title: Laparoendoscopic single-site gastrectomy for a gastric GIST using double-bended instruments.

text: BACKGROUND Laproscopic single-site surgery is the natural evolution of minimally invasive surgery. METHODS A 70-year-old male was planned for a resection of a gastric GIST (gastrointestinal stromal tumor). A Triport trocar (Olympus, Aartselaar, Belgium) was placed through a 2-cm periumbilical incision. Besides the placement of a Nathanson liver retractor in the subxiphoidal position, no additional trocars had to be added. The partial gastrectomy was carried out by using clinical prototypes of double-bended intruments and of a "goose neck" videolaparoscope, all specially designed for single-port surgery. RESULTS Total operative time was 140 minutes, and estimated blood loss was 10 mL. No intra- or postoperative complications occurred. Hospital stay was 4 days. Final pathology revealed the complete resection of a GIST tumor of gastric origin. CONCLUSIONS We have demonstrated the technical feasibility and described the detailed surgical technique of laparoendoscopic single-site surgery gastric wedge resection.


title: Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings-Personal Protective and Environmental Measures.

text: There were 3 influenza pandemics in the 20th century, and there has been 1 so far in the 21st century. Local, national, and international health authorities regularly update their plans for mitigating the next influenza pandemic in light of the latest available evidence on the effectiveness of various control measures in reducing transmission. Here, we review the evidence base on the effectiveness of nonpharmaceutical personal protective measures and environmental hygiene measures in nonhealthcare settings and discuss their potential inclusion in pandemic plans. Although mechanistic studies support the potential effect of hand hygiene or face masks, evidence from 14 randomized controlled trials of these measures did not support a substantial effect on transmission of laboratory-confirmed influenza. We similarly found limited evidence on the effectiveness of improved hygiene and environmental cleaning. We identified several major knowledge gaps requiring further research, most fundamentally an improved characterization of the modes of person-to-person transmission.


docid: hwaxlgjn

title: Systematic review of healthcare costs related to mental health conditions among cancer survivors.

text: INTRODUCTION This systematic review examines healthcare costs associated with mental health conditions among cancer survivors in the United States. AREAS COVERED Ten published studies were identified. Studies varied substantially in terms of population, mental health conditions examined, data collection methods, and type of cost reported. Cancer survivors with mental health conditions incurred significantly higher total medical costs and costs of most service types compared to cancer survivors without a mental health condition. Additionally, the total healthcare expenditure related to mental health was higher among cancer survivors compared with people without history of cancer. EXPERT COMMENTARY Mental health conditions are associated with increased healthcare costs among cancer survivors. Future examination of other components of economic burden, including patient out-of-pocket costs, nonmedical costs, such as transportation, childcare, and productivity losses for patients and their caregivers, will be important. Additionally, evaluation of economic burden by cancer site, stage at diagnosis, duration of survivorship, and treatment(s) will increase understanding of the overall impact of mental health conditions on cancer survivors and on the healthcare system.


Supporting colleagues during covid-19: the intensive care consultant.


title: A novel horizontal subsurface flow constructed wetland planted with Typha angustifolia for treatment of polluted water.

text: Rapid population growth and urbanization has put a lot of stress on existing water bodies in most developing countries such as the Marriott Lake of Egypt. Three constructed wetland configurations including Typha angustifolia planted with enhanced atmospheric aeration by using perforated pipes networks (CWA), planted without perforated pipe network (CWR), and a control non-planted and without perforated pipes wetland (Control) were used in the study. Changes in physicochemical properties and microbial community over four seasons and hydraulic loading rate (HLR) (50, 100, 200, 300, and 400 L day-1 m-1) were monitored using influent from Marriott Lake in Egypt. Overall, the removal performance followed the sequence CWA>CWR>control. Turbidity removal of 98.4%; biochemical oxygen demand (BOD5) removal of 83.3%; chemical oxygen demand (COD) removal of 95.8%; NH3-N removal of 99.9%; total nitrogen (TN) removal of 94.7%; NO3--N and NO2--N increased; total P (TP) removal of 99.7%, Vibrio sp. of 100%, Escherichia coli 100%; total bacterial count of 92.3%; and anaerobic bacteria reduction of 97.5% were achieved by using CWA. Seasonal variation and variation in HLRs had significant effect on performance. The modified planted CWA system enhances the removal of pollutants and could present a novel route for reducing the cost associated with integrating artificial aeration into wetlands.


title: Clients' perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis.

text: BACKGROUND Governments and health systems are increasingly using mobile devices to communicate with patients and the public. Targeted digital client communication is when the health system transmits information to particular individuals or groups of people, based on their health or demographic status. Common types of targeted client communication are text messages that remind people to go to appointments or take their medicines. Other types include phone calls, interactive voice response, or multimedia messages that offer healthcare information, advice, monitoring, and support. OBJECTIVES To explore clients' perceptions and experiences of targeted digital communication via mobile devices on topics related to reproductive, maternal, newborn, child, or adolescent health (RMNCAH). SEARCH METHODS We searched MEDLINE (OvidSP), MEDLINE In-Process & Other Non-Indexed Citations (OvidSP), Embase (Ovid), World Health Organization Global Health Library, and POPLINE databases for eligible studies from inception to 3-6 July 2017 dependant on the database (See appendix 2). SELECTION CRITERIA We included studies that used qualitative methods for data collection and analysis; that explored clinets' perceptions and experiences of targeted digital communication via mobile device in the areas of RMNCAH; and were from any setting globally. DATA COLLECTION AND ANALYSIS We used maximum variation purposive sampling for data synthesis, employing a three-step sampling frame. We conducted a framework thematic analysis using the Supporting the Use of Research Evidence (SURE) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether potential implementation barriers identified in our synthesis had been addressed in the trials included in the related Cochrane Reviews of effectiveness. MAIN RESULTS We included 35 studies, from a wide range of countries on six continents. Nineteen studies were conducted in low- and middle-income settings and sixteen in high-income settings. Some of the studies explored the views of people who had experienced the interventions, whereas others were hypothetical in nature, asking what people felt they would like from a digital health intervention. The studies covered a range of digital targeted client communication, for example medication or appointment reminders, prenatal health information, support for smoking cessation while pregnant, or general sexual health information.Our synthesis showed that clients' experiences of these types of programmes were mixed. Some felt that these programmes provided them with feelings of support and connectedness, as they felt that someone was taking the time to send them messages (moderate confidence in the evidence). They also described sharing the messages with their friends and family (moderate confidence).However, clients also pointed to problems when using these programmes. Some clients had poor access to cell networks and to the internet (high confidence). Others had no phone, had lost or broken their phone, could not afford airtime, or had changed their phone number (moderate confidence). Some clients, particularly women and teenagers, had their access to phones controlled by others (moderate confidence). The cost of messages could also be a problem, and many thought that messages should be free of charge (high confidence). Language issues as well as skills in reading, writing, and using mobile phones could also be a problem (moderate confidence).Clients dealing with stigmatised or personal health conditions such as HIV, family planning, or abortion care were also concerned about privacy and confidentiality (high confidence). Some clients suggested strategies to deal with these issues, such as using neutral language and tailoring the content, timing, and frequency of messages (high confidence).Clients wanted messages at a time and frequency that was convenient for them (moderate confidence). They had preferences for different delivery channels (e.g. short message service (SMS) or interactive voice response) (moderate confidence). They also had preferences about message content, including new knowledge, reminders, solutions, and suggestions about health issues (moderate confidence). Clients' views about who sent the digital health communication could influence their views of the programme (moderate confidence).For an overview of the findings and our confidence in the evidence, please see the 'Summary of qualitative findings' tables.Our matrix shows that many of the trials assessing these types of programmes did not try to address the problems we identified, although this may have been a reporting issue. AUTHORS' CONCLUSIONS Our synthesis identified several factors that can influence the successful implementation of targeted client communication programmes using mobile devices. These include barriers to use that have equity implications. Programme planners should take these factors into account when designing and implementing programmes. Future trial authors also need to actively address these factors and to report their efforts in their trial publications.


title: Amyotrophic lateral sclerosis: sonographic evaluation of dysphagia.

text: PURPOSE The authors sought to determine the role of video ultrasonography (VUS) in the diagnostic assessment of dysphagia in patients with amyotrophic lateral sclerosis (ALS). MATERIALS AND METHODS Nine patients underwent simultaneous static and dynamic VUS examination and videofluoroscopy (VFS) of swallowing. RESULTS At the static phase, VUS showed 5/9 patients had lingual atrophy. Abnormal bolus position was observed in 6/9 patients at VUS and 3/9 at VFS. Both techniques identified an inability to keep the bolus in the oral cavity in 4/9 patients. At the dynamic phase, reduced lingual movement was observed in 5/9 patients at VUS and 2/9 at VFS. Disorganised tongue movement was seen in 3/9 patients at VUS and in 2/9 at VFS. Fragmented swallowing was only visualised at VUS. Stagnation of ingested material was never visualised at VUS, whereas it was clearly depicted in 2/9 patients at VFS. CONCLUSIONS VUS can be integrated into the diagnostic protocol for evaluating swallowing in patients with ALS, as it has higher sensitivity than VFS in assessing the dynamic factors that represent the early signs of dysphagia.


title: Laparoscopic urorectal fistula repair: value of the salvage prostatectomy and review of current approaches.

text: BACKGROUND AND PURPOSE The surgical approach and repair for urorectal fistula (URF) is a challenging task. A variety of techniques have been described to treat URFs, and the laparoscopic approach has been approved as an efficient tool for even some complex fistulas. We aimed to report our laparoscopic experience for complex URF repair with special emphasis on salvage prostatectomy. PATIENTS AND METHODS The study included four men (59-75 years), with laparoscopic repair for complex URFs. URF developed after transurethral resection of the prostate in patients 2 and 3 and after radical prostatectomy in patient 4. Patient 1 had received combined radiotherapy and chemotherapy for the rectal carcinoma; a prostatic abscess developed that resulted at the end in URF. Laparoscopic salvage prostatectomy was performed for patients 1 and 2. A transvesical laparoscopic approach was performed for patient 3, and a transperitoneal transvesical technique was performed for patient 4. A tunica vaginalis flap was used for patient 1, and peritoneal interposition flaps were developed in patients 2 and 4 mL, and no patients needed intraoperative blood transfusion. Postoperative hospital stay was 12 to 34 days. The urethral catheter was removed on postoperative day 11 to 32, and cystography showed no leakage of contrast except in patient 1. CONCLUSIONS Laparoscopic URF repair is safe and efficacious in experienced hands even in complex cases, and salvage laparoscopic prostatectomy seems like a valuable operative option. The technique requires advanced experience, however, particularly with pelvic surgery and intracorporeal suturing.


title: Micro-single-photon emission computed tomography image acquisition and quantification of sodium-iodide symporter-mediated radionuclide accumulation in mouse thyroid and salivary glands.

text: BACKGROUND Micro-single-photon emission computed tomography (SPECT) provides a noninvasive way to evaluate the effects of genetic and/or pharmacological modulation on sodium-iodide symporter (NIS)-mediated radionuclide accumulation in mouse thyroid and salivary glands. However, parameters affecting image acquisition and analysis of mouse thyroids and salivary glands have not been thoroughly investigated. In this study, we investigated the effects of region-of-interest (ROI) selection, collimation, scan time, and imaging orbit on image acquisition and quantification of thyroidal and salivary radionuclide accumulation in mice. METHODS The effects of data window minima and maxima on thyroidal and salivary ROI selection using a visual boundary method were examined in SPECT images acquired from mice injected with (123)I NaI. The effects of collimation, scan time, and imaging orbit on counting linearity and signal intensity were investigated using phantoms filled with various activities of (123)I NaI or Tc-99m pertechnetate. Spatial resolution of target organs in whole-animal images was compared between circular orbit with parallel-hole collimation and spiral orbit with five-pinhole collimation. Lastly, the inter-experimental variability of the same mouse scanned multiple times was compared with the intra-experimental variability among different mice scanned at the same time. RESULTS Thyroid ROI was separated from salivary glands by empirically increasing the data window maxima. Counting linearity within the range of 0.5-14.2 μCi was validated by phantom imaging using single- or multiple-pinhole collimators with circular or spiral imaging orbit. Scanning time could be shortened to 15 minutes per mouse without compromising counting linearity despite proportionally decreased signal intensity. Whole-animal imaging using a spiral orbit with five-pinhole collimators achieved a high spatial resolution and counting linearity. Finally, the extent of inter-experimental variability of NIS-mediated radionuclide accumulation in the thyroid and salivary glands by SPECT imaging in the same mouse was less than the magnitude of variability among the littermates. CONCLUSIONS The impacts of multiple variables and experimental designs on micro-SPECT imaging and quantification of radionuclide accumulation in mouse thyroid and salivary glands can be minimized. This platform will serve as an invaluable tool to screen for pharmacologic reagents that differentially modulate thyroidal and salivary radioiodine accumulation in preclinical mouse models.


Immune Thrombocytopenia (ITP) in a SARS-CoV-2 Positive Pediatric Patient.


title: Total laparoscopic retrieval of inferior vena cava filter.

text: While there is some local variability in the use of inferior vena cava filters and there has been some evolution in the indications for filter placement over time, inferior vena cava filters remain a standard option for pulmonary embolism prophylaxis. Indications are clear in certain subpopulations of patients, particularly those with deep venous thrombosis and absolute contraindications to anticoagulation. There are, however, a variety of reported inferior vena cava filter complications in the short and long term, making retrieval of the filter desirable in most cases. Here, we present the case of a morbidly obese patient complaining of chronic abdominal pain after inferior vena cava filter placement and malposition of the filter with extensive protrusion outside the inferior vena cava. She underwent successful laparoscopic retrieval of her malpositioned inferior vena cava filters after failure of a conventional endovascular approach.


title: Stitch versus scar--evaluation of laparoscopic pediatric inguinal hernia repair: a pilot study in a rabbit model.

text: BACKGROUND Many have questioned whether the laparoscopic, percutaneous hernia repair technique is as durable as an open repair in which the sac is divided and ligated. We set out to assess if the suture alone causes enough injury and scar over time to obliterate the internal ring. MATERIALS AND METHODS In total, 28 male rabbits with congenital patent processus vaginalis underwent laparoscopic repair with the subcutaneous endoscopically assisted ligation technique. For Group 1 the repairs were evaluated laparoscopically at predetermined time points before and after removal of the ligating suture. Group 2 assessed the effect of sharp peritoneal trauma at the time of repair and was evaluated at 2 and 4 weeks. RESULTS When durability of repair with suture alone was evaluated, all repairs failed after insufflation to 35 mm Hg after suture removal out to a time point of 12 weeks. In the peritoneal trauma group, at the 2- and 4-week survival time point, 87.5% and 100%, respectively, of repairs remained intact after removal of suture. In contrast, only 25% and 12.5%, respectively, of defects remained closed in the animals repaired with suture ligation alone. CONCLUSIONS The laparoscopic, percutaneous hernia repair may rely heavily on the suture itself to prevent recurrence. In the event of suture failure, this could lead to an increasingly high recurrence rate. The addition of minor peritoneum trauma may induce sufficient scarring to provide a more durable repair.


title: Embroidered archimedean spiral electrodes for contactless prosthetic control.

text: With continuous advancements on active prosthetics the detection of the user's intention becomes the new technological bottleneck. While electromyography (EMG) is widely used to detect individual muscular contributions, sweat and relative sensor movements degrade the quality of the signal over time. In this paper, we bypass the problems created with the skin contact analyzing the muscular activation with Archimedean Spiral (AS) electrodes. We compare traditional EMG electrodes with AS electrodes, stacked up in textile embroidered layers to improve their functionality, and eventually adding a layer of cloth/silicon between the electrodes and the human skin to ascertain the feasibility of the method. We use n=9 volunteers to perform a loaded wrist extension and record signals from the extensor digitorum muscle group. We evaluate the amplitude and noise from all results and conclude that the AS electrode is capable of detecting muscular activation without touching the skin. As part of a low-cost prosthetic initiative, this EMG alternative can be potentially embedded to the prosthetic socket to improve usage and reduce adaptation problems.


title: Totally laparoscopic versus open gastrectomy for gastric cancer: a matched cohort study.

text: BACKGROUND The role of laparoscopic surgery for the treatment of gastric cancer is still controversial, particularly in terms of oncologic efficacy. The aim of this study was to compare short-term outcomes of laparoscopic and open resection for gastric cancer at a single Western institution. SUBJECTS AND METHODS This study was designed as a matched cohort study from a prospective gastric cancer database. Forty-one patients undergoing laparoscopic gastrectomy for gastric cancer between June 2008 and January 2012 were matched with 41 patients undergoing open gastrectomy in the same time period. Patient pairing was done according to age, gender, type of gastrectomy (subtotal or total), and tumor stage via a randomized statistical method. The short-term outcomes and oncologic adequacy of the laparoscopic and open procedures were compared. A D2 lymph node dissection was performed in the majority of patients in both groups. RESULTS The two study groups were similar with respect to patient and tumor characteristics. Laparoscopic procedures were associated with a decreased blood loss (118.7 versus 312.4 mL, P<.005), incidence of surgery-unrelated complications (3 versus 9 patients, P<.05), and duration of hospital stay (8.1 versus 11.5 days, P<.05) but increased operative time for both subtotal (223.5 versus 158.2 minutes, P<.001) and total (298.1 versus 185.5 minutes, P<.001) gastrectomies. The mean number of retrieved lymph nodes after D2 dissection was similar: 30.0 for laparoscopic and 29.7 for open patients. CONCLUSIONS Within the limitations of a nonrandomized analysis, this study shows that the laparoscopic approach is a safe and oncologically adequate option for the treatment of gastric cancer, which compares favorably with open gastrectomy in short-term outcomes.


title: Comparison between effect of desflurane/remifentanil and propofol/remifentanil anesthesia on somatosensory evoked potential monitoring during scoliosis surgery-A randomized controlled trial.

text: BACKGROUND Drugs used in anesthesia can affect somatosensory evoked potential (SSEP) monitoring, which is used routinely for intraoperative monitoring of spinal cord integrity during spinal surgery. OBJECTIVE The objective of this study was to determine whether combined total intravenous anesthesia (TIVA) technique with propofol/remifentanil is associated with less SSEP suppression when compared to combined volatile agent desflurane/remifentanil anesthesia during corrective scoliosis surgery at a comparable depth of anesthesia. DESIGN It is a randomized controlled trial. SETTING The study was conducted at the Single tertiary University Hospital during October 2014 to June 2015. PATIENTS Patients who required SSEP and had no neurological deficits, and were of American Society of Anesthesiologist I and II physical status, were included. Patients who had sensory or motor deficits preoperatively and significant cardiovascular and respiratory disease were excluded. A total of 72 patients were screened, and 67 patients were randomized and allocated to two groups: 34 in desflurane/remifentanil group and 33 in TIVA group. Four patients from desflurane/remifentanil group and three from TIVA group were withdrawn due to decrease in SSEP amplitude to <0.3 µV after induction of anesthesia. Thirty patients from each group were analyzed. INTERVENTIONS Sixty-seven patients were randomized to receive TIVA or desflurane/remifentanil anesthesia. MAIN OUTCOME MEASURES The measurements taken were the amplitude and latency of SSEP monitoring at five different time points during surgery: before and after the induction of anesthesia, at skin incision, at pedicle screw insertion, and at rod insertion. RESULTS Both anesthesia techniques, TIVA and desflurane/remifentanil, resulted in decreased amplitude and increased latencies of both cervical and cortical peaks. The desflurane/remifentanil group had a significantly greater reduction in the amplitude ( p = 0.004) and an increase in latency ( p = 0.002) of P40 compared with the TIVA group. However, there were no differences in both amplitude ( p = 0.214) and latency ( p = 0.16) in cervical SSEP between the two groups. CONCLUSIONS Compared with TIVA technique, desflurane/remifentanil anesthesia caused more suppression in cortical SSEP, but not in cervical SSEP, at a comparable depth of anesthesia.


title: Epidemic characteristics of COVID-19 in four Chinese cities.

text: In December 2019, there was an outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China. The number of patients in China has risen to 31,000. We collected patient data from four Chinese cities (Hefei, Hangzhou, Wenzhou, Shenzhen) and described epidemiologic characteristics. As of 6 February 2020, we extracted data from 950 patients from the four cities. There were 477 (50.21%) males and 473 (49.79%) females of age (mean ± SD) 45.64 ± 15.59 years. Before contracting COVID-19, 299 patients had contact with Wuhan residents or contact with patients diagnosed with COVID-19 (31.47%). Also, 138 patients had SARS-CoV-2 infection of unknown source (14.53%). COVID-19 patients in the four cities were mainly from Wuhan originally, and had spread infection locally. Therefore, the initial stage of SARS-CoV-2 transmission in cities outside Wuhan were mainly input. Cutting off input and controlling community communication would reduce local incidence.


title: The First Reactive Arthritis Case Associated with COVID-19.

text: Novel coronavirus disease 2019 (COVID-19) arised from Wuhan Province in China in December 2019, has quickly become a global public health emergency. The first confirmed COVID-19 patient in Turkey was reported on 11th March 2020. A 73-year-old man with diabetes mellitus, hypertension and coronary heart disease presented to emergency department with a history of fever, weakness, and dry cough for one week. Nasopharyngeal and oropharyngeal swabs were positive for COVID-19. He was treated with ceftriaxone, hidroxychloroquine and azitromycin Severeal days after completion of COVID-19 treatment, asymetric oligoarticular arthritis in his lower extremities were developed. In the course of time, clinicians all over the world experienced several different forms of COVID-19. In this case, we report the first reactive artrhritis associated with COVID-19 infection. This article is protected by copyright. All rights reserved.


docid: evlrmoqt

title: Economic aspects of preventing health care-associated infections in the intensive care unit.

text: Infection prevention is critical to providing a high standard of care in the intensive care unit (ICU). Recent focus on eliminating health care–associated infections (HAIs) has met with variable results. Although evidence-based as far as their components, policy-driven bundled HAI prevention interventions have been evaluated in a limited and potentially biased fashion for their effectiveness, and analyses of their cost-effectiveness are lacking. We use ventilator-associated pneumonia as the case study to illustrate the pitfalls and challenges of arriving at the optimal HAI preventive strategies in the ICU.


title: Preoperative diagnostic for periprosthetic joint infection prior to total knee revision arthroplasty.

text: Periprosthetic joint infection (PJI) after total knee arthroplasty remains a challenging problem. The aim of this study was to evaluate the accuracy of diagnostic knee aspiration and serum inflammatory markers in diagnostic of a PJI after total knee arthroplasty. Within 2011 and 2012, 46 patients received a one- or two-stage revision arthroplasty of the knee joint. These patients received a total number of 77 operations. A preoperative aspiration was performed in each case. We analyzed the microbiological and histological examinations of the samples from the aspiration and from the revision operation and additionally estimated serum inflammatory markers. The diagnostic aspiration had a specificity of 0.87, a sensitivity of 0.39, a positive predictive value of 0.67 and a negative predictive value of 0.68. For C-reactive protein the specificity was 0.61 and the sensitivity was 0.48, the serum white blood cell count had a specificity of 0.98 and a sensitivity of 0.23. Our data queries whether diagnostic joint aspiration or serum inflammatory markers are sufficient to verify or exclude a PJI.


title: Advances in laparoscopic surgery in urology.

text: In the past 10 years, laparoscopy has been challenged by robotic surgery; nevertheless, laparoscopic techniques are subject to continuous change. Ultrahigh definition is the next development in video technology, it delivers fourfold more detail than full high definition resulting in improved fine detail, increased texture, and an almost photographic emulsion of smoothness of the image. New 4K ultrahigh-definition technology might remove the current need for the use of polarized glasses. New devices for laparoscopy include advanced sealing devices, instruments with six degrees of freedom, ergonomic platforms with armrests and a chest support, and camera holders. A manually manipulated robot-like device is still at the experimental stage. Robot-assisted surgery has substantially revolutionized laparoscopy, increasing its distribution; however, robot-assisted surgery is associated with considerable costs. All technical improvements of laparoscopic surgery are extremely valuable to further simplify the use of classical laparoscopy.


title: Peritoneal microdialysis as a tool for detecting anastomotic leakage in patients after left-side colon and rectal resection. A systematic review.

text: OBJECTIVE The objective was to evaluate peritoneal microdialysis in the detection of clinical anastomotic leakage after left-sided colon and rectal resection through a systematic review. METHODS A systematic review (PRISMA guidelines) based on a systematic search through PubMed, Cochrane Library, and EMBASE (1 February 2017) was performed. Methodological index of non-randomised studies score was selected to assess the methodological quality. Patient demographics and raw data for intraperitoneal microdialysis concentrations of glucose, lactate, glycerol and pyruvate for 5 d postoperative were obtained from the respective study groups. RESULTS Ten studies with a total of 128 patients were included. Thirty (23%) patients developed clinical anastomotic leakage. The area under the curve for intraperitoneal lactate concentration was significant higher in patients with anastomotic leakage (58.2; 95% CI 39.2, 77.2) compared with the no leakage group (41.0; 95% CI 35.2, 46.1; p = .007). Receiver operating characteristic curve analysis of the maximum measured lactate concentration demonstrated 25% sensitivity, 88% specificity and 74% accuracy for AL at a cut-off value of 9.8 mmol/L. The odds ratio for a 5 mmol/L increase in lactate in relation to the risk of AL was 2.9 (CI 1.1, 8.0). CONCLUSIONS Increased intraperitoneal lactate concentration within the first 5 d postoperative was significantly associated with clinical anastomotic leakage, but with low predictive values. The microdialysis method is not yet ready for clinical implication before large prospective studies have defined cut off values for a biologic marker in the setting of a clear definitions of leakage.


title: Abatement of xenon and iodine emissions from medical isotope production facilities.

text: The capability of the International Monitoring System (IMS) to detect xenon from underground nuclear explosions is dependent on the radioactive xenon background. Adding to the background, medical isotope production (MIP) by fission releases several important xenon isotopes including xenon-133 and iodine-133 that decays to xenon-133. The amount of xenon released from these facilities may be equivalent to or exceed that released from an underground nuclear explosion. Thus the release of gaseous fission products within days of irradiation makes it difficult to distinguish MIP emissions from a nuclear explosion. In addition, recent shortages in molybdenum-99 have created interest and investment opportunities to design and build new MIP facilities in the United States and throughout the world. Due to the potential increase in the number of MIP facilities, a discussion of abatement technologies provides insight into how the problem of emission control from MIP facilities can be tackled. A review of practices is provided to delineate methods useful for abatement of medical isotopes.


docid: ejrcujnx

title: Clinical ethics during the Covid-19 pandemic: Missing the trees for the forest.

text: The SARS-CoV2 pandemic has exposed the acute vulnerability of the health systems of countries worldwide. While countries are scrambling to contain the spread of the infection, the focus is largely on infection prevention strategies such as isolation, quarantine, physical distancing, hand hygiene, cough etiquette and country-wide lock-down. Important ethical concerns arise in the context of the public health interventions. However, while focusing on the forest, the population, attention must also be paid to the trees, the individuals who suffer the illness. This article focuses on the ethical conflicts between the largely public health- driven focus of the Covid19 prevention and containment measures versus patient-centred care for those who suffer the illness and the consequent moral distress of healthcare providers. The key argument is for countries to mainstream clinical ethics considerations for care of patients with Covid-19 as well as "non-Covid-19" illnesses. Keywords: SARS-CoV2, Covid 19, clinical ethics, duty to care, allocation of scarce resources, moral distress.


Experimental Aerosol Survival of SARS-CoV-2 in Artificial Saliva and Tissue Culture Media at Medium and High Humidity.


title: Cathepsin L functionally cleaves the severe acute respiratory syndrome coronavirus class I fusion protein upstream of rather than adjacent to the fusion peptide.

text: Unlike other class I viral fusion proteins, spike proteins on severe acute respiratory syndrome coronavirus virions are uncleaved. As we and others have demonstrated, infection by this virus depends on cathepsin proteases present in endosomal compartments of the target cell, suggesting that the spike protein acquires its fusion competence by cleavage during cell entry rather than during virion biogenesis. Here we demonstrate that cathepsin L indeed activates the membrane fusion function of the spike protein. Moreover, cleavage was mapped to the same region where, in coronaviruses carrying furin-activated spikes, the receptor binding subunit of the protein is separated from the membrane-anchored fusion subunit.


title: Incident user cohort study of risk for gastrointestinal bleed and stroke in individuals with major depressive disorder treated with antidepressants.

text: OBJECTIVE To examine the association between exposure to newer antidepressants and risk of gastrointestinal (GI) and other bleeding complications among individuals with major depressive disorder (MDD). DESIGN This study uses an incident user cohort design to compare associations between incidence of vascular/bleeding events and the relative affinity (low, moderate or high) of the antidepressant for the serotonin transporter during an exposure risk period for each patient. SETTING New England healthcare system electronic medical record database. PARTICIPANTS 36 389 individuals with a diagnosis of MDD and monotherapy with a selective serotonin reuptake inhibitor, serotonin-norepinephrine reuptake inhibitor or other new-generation antidepressant were identified from among 3.1 million patients in a New England healthcare system. PRIMARY AND SECONDARY OUTCOME MEASURES Rates of bleeding or other vascular complications, including acute liver failure, acute renal failure, asthma, breast cancer and hip fractures. RESULTS 601 GI bleeds were observed in the 21 462 subjects in the high-affinity group versus 333 among the 14 927 subjects in the lower affinity group (adjusted RR: 1.17, 95% CI 1.02 to 1.34). Similarly, 776 strokes were observed in the high-affinity group versus 434 in the lower affinity treatment group (adjusted RR: 1.18, 95% CI 1.06 to 1.32). No significant association with risk for a priori negative control outcomes, including acute liver failure, acute renal failure, asthma, breast cancer and hip fractures, was identified. CONCLUSIONS Use of antidepressants with high affinity for the serotonin transporter may confer modestly elevated risk for GI and other bleeding complications. While multiple methodologic limitations must be considered, these results suggest that antidepressants with lower serotonin receptor affinity may be preferred in patients at greater risk for such complications.


title: Recombination, reservoirs, and the modular spike: mechanisms of coronavirus cross-species transmission.

text: Over the past 30 years, several cross-species transmission events, as well as changes in virus tropism, have mediated significant animal and human diseases. Most notable is severe acute respiratory syndrome (SARS), a lower respiratory tract disease of humans that was first reported in late 2002 in Guangdong Province, China. The disease, which quickly spread worldwide over a period of 4 months spanning late 2002 and early 2003, infected over 8,000 individuals and killed nearly 800 before it was successfully contained by aggressive public health intervention strategies. A coronavirus (SARS-CoV) was identified as the etiological agent of SARS, and initial assessments determined that the virus crossed to human hosts from zoonotic reservoirs, including bats, Himalayan palm civets (Paguma larvata), and raccoon dogs (Nyctereutes procyonoides), sold in exotic animal markets in Guangdong Province. In this review, we discuss the molecular mechanisms that govern coronavirus cross-species transmission both in vitro and in vivo, using the emergence of SARS-CoV as a model. We pay particular attention to how changes in the Spike attachment protein, both within and outside of the receptor binding domain, mediate the emergence of coronaviruses in new host populations.


title: Neuroimaging biomarkers of psychogenic erectile dysfunction: protocol for a systematic review.

text: INTRODUCTION Erectile dysfunction (ED) is the most common male sexual disorder that severely impacts the sexual performance and quality of life of men. As the main subtype of ED, psychogenic ED (pED) has been demonstrated to be a genitourinary disease and also associated with alterations in both brain structure and function. However, the scattered neuroimaging evidence from individual studies has not yet been integrated, and the central pathological alterations associated with pED remain unclear. The objective of this systematic review is to integrate and assess the evidence of the impact of pED on brain structure and function. METHODS AND ANALYSIS Five databases (PubMed, EMBASE, Web of Science, China Biology Medicine Database and China National Knowledge Infrastructure (CNKI)) will be systematically searched from inception to 1 October 2019 (the anticipated completion date of this review), with language restricted to English and Chinese. Studies focusing on the structural or functional alterations in patients with pED will be retrieved. The study selection process will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and quality assessment will be conducted with a customised checklist. After data extraction, a qualitative review will be performed to synthesise the structural and functional brain alterations as well as the correlations between the altered cerebral structures and functions and the clinical characteristics of patients with pED. If the collected data make it feasible, an activation likelihood estimation meta-analysis will also be launched. ETHICS AND DISSEMINATION Ethical approval is not required as primary data will not be collected. This review will be published in a peer-reviewed journal and presented at conferences. PROSPERO REGISTRATION NUMBER CRD42019117206.


Emerging diseases. Researchers scramble to understand camel connection to MERS.


docid: rejfxvkf

title: Double lumen endotracheal tube for percutaneous tracheostomy.

text: BACKGROUND Percutaneous dilational tracheostomy is normally a bronchoscope-guided procedure. The insertion of a bronchoscope into an endotracheal tube (ETT) affects resistance, flow, and alveolar pressure. To improve airway management and ventilation during percutaneous tracheostomy, we developed a double lumen endotracheal tube (DLET). The aim of this in vitro study was to compare the linear constant of the Rohrer equation (K1), the nonlinear constant of the Rohrer equation (K2), the inspiratory and expiratory airway resistance, and ventilatory and airway pressures using the DLET with different standard sized ETTs. METHODS A trachea and lung model was used to compare the DLET to ETTs with 7, 7.5, and 8 mm inner diameters with and without a bronchoscope (4.5 mm external diameter), and 4 and 5 mm inner diameter ventilation tubes (F4, F5) of a translaryngeal tracheostomy. For each device, the pressure drop across the device and the Rohrer equation linear constant (K1) and nonlinear constant (K2) were calculated during a continuous flow of 10-90 L/min, the inspiratory and expiratory airway resistance values were calculated during volume controlled mechanical ventilation, and respiratory airway pressure values were calculated during volume and pressure controlled mechanical ventilation. RESULTS DLET had lower K2, pressure drop, and inspiratory and expiratory airway resistance compared with conventional ETTs plus fiberoptic bronchoscope. Furthermore, during mechanical ventilation, DLET had a lower value of peak pressure, mean pressure, and intrinsic PEEP than the other ETTs plus fiberoptic bronchoscope. CONCLUSIONS Use of the DLET during percutaneous dilational tracheostomy allows fiberoptic bronchoscopy without imposing excessive airway resistance. Reduced tube resistance during this procedure may confer additional safety in what is well known to be a hazardous procedure.


title: [The coronavirus COVID-19 pandemic. Past experience and scientific evidence at the end of March 2020].

text: The COVID-19 epidemic has unexpectedly affected everyone, both professionals and lay people, although the possibility of a global pandemic has long been theoretically considered by epidemiologists, infectologists on the one hand, and sociologists, communication and even social behavioral behaviorists in theory. Yet, faced with "real-time" events, daily infection and mortality statistics, almost everyone feels ignorant or confusingly inexperienced. This summary is intended to provide an overview of scientific evidence. Compiled at the end of March 2020, the not-so-complete material, of course, contains quite a few elements that will be surpassed in a few weeks. The authors hope that in a forthcoming publication we can all report on a much better and more hopeful outlook. Orv Hetil. 2020; 161 (17): 644-651.


title: New evidence in trauma resuscitation - is 1:1:1 the answer?

text: Traumatic injury is a common problem, with over five million worldwide deaths from trauma per year. An estimated 10 to 20% of these deaths are potentially preventable with better control of bleeding. Damage control resuscitation involves early delivery of plasma and platelets as a primary resuscitation approach to minimize trauma-induced coagulopathy. Plasma, red blood cell and platelet ratios of 1:1:1 appear to be the best substitution for fresh whole blood; however, the current literature consists only of survivor bias-prone observational studies.


title: Totally laparoscopic gastrectomy for gastric cancer.

text: BACKGROUND AND OBJECTIVES Recent studies have supported minimally invasive techniques as a viable alternative to open surgery in the treatment of gastric cancer. The goal of this study is to review our institution's experience with totally laparoscopic gastrectomy for the treatment of both early- and advanced-stage gastric cancer. METHODS A retrospective study was conducted to examine the short-term outcomes of laparoscopic gastrectomy performed at Monmouth Medical Center between May 2003 and June 2012. We reviewed postoperative complications, surgical margins, number of resected lymph nodes, estimated blood loss, length of stay, narcotic use, and recurrence rate. RESULTS Forty patients were included in the study. There were 21 cases of adenocarcinoma, 15 cases of gastrointestinal stromal tumor, 2 cases of carcinoid, 1 case of small cell neuroendocrine tumor, and 1 case of squamous cell carcinoma. The mean operative time was 220 minutes (range, 67- 450 minutes). The median length of stay was 6 days (range, 1-37 days). The mean number of harvested lymph nodes was 11. Early postoperative complications occurred in 7 patients and included anastomotic stricture, wound infection, intra-abdominal abscess, bowel obstruction, and esophageal pneumatosis. There were two deaths. The Kaplan-Meier 5-year overall and recurrence-free survival rate for all cases of adenocarcinoma was 63.2%. CONCLUSIONS Totally laparoscopic gastrectomy is a reasonable option for the treatment of gastric malignancy, with early data showing acceptable survival rates and perioperative outcomes. Large-scale randomized trials are still needed to confirm oncologic equivalency to open gastrectomy in patients with advanced disease.


title: Aerosol Box 2.0: Adjustments and Improvements Made in Mexico for Intubating Patients During the Coronavirus Disease 2019 Pandemic.

text: In January 2020, a global pandemic was declared by the World Health Organization authorities for coronavirus disease 2019 (COVID-19). Since then, we have looked for ways to avoid transmission with mitigation measures and social distancing. However, areas with a high incidence of COVID-19 have struggled to maintain adequate supplies of personal protective equipment (PPE) essential for health workers. Many innovations have been proposed to assist providers including barriers to use during airway management. We present adaptations to previously described intubation or "aerosol" boxes.


title: Changing practice and improving care using a low-risk tracheotomy clinical pathway.

text: IMPORTANCE Tracheotomy is a common procedure. Postoperative care is usually managed by nonexpert clinicians. Prolonged decannulation is associated with a high incidence of complications. At present, no clinical protocol exists to guide clinicians through decannulation. To address this deficiency, we developed a low-risk tracheotomy clinical pathway. OBJECTIVE To determine the effect of our low-risk tracheotomy clinical pathway on the time to decannulation and to determine its safety and sustainability by assessing the incidence of adverse events. DESIGN, SETTING, AND PARTICIPANTS Our study combined retrospective and prospective cohorts from July 1, 2008, through January 31, 2012. Low-risk adult patients undergoing tracheotomy at a tertiary care hospital constituted the study population. A baseline cohort of 26 patients underwent retrospective assessment. After development of the pathway, a pilot group of 34 consecutive patients underwent evaluation; of these, 13 were ineligible because of high-risk factors, which included potential upper airway obstruction, unfavorable neck anatomy, or medical factors such as coagulopathy. To assess the sustainability of the pathway, a follow-up cohort underwent assessment. Of 107 consecutive patients, 39 met the low-risk criteria. Length of follow-up was 30 days after decannulation. INTERVENTION The low-risk tracheotomy clinical pathway, which provides a stepwise approach to decannulation. MAIN OUTCOMES AND MEASURES Total time to decannulation (in days). We hypothesized that the pathway would reduce the total time to decannulation. The secondary outcome constituted adverse events. All hypotheses were formulated before data collection. RESULTS Mean (SD) total time to decannulation in the baseline cohort was 15.50 (12.08) days. After implementation of the pathway in the pilot cohort, mean (SD) total time to decannulation decreased to 5.74 (2.79) days (P < .001). In the follow-up cohort, mean (SD) total time to decannulation was 8.13 (7.09) days (P = .003). We found no association between adverse events and use of the pathway. CONCLUSIONS AND RELEVANCE Our low-risk tracheotomy clinical pathway is associated with a sustainable decrease in total time to decannulation without any associated increase in adverse events. We therefore believe that this pathway is a safe and effective tool to guide clinicians in the management of tracheotomy.


title: Hybrid surgical and catheter treatment for atrial fibrillation.

text: Advances in surgery for atrial fibrillation from cut and sew technique to thoracoscopy and new energy source have enabled minimally invasive approach which avoids median sternotomy and cardiopulmonary bypass. However, minimally invasive approach is unable to match the outcome of classic surgical technique due to difficulty in creating some of linear ablation lines. Hybrid procedure using catheter mapping and ablation in addition to minimally invasive surgical ablation has gained interest to combine the advantages of both procedures. No large study has been conducted to date comparing this new technique to other existing treatments. The aim of this paper is to review the data on hybrid procedure for atrial fibrillation and assess its early outcome and efficacy.


docid: ipajceyy

title: Endovascular Therapy Is Effective and Safe for Patients With Severe Ischemic Stroke: Pooled Analysis of Interventional Management of Stroke III and Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands Data.

text: BACKGROUND AND PURPOSE We assessed the effect of endovascular treatment in acute ischemic stroke patients with severe neurological deficit (National Institutes of Health Stroke Scale score, ≥20) after a prespecified analysis plan. METHODS The pooled analysis of the Interventional Management of Stroke III (IMS III) and Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trials included participants with an National Institutes of Health Stroke Scale score of ≥20 before intravenous tissue-type plasminogen activator (tPA) treatment (IMS III) or randomization (MR CLEAN) who were treated with intravenous tPA ≤3 hours of stroke onset. Our hypothesis was that participants with severe stroke randomized to endovascular therapy after intravenous tPA would have improved 90-day outcome (distribution of modified Rankin Scale scores), when compared with those who received intravenous tPA alone. RESULTS Among 342 participants in the pooled analysis (194 from IMS III and 148 from MR CLEAN), an ordinal logistic regression model showed that the endovascular group had superior 90-day outcome compared with the intravenous tPA group (adjusted odds ratio, 1.78; 95% confidence interval, 1.20-2.66). In the logistic regression model of the dichotomous outcome (modified Rankin Scale score, 0-2, or functional independence), the endovascular group had superior outcomes (adjusted odds ratio, 1.97; 95% confidence interval, 1.09-3.56). Functional independence (modified Rankin Scale score, ≤2) at 90 days was 25% in the endovascular group when compared with 14% in the intravenous tPA group. CONCLUSIONS Endovascular therapy after intravenous tPA within 3 hours of symptom onset improves functional outcome at 90 days after severe ischemic stroke. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424 (IMS III) and ISRCTN10888758 (MR CLEAN).


title: Epidemiological characteristics of respiratory viruses in patients with acute respiratory infections during 2009-2018 in southern China.

text: BACKGROUND Acute respiratory infections (ARIs) remain a major public threat with high morbidity and mortality all over the world, and viruses are important pathogens that cause ARIs. This work is conducted to better understand the epidemiological characteristics of respiratory viruses circulating in southern China. METHODS Totally 22,680 respiratory samples were collected from ARI patients from 18 hospitals in southern China during 2009-2018, and seven common respiratory viruses including Flu, RSV, PIV, hMPV, ADV, HCoV and HBoV were screened using in-house real-time PCR. RESULTS Totally 9,760 ARI cases (9760/22680, 43.03%) were detected as positive for the 7 common respiratory viruses. The most detected virus was Flu (14.15%), followed by RSV (10.33%) and PIV (5.43%). Flu-A, PIV3 and HCoV-OC43 were the predominant subtypes. Although most of the viruses were more easily detected in inpatients and males, Flu was more likely detected in outpatient and females. Flu infection was more likely to cause URTI (upper respiratory tract infection), whereas RSV infection was more likely to cause pneumonia and bronchitis. The prevalence of Flu was particularly high in 2009. The epidemic level was found notably high in 2014-2018 for RSV, in 2016-2018 for PIV, in the summer of 2018 for ADV, in the summer of 2016 and winter of 2018 for HCoV, and in the summer of 2011 and autumn of 2018 for HBoV. The co-detection rate of 7 viruses was 4.70% and RSV, PIV and Flu were the most commonly co-detected viruses. CONCLUSIONS This work demonstrates the epidemiological characteristics of 7 common respiratory viruses in ARI patients in southern China.


docid: obmyobgl

title: Testing for Respiratory Viruses in Children: To Swab or Not to Swab.

text: Importance While most viral respiratory tract infections can be diagnosed clinically, clinicians frequently order tests to identify the specific offending virus. While there has been tremendous growth in the variety, availability, and sophistication of the types of respiratory viral tests, there may have been less critical thought and discussion among frontline clinicians about the clinical utility and specific indications for testing. We summarize the rationale historically used to support respiratory virus testing in children, with a review of the supporting evidence. We outline potential considerations and limitations of the various types of respiratory viral tests and suggest some clinical indications where viral testing may play an important role in clinical management. Observations The main value of testing for viruses in children who present with a respiratory tract infection is to differentiate between viral and bacterial infections, hopefully facilitating clinical decision making regarding further investigations and the need for antibiotics. We have highlighted commonly cited rationale used to support testing and the generally poor evidence on which to base this rationale. In addition, difficulties with interpretation of respiratory viral testing results include somewhat poor diagnostic test characteristics for some tests, uncertainty regarding true positives and causation of illness, delay in receiving the test result, and the incidence of concurrent bacterial infections or the presence of multiple viruses. We have given some examples of clinical scenarios where respiratory viral testing results could be expected to contribute to more appropriate clinical management decisions. Conclusions and Relevance It is not good enough to "do" just because we "can." We suggest that for many healthy immune-competent children presenting with typical viral respiratory tract symptoms, the diagnosis can be made clinically, and frontline clinicians should think critically before automatically requesting a somewhat uncomfortable, expensive respiratory viral test, the result of which may not contribute to the child's treatment.


docid: xspvyzgh

title: Single port-assisted fully laparoscopic abdominoperineal resection (APR) with immediate V-RAM flap reconstruction of the perineal defect.

text: Abdominoperineal resection (APR) of anorectal cancers after neoadjuvant chemoradiotherapy may incur significant perineal morbidity. While vertical rectus abdominis muscle (V-RAM) flaps can fill the pelvic resection space with health tissue, their use has previously been described predominantly in association with laparotomy. Here, we describe a means of combination laparoscopic APR with V-RAM flap reconstruction that allows structural preservation of the entire abdominal wall throughout the oncological resection and of the deep parietal layers after V-RAM donation. Furthermore, a single port access device used at the end colostomy site allows a second senior surgeon assist with an additional two working instruments for the purpose of improved pelvic tissue retraction, especially useful in obese patients.


title: Uniportal video-assisted thoracoscopic pneumonectomy.

text: Video-assisted thoracoscopic surgery (VATS) was introduced nearly 2 decades ago and has experienced an exponential increase for lung cancer treatment. A pneumonectomy can be performed by video-assisted thoracoscopic surgery and the lung usually fits through the incision as usually used for VATS lobectomy. The most common approach for pneumonectomy is undertaken with 3 or 4 incisions, including a utility incision of about 3-6 cm. However, this resection is amenable by using only a single utility-incision. This chapter describes the technique for pneumonectomies by single-incision thoracoscopic approach with no rib spreading.


title: Reconstruction after proximal gastrectomy for early gastric cancer in the upper third of the stomach: an analysis of our 13-year experience.

text: BACKGROUND Fundoplication during esophagogastrostomy (EG) after proximal gastrectomy (PG) is a useful procedure to prevent reflux esophagitis, but it is unclear how much of the remnant stomach should be wrapped around the esophagus. METHODS We analyzed data from 101 patients who underwent PG for upper third early gastric cancer between 1999 and 2011. In all, 64 patients underwent EG, 25 underwent jejunal interposition (JI), and 12 underwent jejunal pouch interposition (JPI). We compared intraoperative details and postoperative outcomes, and investigated the relationships between the degree of the fundoplication during EG and endoscopic findings. RESULTS The length of the operation was significantly shorter in the EG group than in the other 2 groups (P < .05), and the intraoperative blood loss was significantly less in the EG group (P < .05). The JI and the JPI groups had significantly greater rates of early complications than did the EG group (P = .01). Reflux esophagitis was present in 22% of patients in the EG group, 8% in the JPI group, and none in the JI group. In the EG group, reflux esophagitis was significantly less common in patients with a >180° wrap of the remnant stomach around the esophagus than in patients with a smaller wrap (P = .0008). The rate of body weight loss was significantly less in the EG group compared with the other 2 groups (P < .05). CONCLUSION Considering the low invasiveness of the procedure and postoperative outcomes, we consider that EG with a >180° wrap as the optimal reconstructive procedure.


title: Combined endoscopic transcervical-transoral robotic approach for resection of parapharyngeal space tumors.

text: BACKGROUND Parapharyngeal space tumors (PPSTs) pose exposure challenges; they are routinely resected by the transcervical approach using blunt/blind finger dissection, increasing the risk of tumor spillage and of neurovascular injury. Large PPSTs or those located high at the skull base often require mandibulotomy or an infratemporal fossa approach, baring considerable morbidity. METHODS The novel minimally invasive approach described, utilizes endoscopic equipment introduced transcervically for circumferential separation of the tumor from the neurovascular structures of the skull base. After the tumor is separated, it is removed en bloc, via transoral robotic surgery (TORS). RESULTS The technique provides improved visualization and safe vascular control with minimum tumor stress, preventing the need of blunt/blind finger dissections, and allowing complete tumor removal while minimizing tumor spillage, nerve injury, and blood loss, maintaining excellent cosmetic and functional results. CONCLUSION This approach could be utilized for the removal of large benign PPSTs, or small PPSTs located high at the skull base. © 2017 Wiley Periodicals, Inc. Head Neck 39: 786-790, 2017.


title: Micro-CT imaging as a method for comparing perfusion in graduated-height and single-height surgical staple lines.

text: Background Wound healing is a goal for advanced technology in the surgical space to benefit clinical outcomes. Surgical staplers are commonly used in a variety of open and minimally invasive abdominal and thoracic procedures. Assessment of wound healing traits, such as perfusion, has been challenging due to technical limitations. A novel technique that utilizes micro-computed tomography methodology to measure perfusion was designed to compare the micro-perfusion of staple lines between commercial stapler reloads that employ different staple height strategies. Materials and methods Following an Institutional Animal Care and Use Committee-approved protocol, rats were euthanized and immediately heparinized prior to a subtotal gastrectomy with either graduated-height or single-height staples. Rats were then perfused with barium, following which stomachs were removed and immediately fixed in formalin to prevent degradation. Stomachs were then imaged using micro-computed tomography and subsequent analysis was utilized to quantify fluid volume and patent vasculature proximity to staples within the staple line region for each group. Results Average perfusion volume was significantly higher with graduated-height staples (0.33% ± 0.18%) compared to single-height staples (0.16% ± 0.09%, P=0.011). Average vessel-to-staple line distance was not significant but trended lower with graduated-height staples (0.35±0.02 mm) compared to single-height staples (0.36±0.03 mm, P=0.18). Discussion Graduated-height staples had significantly higher perfusion volume than single-height staples, which likely has a downstream benefit on wound healing and clinical outcomes. Conclusion This study shows a higher perfusion volume around the staple lines using graduated-height staples as compared to single-height staples and this may contribute to better wound healing in patients.


title: Role of personality disorder in randomised controlled trials of pharmacological interventions for adults with mood disorders: a protocol for a systematic review and meta-analysis.

text: INTRODUCTION Remission rates for mood disorders, including depressive and bipolar disorders, remain relatively low despite available treatments, and many patients fail to respond adequately to these interventions. Evidence suggests that personality disorder may play a role in poor outcomes. Although personality disorders are common in patients with mood disorders, it remains unknown whether personality disorder affects treatment outcomes in mood disorders. We aim to review currently available evidence regarding the role of personality disorder on pharmacological interventions in randomised controlled trials for adults with mood disorders. METHODS AND ANALYSIS A systematic search of Cochrane Central Register of Controlled Clinical Trials (CENTRAL) via cochranelibrary.com, PubMed via PubMed, EMBASE via embase.com, PsycINFO via Ebsco and CINAHL Complete via Ebsco databases will be conducted to identify randomised controlled trials that have investigated pharmacological interventions in participants aged 18 years or older for mood disorders (ie, depressive disorders and bipolar spectrum disorders) and have also included assessment of personality disorder. One reviewer will screen studies against the predetermined eligibility criteria, and a second reviewer will confirm eligible studies. Data will be extracted by two independent reviewers. Methodological quality and risk of bias will be assessed using the Cochrane Risk of Bias tool. A systematic review, and if sufficient evidence is identified, a meta-analysis will be completed. Meta-analysis will be conducted using the standardised mean difference approach and reported with 95% CIs. A random effects model will be employed and statistical heterogeneity will be evaluated using the I2 statistic. Prespecified subgroup analyses will be completed. ETHICS AND DISSEMINATION As this systematic review will use published data, ethics permission will not be required. The outcomes of this systematic review will be published in a relevant scientific journal and presented at a research conference. TRIAL REGISTRATION NUMBER CRD42018089279.


title: Association of Respiratory Picornaviruses With High Acuity and Severe Illness in a Pediatric Health Care System.

text: OBJECTIVES We aimed to determine the illness severity associated with respiratory picornaviruses (rhinovirus/enterovirus). METHODS Electronic medical records of pediatric emergency department (PED) visits were reviewed. The percent positive of respiratory pathogens, tested by using viral polymerase chain reaction panel, was determined for the July 2012 to June 2013 period. Logistic regression was used to determine the association of picornaviruses, respiratory syncytial virus (RSV), and influenza with ICU admission during the 2012-2013 academic year. Medical records of visits leading to ICU admission with picornaviruses were reviewed. RESULTS During 2012-2013, picornaviruses were more commonly identified (22.6%) among admitted patients than influenza (6.4%) or RSV (15.1%). Picornaviruses and RSV were associated with ICU admission (picornaviruses: adjusted odds ratio [aOR], 1.99 [95% confidence interval (CI): 1.68-2.36]; RSV: aOR, 1.49 [95% CI: 1.20-1.85]) while influenza was not (aOR, 0.93 [95% CI: 0.66-1.29]). Of visits resulting in ICU admission, 79% were from patients with previous high-risk medical conditions, of which asthma or a history of wheezing was the most common (43%). CONCLUSIONS Picornaviruses can be associated with severe disease in children, especially those with underlying medical conditions. During times of high picornavirus activity, hospitals should target infection control measures to limit the spread of picornaviruses and protect the vulnerable patients. Future research into targeted therapies for picornaviruses and vaccines is needed.


title: The APPCN multisite didactic initiative: Development, benefits, and challenges.

text: Objective: The Covid-19 pandemic disrupted instructional activity in neuropsychology training programs. In response, the Association of Postdoctoral Programs in Clinical Neuropsychology (APPCN) launched a multisite didactic initiative (MDI). This manuscript describes the development and implementation of the MDI and presents findings from a recently conducted online survey concerning MDI participation.Methods: Faculty and trainees at APPCN member programs were recruited to complete the MDI survey, administered using the Qualtrics platform, through email announcements and via website link and on-screen quick response code shared at online didactic sessions. The MDI survey instrument was designed to capture basic demographics and professional role; information regarding level of site participation, benefits of participation, barriers to participation, online conference platform(s) used, and interest in continued participation; as well as anxiety and work engagement ratings.Results: The response rate was estimated to be 21-29%. Transition to videoconferencing for didactics was noted by 80% due to Covid-19, with 17% of respondents experiencing cancellation or reduction in didactic activities. About 79% endorsed that participation in MDI activities was always or nearly always beneficial. Barriers to participation included not having time, difficulty accessing didactic information, and not knowing about the MDI. Interestingly, trainees at nonparticipating sites reported greater anxiety than trainees at participating sites.Conclusion: It is hoped that these findings will inform future efforts to develop and implement online training activities. The benefits reported by respondents suggest that this work is warranted, while reported barriers to participation identify areas for improvement.


title: Enhance Mandibular Symphyseal Surface Bone Growth with Autologous Mesenchymal Stem Cell Sheets: An Animal Study.

text: INTRODUCTION The size and shape of the chin strongly influence facial profile and harmony. The current correction of chin deficiency mostly relies on genioplasty surgery involving osteotomy. To avoid osteotomy, one possible alternative is to enhance bone growth at the mental protuberance area with cell sheet transplantation. This study was undertaken to evaluate the efficacy of this approach in a pig model. MATERIALS AND METHODS Five 4-month-old pigs were included for mandibular bone marrow aspiration and MSC isolation. Triple-layer MSC sheets were then fabricated and utilized using culture-expanded MSCs. Four weeks after bone marrow aspiration, subperiosteal pockets were created on the labial symphyseal surface, followed by transplantation of autogenous MSC sheets to one randomly chosen side with the other side (control) receiving no transplantation. Six weeks after the surgery, the pigs were euthanized and the specimens from both sides were collected for computed tomography (CT) and histological and immunohistochemical analysis. Measurements between the experimental and control sides were compared using paired t tests. RESULTS MSC sheet fabrication and transplantation were reliably conducted. The labial cortical bone thickness increased significantly with MSC sheet transplantation by an average of 2 mm (p = 0.0001). The average measurements of mineral apposition rate and cell proliferation at the cell sheet side tended to be higher than the control side although the differences did not reach statistical significance (p = 0.1-0.2). Tissue mineral density measurements from CT images and bone volume fraction (BV/TV) measurements from histologic images were identical between the two sides (p > 0.5). CONCLUSION These data provide a proof of concept that autologous MSC sheets may be transplanted to the subperiosteal region of the mandibular symphysis to stimulate local surface bone growth. NO LEVEL ASSIGNED This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.


title: Unique sequence characteristics of genes in the leftmost region of unique long region in duck enteritis virus.

text: OBJECTIVE Our objective was to further understand the evolutionary position of duck enteritis virus (DEV) in the family Herpesviridae and to determine the genomic structure in the leftmost region of the unique long region (UL) of DEV. METHODS 'Targeted gene walking PCR' was used to amplify the unknown gene of DEV clone-03 strain adjacent to known sequences in the UL region. Open reading frames (ORFs) were determined by Gene Runner and an online transcriptional element search engine. The phylogenetic tree was constructed by DNAStar based on the deduced amino acid sequences. RESULTS A fragment of 13,947 bp, containing 5 ORFs (designated ICP4, ORF1, ORF2, LORF2 and LORF3, respectively), was amplified from the DEV clone-03 strain genome. In addition, a tandem repeat region of alpha-type-like sequences was detected between ICP4 and LORF2. Phylogenetic analysis of ICP4 indicated that DEV ICP4 should be clustered into Varicellovirus. DEV ORF1 and ORF2 were unique among herpesviruses. Additionally, the existence and characteristics of LORF2 and LORF3 indicated a close relationship with Mardivirus members. CONCLUSION The characteristics and gene content in the leftmost end of the UL region of the DEV genome showed that the DEV genome is different from those of other herpesviruses.


title: Five-year success rate of resin-bonded fixed partial dentures: A systematic review.

text: OBJECTIVES To assess and compare the 5-year success rate of resin-bonded fixed partial dentures (RBFPDs) fabricated from different materials. METHODS An electronic search on 3 databases from January 1965 to March of 2017 was done for human randomized clinical trials (RCTs), and prospective and retrospective cohort studies. The key words used in the search were: Bridge OR bridges OR fixed partial OR fixed dental AND resin bonded OR Maryland OR ceramic bonded. Quality assessment was done using the Newcastle-Ottawa scale. Success was defined as the RBFPDs remaining in situ and not having experienced debonding, biological failures, or mechanical failures at the examination visit. RESULTS Meta analyses of the included studies showed an estimated 5-year success rate of 88.18% for the metal framework RBFPDs and 84.41% for the nonmetal framework RBFPDs. The estimated 5-year success rate for each nonmetal material category was 92.07% for zirconia, 94.26% for In-Ceram alumina, and 84.83% for fiber-reinforced composite. The failure rate was not statistically significant among the single, double, and multiple retainers RBFPDs (P > .05). Technical complications were the main reason for failures. CONCLUSION The 5-year clinical performance of RBFPDs is similar to the performance of conventional fixed partial dentures (FPDs) and implant-supported crowns. CLINICAL SIGNIFICANCE Clinicians should consider using RBFPDs more often because their clinical performance is similar to the performance of conventional FPDs and implant-supported crowns.


title: Hernia repair and simultaneous continuous ambulatory peritoneal dialysis (CAPD) catheter implantation: feasibility and outcome.

text: BACKGROUND Occurrence of abdominal wall hernias during and before peritoneal dialysis constitutes a pivotal role in treatment discontinuation, failure, and exclusion from this dialysis method. We herein present a single-center experience regarding a one-stage surgical strategy, including hernia repair and simultaneous peritoneal dialysis catheter implantation. PATIENTS AND METHODS Over a 4-year period, 123 patients underwent peritoneal dialysis catheter implantation and 23 patients (19%) had concomitant abdominal wall hernias and were enrolled in this monocentric prospective study. Data collection included recurrent and new-onset hernias, surgical site infection, 1-year and 2-year catheter survival. RESULTS In 23 patients, 27 hernia repairs combined with peritoneal dialysis catheter implantation were performed. Median age was 52 years (range, 30-85 years) and 18/23 (78%) patients were male. There were no recurrent hernias and no early surgical site infections. Daily flushing was regularly started on the 1st to 3rd postoperative day. Five patients (22%) developed hernias on other anatomical sites, which required hernia repair and perioperative discontinuation of peritoneal dialysis. After a median follow-up of 37 months (range, 28-87 months), 96% of all implanted catheters were still working. CONCLUSION Hernia repair and simultaneous peritoneal dialysis catheter implantation are associated with no recurrent hernias, an early start of peritoneal dialysis, a very low postoperative morbidity and very high 1-year and 2-year catheter survival.


title: Human Norovirus NS3 Has RNA Helicase and Chaperoning Activities.

text: RNA-remodeling proteins, including RNA helicases and chaperones, act to remodel RNA structures and/or protein-RNA interactions and are required for all processes involving RNAs. Although many viruses encode RNA helicases and chaperones, their in vitro activities and their roles in infected cells largely remain elusive. Noroviruses are a diverse group of positive-strand RNA viruses in the family Caliciviridae and constitute a significant and potentially fatal threat to human health. Here, we report that the protein NS3 encoded by human norovirus has both ATP-dependent RNA helicase activity that unwinds RNA helices and ATP-independent RNA-chaperoning activity that can remodel structured RNAs and facilitate strand annealing. Moreover, NS3 can facilitate viral RNA synthesis in vitro by norovirus polymerase. NS3 may therefore play an important role in norovirus RNA replication. Lastly, we demonstrate that the RNA-remodeling activity of NS3 is inhibited by guanidine hydrochloride, an FDA-approved compound, and, more importantly, that it reduces the replication of the norovirus replicon in cultured human cells. Altogether, these findings are the first to demonstrate the presence of RNA-remodeling activities encoded by Caliciviridae and highlight the functional significance of NS3 in the noroviral life cycle.IMPORTANCE Noroviruses are a diverse group of positive-strand RNA viruses, which annually cause hundreds of millions of human infections and over 200,000 deaths worldwide. For RNA viruses, cellular or virus-encoded RNA helicases and/or chaperones have long been considered to play pivotal roles in viral life cycles. However, neither RNA helicase nor chaperoning activity has been demonstrated to be associated with any norovirus-encoded proteins, and it is also unknown whether norovirus replication requires the participation of any viral or cellular RNA helicases/chaperones. We found that a norovirus protein, NS3, not only has ATP-dependent helicase activity, but also acts as an ATP-independent RNA chaperone. Also, NS3 can facilitate in vitro viral RNA synthesis, suggesting the important role of NS3 in norovirus replication. Moreover, NS3 activities can be inhibited by an FDA-approved compound, which also suppresses norovirus replicon replication in human cells, raising the possibility that NS3 could be a target for antinoroviral drug development.


title: Transcatheter coil embolization of iatrogenic coronary artery-left ventricle fistula after mitral valve replacement.

text: Acquired causes of coronary fistulas are rare disorders and may develop following coronary atherosclerosis, infection, or trauma (iatrogenic). Iatrogenic coronary fistulas may be acquired secondary to surgical or nonsurgical interventions. We describe a case of an iatrogenic coronary artery-left ventricle fistula following mitral valve replacement surgery, presented with ventricular arrhythmia and heart failure. In a unique technique, we implanted three coils with the aid of a Scepter C balloon with inflation at the ostial portion of the left circumflex artery.


title: Renal complications in COVID-19: A systematic review and meta-analysis.

text: Purpose: Emerging data suggests coronavirus disease 2019 (COVID-19) has extrapulmonary manifestations but its renal manifestations are not clearly defined. We aimed to evaluaterenal complications of COVID-19 and their incidence using a systematic meta-analysis.Design: Observational studies reporting renal complications in COVID-19 patients were sought from MEDLINE, Embase and the Cochrane Libraryfrom 2019 to June 2020. The nine-star Newcastle-Ottawa Scale was used to evaluate methodological quality.Incidence with 95% confidence intervals (CIs) were pooled using random-effects models.Results: We included 22observational cohort studies comprising of 17,391COVID-19 patients. Quality scores of studies ranged from 4-6.The pooled prevalence of pre-existing chronic kidney disease (CKD) and end-stage kidney disease was5.2% (2.8-8.1)and 2.3% (1.8-2.8) respectively. The pooled incidence over follow-up of 2-28 days was 12.5% (10.1-15.0) forelectrolyte disturbance (eg, hyperkalaemia), 11.0% (7.4-15.1) foracute kidney injury (AKI) and 6.8% (1.0-17.0) for renal replacement therapy (RRT).In subgroup analyses, there was a higher incidence of AKI inUS populations andgroups with higher prevalence of pre-existing CKD.Conclusions: Frequent renal complicationsreported among hospitalised COVID-19 patientsare electrolyte disturbance, AKI and RRT. Aggressive monitoring and management of these renal complications may help in the prediction of favourable outcomes.Systematic review registration: PROSPERO 2020: CRD42020186873 Key messagesCOVID-19 affects multiple organs apart from the respiratory system; however, its renal manifestations are not clearly defined.In this systematic meta-analysis of 22 observational cohort studies, the prevalence of pre-existing chronic kidney disease (CKD) in COVID-19 patients was5.2%.The most frequent renal complication was electrolyte disturbance (particularly hyperkalaemia)with an incidence of 12.5% followed by acute kidney injury (AKI)with an incidence of 11.0%;US populations andgroups with higher prevalence of CKD had higher incidence of AKI.


title: Traumatic stress within disaster-exposed occupations: overview of the literature and suggestions for the management of traumatic stress in the workplace.

text: BACKGROUND Many people who experience a disaster will do so as part of an occupational group, either by chance or due to the nature of their role. SOURCES OF DATA This review is based on literature published in scientific journals. AREAS OF AGREEMENT There are many social and occupational factors, which affect post-disaster mental health. In particular, effective social support-both during and post-disaster-appears to enhance psychological resilience. AREAS OF CONTROVERSY There is conflicting evidence regarding the best way to support trauma-exposed employees. Many organisations carry out post-incident debriefing despite evidence that this is unhelpful. GROWING POINTS Employees who are well supported tend to have better psychological outcomes and as a result may be more likely to perform well at work. AREAS TIMELY FOR DEVELOPING RESEARCH The development and evaluation of workplace interventions designed to help managers facilitate psychological resilience in their workforce is a priority. Successful interventions could substantially increase resilience and reduce the risk of long-term mental health problems in trauma-exposed employees.


title: Bilateral transient olfactory bulbs edema during COVID-19-related anosmia.

text: An asymptomatic 27-year-old physician is diagnosed SARS-CoV-2 by occupational medicine after contagion (RT-PCR).


Reply: revision otoplasty: an algorithm.


title: Suspected Lateral Periodontal Cyst Presenting Concurrently with Canine Acanthomatous Ameloblastoma in a 2-Year-Old Standard Poodle.

text: Lateral periodontal cysts (LPCs) are odontogenic epithelial cysts composed of nonkeratinized epithelial cells that are in the category of developmental cysts, rather than inflammatory cysts. Lateral periodontal cysts are rare both in people and domestic animals; they are associated with vital teeth and located lateral to a tooth root. Lateral periodontal cysts are typically asymptomatic lesions that are characterized radiographically as a unilocular lucency with well-defined corticated borders. Canine acanthomatous ameloblastoma (CAA) is the most common odontogenic neoplasm in dogs and rarely presents as a cystic lesion. This case report describes the diagnosis and treatment of a cyst that occurred as a swelling apical to a gingival mass that was diagnosed histologically as CAA. Surgical management by conservative gingivectomy, cyst enucleation, and bone grafting was an effective treatment in this patient.


title: Input Connectivity Reveals Additional Heterogeneity of Dopaminergic Reinforcement in Drosophila.

text: Different types of Drosophila dopaminergic neurons (DANs) reinforce memories of unique valence and provide state-dependent motivational control [1]. Prior studies suggest that the compartment architecture of the mushroom body (MB) is the relevant resolution for distinct DAN functions [2, 3]. Here we used a recent electron microscope volume of the fly brain [4] to reconstruct the fine anatomy of individual DANs within three MB compartments. We find the 20 DANs of the γ5 compartment, at least some of which provide reward teaching signals, can be clustered into 5 anatomical subtypes that innervate different regions within γ5. Reconstructing 821 upstream neurons reveals input selectivity, supporting the functional relevance of DAN sub-classification. Only one PAM-γ5 DAN subtype γ5(fb) receives direct recurrent feedback from γ5β'2a mushroom body output neurons (MBONs) and behavioral experiments distinguish a role for these DANs in memory revaluation from those reinforcing sugar memory. Other DAN subtypes receive major, and potentially reinforcing, inputs from putative gustatory interneurons or lateral horn neurons, which can also relay indirect feedback from MBONs. We similarly reconstructed the single aversively reinforcing PPL1-γ1pedc DAN. The γ1pedc DAN inputs mostly differ from those of γ5 DANs and they cluster onto distinct dendritic branches, presumably separating its established roles in aversive reinforcement and appetitive motivation [5, 6]. Tracing also identified neurons that provide broad input to γ5, β'2a, and γ1pedc DANs, suggesting that distributed DAN populations can be coordinately regulated. These connectomic and behavioral analyses therefore reveal further complexity of dopaminergic reinforcement circuits between and within MB compartments.


title: Effect of age on the comparability of bispectral and state entropy indices during the maintenance of propofol-sufentanil anaesthesia.

text: BACKGROUND Manufacturers recommend maintaining anaesthesia at a bispectral index (BIS) or state entropy (SE) index value between 40 and 60. METHODS We prospectively studied 102 patients receiving propofol-sufentanil anaesthesia administered by anaesthetists blinded to these indices. The main endpoint was crude agreement (P(0)), defined as the proportion of agreement between BIS and SE index among three categories: <40, between 40 and 60, and >60. Discrepancies in recommendation (DR) were also considered. A DR is type 1 if BIS or SE is <40, while the other is simultaneously >60. A DR is type 2 when BIS and SE index values are on different sides of a threshold (40 or 60) with three subtypes according to the magnitude of their difference. A linear multiple regression was performed to identify covariates that are independently associated with P(0). RESULTS In total, 12 147 pairs of values were studied. P(0) was 59.9 (24.5%) [mean (sd)]. Thirty-three patients presented more than 50% discordant pairs and only seven patients presented more than 95% concordant pairs. Type 1 DR occurred in only 1.1% of all the pairs. The median (inter-quartile range) number of type 2 DR varied from 5 (3-8) to 2 (1-3) according to the degree of difference. Multivariate analysis showed that age (P=0.0004) and electrode position (P=0.0084) were independently associated with P(0). An increase in the age of 10 yr decreases P(0) by 5%. CONCLUSIONS The agreement between BIS and SE indices is moderate and deteriorates as patients' age increases. This study cannot determine which index is best adapted for elderly patients. Additional work comparing both indices with raw EEG traces is warranted.


title: Establishing public health security in a postwar Iraq: constitutional obstacles and lessons for other federalizing states.

text: The public health consequences of the conflict in Iraq will likely continue after the violence has subsided. Reestablishing public health security will require large investments in infrastructure and the creation of effective systems of governance. On the question of governance, the allocation of powers in the new constitution of Iraq is critical. Given the ease with which public health threats cross borders, the constitution needs to grant to the federal government the legal authority to manage such threats and simultaneously meet international requirements. Unfortunately, the draft constitution does not accomplish this objective. If politically possible, the constitution should be amended to provide the federal government with this authority. If not possible, the Iraqi federal government would have two options. It could attempt to use alternative constitutional powers, such as national security powers. This option would be contentious and the results uncertain. Alternatively, the federal government could attempt to establish collaborative relationships with regional governments. Residual sectarian tensions create potential problems for this option, however. Reflecting on the Iraqi situation, we conclude that other federalizing countries emerging from conflict should ensure that their constitutions provide the federal government with the necessary authority to manage threats to public health security effectively.


title: [Covid-19: An ad hoc public health ethics consultation].

text: In this paper we describe the process and content of our ad hoc public health ethics consultation for a Bavarian health authority in relation to Covid-19.


Covid-19: Doctors sound alarm over hospital transmissions.


China coronavirus: partial border closures into Hong Kong are not enough, say doctors.


Urgent Issues Facing Immigrant Physicians in the United States in the COVID-19 Era.


title: Ex vivo equine medial tibial plateau contact pressure with an intact medial femoral condyle, with a medial femoral condylar defect, and after placement of a transcondylar screw through the condylar defect.

text: OBJECTIVE To determine ex vivo contact data on the equine medial tibial plateau loaded by an intact medial femoral condyle (MFC), by an MFC with an osteochondral defect, and with a screw inserted in lag fashion through the MFC defect. STUDY DESIGN Ex vivo experiment. ANIMALS Stifles (n = 6). Horses (n = 4). METHODS Stifle joints were axially loaded to 1800 N at 155°, 145°, and 130°, under 3 conditions: Intact, MFC with a 15 mm circular osteochondral defect, and with a transcondylar screw inserted in lag fashion through the defect. An electronic pressure sensor (Tekscan®) on the medial tibial plateau recorded contact area, force, peak pressure, and contact maps. Stress load (N/cm(2) ) was calculated for the entire medial plateau and in 3 sub-regions; cranial, caudal, and central. Significance was set at P ≤ .05. RESULTS Flexion increased force, contact area, and stress load for all conditions. An MFC defect significantly reduced force at both flexion angles and contact area at 145°. The transcondylar screw returned force to intact values at 130° and reduced contact area in extension. Intact MFC contact maps revealed pressure peaks on the central cartilage at all angles and contact pressure and area expansion and caudal movement with flexion. Contact maps with an MFC defect amplified the caudal and abaxial pressure movement during flexion, and the screw did not further change them. CONCLUSIONS Stifle flexion increases force, contact area, and stress load on the medial tibial plateau and is most pronounced caudally. An MFC defect alters load on the medial tibial plateau, and a transcondylar screw may reverse some of those changes.


title: Assessing cerebrovascular autoregulation in infants with necrotizing enterocolitis using near-infrared spectroscopy.

text: BACKGROUND We assessed cerebrovascular autoregulation (CAR) in preterm infants with definite necrotizing enterocolitis (NEC), Bell's stage 2 or 3, and infants without NEC, using near-infrared spectroscopy. We hypothesized that CAR would be more often impaired in infants with NEC compared with infants without NEC. METHODS We measured cerebral regional tissue oxygen saturation, arterial oxygen saturation, and mean arterial blood pressure (MABP) during 48 h. We calculated the correlation between cerebral fractional tissue oxygen extraction and MABP for each patient. A statistically significant negative correlation reflected impaired CAR. RESULTS We included 15 infants with definite NEC (median (range) gestational age 27.4 (25.6-34.7) wk; birth weight 1,070 (670-2,400) g) and 13 infants without NEC (gestational age 27.9 (26.3-34.7) wk; birth weight 980 (640-2,640) g). Fourteen infants had a statistically significant negative correlation (ρ -0.468 to-0.104), of whom five were infants without NEC (5/13; 38%) and nine with definite NEC (9/15; 60%). The difference in prevalence of impaired CAR was not statistically significant. CONCLUSION Impaired CAR is present in a substantial proportion of infants with definite NEC, which may predispose them to NEC-associated neurological damage.


title: Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery.

text: BACKGROUND Studies have suggested that increasing whole body blood flow and oxygen delivery around the time of surgery reduces mortality, morbidity and the expense of major operations. OBJECTIVES To describe the effects of increasing perioperative blood flow using fluids with or without inotropes or vasoactive drugs. Outcomes were mortality, morbidity, resource utilization and health status. SEARCH METHODS We searched CENTRAL (The Cochrane Library 2012, Issue 1), MEDLINE (1966 to March 2012) and EMBASE (1982 to March 2012). We manually searched the proceedings of major conferences and personal reference databases up to December 2011. We contacted experts in the field and pharmaceutical companies for published and unpublished data. SELECTION CRITERIA We included randomized controlled trials with or without blinding. We included studies involving adult patients (aged 16 years or older) undergoing surgery (patients having a procedure in an operating room). The intervention met the following criteria. 'Perioperative' was defined as starting up to 24 hours before surgery and stopping up to six hours after surgery. 'Targeted to increase global blood flow' was defined by explicit measured goals that were greater than in controls, specifically one or more of cardiac index, oxygen delivery, oxygen consumption, stroke volume (and the respective derived indices), mixed venous oxygen saturation (SVO(2)), oxygen extraction ratio (0(2)ER) or lactate. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data. We contacted study authors for additional data. We used Review Manager software. MAIN RESULTS We included 31 studies of 5292 participants. There was no difference in mortality: 282/2615 (10.8%) died in the control group and 238/2677 (8.9%) in the treatment group, RR of 0.89 (95% CI 0.76 to 1.05, P = 0.18). However, the results were sensitive to analytical methods and the intervention was better than control when inverse variance or Mantel-Haenszel random-effects models were used, RR of 0.72 (95% CI 0.55 to 0.95, P = 0.02). The results were also sensitive to withdrawal of studies with methodological limitations. The rates of three morbidities were reduced by increasing global blood flow: renal failure, RR of 0.71 (95% CI 0.57 to 0.90); respiratory failure, RR of 0.51 (95% CI 0.28 to 0.93); and wound infections, RR of 0.65 (95% CI 0.51 to 0.84). There were no differences in the rates of nine other morbidities: arrhythmia, pneumonia, sepsis, abdominal infection, urinary tract infection, myocardial infarction, congestive cardiac failure or pulmonary oedema, or venous thrombosis. The number of patients with complications was reduced by the intervention, RR of 0.68 (95% CI 0.58 to 0.80). Hospital length of stay was reduced in the treatment group by a mean of 1.16 days (95% CI 0.43 to 1.89, P = 0.002). There was no difference in critical care length of stay. There were insufficient data to comment on quality of life and cost effectiveness. AUTHORS' CONCLUSIONS It remains uncertain whether increasing blood flow using fluids, with or without inotropes or vasoactive drugs, reduces mortality in adults undergoing surgery. The primary analysis in this review (mortality at longest follow-up) showed no difference between the intervention and control, but this result was sensitive to the method of analysis, the withdrawal of studies with methodological limitations, and is dominated by a single large RCT. Overall, for every 100 patients in whom blood flow is increased perioperatively to defined goals, one can expect 13 in 100 patients (from 40/100 to 27/100) to avoid a complication, 2/100 to avoid renal impairment (from 8/100 to 6/100), 5/100 to avoid respiratory failure (from 10/100 to 5/100), and 4/100 to avoid postoperative wound infection (from 10/100 to 6/100). On average, patients receiving the intervention stay in hospital one day less. It is unlikely that the intervention causes harm. The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced.


title: In vitro assessment of the performance of a new multiband mucosectomy device for endoscopic resection of early upper gastrointestinal neoplasia.

text: BACKGROUND AND STUDY AIMS Multiband mucosectomy (MBM) is widely used for the endoscopic resection of early neoplasia in the upper gastrointestinal tract. A new MBM-device may have advantages over the current MBM-device with improved visualization, easier passage of accessories, and higher suction power due to different trip wire and cap. METHODS Rubber bands were released one by one for both MBM-devices while endoscopic images were collected. First, free endoscopic view was assessed by computer-assisted measurements (quantitative) and by ranking the images by a panel of 11 endoscopists (qualitative). Second, using a visual analog scale, three 'blinded' endoscopists assessed introduction and advancement of three types of endoscopic devices through the working channel of a diagnostic endoscope with the MBM-devices assembled. Third, suction power was evaluated by a manometer attached to the cap of the assembled MBM-devices in four endoscopes. Negative pressures were measured after 5 and 10 s of suction and repeated five times. The passage and suction experiments were performed with dry trip wires and repeated after soaking with bloody, mucous fluids. RESULTS With all bands present, endoscopic views were 90 and 40% in the new and current MBM-device, respectively. With the release of more bands, differences slowly disappeared. The panel scored a better endoscopic view in the new MBM-device (p = 0.03). Passage of all accessories was considered significantly easier in the new MBM-device. With the associated snare in the working channel, suction power was significantly better with the new MBM-device. CONCLUSION Compared to the currently available MBM-device, the new MBM-device provides improved endoscopic visibility, smoother passage of accessories, and higher suction power.


Can China's COVID-19 strategy work elsewhere?