-19 to summarize the research hotspots and make a review, to provide reference for researchers in the world. MATERIALS AND METHODS We conducted a search in PubMed using the keywords "COVID-19" from inception to March 1, 2020. Identified and analyzed the data included title, corresponding author, language, publication time, publication type, research focus. RESULTS 183 publications published from 2020 January 14 to 2020 February 29 were included in the study. The first corresponding authors of the publications were from 20 different countries. Among them, 78 (42.6%) from the hospital, 64 (35%) from the university and 39 (21.3%) from the research institution. All the publications were published in 80 different journals. Journal of Medical Virology published most of them (n=25). 60 (32.8%) were original research, 29 (15.8%) were review, 20 (10.9%) were short communications. 68 (37.2%) epidemiology, 49 (26.8%) virology and 26 (14.2%) clinical features. CONCLUSIONS According to our review, China has provided a large number of research data for various research fields, during the outbreak of COVID-19. Most of the findings play an important role in preventing and controlling the epidemic around the world. With research on the COVID-19 still booming, new vaccine and effective medicine for COVID-19 will be expected to come out in the near future with the joint efforts of researchers worldwide.


title: Laparoscopic liver resection with selective prior vascular control.

text: BACKGROUND Selective control of vascular inflow can reduce blood loss and transfusion rates and may be particularly efficient in laparoscopic liver resection (LLR). The aim of this study was to evaluate the efficacy of selective prior vascular control (PVC) in patients undergoing laparoscopic or open liver resections (OLR). METHODS Between 1999 and 2008, 52 patients underwent LLR with PVC with prospective data collection and were compared with patients undergoing OLR with PVC. RESULTS There was no difference in the operative time between the 2 groups. Blood loss and transfusion rates were lower in patients who underwent LLR (367 vs 589 mL, P = .001; 3.8% vs 17.3%, P = .05, respectively). Morbidity did not differ significantly between the 2 groups. Hospital stay was longer in the OLR group (11.0 vs 7.4 days, P = .001). CONCLUSIONS PVC during LLR was feasible and improved intraoperative and postoperative results. Selective PVC should be obtained in LLR whenever possible.


title: Predictors and Outcomes Associated with Rescue Therapy in SWIFT.

text: INTRODUCTION In the Solitaire With the Intention For Thrombectomy (SWIFT) trial, rescue therapy was used when the Solitaire or Merci device was unable to restore vessel patency. Markers for nonrecanalization in acute stroke have been reported for intravenous tissue plasminogen activator; however, similar predictors are not known for endovascular therapy. We sought to identify predictors and outcomes associated with rescue therapy in the SWIFT trial. METHODS Rescue therapy included the use of an alternative device, agent, or maneuver following failure to recanalize with three retrieval attempts using the initial device. Clinical, angiographic, and demographic data was reviewed. RESULTS Among a total of 144 patients enrolled, 43 (29.9%) required rescue therapy. We used the same baseline demographics for patients with and without rescue therapy. Rescue therapy was used in a higher percentage of patients randomized to the Merci group compared with the Solitaire group (43 vs. 21%, p = 0.009). Patients with rescue therapy experienced a longer recanalization time (p < 0.001), a lower percentage of successful recanalization (p < 0.001), and a lower percentage of good outcome (p = 0.009). In multivariate analysis, patients randomized to the Merci group (OR 3.99, 95% CI 1.58, 10.10) and age >80 years (OR 3.51, 95% CI 1.06, 11.64) were predictors of rescue therapy. CONCLUSIONS Merci treatment group and age were predictors of rescue therapy, while a trend toward an increased need of rescue therapy was observed with hypertension and proximal clot location. Rescue therapy was associated with fewer good outcomes. These findings may reflect targets for improvement in endovascular therapy.


docid: bqggtngm

title: COVID-19: Challenges and Lessons Learned from Early Career Investigators.

text: In March 2020, the United States experienced an unprecedented event that suddenly demanded that researchers cease all nonessential activities to mitigate the rapid spread of the SARS-CoV2. Within the research community, the impact of this cessation on early career investigators was significant, in part because the support systems (i.e., mentors and institutions) that early career investigators typically rely on were also significantly impacted. This article presents the stories of the impact of COVID-19 on early career investigators within the NIH Building Interdisciplinary Research Careers in Women's Health and Women's Reproductive Health Research K12 career development programs. We discuss the common challenges that we faced across our respective fields ranging from basic to clinical to epidemiological women's health research, including the impact it had on our career trajectories. In addition, we share lessons learned in an effort to strengthen our research workforce and increase our resiliency during this and future challenges.


title: Hemostasis in thyroid surgery: harmonic scalpel versus other techniques--a meta-analysis.

text: OBJECTIVE The objective is to systematically review the literature studying the harmonic scalpel versus other hemostatic techniques in thyroid surgical patients. Although thyroidectomy is one of the most common surgical procedures, the safest, most efficient, and cost-effective way to achieve hemostasis is hotly debated. DATA SOURCES We searched the electronic databases Medline and the Cochrane Library using relevant search strategies. REVIEW METHODS Two reviewers (G.W., T.E.) independently assessed titles and abstracts of 72 identified studies. Twelve prospective randomized controlled studies were considered relevant and included in this meta-analysis (1153 patients). RESULTS In all studies, operating time was reduced by using the harmonic scalpel. Compared with surgical hemostasis by suture ligation or suture/clip ligation combined with electrocauterization or electrothermal bipolar vessel sealer (n = 602), the mean operating time reduction for the harmonic scalpel was equivalent to 22.67 minutes (95% CI, -27.98; -17.37, P < 0.00001) or nearly 25 percent of the total operating room time. When harmonic scalpel was used, blood loss was reduced significantly by 20.03 mL (95% CI, -27.83; -12.22, P < 0.00001), and a mean reduction in postoperative pain (0.86 points [95% CI, -1.60; -0.13, P = 0.02]) was measured. Length of stay was reduced by 0.12 days (95% CI, -0.25; 0.00, P = 0.05). Differences regarding volume of drainage fluid were in favor of harmonic scalpel but not statistically significant; complications were similar in both groups. CONCLUSION There is clear evidence that using the harmonic scalpel for hemostasis in thyroid surgery significantly reduces operating time and blood loss and that it is not associated with an increase in volume of drainage fluid, complication rate, or hospital stay.


title: Learning curves in expert and non-expert laparoscopic surgeons for robotic suturing with the da Vinci(®) Surgical System.

text: We investigated learning curves for robotic suturing of expert and non-expert laparoscopic surgeons to explore the length of time required to reach an acceptable plateau of technical skills. Laparoscopic suturing skills were evaluated in a training box with conventional laparoscopic instrumentation in phase 1. In phase 2, robotic suturing skills were evaluated during a training program on non-surviving animals by analyzing time required for five intracorporal stitches on the small bowel. Learning curves were plotted. A significant difference in technical skills between the expert and non-expert surgeons was demonstrated in phase 1 and at the beginning of phase 2. Both surgeons reached a learning-curve plateau exhibiting similar robotic suturing skills at the end of 90 min of training. Skills were subsequently retained equally by both surgeons. Short duration of training was sufficient for the non-expert laparoscopic surgeon to match the robotic suturing performance of the expert laparoscopic surgeon.


title: [Countermeasures and treatment for aortic acute syndrome with novel coronavirus pneumonia].

text: The novel coronavirus pneumonia (NCP) has cost a great loss to the health and economic property of Chines people. Under such a special circumstance, how to deal with such patients with acute aortic syndrome has become a serious challenge. Rapid diagnosis of concomitant NCP, safe and effective transportation, implementation of the interventional procedure, protection of vascular surgical team and postoperative management and follow-up of such patients have become urgent problems for us. Combined with the latest novel government documents, the literature and the experiences from Wuhan, we answered the above questions briefly and plainly. It also hopes to inspire the national vascular surgeons to manage critical emergencies in vascular surgery and even routine vascular diseases with NCP, as a final point to limit the severe epidemic situation, and minimize the damage of NCP.


title: Dysphagia in the intensive care unit in Switzerland (DICE) - results of a national survey on the current standard of care.

text: INTRODUCTION Oropharyngeal dysphagia (OD) is often observed in critically ill patients. In most affected patients OD persists throughout hospital stay and negatively impacts on clinical outcomes. Here we systematically explore routine clinical practice standards for recognition/screening, diagnosis and treatment of OD in accredited Swiss ICUs. METHODS An online, 23-item questionnaire-based survey was performed to investigate current standards of care for OD in Switzerland (DICE). All (n = 49) accredited Swiss teaching hospitals providing specialist training for adult intensive care medicine were contacted. Senior intensivists were interviewed on how they would screen for, diagnose and treat OD in the ICU. RESULTS The total response rate was 75.5%, with information available on all tertiary care academic centres. 67.6% (25/37) of institutions stated that they have established standard operating procedures for OD using a mostly sequential diagnostic approach (86.5%, 32/37). In 75.7% (28/37) of institutions, OD confirmation is performed without the use of instrumental techniques such as flexible (or fibre-endoscopic) evaluation of swallowing (FEES). Presumed key risk factors for OD were admission for acute neurological illness, long-term mechanical ventilation, ICU-acquired weakness and pre-existing neurological disease. Reported presumed OD-related complications typically include aspiration-induced pneumonia, increased rates of both reintubation and tracheostomy and increased ICU readmission rates. CONCLUSIONS Many Swiss ICUs have established standard operating procedures, with most using sequential clinical approaches to assess ICU patients at risk of dysphagia. OD confirmation is mostly performed using non-instrumental techniques. In general, it appears that awareness of OD and ICU educational curricula can be further optimised.


title: Metabolic syndrome and its components in adult hypopituitary patients.

text: PURPOSE To evaluate the prevalence of metabolic syndrome (MetS) and its components in adult hypopituitary patients. PATIENTS AND METHODS Retrospective, cross-sectional analysis of a cohort of hypopituitary adult patients followed in a single reference center for pituitary diseases. MetS was defined by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) criteria. Patients with 18 years or older, presenting two or more anterior pituitary deficiencies associated or not with diabetes insipidus (DI), were included, while patients with hypopituitarism due to Acromegaly or Cushing's disease were excluded. RESULTS We studied 99 hypopituitary patients (52 males, mean age 50.1 ± 16.3 years, mean age at diagnosis 33.7 ± 17.6 years) who have been followed for a mean time of 15.9 ± 10.1 years. Hypothalamic-pituitary tumors and non-tumoral etiologies were observed in 53.4% and 46.6% of the cases, respectively. FSH/LH, GH, TSH, ACTH deficiency and DI was present in 99%, 98.6%, 96%, 81.8%, and 23.2%, respectively. The prevalence of MetS was 39.4% and was significantly higher in patients older than 50 years (p = 0.02), overweight/obese (p < 0.001), with hypopituitarism diagnosed in adult life (p = 0.02), who did not replace GH (p = 0.004) and in smokers (p = 0.007). In the logistic regression model, body mass index (BMI) and GH replacement were significantly associated with the presence of MetS. Reduced HDL cholesterol was the most prevalent component of MetS in hypopituitary patients. CONCLUSIONS MetS is a common finding in adult hypopituitary patients, which is mainly influenced by increased BMI and untreated GH deficiency. Trial Registration number (Plataforma Brasil): CAAE 51008815.2.0000.0096 (May 31, 2017) .


title: Treatment planning in microwave thermal ablation: clinical gaps and recent research advances.

text: Microwave thermal ablation (MTA) is a minimally invasive therapeutic technique aimed at destroying pathologic tissues through a very high temperature increase induced by the absorption of an electromagnetic field at microwave (MW) frequencies. Open problems, which are delaying MTA applications in clinical practice, are mainly linked to the extremely high temperatures, up to 120 °C, reached by the tissue close to the antenna applicator, as well as to the ability of foreseeing and controlling the shape and dimension of the thermally ablated area. Recent research was devoted to the characterisation of dielectric, thermal and physical properties of tissue looking at their changes with the increasing temperature, looking for possible developments of reliable, automatic and personalised treatment planning. In this paper, a review of the recently obtained results as well as new unpublished data will be presented and discussed.


title: UREKA: umbilical ring easy kannula access.

text: BACKGROUND AND OBJECTIVES Standard techniques of laparoscopic access involve creating an abdominal wall defect and can result in complications. We describe the umbilical ring easy kannula access (UREKA) technique, evaluating safety and a decrease in complications related to port placement. METHODS UREKA is performed via a supra- or infraumbilical incision followed by circumferential dissection of the umbilical stalk. The umbilical skin is dissected free from the fascia, exposing the umbilical ring. Pneumoperitoneum is established either before or after placement of a dilating port through the open ring. We reviewed all laparoscopic procedures performed by one pediatric surgeon over 14 months using UREKA. RESULTS Ninety-four patients underwent laparoscopic surgery with initial port placement via UREKA. Appendectomy (n=57) was the most common procedure, followed by fundoplication (15) and cholecystectomy (10). No intestinal, solid organ, vascular, or bladder injuries related to port placement occurred. The only postoperative complication was a superficial wound infection in a 135-kg patient following cholecystectomy, treated successfully with oral antibiotics alone. CONCLUSION The umbilical ring persists to some degree in all pediatric patients and provides a safe portal of entry for laparoscopic surgery. UREKA has few complications and is a straightforward, reproducible technique for gaining initial laparoscopic access.


title: Estimated and measured core temperature responses to high-intensity warm weather military training: implications for exertional heat illness risk assessment.

text: OBJECTIVE Humans avoid overheating through physiological and behavioral mechanisms. However, elite athletes, industrial workers, and military personnel, driven by the tasks at hand, may choose to continue working and face an increased risk of exertional heat illness (EHI). We wanted to examine the efficacy of a new core temperature (Tcr) estimation algorithm in assessing EHI risk. APPROACH Physiological responses of 21 male Royal Marines recruits (age 21±2 y, height 1.79±0.05 m, weight 80.5±7.2 kg) were collected during a physically-demanding criterion road march (14.5 km in 90 min with a 9.6 kg load; air temperature 16°C, relative humidity ≥ 84%). Measured Tcr (thermometer pill) and estimated Tcr (ECTempTM Tcr-est) were compared. MAIN RESULTS Measured Tcr either increased to an asymptote Tcr < 39.5°C (WARM; n=11), or progressively increased to Tcr > 40.0°C (HOT; n=10). In the HOT group, Tcr-est reflected measured Tcr up to Tcr = 40.0°C (Bias = -0.10 ± 0.37°C, root mean square error = 0.37 ± 0.13°C). In the WARM group, Tcr-est overestimated Tcr (Bias = 0.34 ± 0.40°C) and was higher from mid-point to end. A logistic regression (Skin temperature approximate entropy and mean heart rate) was able to predict group membership (95% accuracy) at 20 minutes, allowing a WARM group ECTemp(TM) correction factor (corrected Bias=0.00 ± 0.29°C). SIGNIFICANCE The Tcr-est successfully tracked Tcr in the HOT group with high risk of exertional heat illness (EHI) (40% incidence). Skin temperature complexity shows promise as a non-invasive means of insight into the state of thermoregulatory control mechanisms.


title: Single-Incision Laparoscopic Liver Resection for Colorectal Metastasis through Stoma Site at Time of Reversal of Diversion Ileostomy: A Case Report.

text: Minimally invasive surgical techniques for liver tumors are gaining increased acceptance as an alternative to traditional resections by laparotomy. In this article we describe a laparoscopic liver resection of a metastatic lesion in a patient primarily operated for colorectal cancer. The resection was conducted as a single port procedure through the stoma aperture at time of reversal of the diversion ileostomy. Sigle incision liver resections may be less traumatic than conventional laparoscopy and could be applied in selected patients with both benign and malignant liver tumors.


title: Ig-like ACE2 protein therapeutics: A revival in development during the COVID-19 pandemic.

text: While the potential therapeutic utility of angiotensin-converting enzyme 2 (ACE2) is well established, the clinical development of ACE2 drugs has been limited, likely due in part to the short half-life of the protein. In contrast, Ig-like ACE2 fusion proteins have exhibited greatly extended plasma half-life in vivo, and they have been shown to have a potent neutralization effect against SARS-CoV-2. Clinical investigation of Ig-like ACE2 fusion proteins as COVID-19 interventions is thus warranted.


title: Temperature measurements with a temporal scanner: systematic review and meta-analysis.

text: OBJECTIVES Systematic review and meta-analysis on the diagnostic accuracy of temporal artery thermometers (TAT). DESIGN Systematic review and meta-analysis. The index test consisted of temperature measurement with TAT. The reference test consisted of an estimation of core temperature. PARTICIPANTS Clinical patients as well as healthy participants, with or without fever. INTERVENTIONS Literature search in PubMed, Embase, Cinahl and Web of Science. Three reviewers selected articles for full-text reading after which a further selection was made. Risk of bias was assessed with QUADAS-2. Pooled difference and limits of agreement (LoA) were estimated with an inverse variance weighted approach. Subgroup and sensitivity analyses were performed. Sensitivity and specificity were estimated using hierarchical models. Quality of evidence was assessed according to the GRADE system. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was measurement accuracy expressed as mean difference ± 95% LoA. A secondary outcome was sensitivity and specificity to detect fever. If tympanic thermometers were assessed in the same population as TAT, these results were recorded as well. RESULTS 37 articles comprising 5026 participants were selected. Pooled difference was -0.19 °C (95% LoA -1.16 to 0.77 °C), with moderate quality of evidence. Pooled sensitivity was 0.72 (95% CI 0.61 to 0.81) with a specificity of 0.94 (95% CI 0.87 to 0.97). The subgroup analysis revealed a trend towards underestimation of the temperature for febrile patients. There was a large heterogeneity among included studies with wide LoA which reduced the quality of evidence. CONCLUSIONS TAT is not sufficiently accurate to replace one of the reference methods such as rectal, bladder or more invasive temperature measurement methods. The results are, however, similar to those with tympanic thermometers, both in our meta-analysis and when compared with others. Thus, it seems that TAT could replace tympanic thermometers with the caveat that both methods are inaccurate. TRIAL REGISTRATION NUMBER CRD42014008832.


title: A modified open surgery technique for peritoneal dialysis catheter placement decreases catheter malfunction.

text: BACKGROUND This retrospective study was conducted to evaluate the effect of a new, modified open surgery technique on catheter-related malfunction. METHODS During the period from January 1997 to June 2009, 216 patients received initial peritoneal catheters. For the present study, patients were divided into four groups according to the catheter types and the surgery techniques: TO-S: traditional open surgery, straight Tenckhoff catheter TO-C: traditional open surgery, coiled Tenckhoff catheter TO-SN: traditional open surgery, swan-neck catheter MO-S: modified open surgery, straight Tenckhoff catheter The modified surgery was characterized by a low incision site, a short intra-abdominal catheter segment and an additional upward straight subcutaneous tunnel. All patients were followed up for 2 years or until death. Survival rates, complications caused by catheter placement, and the probability of malfunction-free catheter survival were compared between the groups. RESULTS Catheter malfunction was the most frequent mechanical complication, found in 31 patients (14.4%), who experienced 38 malfunctions. Only 2 episodes of catheter malfunction were found in the MO-S group, representing a rate significantly less than those in the TO-S and TO-C groups (both p < 0.05). Kaplan-Meier curves for malfunction-free PD catheter survival showed a significantly different malfunction-free probability for the various groups (p = 0.009). After 2 years of follow-up, 136 patients (63.0%) survived with their initial PD catheter. The initial catheter survival rate was 76.8% in the MO-S group. Kaplan-Meier curves for initial catheter survival showed that the highest survival rate was found in the MO-S group (p = 0.001). CONCLUSIONS The modified open surgery technique is a reliable method for catheter placement.


title: Quality of Care and Outcomes for Patients With Stroke in the United States Admitted During the International Stroke Conference.

text: Background Patients presenting to hospitals during non-weekday hours experience worse outcomes, often attributed to reduced staffing. The American Heart Association International Stroke Conference ( ISC ) is well attended by stroke clinicians. We sought to determine whether patients with acute ischemic stroke ( AIS ) admitted during the ISC receive less guideline-adherent care and experience worse outcomes. Methods and Results We performed a retrospective cohort study of US hospitals participating in Get With The Guidelines-Stroke and assessed use of intravenous tissue plasminogen activator, other quality measures, and outcomes for patients with AIS admitted during the ISC compared with those admitted the weeks before and after the conference. A total of 69 738 patients with AIS were included: mean age, 72 years; 52% women; 29% nonwhite. There was no difference between the average weekly number of AIS cases admitted during ISC weeks versus non- ISC weeks (1984 versus 1997; P=0.95). Patient and hospital characteristics were similar between ISC and non- ISC time periods. There were no significant differences in 14 quality metrics and 5 clinical outcomes between patients with AIS treated during the ISC versus non- ISC weeks. Patients with AIS who presented within 2 hours of onset had no difference in the likelihood of receiving intravenous tissue plasminogen activator within 3 hours (adjusted odds ratio, 0.89; 95% confidence interval, 0.77-1.03; P=0.13) or the likelihood of receiving intravenous tissue plasminogen activator within 60 minutes of arrival (adjusted odds ratio, 0.92; 95% confidence interval, 0.83-1.02; P=0.13). Conclusions Patients with acute stroke admitted to Get With The Guidelines-Stroke hospitals during ISC received the same quality care and had similar outcomes as patients admitted at other times.


title: Cardiovascular dynamics during peroral endoscopic myotomy for esophageal achalasia: a prospective observational study using non-invasive finger cuff-derived pulse wave analysis.

text: Peroral endoscopic myotomy (POEM) is natural orifice transluminal endoscopic surgery to treat esophageal achalasia. During POEM, cardiovascular dynamics can be impaired by capnoperitoneum, capnomediastinum, and systemic carbon dioxide accumulation. We systematically investigated changes in cardiovascular dynamics during POEM. We included 31 patients having POEM in this single-center prospective observational study. Before and every 5 min during POEM we measured mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), stroke volume index (SVI), and systemic vascular resistance index (SVRI) using non-invasive finger cuff-derived pulse wave analysis. During POEM, the median MAP was higher than the median baseline MAP of 77 (67;86) mmHg. HR (median at baseline: 67 (60;72) bpm), CI (2.8 (2.5;3.2) L/min/m2), SVI (42 (34;51) mL/m2), and SVRI (1994 (1652; 2559) dyn × s × cm-5 × m-2) remained stable during POEM. Mixed model-derived 95% confidence limits of hemodynamic variables during POEM were 72 to 106 mmHg for MAP, 65 to 79 bpm for HR, 2.7 to 3.3 L/min/m2 for CI, 37 and 46 mL/m2 for SVI, and 1856 and 2954 dyn × s × cm-5 × m-2 for SVRI. POEM is a safe procedure with regard to cardiovascular dynamics as it does not markedly impair MAP, HR, CI, SVI, or SVRI.


title: Colorblind Algorithms: Racism in the Era of COVID-19.

text: This commentary offers a critique of the recent policy document issued by White et al. (2020) to guide critical care resource (e.g. ventilators) allocation during public health emergencies such as COVID-19. We argue that, if disseminated widely, this criteria would result in a racially inequitable resource distribution in the current COVID-19 crisis. We link the White et al. (2020) resource distribution protocol to other "colorblind" healthcare algorithms that have relied on seemingly objective but fundamentally biased data, thereby reinforcing and exacerbating pre-existing racial health disparities. We suggest a health equity framework to ensure unbiased distribution of critical care resources during COVID-19 and in general practice.


title: Lumbar sympathicolysis in patients with severe peripheral artery disease: hemodynamics of the lower limbs determined by near-infrared spectroscopy, color coded duplex sonography, and temperature measurement.

text: The objective was to investigate the effects of CT-guided lumbar sympathicolysis on somatic regional oxygen saturation, arterial flow velocity, and skin temperature of the lower limbs in patients with advanced peripheral artery disease (PAD). CT-guided lumbar sympathicolysis was additionally performed after successful revascularization therapy in 61 patients with PAD in categories 5 and 6 according to Rutherford. Somatic regional oxygen saturation in the distal lower limbs was determined semiquantitatively with a near-infrared spectroscopy (NIRS) system. Before and after intervention, peak flow and end-diastolic flow velocity in the dorsalis pedis artery were determined by means of color-coded duplex sonography, and the skin temperature of the feet was measured with an infrared thermometer. After CT-guided lumbar sympathicolysis, somatic regional oxygen saturation, peak flow, end-diastolic flow velocity, and skin temperature in the lower limbs increased significantly.


title: What Systematic Reviews Exist for the Effectiveness of Orthopaedic Interventions.

text: Introduction Orthopaedics procedures are frequent and expensive, but highly cost effective in improving the quality of life. The purpose of this study was to determine the number and topics of systematic overviews on the effectiveness of orthopaedic interventions. Methods We performed a review of PubMed, Ovid Embase, Scopus, OrthoEvidence, and the Cochrane Library for dates of publication from January 1, 2006, to February 3, 2017, to identify systematic overviews of randomized clinical trials for the effectiveness of therapeutic interventions involving orthopaedic surgeons. Abstracts were excluded based on the following sequentially applied criteria: (1) the systematic review did not include an intervention for an orthopaedic condition; the intervention was not therapeutic; the intervention was not likely to be applied or influenced by an orthopaedic surgeon; (2) the study was not a systematic review or the study was a single randomized controlled trial, and/or it included nonhuman studies; (3) the systematic review included nonrandomized studies; and (4) the systematic review did not state moderate or strong evidence in support of the study conclusion(s). Results Of the 6,864 abstracts found in the searches, 6,145 were excluded yielding 719 systematic overviews. Contrary to conventional wisdom, this study identified 719 reviews of randomized controlled trials of therapeutic orthopaedic interventions. The interventions were classified as surgical in 383 (55%), medication in 245 (34%), and rehabilitation in 42 (6%), and other nonsurgical interventions in 39 (5%). Discussion This study identified many systematic overviews of orthopaedic interventions. The findings of this study could both influence clinical practice and, given the frequency of orthopaedic procedures, have a major public health impact.


The impact of COVID-19 on rheumatology clinical practice and university teaching in Sydney, Australia.


title: Management of gastrointestinal leaks after surgery for clinically severe obesity.

text: BACKGROUND Gastrointestinal leaks after bariatric surgery are the primary cause of serious morbidity and mortality nationwide. Enteric leaks can differ in severity, presentation, and management, depending on the type of bariatric surgery performed. Our objective was to describe the clinical presentation and treatment outcomes in patients who developed postoperative leaks at a university hospital bariatric referral center. METHODS A retrospective observational study using descriptive statistics was conducted on data from 1499 bariatric operations performed at our institution from 1994 to 2010. The procedures included a variant of biliopancreatic diversion with long limb reconstruction (BPD-LL) in 820 patients (791 open and 29 laparoscopic), Roux-en-Y gastric bypass (RYGB) in 301 patients (105 open and 196 laparoscopic), and sleeve gastrectomy (SG) in 208 patients (5 open and 203 laparoscopic). RESULTS Of these patients, 30 (2%) developed a postoperative leak at a median of 18 days (range 2-32) postoperatively. The primary procedure was laparoscopic SG in 12 patients (5.8%), laparoscopic RYGB in 5 patients (1.6%), and BPD-LL (12 open and 1 laparoscopic) in 13 patients (1.6%). In all patients who underwent laparoscopic SG, the leak site was along the staple line. The gastrojejunal anastomosis was leaking in 4 (80%) and 12 (92.3%) patients in the RYGB and BPD-LL group, respectively. The enteroenteral anastomosis was leaking in 1 patient each in the RYGB and BPD-LL groups (20% and 7.7%, respectively). Three patients (10%; 2 from the BPD-LL group and 1 from the RYGB group) presented with generalized peritonitis and underwent emergency re-exploration; nonoperative treatment was successful in the remaining 27 patients (90%). Stent placement for persistent gastrocutaneous fistula was used in 9 patients (30%; 8 from the SG cohort and 1 from the BPD-LL group). The overall mortality rate was 3.3%. CONCLUSION In our experience, most leaks resulting from antiobesity surgery were successfully managed using nonoperative methods. Rapid management of gastrointestinal leaks using computed tomography-guided drainage and/or intraluminal stent placement could be the treatment of choice in selected patients.


title: Impact of onset-to-reperfusion time on stroke mortality: a collaborative pooled analysis.

text: BACKGROUND Onset-to-reperfusion time has been reported to be associated with clinical prognosis. However, its impact on mortality remained to be assessed. Using a collaborative pooled analysis, we examined whether early mortality after successful endovascular treatment is time dependent. METHODS AND RESULTS In a collaborative pooled analysis of 7 endovascular databases, we assessed the impact of onset-to-reperfusion time in large-artery occlusion (internal carotid artery or middle cerebral artery) on outcomes. Successful reperfusion was defined as complete or partial restoration of blood flow within 8 hours from symptom onset. Primary outcome was 90-day all-cause mortality. Secondary outcomes included 90-day favorable outcome (modified Rankin Scale score, 0-2), 90-day excellent outcome (modified Rankin Scale score, 0-1), and occurrence of any intracerebral hemorrhage within 24 to 36 hours after treatment. A total of 480 cases with successful reperfusion (median time, 285 minutes) contributed to the present pooled analysis (120 with internal carotid artery occlusion and 360 with isolated middle cerebral artery occlusion). Increasing onset-to-reperfusion time was associated with an increased rate of mortality and intracerebral hemorrhage and with a decreased rate of favorable and excellent outcomes, without heterogeneity across studies. The adjusted odds ratio for each 30-minute time increase was 1.21 (95% confidence interval, 1.09-1.34; P<0.001) for mortality, 0.79 (95% confidence interval, 0.72-0.87) for favorable outcome, 0.78 (95% confidence interval, 0.71-0.86) for excellent outcome, and 1.21 (95% confidence interval, 1.10-1.33) for intracerebral hemorrhage. CONCLUSION Onset-to-reperfusion time affects mortality and favorable outcome and should be considered the main goal in acute stroke patient management.


From 'Do No Harm' to 'Do Maximal Good': an evolving concept.


title: Tracking Electroencephalographic Changes Using Distributions of Linear Models: Application to Propofol-Based Depth of Anesthesia Monitoring.

text: OBJECTIVE Tracking brain states with electrophysiological measurements often relies on short-term averages of extracted features and this may not adequately capture the variability of brain dynamics. The objective is to assess the hypotheses that this can be overcome by tracking distributions of linear models using anesthesia data, and that anesthetic brain state tracking performance of linear models is comparable to that of a high performing depth of anesthesia monitoring feature. METHODS Individuals' brain states are classified by comparing the distribution of linear (auto-regressive moving average-ARMA) model parameters estimated from electroencephalographic (EEG) data obtained with a sliding window to distributions of linear model parameters for each brain state. The method is applied to frontal EEG data from 15 subjects undergoing propofol anesthesia and classified by the observers assessment of alertness/sedation (OAA/S) scale. Classification of the OAA/S score was performed using distributions of either ARMA parameters or the benchmark feature, Higuchi fractal dimension. RESULTS The highest average testing sensitivity of 59% (chance sensitivity: 17%) was found for ARMA (2,1) models and Higuchi fractal dimension achieved 52%, however, no statistical difference was observed. For the same ARMA case, there was no statistical difference if medians are used instead of distributions (sensitivity: 56%). CONCLUSION The model-based distribution approach is not necessarily more effective than a median/short-term average approach, however, it performs well compared with a distribution approach based on a high performing anesthesia monitoring measure. SIGNIFICANCE These techniques hold potential for anesthesia monitoring and may be generally applicable for tracking brain states.


title: Leishmania infection in bats from a non-endemic region of Leishmaniasis in Brazil.

text: Leishmaniasis is a complex of zoonotic diseases caused by parasites of the genus Leishmania, which can develop in domestic as well as wild animals and humans throughout the world. Currently, this disease is spreading in rural and urban areas of non-endemic regions in Brazil. Recently, bats have gained epidemiological significance in leishmaniasis due to its close relationship with human settlements. In this study, we investigated the presence of Leishmania spp. DNA in blood samples from 448 bats belonging to four families representing 20 species that were captured in the Triangulo Mineiro and Alto Paranaiba areas of Minas Gerais State (non-endemic areas for leishmaniasis), Brazil. Leishmania spp. DNA was detected in 8·0% of the blood samples, 41·6% of which were Leishmania infantum, 38·9% Leishmania amazonensis and 19·4% Leishmania braziliensis. No positive correlation was found between Leishmania spp. and bat food source. The species with more infection rates were the insectivorous bats Eumops perotis; 22·2% (4/18) of which tested positive for Leishmania DNA. The presence of Leishmania in the bat blood samples, as observed in this study, represents epidemiological importance due to the absence of Leishmaniasis cases in the region.


Endoscopic vacuum therapy in the management of anastomotic insufficiency after pancreaticoduodenectomy.


title: Investigating the Effects of Mass Media Exposure on the Uptake of Preventive Measures by Hong Kong Residents during the 2015 MERS Outbreak: The Mediating Role of Interpersonal Communication and the Perception of Concern.

text: In 2015, South Korea experienced the largest outbreak to date of the Middle East Respiratory Syndrome (MERS-CoV) outside the Middle East. Fears related to a potential spread of the disease led to an increased alert level as well as heightened media coverage in the neighboring Hong Kong. A cross-sectional survey (N = 533) among residents of Hong Kong was conducted to assess the relationships between the effects of outbreak-related mass media coverage, interpersonal communication, the perceived level of concern in one's close environment, and the uptake of preventive measures. A serial multiple mediator model finds that interpersonal communication and higher perceived concern indirectly influence the effects of media coverage on the engagement in preventive actions. These results expand previous research on the mediating role of interpersonal communication and support assumptions about a modified two-step flow of communication in the context of a public health emergency.


title: Regional Contributions to Poststroke Disability in Endovascular Therapy.

text: Background and Purpose The relative contribution of each Alberta Stroke Program Early CT Score (ASPECTS) region to poststroke disability likely varies across regions. Determining the relative weights of each ASPECTS region may improve patient selection for endovascular stroke therapy (EST). Methods In the combined Solitaire Flow Restoration with the Intention for Thrombectomy (SWIFT), Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), and Solitaire Flow Restoration with the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) databases, we identified patients treated with the Solitaire stent retriever. Using 24-h CT scan, a multivariate ordinal regression was used to determine the relative contribution of each ASPECTS region to clinical outcome separately in each hemisphere. The coefficients from the regression were used to create a weighted ASPECTS (wASPECTS), which was compared with the original ASPECTS to predict 90-day modified Rankin Scale disability outcomes in an independent validation cohort. Results Among 342 patients treated with EST, the average age was 67 years, 57% were female, and the median National Institutes of Health Stroke Scale (NIHSS) score was 17 (IQR 13-20). The median ASPECTS at presentation was 8 (IQR 7-10). The most commonly involved ASPECTS regions on 24-h CT were the lentiform nuclei (70%), insula (55%), and caudate (52%). In multivariate analysis, preservation of M6 (β = 9.7) and M4 (β = 4.4) regions in the right hemisphere was most strongly predictive of good outcome. For the left hemisphere, M6 (β = 5.5), M5 (β = 4.1), and M3 (β = 3.1) generated the greatest parameter estimates, though they did not reach statistical significance. A wASPECTS incorporating all 20 parameter estimates resulted in improved discrimination against the original ASPECTS in the independent cohort (C-statistic 0.78 vs. 0.67, right hemisphere). Conclusions For both right and left hemisphere, preservation of the high cortical regions was more strongly associated with improved outcomes compared to the deep regions. Our findings support taking into consideration the location and relative weightings of the involved ASPECTS regions when evaluating a patient for EST.


title: An overview of the genetic variations of the SARS-CoV-2 genomes isolated in Southeast Asian countries.

text: Monitoring the mutation dynamics of human severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is critical in understanding its infectivity, virulence and pathogenicity for development of a vaccine. In an "age of mobility", the pandemic highlights the importance and vulnerability of regionalisation and labour market interdependence in Southeast Asia. We intend to characterise the genetic variability of viral populations within the region to provide preliminary information for regional surveillance in the future. By analysing 142 complete genomes from South East Asian (SEA) countries, we identified three central variants distinguished by nucleotide and amino acid changes.


title: The American Heart Association COVID-19 CVD Registry powered by Get With The Guidelines®.

text: Background: In response to the public health emergency created by the COVID-19 pandemic, American Heart Association volunteers and staff aimed to rapidly develop and launch a resource for the medical and research community to expedite scientific advancement through shared learning, quality improvement, and research. In less than 4 weeks after it was first announced on April 3, 2020, AHA's COVID-19 CVD Registry powered by Get With The Guidelines® (GWTG) received its first clinical records. Methods and Results: Participating hospitals are enrolling consecutive hospitalized patients with active COVID-19 disease, regardless of CVD status. This hospital quality improvement program will allow participating hospitals and health systems to evaluate patient-level data including mortality rates, intensive care unit (ICU) bed days, and ventilator days from individual review of electronic medical records of sequential adult patients with active COVID-19 infection. Participating sites can leverage these data for onsite, rapid quality improvement and benchmarking versus other institutions. After 9 weeks, more than 130 sites have enrolled in the program and more than 4,000 records have been abstracted in the national dataset. Additionally, the aggregate dataset will be a valuable data resource for the medical research community. Conclusions: The AHA COVID-19 CVD Registry will support greater understanding of the impact of COVID-19 on cardiovascular disease and will inform best practices for evaluation and management of patients with COVID-19.


title: Clinical Outcomes After the Nonoperative Management of Lateral Patellar Dislocations: A Systematic Review.

text: Background The first-line treatment for patellar dislocations is often nonoperative and consists of physical therapy and immobilization techniques, with various adjuncts employed. However, the outcomes of nonoperative therapy are poorly described, and there is a lack of quality evidence to define the optimal intervention. Purpose To perform a comprehensive review of the literature and assess the quality of studies presenting patient outcomes from nonoperative interventions for patellar dislocations. Study Design Systematic review; Level of evidence, 4. Methods The MEDLINE, AMED, Embase, CINAHL, Cochrane Library, PEDro, and SPORTDiscus electronic databases were searched through July 2017 by 3 independent reviewers. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Study quality was assessed using the CONSORT (Consolidated Standards for Reporting Trials) criteria for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies and case series. Results A total of 25 studies met our inclusion criteria, including 12 randomized controlled trials, 7 cohort studies, and 6 case series, consisting of 1066 patients. Studies were grouped according to 4 broad categories of nonoperative interventions based on immobilization, weightbearing status, quadriceps exercise type, and alternative therapies. The most commonly used outcome measure was the Kujala score, and the pooled redislocation rate was 31%. Conclusion This systematic review found that patient-reported outcomes consistently improved after all methods of treatment but did not return to normal. Redislocation rates were high and close to the redislocation rates reported in natural history studies. There is a lack of quality evidence to advocate the use of any particular nonoperative technique for the treatment of patellar dislocations.


title: Deployment of convalescent plasma for the prevention and treatment of COVID-19.

text: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease (COVID-19), has spurred a global health crisis. To date, there are no proven options for prophylaxis for those who have been exposed to SARS-CoV-2, nor therapy for those who develop COVID-19. Immune (i.e. "convalescent") plasma refers to plasma that is collected from individuals, following resolution of infection and development of antibodies. Passive antibody administration through transfusion of convalescent plasma may offer the only short-term strategy to confer immediate immunity to susceptible individuals. There are numerous examples, where convalescent plasma has been used successfully as post-exposure prophylaxis and/or treatment of infectious diseases, including other outbreaks of coronaviruses (e.g., SARS-1, Middle East Respiratory Syndrome [MERS]). Convalescent plasma has also been used in the COVID-19 pandemic; limited data from China suggest clinical benefit, including radiological resolution, reduction in viral loads and improved survival. Globally, blood centers have robust infrastructure to undertake collections and construct inventories of convalescent plasma to meet the growing demand. Nonetheless, there are nuanced challenges, both regulatory and logistical, spanning donor eligibility, donor recruitment, collections and transfusion itself. Data from rigorously controlled clinical trials of convalescent plasma are also few, underscoring the need to evaluate its use objectively for a range of indications (e.g., prevention vs treatment) and patient populations (e.g., age, comorbid disease). We provide an overview of convalescent plasma, from evidence of benefit, regulatory considerations, logistical work flow and proposed clinical trials, as scale up is brought underway to mobilize this critical resource. .


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title: Determinants of access to HIV testing and counselling services among female sex workers in sub-Saharan Africa: a systematic review.

text: BACKGROUND HIV testing and counselling (HTC) is an essential component for HIV prevention and a critical entry point into the HIV continuum of care and treatment. Despite the importance of HTC for HIV control, access to HTC services among female sex workers (FSWs) in sub-Saharan Africa (SSA) remains suboptimal and little is known about factors influencing FSWs' access to HTC. Guided by the client-centred conceptual framework, we conducted a systematic review to understand the facilitators and barriers influencing FSWs in SSA to access HTC services. METHODS A systematic search was conducted in MEDLINE, POPLINE and Web of Science databases for literature published between January 2000 and July 2017. References of relevant articles were also searched. We included primary studies of any design, conducted in SSA and published in the English language. Studies conducted in multi-sites inclusive of SSA were included only if data from sites in SSA were separately analysed and reported. Similarly, studies that included other subpopulations were only eligible if a separate analysis was done for FSWs. This review excluded papers published as systematic reviews, editorial comments and mathematical modelling. The protocol for this review is registered in the Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42017062203. RESULTS This review shows that factors related to approachability, acceptability, availability, affordability and appropriateness of the services are crucial in influencing access to HTC services among FSWs in SSA. These factors were mediated by individual attributes such as HIV risk perceptions, awareness of the availability of HTC, and perceptions of the importance and quality of HTC services. The decision to utilise HTC was predominantly hampered by discriminatory social norms such as HIV stigma and criminalisation of sex work. CONCLUSIONS FSWs' access to HTC is facilitated by multiple factors, including individual awareness of the availability of HTC services, and perceived quality of HTC especially with regard to assured confidentiality. Concerns about HIV stigma and fear about discrimination due to community intolerance of sex work acted as major barriers for FSWs to seek HTC services from the facilities offering health services to the general population.


title: Patient safety: this is public health.

text: Avoidable patient harm is a major public health concern, and may already have surpassed heart disease as the leading cause of death in the United States. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalized in recent years, but specialist degree programs in the field remain scarce. Healthcare organizations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement.


title: Barbed sutures in aesthetic plastic surgery: evolution of thought and process.

text: The evolution of barbed suture technologies and their application in the field of plastic surgery is now in its third decade. Much has been learned along the way. Initial excitement was often followed by disappointment as we learned more about the limited longevity of minimally invasive procedures and complications arising from various suture designs of the past. Some of the early designs, developed primarily for use in aesthetic facial procedures, included free-floating, bidirectionally barbed, nonabsorbable sutures; unidirectional barbed, nonabsorbable sutures; anchored, bidirectional, nonabsorbable double-threaded sutures; and a technology combining a nonabsorbable knotted thread and absorbable cones. More recently, a new, absorbable, unidirectional barbed suture design has become available. However, it should be noted that very limited data are available for any of the modified suture designs used in this field, and much of what has been published is based on the experience of a single user. The author has used the bidirectionally barbed Quill Knotless Tissue-Closure Device (Angiotech Pharmaceuticals, Inc, Vancouver, British Columbia, Canada), the most common barbed suture in both facial and other aesthetic plastic surgery procedures, with considerable success in various open aesthetic facial procedures, including suspension of the brow and midface, platysmaplasty, and lateral neck suspension. It is the author's experience that completion of 1 to 2 cases with this technology is sufficient to achieve competency in the closure techniques discussed in this article and that time savings can be realized using this device in various breast and body contouring procedures, including mastopexy, reduction mammoplasty, abdominoplasty, bodylift, and brachioplasty.


title: Successful identification of pathogens by polymerase chain reaction (PCR)-based electron spray ionization time-of-flight mass spectrometry (ESI-TOF-MS) in culture-negative periprosthetic joint infection.

text: BACKGROUND The diagnosis of periprosthetic joint infection poses many challenges, one of which is the difficulty of isolating the infecting organism. Recently, a sophisticated modality (the Ibis Biosciences T5000 biosensor system) has been introduced that uses pan-domain primers in a series of polymerase chain reactions (PCRs) to identify and speciate essentially all bacteria and fungi as well as to identify key antibiotic resistance genes. We investigated the role of the Ibis in identifying infecting organisms in cases of known and suspected periprosthetic joint infection. METHODS Synovial fluid specimens were collected prospectively from eighty-two patients undergoing eighty-seven arthroplasty procedures (sixty-five knee revisions, fifteen hip revisions, and seven primary knee arthroplasties) and were sent for both conventional culture and Ibis analysis. The surgeon's clinical determination of the cause for revision arthroplasty was failure due to infection in twenty-three cases and noninfectious failure in fifty-seven cases. RESULTS In the twenty-three cases that were considered on clinical grounds to involve a periprosthetic joint infection, the Ibis detected the same pathogen isolated by conventional culture in seventeen of eighteen cases and also detected one or more organisms in four of the five culture-negative cases. In addition, the Ibis detected organisms in fifty (88%) of the fifty-seven cases in which revision arthroplasty was performed for a presumed noninfectious failure. CONCLUSIONS The Ibis technology was not only effective at detecting organisms in cases of suspected periprosthetic joint infection in which cultures were negative, but it also suggested that many of the revision arthroplasty cases that have previously been considered to be purely aseptic may have a component of unrecognized, subclinical infection.


title: Cetuximab Plus Chemoradiotherapy in Immunocompetent Patients With Anal Carcinoma: A Phase II Eastern Cooperative Oncology Group-American College of Radiology Imaging Network Cancer Research Group Trial (E3205).

text: Purpose Squamous cell carcinoma of the anal canal (SCCAC) is characterized by high locoregional failure (LRF) rates after sphincter-preserving definitive chemoradiation (CRT) and is typically associated with anogenital human papilloma virus infection. Because cetuximab enhances the effect of radiation therapy in human papilloma virus-associated oropharyngeal squamous cell carcinoma, we hypothesized that adding cetuximab to CRT would reduce LRF in SCCAC. Methods Sixty-one patients with stage I to III SCCAC received CRT including cisplatin, fluorouracil, and radiation therapy to the primary tumor and regional lymph nodes (45 to 54 Gy) plus eight once-weekly doses of concurrent cetuximab. The study was designed to detect at least a 50% reduction in 3-year LRF rate (one-sided α, 0.10; power 90%), assuming a 35% LRF rate from historical data. Results Poor risk features included stage III disease in 64% and male sex in 20%. The 3-year LRF rate was 23% (95% CI, 13% to 36%; one-sided P = .03) by binomial proportional estimate using the prespecified end point and 21% (95% CI, 7% to 26%) by Kaplan-Meier estimate in a post hoc analysis using methods consistent with historical data. Three-year rates were 68% (95% CI, 55% to 79%) for progression-free survival and 83% (95% CI, 71% to 91%) for overall survival. Grade 4 toxicity occurred in 32%, and 5% had treatment-associated deaths. Conclusion Although the addition of cetuximab to chemoradiation for SCCAC was associated with lower LRF rates than historical data with CRT alone, toxicity was substantial, and LRF still occurs in approximately 20%, indicating the continued need for more effective and less toxic therapies.


title: Transanal endoscopic video-assisted (TEVA) excision.

text: BACKGROUND Transanal endoscopic video-assisted (TEVA) excision represents an alternative approach for the surgical treatment of middle and upper rectal lesions not amenable to colonoscopic removal. Utilizing principles of single-incision laparoscopic surgery, this novel minimally invasive approach optimizes access for safe and complete removal of these lesions without the need for a formal rectal resection. We describe our technique and early outcomes with TEVA excision. METHODS Between March 2010 and September 2011, TEVA excision was performed for patients presenting for management of rectal lesions not amenable to colonoscopic or standard transanal removal. Patients were selected if they presented with benign disease or superficial adenocarcinoma, and the proximal extent of the lesion extended beyond 8 cm from the anal verge. Demographic, intraoperative, and postoperative data were assessed. A SILS™ port was placed in the anal canal for access in all cases. Standard laparoscopic instruments were utilized for visualization, full-thickness transanal excision, and primary closure. RESULTS Twenty patients (50% male) with a mean age of 64.6 ± 10.9 years, mean body mass index of 28.2 ± 4.9 kg/m(2), and median American Society of Anesthesiologist score of 2 underwent TEVA excision. Fourteen patients (70%) presented with benign disease and six patients (30%) presented with malignant disease. The mean size of the lesions was 3.0 ± 1.4 cm, and the mean distance from the anal verge was 10.6 ± 2.4 cm. All excisions were successfully completed with a mean operative time of 79.8 ± 25.1 (range, 45-135) min. The mean length of hospital stay was 1.1 ± 0.7 (range, 0-3) days. CONCLUSIONS TEVA excision is a safe and feasible approach for local excision of rectal lesions not otherwise amenable to standard techniques. Continued investigation and development will be important to establish its role in minimally invasive colorectal surgery.


title: Thoracoscopic esophagectomy in prone versus decubitus position: ergonomic evaluation from a randomized and controlled study.

text: BACKGROUND The prone position (PP) and decubitus position (DP) have both been used for thoracoscopic esophagectomy. However, which of these positions is ergonomically better for the operating surgeon is unknown. In this randomized controlled trial (NCT01144325), we aimed to assess the surgeon's physical and mental stress in operating on patients in the PP compared with that in the DP. METHODS From October 2012 to June 2013, 67 consecutive patients who underwent a three-stage minimally invasive esophagectomy were randomly assigned to the DP or the PP during the thoracic stage. The same senior surgeon performed all operations. Objectively, the surgeon's spontaneous eye blink rate was recorded during thoracoscopic esophagectomy. Subjectively, the physician's musculoskeletal symptoms were rated on a scale ranging from 1 (uninfluenced) to 10 (maximum fatigue). Clinical characteristics, including patient demographics and operative features of the two patient groups, were statistically compared. RESULTS There were 35 patients in the PP group and 32 in the DP group. The two groups were comparable in patient demographics. The thoracic stage of the operation was longer in the DP group than in the PP group (87 ± 24 minutes vs 68 ± 22 minutes, p < 0.001), and the volume of blood loss was higher (89 ± 18 mL vs 67 ± 16 mL, p < 0.001). The surgeon's eye blink rate at the end of thoracic stage decreased more from baseline in the DP group than in the PP group (3.0 ± 1.4 blinks/min vs 1.2 ± 0.9 blinks/min, p < 0.001), and the surgeon's symptom scale score was higher after operation with the patient in the DP than in the PP (6.29 ± 1.54 vs 3.13 ± 2.82, p < 0.001). No conversion to open thoracotomy was recorded in either group. CONCLUSIONS Thoracoscopic esophagectomy in the PP provided less workload and better ergonomic results than the DP. Further study based on a larger number of patients is required to confirm these findings.


title: Transjugular retrieval of a knotted peripherally inserted central venous catheter (Epicutaneo-Cava catheter) in a neonate.

text: Knotting of intravascular catheters has been well described, and all such cases documented in the literature have occurred during catheter insertion. Knot formation has not been reported during the removal of a peripherally inserted central venous line (Epicutaneo-Cava 2 French 24 gauge) in a neonate. The mechanism of knotting in our case is not fully understood. This case emphasizes the value of plain radiography in detecting the presence of a knot in the line, and is being presented to raise the awareness about knot formation if undue resistance is felt during line removal. Early recognition of this rare but serious complication may avoid line fracture and potential fragment embolization.


title: Exercise interventions for mental disorders in young people: a scoping review.

text: Aims This scoping review determines the breadth and outcomes of controlled trials testing the effect of physical activity/exercise interventions across mental health outcomes in young people with a mental disorder. Methods The literature search was conducted using the open-access 'Evidence Finder', a comprehensive youth mental health-specific database that is systematically populated from MEDLINE, Embase, PsycINFO and Cochrane CENTRAL databases. Results Sixteen publications were identified after meeting the following eligibility criteria: (1) participants were young people (mean age 12-25.9 years) with a mental disorder diagnosed by a trained clinician or by reaching a predefined cut score on a symptom measure, (2) interventions were exercise, (3) designs were randomised or non-randomised controlled trials, (4) outcomes were mental health related. Eight studies included young people with depression, three included people with psychosis/schizophrenia, three included people with eating disorders and two included people with anxiety. The available evidence suggests that moderate-to-vigorous-intensity exercise may be beneficial, particularly for reducing depression. The available evidence for other intervention intensities, and for other mental disorders, is mixed. Conclusions Overall, the evidence regarding the impact of exercise interventions on a range of mental health outcomes in clinical populations of young people with various mental disorders looks promising but requires further development. Findings from this scoping review can inform the development of future exercise interventions in the youth mental health field.


title: Laparoscopic Intragastric Surgery With Endoscopic Assistance: A 2 Gastrostomy Approach With Multiple Applications.

text: PURPOSE Laparoscopic intragastric resection is a surgical modality with acceptable oncologic outcomes for gastrointestinal stromal tumors and leiomyomas, particularly for masses located near the gastroesophageal junction (GEJ). We describe our technique of 2 gastrostomy laparoscopic, intragastric resection with endoscopic assistance. METHODS We detail our technique and report a unique application of this versatile approach. RESULTS Between December 2015 and July 2016, 4 patients underwent our combined technique of intragastric surgery. Complete resection was performed in the 2 patients who had gastrointestinal stromal tumors and 1 patient with a leiomyoma without complications. One patient had the unique diagnosis of gastritis cystica profunda. This mass could not be resected, but an effective Tru-cut core needle biopsy was obtained, and the mass was able to be diagnosed and decompressed. CONCLUSIONS Our technique of 2 gastrostomy laparoscopic intragastric surgery is feasible and offers an effective oncologic approach for resection of tumors near the GEJ.