title: Coping with the covid-19 Crisis: An overview of service adaptation and challenges encountered by a rural Psychiatry of Later Life (POLL) Team.

text: The Covid-19 pandemic has posed many challenges in maintaining standards of care and treatment for patients while managing the increased anxieties of patients, carers and the public in general. This paper highlights several clinical, administrative, medicolegal and IT implications of Covid-19 on the delivery of mental healthcare to an elderly vulnerable patient cohort due to recommended social distancing measures. Our Psychiatry of Later Life team has adapted to this by restricting face-to-face consultation, while continuing to provide telephone support. We have modified our documentation standard and have improved some aspects of our team working by facilitating flexible working arrangement and relevant training for staff as well as by embracing new technology. Notwithstanding the challenges therefore, this exceptional time has also opened avenues for new and innovative opportunities that can be further explored even when the current crisis eventually passes.


title: New technologies for reporting real-time emergent infections.

text: Novel technologies have prompted a new paradigm in disease surveillance. Advances in computation, communications and materials enable new technologies such as mobile phones and microfluidic chips. In this paper we illustrate examples of new technologies that can augment disease detection. We describe technologies harnessing the internet, mobile phones, point of care diagnostic tools and methods that facilitate detection from passively collected unstructured data. We demonstrate how these can all assist in quicker detection, investigation and response to emerging infectious events. Novel technologies enable collection and dissemination of epidemic intelligence data to both public health practitioners and the general public, enabling finer temporal and spatial resolution of disease monitoring than through traditional public health processes.


Covid-19: The time to shield all pregnant frontline workers is now.


title: [Novel coronavirus pneumonia (COVID-19) CT distribution and sign features].

text: Objective: To investigate the imaging findings of 2019 novel coronavirus pneumonia (COVID-19). Methods: From January 20 to February 5, 2020, a total of 130 patients diagnosed with COVID-19 from seven hospitals in China were collected. The imaging data were reviewed and analyzed in detail. Results: (1) Distribution: the lesion detected in the lung unilaterally in 14 cases (10.7%) and bilaterally in 116 cases (89.3%). According to the distribution in the lobes of the lung, all cases could be classified into subpleural distribution (102 cases, 78.4%), centrilobular distribution (99 cases, 76.1%) and diffused distribution (8 cases, 6.1%). (2) Number of lesions: single lesion 9 cases (6.9%); multiple lesions 113 cases (86.9%), diffuse lesions 8 cases (6.1%). (3) Imaging density: 70 cases (53.8%) of ground-glass opacity (GGO), 60 cases (46.2%) of GGO + consolidation. (4) Accompanying signs: 100 cases (76.9%) with vascular thickening, 98 cases (75.3%) with "pleural parallel sign" ; "intralobular septal thickening" in 100 cases (76.9%); "halo sign" in 13 cases (10%); "reversed-halo sign" in 6 cases (4.6%); pleural effusion in 3 cases (2.3 %), and pneumatocele in 2 cases (1.5%); no case with pulmonary cavity. Among 35 patients that underwent follow-up CT, 21 patients (60%) improved while 14 (40%) exacerbated. Conclusions: COVID-19 imaging characteristic mainly has subpleural, centrilobular and diffused distribution. The first two distributions can overlap or progress to diffused distribution. In the later period, it was mainly manifested as organizing pneumonia and fibrosis. The most valuable characteristic is the pleural parallel sign.


title: Comparing effects of continuous glucose monitoring systems (CGMs) and self-monitoring of blood glucose (SMBG) amongst adults with type 2 diabetes mellitus: a systematic review protocol.

text: BACKGROUND Continuous glucose monitorings (CGMs) have been used to manage diabetes with reasonable glucose control amongst patients with type 2 diabetes (T2D) in recent decades. CGMs measure interstitial fluid glucose levels to provide information about glucose levels, which identify fluctuation that would not have been identified with conventional self-monitoring. Self-monitoring of blood glucose (SMBG) is a classical tool to measure glycaemic changes. However, the effectiveness of glucose control, hypoglycemia, weight change, quality of life and user satisfaction, are needed to evaluate and compare CGMs and SMBG amongst adults with T2D. METHODS The review will compare the various forms of CGM systems (i.e flash CGM, real-time CGM, retrospective CGM) versus SMBG or usual intervention regarding diabetes management amongst adults with T2D. The following databases will be searched: Cochrane Library, PubMed, EMBASE, CINAHL, PsycINFO, Scopus and grey literature (ClinicalTrials.gov, PsycEXTRA, ProQuest Dissertations, Google Scholar and Theses Global) for the identification of studies. The studies involving adults (aged ≥ 18 years old) will be included. We will only include and summarise randomised clinical trials (RCTs) with respect to authors, publication type, year, status and type of devices. Studies published in English between February 2010 and March 2020, will be included as the field of CGMs amongst T2D patients has emerged over the last decade. Primary outcomes will be HbA1c (glycosylated haemoglobin level) (mmol/L), body weight (kg), time spent with hypoglycaemia (< 70 mg/dl) or hyperglycaemia (≥ 180 mg/dl), blood pressure (< 140/90 mmHg is considered as good management) and quality of life (understanding and feeling of living situation based on culture and value system). Secondary outcome measures will be user satisfaction (patient or treatment/intervention satisfaction or satisfaction scale) and barriers (physical and mental difficulties or issues). Study selection, data extraction and risk of bias assessment will be conducted independently by at least two reviewers. A third reviewer will determine and resolve discrepancies. Moreover, the quality of the evidence of the review will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation tool (GRADE). DISCUSSION The review will synthesise evidence on the comparison between using CGMs and SMBG. The results will support researchers and health professionals to determine the most effective methods/technologies in the overall diabetes management. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020149212.


title: Diagnostic applications of high-throughput DNA sequencing.

text: Advances in DNA sequencing technology have allowed comprehensive investigation of the genetics of human beings and human diseases. Insights from sequencing the genomes, exomes, or transcriptomes of healthy and diseased cells in patients are already enabling improved diagnostic classification, prognostication, and therapy selection for many diseases. Understanding the data obtained using new high-throughput DNA sequencing methods, choices made in sequencing strategies, and common challenges in data analysis and genotype-phenotype correlation is essential if pathologists, geneticists, and clinicians are to interpret the growing scientific literature in this area. This review highlights some of the major results and discoveries stemming from high-throughput DNA sequencing research in our understanding of Mendelian genetic disorders, hematologic cancer biology, infectious diseases, the immune system, transplant biology, and prenatal diagnostics. Transition of new DNA sequencing methodologies to the clinical laboratory is under way and is likely to have a major impact on all areas of medicine.


title: Weight-adapted surgical approach for laparoendoscopic single-site surgery in pediatric patients using low-cost reusable instrumentation: a prospective analysis.

text: OBJECTIVES Laparoendoscopic single-site surgery (LESS) in pediatric patients has emerged as a viable alternative to standard laparoscopy. The aim of our investigation was to assess different surgical approaches for LESS, stratifying by weight. SUBJECTS AND METHODS From March 2010 to April 2012 LESS was performed in 42 children. Children weighing below 10 kg underwent LESS through an umbilical incision using two 3-mm trocars and one 5-mm trocar. Patients above 10 kg were operated on using a metal multiuse single-site single port (X-Cone; Karl Storz Endoskope, Tuttlingen, Germany). Conventional straight laparoscopic instruments were used in all cases. RESULTS Mean age at operation was 100 months (range, 0.25-207 months), and mean weight was 27 kg (range, 3.1-82 kg). Median operating time was 74 minutes (range, 36-300 minutes). Eighteen children underwent LESS using two 3-mm trocars and one 5-mm trocar; 1 case required two 5-mm trocars and one 10-mm trocar. Twenty-three patients were operated on with the multiuse device. All operations were carried out safely in a standard laparoscopic transperitoneal technique with full achievement of the surgical target. In none of the patients was an intraoperative complication noticed. Postoperatively two complications were noted, which resolved spontaneously. CONCLUSIONS LESS for pediatric patients can be done safely and efficiently with even less trauma than in conventional laparoscopy irrespective of age and weight. However, different surgical approaches have to be considered as disposable single-site ports are not available for infants and small children. To decrease operative expenses, conventional multiuse trocars and a multiuse single-site port were used with conventional laparoscopic instruments.


title: The effect of continuous positive airway pressure on stair-climbing performance in severe COPD patients.

text: Stair climbing is associated with dynamic pulmonary hyperinflation and the development of severe dyspnea in patients with chronic obstructive pulmonary disease (COPD). This study aimed to assess whether (i) continuous positive airway pressure (CPAP) applied during stair climbing prevents dynamic hyperinflation and thereby reduces exercise-induced dyspnea in oxygen-dependent COPD-patients, and (ii) the CPAP-device and oxygen tank can be carried in a hip belt. In a randomised cross-over design, oxygen-dependent COPD patients performed two stair-climbing tests (44 steps): with supplemental oxygen only, then with the addition of CPAP (7 mbar). The oxygen tank and CPAP-device were carried in a hip belt during both trials. Eighteen COPD patients were included in the study. Although all patients could tolerate stair climbing with oxygen alone, 4 patients were unable to perform stair climbing while using CPAP. Fourteen COPD patients (mean FEV1 36 ± 14% pred.) completed the trial and were analyzed. The mean flow rate of supplemental oxygen was 3 ± 2 l/min during stair climbing. Lung hyperinflation, deoxygenation, hypoventilation, blood lactate production, dyspnea and the time needed to manage stair climbing were not improved by the application of CPAP (all p > 0.05). However, in comparison to climbing with oxygen alone, limb discomfort was reduced when oxygen was supplemented with CPAP (p = 0.008). In conclusion, very severe COPD patients are able to carry supporting devices such as oxygen tanks or CPAP-devices in a hip belt during stair climbing. However, the application of CPAP in addition to supplemental oxygen during stair climbing prevents neither exercise-induced dynamic hyperinflation, nor dyspnea.


title: Neonatal diabetes due to potassium channel mutation: response to sulfonylurea according to the genotype.

text: OBJECTIVE A precision medicine approach is used to improve treatment of patients with monogenic diabetes. Herein we searched SU efficiency according to the genotype-phenotype correlation, dosage used and side effects. RESEARCH DESIGN AND METHODS Systematic review conducted according the PRISMA control criteria identifying relevant studies evaluating the in vivo and in vitro sensitivity of ATP-dependent potassium channels according to the characteristics of genetic mutation. RESULTS 103 selected articles with complete data in 502 cases in whom 413 (82.3%) had mutations in KCNJ11 (#64) and 89 in ABCC8 (# 56). Successful transfer from insulin to SU was achieved in 91% and 86.5% patients, respectively at a mean age of 36.5 months (0-63 years). Among patients with KCNJ11 and ABCC8 mutations 64 & 46 were associated with constant success,5 & 5 to constant failure, and 10 and 4 to variable degrees of reported success rate, respectively. The glibenclamide dosage required for each genotype ranged from 0.017 to 2.8 mg / kg / day. Comparing both the in vivo and in vitro susceptibility results, some mutations appear more sensitive than others to sulfonylurea treatment. Side effects were reported in 17 /103 of the included articles: mild gastrointestinal symptoms and hypoglycaemia were the most common. One premature patient had an ulcerative necrotizing enterocolitis which association with SU is difficult to ascertain. CONCLUSIONS Sulfonylurea are an effective treatment for monogenic diabetes due to KCNJ11 and ABCC8 genes mutations. The success of the treatment is conditioned by differences in pharmacogenetics, younger age, pharmacokinetics, compliance and maximal dose used. This article is protected by copyright. All rights reserved.


title: Clinical Evaluations of a Novel Thread Lifting Regimen Using Barbed Polyglyconate Suture for Facial Rejuvenation: Analysis Using a 3-Dimensional Imaging System.

text: BACKGROUND Thread lifting with absorbable sutures has recently gained prominence for rejuvenating ptotic and sagging soft tissues in aging face. A barbed, delayed absorbable polyglyconate monofilament shows significantly high tensile loads with superior flexibility and elasticity. OBJECTIVE To evaluate the safety and efficacy of novel thread lifting regimen with barbed polyglyconate suture for counteracting the descent and laxity of the aging face. METHODS A retrospective chart review was conducted for 25 Korean patients with mild to moderate facial skin laxity receiving thread lifting procedures using barbed polyglyconate suture. Dermatologists' objective assessments using a 5-point Global Aesthetic Improvement Scale (GAIS), 3D imaging system, and subjective satisfaction were recorded at baseline and 4 months after treatments. RESULTS In most patients (84%), GAIS scores were more than score 3 ("improved"), with 40% of score 4 ("much improved") and 24% of score 5 ("excellent") at the follow-up point. Subjective assessments paralleled these patterns. Three-dimensional analysis quantitatively showed volume migration of low face upward, clinically interpreted as facial lifting. No serious adverse effect was observed. CONCLUSION This novel thread lifting procedure using barbed polyglyconate suture is a safe and effective method for tightening and lifting for aging face with mild to moderate face sagging.


docid: quacnyiy

title: Preclinical and clinical studies of peptide receptor radionuclide therapy.

text: In the 1980s, the (111)In-labeled somatostatin analog OctreoScan (Covidien, Hazelwood, MO) was developed for imaging of somatostatin receptor subtype 2 (sst(2)) overexpressing tumors. On the basis of this success, peptide receptor radionuclide therapy (PRRT) was developed using similar somatostatin analogs with different therapeutic radionuclides. Clinical application of PRRT demonstrated impressive results on tumor response, overall survival, and quality of life in patients with gastroenteropancreatic neuroendocrine tumors. The peptides 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA), Tyr(3)-octreotate (DOTATATE) and DOTA, Tyr(3)-octreotide (DOTATOC) (brand name Onalta), predominantly targeting sst(2), have been granted Orphan Drug status by the European Medicines Agency and the US Food and Drug Administration for application in PRRT. Besides somatostatin receptor-targeting peptides, multiple other radiopeptide analogs were developed targeting several other receptors overexpressed on various tumors. Some of these peptide analogs, including cholecystokinin, gastrin, gastrin-releasing peptide, arginine-glycine-aspartate (RGD)-peptides, and glucagon-like peptide 1 analogs appeared very promising in preclinical and clinical imaging and PRRT studies. Although the success of PRRT with radiolabeled somatostatin analogs has been established, there is still room for improvement. The therapeutic window of PRRT could be enlarged by the use of new and improved targeting compounds, of which new antagonists with excellent tumor to background ratios are very promising. Furthermore, locoregional administration, improved healthy tissue protection, and combination treatment can be applied to increase the effectiveness of PRRT. Combination treatment might include cocktails of different peptide analogs of different therapeutic radionuclides and of radiolabeled peptides with chemotherapeutic or radiosensitizing agents. This review summarizes results of PRRT and describes clinical and preclinical studies regarding PRRT optimizing strategies.


title: Comparison of nasopharyngeal flocked swabs and aspirates for rapid diagnosis of respiratory viruses in children.

text: BACKGROUND The quality of clinical specimens is a crucial determinant for virological diagnosis. OBJECTIVES We compared the viral diagnostic yield for influenza A and respiratory syncytial virus (RSV) from the recently developed nasopharyngeal flocked swabs (NPFS) with nasopharyngeal aspirates (NPA) collected in parallel from 196 hospitalized children with acute respiratory infection during the peak period of influenza A and RSV activity in Hong Kong. Specimens were tested by RT-PCR for influenza A and RSV and viral load determined. They were also tested by direct immunofluorescence (DIF) for influenza A and B, RSV, parainfluenza types 1-3 and adenovirus. RESULTS Both NPA and NPFS had excellent sensitivity (100%) for detecting influenza A by RT-PCR but NPA was slightly more sensitive than NPFS for detecting RSV by both RT-PCR (100% vs. 92.3%) and DIF (87.2% vs. 84.6%) and for detecting influenza A by DIF (90.2% vs. 82.9%). Viral load for influenza A in NPA and NPFS was not significantly different but that for RSV was higher in NPA. CONCLUSION NPA remains the optimal specimen for diagnosis of respiratory infections by RT-PCR and DIF. However, collection of NPFS is easier to perform in an out-patient setting, was more acceptable to parents and less likely to generate aerosols than NPA engendering potentially less infection control hazard.


title: Contentment in "Songs of the Gorilla Nation: My Journey through Autism": A Humanbecoming Hermeneutic Study.

text: This article is an example of the use of narrative in the form of a memoir to explore the humanly lived experience of contentment. The humanbecoming school of thought provided a philosophical foundation and theoretical framework for this hermeneutic interpretation of Dawn Prince-Hughes' published memoir, "Songs of the Gorilla Nation: My Journey through Autism." The findings-contentment is enduring serenity unfolding with inspiring unburdening as cherished convictions arise amid disharmony answer the research question: what is contentment as humanly lived? This study enhances knowledge about contentment as quality of life.


title: Effect of Laser-Activated Irrigation with Ethylene Diaminetetraacetic Acid and Phytic Acid on the Removal of Calcium Hydroxide and Triple Antibiotic Paste from Root Dentin.

text: OBJECTIVE This study assessed the efficacy of erbium, chromium:yttrium-scandium-gallium-garnet (Er,Cr:YSGG) laser-activated irrigation (LAI) of ethylene diaminetetraacetic acid (EDTA) and phytic acid on the removal of calcium hydroxide (CH) and triple antibiotic paste (TAP) from root canals. BACKGROUND DATA Although some studies investigated the efficacy of LAI of EDTA irrigation, no study has been conducted to investigate the efficacy of LAI of phytic acid in the removal of CH and TAP from root dentin. MATERIALS AND METHODS Root canals of extracted maxillary incisors (n = 80) were instrumented using rotary files and thereafter were split longitudinally. Following preparation of a standardized groove in the apical region of one root half, the roots were randomly divided into two groups according to the intracanal medicaments placed into the grooves: (1) CH and (2) TAP. The roots were reassembled, and the specimens were further assigned into four groups (n = 10/group) defined by the final irrigation solution (EDTA and phytic acid) and irrigation technique (needle irrigation and LAI) used for removal of the medicaments. The data were analyzed statistically using Kruskal-Wallis and Mann-Whitney U tests. RESULTS For both EDTA and phytic acid, LAI was more efficient than needle irrigation in removing both CH and TAP (p < 0.05), but none of the tested techniques completely removed CH. Irrespective of the tested irrigation solutions and techniques, significantly less TAP remained in canals (p = 0.0001), with TAP being completely removed by LAI. Irrigation with phytic acid showed better removal efficacy than EDTA in the absence of statistical significance. CONCLUSIONS Er,Cr:YSGG LAI of EDTA and phytic acid completely removed TAP and effectively reduced CH on root dentin.


Q312: biotech on a roll.


To consider or not antimalarials as a prophylactic intervention in the SARS-CoV-2 (Covid-19) pandemic.


Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn.


title: Just-In-Time Training in a Tertiary Referral Hospital During the COVID-19 Pandemic in Italy.

text: The COVID-19 pandemic is threatening health systems worldwide, requiring extraordinary efforts to contain the virus and prepare health care systems for unprecedented situations. In this context, the entire health care workforce must be properly trained to guarantee an effective response. Just-in-time training has been an efficient solution for rapidly equipping health care workers with new knowledge, skills, and attitudes during emergencies; thus, it could also be an effective training technique in the context of the response to the COVID-19 pandemic. Because of the unexpected magnitude of this health crisis, the health care workforce must be trained in two areas: (1) basic infection prevention and control, including public health skills that are the core of population-based health management and (2) disaster medicine principles, such as surge capacity, allocation of scarce resources, triage, and the ethical dilemmas of rationing medical care. This perspective reports how just-in-time training concepts and methods were applied in a tertiary referral hospital in March 2020, during the COVID-19 pandemic in Northern Italy, one of the hardest hit places in the world.The COVID-19 just-in-time training was designed to provide hospital staff with the competencies they need to work proficiently and safely inside the hospital, including an understanding of the working principles and standard operating procedures in place and the correct use of personal protective equipment. Moreover, this training was intended to address the basic principles of disaster medicine applied to the COVID-19 pandemic. Such training was essential in enabling staff to rapidly attain competencies that most of them lacked because disaster medicine and global health are not included in the curricula of Italian medical and nursing schools. Although a formal evaluation was not performed, this is a useful example of how to create just-in-time training in a large hospital during a crisis of an unprecedented scale.


title: Reduction of anastomotic failure in laparoscopic colorectal surgery using antitraction sutures.

text: BACKGROUND Anastomotic leakage is a major complication in colorectal surgery. This study investigates a new method for reducing anastomotic failure using antitraction sutures. METHODS In 2007, the authors began routine placement of three sutures at every one-third of the circular end-to-end anastomosis to reduce traction. Before the start of the new protocol, 76 patients received laparoscopic colorectal left sided surgery, 21 (28%) of whom received a defunctioning stoma. After the start of the new protocol, 77 patients received laparoscopic colorectal surgery, 6 (8%) of whom received a defunctioning stoma. RESULTS Placement of a defunctioning stoma was significantly reduced (n = 21 vs. 6; P = 0.01). Only one patient (1%) in the sutured group experienced anastomotic leakage compared with six patients in the control group (P = 0.025). Other anastomosis-related complications during the follow-up period, including anastomotic stenosis and intraabdominal abscess, occurred more frequently in the control group, although the difference did not reach significance. CONCLUSION The use of antitraction sutures to support the anastomosis seems to reduce the occurrence of anastomotic leakage in laparoscopic left colorectal surgery. A prospective randomized trial is necessary to prove the decreasing effect of antitraction sutures on anastomotic leakage as well as the major decreasing effect on the necessity of placement of defunctioning stomas.


title: Cowpea mosaic virus-based systems for the expression of antigens and antibodies in plants.

text: This chapter describes the use of Cowpea mosaic virus-based vectors for the production of foreign proteins such as antigens and antibodies in plants. The systems include vectors based on both full-length and deleted versions of RNA-2. In both cases, the modified RNA-2 is replicated by coinoculation with RNA-1. The constructs based on full-length RNA-2 retain the ability to spread systemically throughout an inoculated plant and the infection can be passaged. The vector based on a deleted version of RNA-2 can stably incorporate larger inserts but lacks the ability to move systemically. However, it has the added advantage of biocontainment. In both cases, vector constructs modified to contain a foreign gene of interest can be delivered by agroinfiltration to obtain transient expression of the foreign protein. If required, the same constructs can also be used for stable nuclear transformation. Both types of vector have proved effective for the production in plants of a diverse range of proteins including antigens and antibodies.


title: Journal of Clinical Monitoring and Computing 2016 end of year summary: cardiovascular and hemodynamic monitoring.

text: The assessment and optimization of cardiovascular and hemodynamic variables is a mainstay of patient management in the care for critically ill patients in the intensive care unit (ICU) or the operating room (OR). It is, therefore, of outstanding importance to meticulously validate technologies for hemodynamic monitoring and to study their applicability in clinical practice and, finally, their impact on treatment decisions and on patient outcome. In this regard, the Journal of Clinical Monitoring and Computing (JCMC) is an ideal platform for publishing research in the field of cardiovascular and hemodynamic monitoring. In this review, we highlight papers published last year in the JCMC in order to summarize and discuss recent developments in this research area.


title: A survey for selected avian viral pathogens in backyard chicken farms in Finland.

text: Backyard poultry are regaining popularity in Europe and increased interest in the health and management of non-commercial farms has resulted. Furthermore, commercial poultry farm owners have become concerned about the risk represented by contagious avian diseases that nearby backyard poultry could transmit. Fifty-one voluntary backyard chicken farms were visited between October 2012 and January 2013. Blood samples and individual cloacal swabs were collected from 457 chickens. In 44 farms (86%), one or more of the tested chickens had antibodies against avian encephalomyelitis and chicken infectious anaemia viruses, 24 farms (47%) had chickens seropositive for infectious bronchitis virus, 10 farms (20%) had chickens seropositive for infectious bursal disease virus, six farms (12%) had chickens seropositive for infectious laryngotracheitis virus and two farms (5.4%) had chickens seropositive for avian influenza virus. No farms had chickens seropositive for Newcastle disease virus. Of the 51 farms, five (10%) had chickens positive for coronavirus reverse transcription polymerase chain reaction. A phylogenetic analysis showed that all backyard chicken coronaviruses collected were QX type infectious bronchitis viruses. All chickens tested for avian influenza and Newcastle disease viruses using real time reverse transcription polymerase chain reaction were negative. To our knowledge, there is no evidence to date to suggest that these diseases would have been transmitted between commercial and non-commercial flocks.


title: Evaluation of the radiological gastric capacity and evolution of the BMI 2-3 years after sleeve gastrectomy.

text: BACKGROUND Sleeve gastrectomy is a restrictive procedure for treatment of obese patients with different body mass index (BMI) and presents good results in terms of a reduction of percentage of excess weight loss and BMI. There is no consensus which is the optimal technique regarding to the diameter of the gastric tube, but a capacity of 100-120 ml has been suggested. In this prospective study, we compare the gastric capacity evaluated with barium sulfate or computer-aided tomography (CAT) scan early and 24 months after operation compared to the changes in body weight and BMI reduction in a small group of 15 consecutive patients submitted to sleeve gastrectomy. METHODS Fifteen successive obese patients submitted to laparoscopic sleeve gastrectomy were included. They were studied in order to measure the residual gastric capacity with barium sulfate and CAT scan early (3 days) and late (2 years) after surgery. RESULTS The early postoperative gastric volume was 108 +/- 25 ml (80-120 ml) and 116.2 +/- 78.24 assessed with barium sulfate and CAT scan, respectively. The gastric capacity at the late control increased to 250 +/- 85 and 254 +/- 56.8 assessed with the same techniques. However, patients remained stable with a BMI close to 25 without regain of weight at least at the time of observation. CONCLUSIONS Gastric capacity can increase late after sleeve gastrectomy even after performing a narrow gastric tubulization. It is very important to measure objectively residual gastric volume after sleeve gastrectomy and its eventual increase in order to determine the late clinical results and to indicate eventual strategy for retreatment.


Removing the handle of the Broad Street pump: measures to slow the spread of covid-19 in primary care teams.


title: Hypoxic challenge test applied to healthy children: influence of body positions and exertion on pulse oximetric saturation.

text: BACKGROUND Commercial aircraft are pressurised to ~2438 m (8000 ft) above sea level that equates breathing 15% oxygen at sea level. A preflight hypoxic challenge test (HCT) is therefore recommended for children with cystic fibrosis or other chronic lung diseases and inflight oxygen is advised if pulse oximetric saturation (SpO2) decreases <90%. OBJECTIVE Study responses to a modified HCT, encompassing various body positions and light physical activity, reflecting relevant activities of children during flight, with a view to challenge the evidence of the current cut-off. METHODS Oxygenation, heart rate and ventilation were observed in 34 healthy schoolchildren (17 boys) undergoing a modified HCT, alternating between breathing room air and 15% oxygen in nitrogen while seated, supine, standing and walking at 3 km/h and 5 km/h. RESULTS Nadir SpO2 <90%, median (range), occurred in 9 subjects sitting, 89% (78-89%); 6 supine, 88.5% (87-89%); 9 standing, 89% (85-89%); 23 walking 3 km/h, 87% (74-89%); and 21 walking 5 km/h, 86% (74-89%). Total time <90% for these subjects in seconds was 20 (10-80) sitting, 30 (10-190) supine, 50 (10-150) standing, 80 (10-260) walking 3 km/h and 125 (10-300) walking 5 km/h. Light exercise in general led to lower SpO2: 91% (77-96%), p<0.0001. CONCLUSIONS A modified HCT led to moments of desaturation below 90% in various body positions at rest and during light physical activity in healthy schoolchildren. It is questionable whether the international recommended cut-off of 90% for children with chronic lung disease reflects clinical oxygen dependence during flights.


docid: plmdrmpi

title: Impact of cigarette smoking on extent of coronary artery disease and prognosis of patients with non-ST-segment elevation acute coronary syndromes: an analysis from the ACUITY Trial (Acute Catheterization and Urgent Intervention Triage Strategy).

text: OBJECTIVES This study sought to evaluate the short- and long-term outcomes for smokers with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). BACKGROUND Smoking has been associated with the "paradox" of reduced mortality after acute myocardial infarction (MI). This is thought to be due to favorable baseline characteristics and less diffuse coronary artery disease (CAD) among smokers. METHODS In the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 13,819 patients (29.1% smokers) with moderate- to high-risk NSTE-ACS underwent angiography and, if indicated, revascularization. RESULTS Smokers were significantly younger and had fewer comorbidities than nonsmokers. Incidence of death and MI were comparable at 30 days, although smokers had significantly reduced risks of 30-day major bleeding (hazard ratio [HR]: 0.80, 95% confidence interval [CI]: 0.67 to 0.96; p = 0.016) and 1-year mortality (HR: 0.797, 95% CI: 0.65 to 0.97; p = 0.027). After correction for baseline and clinical differences, smoking was no longer predictive of major bleeding (odds ratio: 1.06, 95% CI: 0.86 to 1.32; p = 0.56) and was associated with higher 1-year mortality (HR: 1.37, 95% CI: 1.07 to 1.7; p = 0.013). This pattern of reversed risk after multivariable correction held true for those smokers requiring percutaneous coronary intervention. Core laboratory angiographic analysis showed that smokers and nonsmokers were comparable in terms of the extent of CAD, Thrombolysis In Myocardial Infarction flow, myocardial blush, and the presence of thrombi. CONCLUSIONS In contrast to the paradox previously described in ST-segment elevation MI, our analysis finds smoking to be an independent predictor of higher 1-year mortality in patients presenting with NSTE-ACS, and our angiographic study demonstrates CAD in smokers that is comparable to that in nonsmokers but evident ∼1 decade earlier. (Acute Catheterization and Urgent Intervention Triage Strategy [ACUITY]; NCT00093158).


title: Dynamic tracheal occlusion improves lung morphometrics and function in the fetal lamb model of congenital diaphragmatic hernia.

text: BACKGROUND Congenital diaphragmatic hernia (CDH) is associated with significant neonatal morbidity and mortality. Although prenatal complete tracheal occlusion (cTO) causes hypoplastic CDH lungs to enlarge, improved lung function has not been demonstrated. Furthermore, cTO interferes with the dynamic pressure change and fluid flow associated with fetal breathing. PURPOSE The purpose of the study was to assess a novel dynamic tracheal occlusion (dTO) device that preserves pressure changes and fluid flow. METHODS In this pilot study, CDH was created in fetal lambs at 65 days of gestational age (GA). At 110 days GA, a cTO device (n = 3) or a dTO device (n = 4) was placed in the fetal trachea. At 135 days GA, lambs were delivered and resuscitated. Unoperated lamb co-twins (n = 5), sham thoracotomy lambs (n = 2), and untreated CDH lambs (n = 3) served as controls. RESULTS Tracheal opening pressure, lung volume, lung fluid total protein, and phospholipid were significantly higher in the cTO group than in the dTO and unoperated control groups. Maximal oxygenation and lung compliance were significantly lower in the cTO group when compared with the unoperated control and dTO groups. CONCLUSION Preliminary results suggest that in the fetal lamb CDH model, dTO restores normal lung morphometrics and function, whereas cTO leads to enlarged but less functional lungs.


title: The human postmenopausal ovary as a tool for evaluation of cryopreservation protocols towards whole ovary cryopreservation.

text: PURPOSE Cryopreservation of a complete ovary may be a future method for fertility preservation in cancer patients. Difficulties exist in cryopreservation of the relatively large ovarian tissue mass. This study evaluates whether a human postmenopausal ovary can be used, as a complement to animal models, in studies of this research field. METHODS Postmenopausal human ovaries (n = 10) were isolated and flushed through ovarian arteries with either the cryoprotectant dimethylsulphoxide or Ringer-Acetate, followed by slow freezing. After thawing, production of androgens during in vitro perfusion and morphology (light/electron microscopy) were assessed. RESULTS The dimethylsulphoxide-cryopreserved ovaries showed larger secretion of androgens during perfusion than Ringer Acetate-cryopreserved ovaries. Light microscopy showed well preserved morphology in both groups. Electron microscopy revealed normal appearance of stroma and vessels in the dimethylsulphoxide group. CONCLUSIONS The study demonstrates the potential to use the postmenopausal human ovary for further studies aiming at optimizing cryopreservation protocols, with special reference to ovarian vascularity and stroma.


title: COVID-19 and endoscopy services in intermediately affected countries: a position statement from the saudi gastroenterology association.

text: With the global pandemic due to coronavirus disease 2019 (COVID-19), there has been a significant strain on healthcare facilities. The infectivity rate, as well as the rate of healthcare workers who have fallen ill to the disease, has raised concerns globally on the proper management of patients as well as the role of safe healthcare provision utilizing personal protective equipment (PPE). Furthermore, the limited supply of PPEs has mandated rationing their use to achieve maximum utility and preservation. Multiple gastroenterology associations have issued guidance and statements that would help healthcare providers in navigating these unprecedented and difficult times, and the Saudi Gastroenterology Association has provided this statement in an effort to bring the most up to date information for the management of endoscopy units in terms of resources, manpower planning, scheduling, as well as infection control policies and leadership.


title: Utilizing integrating network pharmacological approaches to investigate the potential mechanism of Ma Xing Shi Gan Decoction in treating COVID-19.

text: Beginning in December 2019, coronavirus disease 2019 (COVID-19), due to 2019-nCoV infection, emerged in Wuhan and spread rapidly throughout China and even worldwide. Employing combined therapy of modern medicine and traditional Chinese medicine has been proposed, in which Ma Xing Shi Gan Decoction (MXSGD) was recommended as a basic prescription and applied widely in the clinical treatment of COVID-19. We investigated the underlying mechanism of MXSGD in treating COVID-19 utilizing the approaches of integrating network pharmacology. A total of 97 active ingredients of MXSGD were screened out, and 169 targets were predicted. The protein-protein interaction network exhibited hub targets of MXSGD, such as Heat shock protein 90, RAC-alpha serine/threonine-protein kinase, Transcription factor AP-1, Mitogen-activated protein kinase 1, Cellular tumor antigen p53, Vascular endothelial growth factor A, and Tumour necrosis factor. Gene Ontology functional enrichment analysis demonstrated that the biological processes altered within the body after taking MXSGD were closely related to the regulation of such processes as the acute inflammatory response, chemokine production, vascular permeability, response to oxygen radicals, oxidative stress-induced apoptosis, T cell differentiation involved in the immune response, immunoglobulin secretion, and extracellular matrix disassembly. KEGG enrichment analysis indicated that the targets of MXSGD were significantly enriched in inflammation-related pathways, immunomodulation-related pathways, and viral infection-related pathways. The therapeutic mechanisms of MXSGD on COVID-19 may primarily involve the following effects: reducing inflammation, suppressing cytokine storm, protecting the pulmonary alveolar-capillary barrier, alleviating pulmonary edema, regulating the immune response, and decreasing fever.


title: Surgical nuances for removal of retrochiasmatic craniopharyngioma via the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach.

text: Retrochiasmatic craniopharyngiomas are challenging tumors to remove given their deep location and proximity to critical neurovascular structures. Complete surgical removal offers the best chance of cure and prevention of recurrence. The endoscopic endonasal extended transsphenoidal approach offers direct midline access to the retrochiasmatic space through a transplanum transtuberculum corridor. Excellent visualization of the undersurface of the optic chiasm and hypothalamus can be obtained to facilitate bimanual extracapsular dissection to permit complete removal of these formidable tumors. In this report the authors review the endoscopic endonasal extended transsphenoidal approach, with specific emphasis on technical operative nuances in removing retrochiasmatic craniopharyngiomas. An illustrative intraoperative video demonstrating the technique is also presented.


title: A Second Pandemic: Mental Health Spillover From the Novel Coronavirus (COVID-19).

text: The novel coronavirus (COVID-19) pandemic has created an unprecedented global health challenge. There is risk that the outbreak will create a "second pandemic" of mental health crises in health systems and communities. Thus, a comprehensive public health response to the pandemic must include (a) attention to the psychological aspects of hospitalization for patients, families, and staff affected by COVID-19; (b) planning for emergency and acute psychiatric patient care if hospitals become overwhelmed with COVID-19 patients; and (c) innovations for providing mental health care in communities while social distancing is required and health system resources are strained. Nurses and nurse leaders must anticipate these mental health challenges, assist with preparedness in health systems and communities, and advocate for a coordinated response to promote mental wellness and resilience.


title: Early and midterm outcomes after transcatheter embolization of type I endoleaks in 25 patients.

text: OBJECTIVE This study reports the technical success and follow-up results of transcatheter embolization of type I endoleak (ELI) in 25 patients after endovascular aortic repair (EVAR). METHODS Twenty-five patients with ELI (20 men, five women; mean age 80 years; range, 64-96 years) underwent embolization of abdominal ELI (23 proximal, 2 distal endoleaks) after EVAR. All patients were unsuitable for standard endovascular methods for treatment of ELI. The average aneurysm sac size before embolization was 8.2 cm (range, 5.3-12.9 cm). The average time between EVAR and endoleak diagnosis was 685 days (range, 1-4220 days) and from endoleak diagnosis to embolization was 27 days (range, 2-94 days). Onyx (ev3 Endovascular, Inc, Plymouth, Minn) alone or with detachable coils was used for embolization. RESULTS A total of 27 embolization procedures were performed, with two patients having undergone a repeat procedure. Onyx alone was used in 16 cases and Onyx and coils were used in 11. Immediate technical success with complete isolation of the endoleak on completion angiography was achieved in all procedures. Six procedural complications occurred: three puncture site hematomas and three cases of non-target Onyx embolization. None of the complications had long term sequelae. During the follow-up period (average, 311 days; range, 1-1357 days), seven patients (28%) developed endoleak recurrence, and two underwent a second embolization procedure. Of these, one has had no further endoleak recurrence, but the other developed a recurrent endoleak and died of sac rupture. Two of the other five cases of endoleak recurrence were successfully managed by other procedures, one had a persistent endoleak despite aortic cuff placement, and the other two were deemed unsuitable for further intervention. Three of the four patients with persistent endoleaks died of sac rupture. At the average follow-up time of 311 days, freedom from endoleak recurrence was 80%, and freedom from sac growth was 85%. CONCLUSIONS Transcatheter embolization of ELI offers a safe, feasible, and sustainable treatment option for patients who are unsuitable for standard methods of ELI treatment. Additional coil embolization before Onyx injection may result in better outcome.


title: Limited resection trial for pulmonary ground-glass opacity nodules: case selection based on high-resolution computed tomography-interim results.

text: OBJECTIVE Our previous trial for small ground-glass opacity nodule on high-resolution computed tomography suggested all these cancers might have been radically managed with limited resection. Good correlation between radiologic and pathologic findings in early lung adenocarcinomas has been reported. We aimed to confirm limited resection efficacy as radical surgery in patients with high-resolution computed tomography-indicated minimally invasive lung cancer. The purpose of this interim analysis is to report the details of the patient and nodule characteristics, intraoperative cytology capability as a negative margin indicator, and patient outcome with the median follow-up period of 7 years and 4 months. METHODS Enrollment required patients with a tumor ≤2 cm, diagnosed or suspected as a cT1N0M0 carcinoma in the lung periphery and depicted on high-resolution computed tomography as a sub-solid nodule with tumor disappearance ratio ≥0.5. We performed a wedge or segmental resection as appropriate. The primary endpoint is 10 year local recurrence-free survival rate. RESULTS This study started in November 2003, and 101 patients were enrolled as of November 2009. Of them, 95 were eligible for analysis. There were 38 men and 57 women, aged 30-75, averaging 62 years. Tumor sizes ranged from 7 to 20 mm on computed tomography, averaging 15 mm. There were 11 Noguchi type A tumors, 54 type B tumors, 24 type C tumors, one malignant lymphoma and 5 non-cancerous lesions. All cancers showed no vessel invasion. With a median follow-up period of 88 months, there have been no recurrences. CONCLUSION So far, high-resolution computed tomography appears to predict non- or minimally invasive ground-glass opacity lung cancers with high reliability, warranting limited resection as curative surgery in this cohort.


title: Delivery Considerations of Highly Viscous Polymeric Fluids Mimicking Concentrated Biopharmaceuticals: Assessment of Injectability via Measurement of Total Work Done "WT".

text: An account is given of the recent development of the highly viscous complex biopharmaceuticals in relation to syringeability and injectability. The specific objective of this study is to establish a convenient method to examine problem of the injectability for the needle-syringe-formulation system when complex formulations with diverse viscosities are used. This work presents the inter-relationship between needle size, syringe volume, viscosity, and injectability of polymeric solutions having typical viscosities encountered in concentrated biologics, by applying a constant probe crosshead speed on the plunger-syringe needle assembly and continuously recording the force-distance profiles. A computerized texture analyzer was used to accurately capture, display, and store force, displacement, and time data. The force-distance curve and area under the curve are determined, and total work done for complete extrusion of the syringe content was calculated automatically by applying an established Matlab program. Various concentrations (i.e., 0.5-4% w/v of polymeric fluids/dispersions) of polyethylene oxide (PEO) and hydroxypropyl methylcellulose (HPMC) with viscosity ranges of 5-100 cP mimicking concentrated monoclonal antibody solutions and complex biopharmaceutical formulations are investigated. Results indicate that calculated values of total work done to completely extrude the syringe content are the most appropriate parameter that describes viscosity-injection force of dispersed formulations. Additionally, the rheological properties of HPMC and PEO fluids in the context of syringeability and injectability are discussed.


title: Use of a single ventilator to support 4 patients: laboratory evaluation of a limited concept.

text: INTRODUCTION A mass-casualty respiratory failure event where patients exceed available ventilators has spurred several proposed solutions. One proposal is use of a single ventilator to support 4 patients. METHODS A ventilator was modified to allow attachment of 4 circuits. Each circuit was connected to one chamber of 2 dual-chambered, test lungs. The ventilator was set at a tidal volume (V(T)) of 2.0 L, respiratory frequency of 10 breaths/min, and PEEP of 5 cm H(2)O. Tests were repeated with pressure targeted breaths at 15 cm H(2)O. Airway pressure, volume, and flow were measured at each chamber. The test lungs were set to simulate 4 patients using combinations of resistance (R) and compliance (C). These included equivalent C and R, constant R and variable C, constant C and variable R, and variable C and variable R. RESULTS When R and C were equivalent the V(T) distributed to each chamber of the test lung was similar during both volume (range 428-442 mL) and pressure (range 528-544 mL) breaths. Changing C while R was constant resulted in large variations in delivered V(T) (volume range 257-621 mL, pressure range 320-762 mL). Changing R while C was constant resulted in a smaller variation in V(T) (volume range 418-460 mL, pressure range 502-554 mL) compared to only C changes. When R and C were both varied, the range of delivered V(T) in both volume (336-517 mL) and pressure (417-676 mL) breaths was greater, compared to only R changes. CONCLUSIONS Using a single ventilator to support 4 patients is an attractive concept; however, the V(T) cannot be controlled for each subject and V(T) disparity is proportional to the variability in compliance. Along with other practical limitations, these findings cannot support the use of this concept for mass-casualty respiratory failure.


title: Usefulness of contrast-enhanced ultrasonography using Sonazoid for the assessment of therapeutic response to percutaneous radiofrequency ablation for hepatocellular carcinoma.

text: AIM Accurate assessment of the coagulated area is imperative to achieve an excellent outcome from percutaneous radiofrequency ablation (PRFA) for the treatment of hepatocellular carcinoma (HCC). We evaluated the efficacy of contrast-enhanced ultrasonography (CEUS) with the contrast-enhancing agent Sonazoid for precisely assessing the therapeutic effect of PRFA for HCC. METHODS We enrolled 87 consecutive patients with solitary naïve HCC of less than 3 cm in diameter. PRFA treatment was performed with a 17-G cool-tip needle, and CEUS was performed to assess the ablative margin 3 h after the procedure, when the coagulated tumor outline was easiest to discern. The treatment was repeated until an ablative margin greater than 5 mm was confirmed. After CEUS assessment of the therapeutic response, the patients were followed to investigate local tumor recurrence. RESULTS In 78 patients (89.7%), the outline of the coagulated tumors could be recognized by ultrasonography, and CEUS assessment of the ablative margin was successful. The remaining nine patients were assessed by computed tomography. The 5-year cumulative survival rate after the assessment of the treatment response with CEUS was 58.4%, and the 4-year cumulative total recurrence rate was 72.3%. The 5-year cumulative local tumor recurrence rate was very low (2.3%). CONCLUSION The assessment with CEUS at 3 h after the PRFA procedure was successful in the majority of the patients, and it yielded a very low rate of local recurrence.


title: Matrix metalloproteinase 12 silencing: a therapeutic approach to treat pathological lung tissue remodeling?

text: Among the large matrix metalloproteinases (MMPs) family, MMP-12, also referred to as macrophage elastase, plays a significant role in chronic pulmonary pathologies characterized by an intense tissue remodeling such as asthma and COPD. This review will summarize knowledge about MMP-12 structure, functions and mechanisms of activation and regulation, including potential MMP-12 modulation by microRNA. As MMP-12 is involved in many tissue remodeling diseases, efforts have been made to develop specific synthetic inhibitors. However, at this time, very few chemical inhibitors have proved to be efficient and specific to a particular MMP. The relevance of silencing MMP-12 by RNA interference is highlighted. The specificity of this approach using siRNA or shRNA and the strategies to deliver these molecules in the lung are discussed.


title: High-Resolution Scanning Fiber Angioscopy as an Adjuvant to Fluoroscopy During Endovascular Interventions.

text: PURPOSE To demonstrate the feasibility and potential utility of high-resolution angioscopy during common endovascular interventions. METHODS A 3.7-F scanning fiber angioscope was used in 6 Yorkshire pigs to image branch vessel selection, subintimal dissection, wire snaring, and stent placement. The angioscope was introduced in a coaxial fashion within a standard 6-F guide catheter. A clear field of view was provided using continuous heparinized saline flush through the outer guide catheter. The flush flow rate was manually adjusted to provide clear imaging depending on the diameter of the vessel and local blood flow conditions. RESULTS The scanning fiber angioscope was compatible with off-the-shelf catheters and devices commonly used in peripheral and aortic interventions. Video-rate, high-resolution images were obtained during all the interventions tested and provided information that was complementary to simultaneously acquired fluoroscopy. The scanning fiber angioscope was able to detect subintimal dissection and branch vessel stent coverage with higher resolution than fluoroscopy alone. CONCLUSION Endoluminal imaging with the scanning fiber angioscope is feasible with current endovascular devices and provides additional relevant information that cannot be assessed fluoroscopically. The scanning fiber angioscope represents a novel optical platform on which new endovascular techniques may be developed that will minimize radiation and contrast doses for patients.


title: Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair.

text: PURPOSE Recent meta-analyses have shown reduced re-rupture rates for the surgical management of Achilles ruptures. However, percutaneous repair has been demonstrated to lead to improved function and patient satisfaction but greater complications than open repair. In the current economic climate, it is reasonable to consider the financial cost of rupture management for both the patient and the provider. The cost-effectiveness of operative treatment of ruptures of the Achilles tendon was determined based upon theatre occupancy, clinic attendance and cast changes, operative complications and functional assessment score. METHODS The cost-effectiveness of the surgical management of Achilles tendon ruptures between 2005 and 2011 in our unit was audited by comparing 49 patients receiving percutaneous repair to 35 patients whom had open repairs. RESULTS There was no significant difference in complications between the two surgical techniques: (Open vs. Percutaneous) overall rates 14.3 versus 10.4 %: infection; 2.7 versus 2.0 %, transient sural nerve damage: 5.6 versus 8.1 %, wound breakdown: 2.8 versus 0.0 %, re-rupture: 2.8 versus 2.0 %. Achilles Total Rupture Scores (ATRS) were comparable [Open 89 (65-100) at 49 months vs. Percutaneous 88.8 (33-100) at 12 months (n.s.)]. Theatre occupancy (P < 0.00) and hospital stay (P < 0.00) were significantly longer with open repair [43 min (26-70) and 2.9 days (0-4)] compared to percutaneous repair [15 min (12-43) and 1.2 days (0-2)]. Excluding the costs of running the operating theatre, we have estimated the costs of surgery for open repair to be £ 935 and percutaneous repair to be £ 574. CONCLUSIONS This study suggests that percutaneous repair of the Achilles tendon resulted in reduced costs and yet had comparable outcome and complications rates to open repair in surgical management of the Achilles tendon. Percutaneous repair should be considered as the primary method of cost-effective surgical management of Achilles tendon rupture.


title: Utilization of Emergent Neuroimaging for Thrombolysis-Eligible Stroke Patients.

text: BACKGROUND Advances in diagnostic imaging of stroke include multimodal techniques such as noninvasive angiography and perfusion imaging. We aimed to characterize trends in neuroimaging utilization among acute stroke patients. Utilization of multimodal imaging for acute stroke in the community has remained largely uncharacterized despite its increased adoption at academic medical centers. METHODS We quantified neuroimaging utilization in the emergency department (ED) for 1,700 hyperacute stroke patients presenting <2 hours after symptom onset who participated in the National Institutes of Health Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study throughout Los Angeles and Orange Counties. FAST-MAG provided no recommendation as to imaging utilization. RESULTS A total of 1,700 cases were imaged a median (interquartile range [IQR]) of 92 (74-120) minutes after last known well time and 28 (19-41) minutes after ED arrival. The initial scanner used in the ED was computed tomography (CT) in a preponderance of cases (N = 1,612, 95%), with magnetic resonance imaging (MRI) in 88 cases (5%). CT angiography (CTA) was obtained in 192 (11%) and perfusion CT (CTP) in 91 (5.4%) cases. MRI imaging was universally obtained using diffusion-weighted images, 60% with MR angiography and 33% included perfusion imaging. Rates of concomitant CTA or CTP use increased in the later years of the study from 4% in 2005-2006, 2% in 2007-2008, 8% in 2009-2010, and 26% in 2011-2012 (P for trend < .001). CONCLUSIONS Among acute stroke patients, noncontrast CT was the most common initial imaging strategy in clinical practice in the 2005-2012 time period, though use of concomitant CTA grew to one-quarter of cases, suggestive of an upward trend.


title: Comparing the efficacy and safety of direct oral anticoagulants with vitamin K antagonist in cerebral venous thrombosis.

text: Cerebral venous thrombosis (CVT) causes significant disability and mortality. Current guidelines for CVT management support the initial use of unfractionated heparin or low molecular weight heparin followed by longer-term oral vitamin K antagonist (VKA). There has been increasing, albeit limited, evidence for the use of direct oral anticoagulants (DOAC) as an alternative to VKA. We performed a systematic review and meta-analysis of studies that compared the safety and efficacy of DOACs to VKA in treating CVT. A comprehensive literature search was carried out in Medline, Embase and Cochrane Stroke Group Trials Register using a suitable keyword/MeSH term search strategy. All studies published in English comparing outcomes of patients with CVT treated with DOAC or VKA were included. In total, 6 studies (5 observational studies and 1 randomized clinical trial) comprising 412 patients (age range 16-83 years) were analyzed. DOAC was used in 151 patients, while 261 received VKA. The follow-up period was 3-11 months. The efficacy of DOACs was comparable with VKA in terms of partial or full thrombus recanalization (RR 1.02, 95% CI 0.89-1.16) and excellent functional recovery with modified Rankin scale < 2 (RR 1.02, 95% CI 0.93-1.13). Patients treated with DOAC developed lower major bleeding events when compared to VKA, although this did not reach statistical significance (RR 0.44, 95% CI 0.12-1.59). We provide preliminary evidence to support DOAC as effective and safe alternatives to VKA in CVT treatment. We await the results of upcoming randomized trials to further support our results and validate the use of DOAC.


title: Severe chronic bronchitis in advanced emphysema increases mortality and hospitalizations.

text: BACKGROUND Chronic bronchitis in COPD has been associated with an increased exacerbation rate, more hospitalizations, and an accelerated decline in lung function. The clinical characteristics of patients with advanced emphysema and chronic bronchitis have not been well described. METHODS Patients randomized to medical therapy in the National Emphysema Treatment Trial were grouped based on their reports of cough and phlegm on the St. George's Respiratory Questionnaire(SGRQ) at baseline: chronic bronchitis(CB+) and no chronic bronchitis(CB-). The patients were similarly categorized into severe chronic bronchitis(SCB+) or no severe chronic bronchitis (SCB-) based on the above definition plus report of chest trouble. Kaplan-Meier survival analysis was used to determine the relationships between chronic bronchitis and severe chronic bronchitis and survival and time to hospitalization. Lung function and SGRQ scores over time were compared between groups. RESULTS The CB+(N = 234; 38%) and CB- groups(N = 376; 62%) had similar survival (median 60.8 versus 65.7 months, p = 0.19) and time to hospitalization (median 26.9 versus 24.9 months, p = 0.84). The SCB+ group(N = 74; 12%) had worse survival (median 47.7 versus 65.7 months, p = 0.02) and shorter time to hospitalization (median 18.5 versus 26.7 months, p = 0.02) than the SCB- group (N = 536; 88%). Mortality and hospitalization rates were not increased when chest trouble was analyzed by itself. The CB+ and CB-groups had similar lung function and SGRQ scores over time. The SCB+ and SCB-groups had similar lung function over time, but the SCB+ group had significantly worse SGRQ scores. CONCLUSIONS Severe chronic bronchitis is associated with worse survival, shorter time to hospitalization, and worse health-related quality of life.


Emerging Roles of Inflammasomes in Acute Pneumonia.


title: Hormonal Contraceptives and the Acquisition of Sexually Transmitted Infections: An Updated Systematic Review.

text: BACKGROUND Evidence suggests that some forms of hormonal contraception (HC) increase women's risk of non-human immunodeficiency virus sexually transmitted infections (STIs), yet evidence has not been reviewed since 2008. We conducted an updated systematic review to incorporate studies published between January 2009 and June 2017 to examine the relationship between HCs and incident or recurrent STIs. METHODS We searched PubMed and EMBASE to identify prospective studies comparing risk of Chlamydia trachomatis, Neisseria gonorrhoeae, human papillomavirus (HPV), herpes simplex virus type 2 (HSV-2), Treponema pallidum, or Trichomonas vaginalis, between women using HC versus nonhormonal methods or no methods. We summarize results by type of STI and HC and study quality using an adapted Newcastle-Ottawa Quality Assessment Scale. RESULTS Thirty articles met the inclusion criteria. Depo-medroxyprogesterone acetate (DMPA) reduces the risk of trichomoniasis (consistent evidence) and may increase the risk of HSV-2 (strong effect, few studies); inconclusive evidence exists for HPV, chlamydia, gonorrhea, and syphilis. Data on oral contraceptive pills (OCPs; generally not differentiated whether combined or progestin-only pills) suggest that use is associated with a reduced risk of trichomoniasis with inconclusive findings for HSV-2, HPV, chlamydia, gonorrhea, and syphilis. Very few studies included norethisterone enanthate (Net-En) injectable, implants or the levonorgestrel intrauterine device. CONCLUSIONS Depo-medroxyprogesterone acetate and OCPs reduce the risk of trichomoniasis and DMPA may increase the risk of HSV-2. However, the potential for confounding cannot be ruled out. Future studies should specify the type of injectable or OCP used to increase understanding of biological pathways; more research is needed on implants and hormonal intrauterine devices.


title: Drosophila Nora virus capsid proteins differ from those of other picorna-like viruses.

text: The recently discovered Nora virus from Drosophila melanogaster is a single-stranded RNA virus. Its published genomic sequence encodes a typical picorna-like cassette of replicative enzymes, but no capsid proteins similar to those in other picorna-like viruses. We have now done additional sequencing at the termini of the viral genome, extending it by 455 nucleotides at the 5' end, but no more coding sequence was found. The completeness of the final 12,333-nucleotide sequence was verified by the production of infectious virus from the cloned genome. To identify the capsid proteins, we purified Nora virus particles and analyzed their proteins by mass spectrometry. Our results show that the capsid is built from three major proteins, VP4A, B and C, encoded in the fourth open reading frame of the viral genome. The viral particles also contain traces of a protein from the third open reading frame, VP3. VP4A and B are not closely related to other picorna-like virus capsid proteins in sequence, but may form similar jelly roll folds. VP4C differs from the others and is predicted to have an essentially α-helical conformation. In a related virus, identified from EST database sequences from Nasonia parasitoid wasps, VP4C is encoded in a separate open reading frame, separated from VP4A and B by a frame-shift. This opens a possibility that VP4C is produced in non-equimolar quantities. Altogether, our results suggest that the Nora virus capsid has a different protein organization compared to the order Picornavirales.


title: The Future of Robotic Surgery in Pediatric Urology: Upcoming Technology and Evolution Within the Field.

text: Since the introduction of the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) in 1999, the market for robot assisted laparoscopic surgery has grown with urology. The initial surgical advantage seen in adults was for robotic prostatectomy, and over time this expanded to the pediatric population with robotic pyeloplasty. The introduction of three-dimensional visualization, tremor elimination, a 4th arm, and 7-degree range of motion allowed a significant operator advantage over laparoscopy, especially for anastomotic suturing. After starting with pyeloplasty, the use of robotic technology with pediatric urology has expanded to include ureteral reimplantation and even more complex reconstructive procedures, such as enterocystoplasty, appendicovesicostomy, and bladder neck reconstruction. However, limitations of the Da Vinci Surgical Systems still exist despite its continued technological advances over multiple generations in the past 20 years. Due to the smaller pediatric market, less focus appears to have been placed on the development of the smaller 5 mm instruments. As pediatric urology continues to utilize robotic technology for minimally invasive surgery, there is hope that additional pediatric-friendly instruments and components will be developed, either by Intuitive Surgical or one of the new robotic platforms in development that are working to address many of the shortcomings of current systems. These new robotic platforms include improved haptic feedback systems, flexible scopes, easier maneuverability, and even adaptive machine learning concepts to bring robotic assisted laparoscopic surgery to the next level. In this report, we review the present and upcoming technological advances of the current Da Vinci surgical systems as well as various new robotic platforms, each offering a unique set of technological advantages. As technology progresses, the understanding of and access to these new robotic platforms will help guide pediatric urologists into the next forefront of minimally invasive surgery.


An Ulcer Base Rhythmically Pulsating With Cardiac Contractions: A Manifestation of Gastrocardiac Fistula.


title: Combination of general anesthesia and peripheral nerve block with low-dose ropivacaine reduces postoperative pain for several days after outpatient arthroscopy: A randomized controlled clinical trial.

text: BACKGROUND Effective methods for postoperative pain relief are an important concern in outpatient surgery. For arthroscopies we combine a single-shot peripheral nerve block using low-volume, low-concentration ropivacaine with general anesthesia. We hypothesized that the patients would have less postoperative pain and be more rapidly home ready than after general anesthesia alone. METHODS Patients (American Society of Anesthesiologists I-III, 18-80 years old) scheduled for outpatient arthroscopy on the upper or lower extremity were randomized to have either a combination of peripheral nerve block and general anesthesia (NB + GA, study group) or general anesthesia alone (GA, control group). The relevant nerve was localized by ultrasound and 10 mL ropivacaine 0.2% was injected. General anesthesia was with propofol and remifentanil. Numeric rating scales were used to assess pain and patient satisfaction in the recovery room, on the evening of surgery, and on the following 2 days. RESULTS A total of 120 patients participated in the study (NB + GA: 61; GA: 59). The percentage of patients reporting relevant pain in the recovery room were 0% versus 44% (P < 0.001), on the evening after surgery 3% versus 80% (P < 0.001), and on days 1 and 2 postsurgery 12% versus 73% and 12% versus 64% (NB + GA vs GA, respectively). Median time to home discharge was NB + GA 34.5 min (range 15-90) versus GA 55 min (20-115) (P < 0.001). CONCLUSIONS The combination of a peripheral nerve block with low-dose ropivacaine and general anesthesia reduced postoperative pain compared with general anesthesia alone for several days after outpatient arthroscopy. It also shortened the time to home discharge.


Quality indicators for ERCP.


Role of the pharmacist during the COVID-19 pandemic: a time to rethink strategies.


title: Resolution of bilateral moyamoya associated collateral vessel aneurysms: Rationale for endovascular versus surgical intervention.

text: BACKGROUND Management of aneurysms associated with deep collateral vessels in moyamoya disease is challenging both from an endovascular and a surgical standpoint. Difficulties with access or localization, and compromise of the collateral circulation with subsequent ischemia are the primary concerns, making direct obliteration potentially unfeasible or risky. Alternatively, superficial temporal artery-middle cerebral artery bypass is another potential strategy for resolution of these aneurysms. CASE DESCRIPTION Presented are the findings and management for a patient with moyamoya disease and bilateral deep collateral vessel aneurysms, successfully treated with endovascular obliteration following a right-sided hemorrhage and subsequently with bypass for an unruptured but growing contralateral aneurysm. CONCLUSIONS A rationale and approach to management is outlined, as derived from review of the current literature and the illustrative case with bilateral collateral vessel aneurysms.


title: Circulating Apolipoprotein A-IV presurgical levels are associated with improvement in insulin sensitivity after Roux-en-Y gastric bypass surgery.

text: BACKGROUND Apolipoprotein A-IV (ApoA-IV) has been shown to be involved in obesity and diabetes pathogenesis in animal studies, but its role in humans is uncertain. OBJECTIVES The objective of this study was to determine the relation of ApoA-IV with changes in glucose metabolism and weight after bariatric surgery. SETTING University Hospital. METHODS The patients (n = 49) included lean controls (n = 8) and patients before and after a mean of 7 months after laparoscopic adjustable gastric banding (LAGB, n = 12), laparoscopic Roux-en-Y gastric bypass (RYGB, n = 22), or laparoscopic sleeve gastrectomy (SG, n = 11). ApoA-IV and other hormone assays were performed in the fasting and the postprandial state. Pearson's correlation analyses controlled for baseline BMI and percent excess weight loss (EWL) were used to determine relationships between ApoA-IV levels and insulin resistance (HOMA-IR). RESULTS With all bariatric procedures combined, the change in ApoA-IV [533 versus 518 microg/L, P = .813] or ApoA-IV area under the curve (AUC - 1072 versus 1042, P = .939) was not significant. None of the surgeries individually affected levels of fasting or ApoA-IV AUC. Bariatric surgery resulted in a decrease in HOMA-IR (5.3 versus 2.0, P<.001). In the RYGB group, higher baseline ApoA-IV levels correlated with decrease in HOMA-IR [r = -.6, P = .008]. This relationship was independent of EWL and was not observed in the LAGB or SG group. There was no association of ApoA-IV levels with EWL, insulin secretion, Peptide-YY, or leptin levels. CONCLUSION Preoperative ApoA-IV levels, rather than changes in levels, positively correlate with improvements in insulin sensitivity independent of weight loss after RYGB.


title: Maximizing Safety in the Conduct of Alzheimer's Disease Fluid Biomarker Research in the Era of COVID-19.

text: The Corona virus disease 2019 (COVID-19) pandemic led to an abrupt halt of many Alzheimer's disease (AD) research studies at sites spanning the world. This is especially true for studies requiring in-person contact, such as studies collecting biofluids. Since COVID-19 is likely to remain a threat for an extended period, the resumption of fluid biomarker studies requires the development and implementation of procedures that minimize the risk of in-person visits to participants, staff, and individuals handling the biofluid samples. Some issues to consider include structuring the visit workflow to minimize contacts and promote social distancing; screening and/or testing participants and staff for COVID-19; wearing masks and performing hand hygiene; and precautions for handling, storing, and analyzing biofluids. AD fluid biomarker research remains a vitally important public health priority and resuming studies requires appropriate safety procedures to protect research participants and staff.


title: Direct innominate artery cannulation: An alternate technique for antegrade cerebral perfusion during aortic hemiarch reconstruction.

text: OBJECTIVE We describe an alternate technique for establishing antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest via direct, central cannulation of the innominate artery. METHODS From 2009 to 2015, 100 elective hemiarch reconstructions for proximal aortic aneurysms were performed under moderate hypothermic circulatory arrest (MHCA). Cerebral perfusion was instituted with ACP via direct cannulation of the innominate artery. RESULTS Mean patient age was 63 ± 13 years (72 men; 72%). Mean MHCA temperature was 27.3°C ± 1.0°C (median, 28°C). Mean ACP time was 17 ± 4 minutes and mean crossclamp time was 134 ± 42 minutes. Proximal reconstruction included root replacement with composite valved graft (n = 47), valve sparing root reimplantation (n = 16), and aortic valve replacement (n = 19). In-hospital 30-day mortality (n = 1; 1%), stroke (1; 1%), reversible ischemic neurologic deficit (n = 1; 1%), coma (n = 0), and renal failure (n = 1; 1%) rates were low. There was no incidence of injury or dissection of the innominate artery. CONCLUSIONS Direct, central innominate artery cannulation for ACP yields excellent outcomes. This technique is safe, provides excellent cerebral protection during circulatory arrest and simplifies the circulatory management strategy for elective ascending aortic and hemiarch reconstruction.


title: A lesson learned from Middle East respiratory syndrome (MERS) in Saudi Arabia.

text: Middle East respiratory syndrome (MERS) caused by novel Corona virus hit Kingdom of Saudi Arabia (KSA) and resulted in hundreds of mortality and morbidity, fears and psychosocial stress among population, economic loss and major political change at Ministry of Health (MoH). Although MERS discovered two years ago, confusion still exists about its origin, nature, and consequences. In 2003, similar virus (SARS) hit Canada and resulted in a reform of Canada's public health system and creation of a Canadian Agency for Public Health, similar to the US Centers for Disease Control (CDC). The idea of Saudi CDC is attractive and even "sexy" but it is not the best option. Experience and literature indicate that the best option for KSA is to revitalize national public health systems on the basis of comprehensive, continuing, and integrated primary health care (PHC) and public health (PH). This article proposes three initial, but essential, steps for such revitalization to take place: political will and support, integration of PHC and PH, and on-job professional programs for the workforce. In addition, current academic and training programs for PHC and PH should be revisited in the light of national vision and strategy that aim for high quality products that protect and promote healthy nation. Scientific associations, medical education research chair, and relevant academic bodies should be involved in the revitalization to ensure quality of process and outcomes.


title: Robotic single-site hysterectomy in low risk endometrial cancer: a pilot study.

text: BACKGROUND To evaluate the feasibility and the safety of robotic single-site hysterectomy (RSSH) in low risk early endometrial cancer. METHODS Patients with clinical low risk early endometrial cancer were enrolled onto a prospective cohort trial. All surgical procedures were performed through a single 2-2.5 cm umbilical incision, with a multichannel system consisting of a five-lumen port providing access for two single-site instruments (da Vinci Si Surgical System, Intuitive Surgical, Sunnyvale, CA), the 8.5 mm 3D HD endoscope, a 5/10 mm accessory port, and an insufflation adaptor. RESULTS Between December 2011 and June 2012, a total of 17 patients were included in our pilot study. The median age of the patients was 64 years (range, 42-84 years), and median body mass index was 26.6 kg/m(2) (range, 18-52 kg/m(2)). One patient was excluded from the study as a result of pelvic metastasis during inspection of abdominal cavity, and another patient was converted to vaginal surgery as a result of problems of hypercapnia. The median docking time, console time, and total operative time was 8 min (range, 5-14 min), 48 min (range, 45-51 min), and 90 min (range, 70-147 min), respectively. The median blood loss was 75 mL (range, 50-150 mL). No laparoscopy/laparotomy conversion was registered. The median time to discharge was 2 days (range, 1-3 days). Neither intraoperative nor postoperative complications occurred. At a median of 7.5 months' follow-up, all patients were disease-free. CONCLUSIONS RSSH is technically feasible in patients affected by low risk early endometrial cancer. Additional studies with gynecologic oncologic cases should be performed to explore the possible benefits of RSSH.


title: Comparison between iloprost and alprostadil for protection against ischemia/reperfusion injury in a rat model

text: Background/aim: Alprostadil and iloprost are successful agents used for both pulmonary hypertension and extremity ischemia treatment. Different systemic effects of these agents may change the preferences of clinical usage. Superiority of preventing ischemia/ reperfusion (IR) injury is a criterion for clinical preference of these agents. The present study was designed to compare the protective effects of alprostadil and iloprost in a rat model of IR injury. Materials and methods: Twenty-three male Sprague Dawley rats were used (aged 8-12 weeks, mean weight 230 ± 30 g). They were randomized into 4 groups: Group 1 (iloprost + IR), Group 2 (alprostadil + IR), Group 3 (saline + IR), and Group 4 (control). Under general anesthesia, in all groups except Group 4, the abdominal region was explored and the abdominal aorta was temporarily clamped for 60 min. After the clamp was removed, 120 min of reperfusion was applied. In Group 4, the rats were placed under general anesthesia and abdominal exploration was performed without the IR procedure. For all rats, body temperature was kept at 36 °C with a heater pad through the whole procedure. The rats were euthanized under general anesthesia to remove the kidneys and lungs for study. Histopathological and biochemical analyses were conducted with kidney and lung tissues. Histopathological scoring was done by analyzing cellular damage at tissue level. Malondialdehyde (MDA), superoxide dismutase, and glutathione levels were studied for biochemical analysis. Results: Histopathologic analysis showed that, as compared with alprostadil, iloprost provided a significantly higher level of renal protection against IR injury (P < 0.01). Renal tissue levels of MDA were significantly lower in the alprostadil group as compared to Group 3 (P < 0.05). Conclusion: Alprostadil and iloprost seem to provide protection against IR injury, with iloprost being more protective in renal tissue. Alprostadil is more effective than iloprost in protecting lung tissue against IR injury.


Protecting Our Front Line.


title: Reducing the spread of occult uterine sarcoma at the time of minimally invasive gynecologic surgery.

text: PURPOSE This review covers the most recent evidence to discuss the incidence of occult uterine sarcoma, whether morcellation increases tumor dissemination or mortality, and whether there is a difference between different types of morcellation. We will also discuss techniques to reduce the spread of an undiagnosed uterine sarcoma. METHOD A comprehensive literature search was made in Pubmed, Medline, the Cochrane Library, and Google Scholar for articles related to the incidence of occult uterine sarcoma after morcellation. RESULTS Fibroids are benign uterine tumors and are a common indication for gynecologic surgery. Increasingly, gynecologists are approaching these surgeries with minimally invasive techniques. Uterine sarcomas are rare malignant mesenchymal tumors that are difficult to distinguish preoperatively from uterine fibroids. CONCLUSION During a minimally invasive surgery, there is a risk of disseminating an occult sarcoma during tissue extraction. Minimally invasive gynecologists are tasked with balancing taking a minimally invasive approach, which is shown to result in better patient outcomes, with minimizing the risk of spreading an occult sarcoma.


docid: czlpdpkh

title: Burnout Disrupts Anxiety Buffer Functioning Among Nurses: A Three-Way Interaction Model.

text: Over the last 40 years, job burnout has attracted a great deal of attention among researchers and practitioners and, after decades of research and interventions, it is still regarded as an important issue. With the aim of extending the Anxiety Buffer Disruption Theory (ABDT), in this paper we argue that high levels of burnout may disrupt the anxiety buffer functioning that protects people from death concerns. ABDT was developed from Terror Management Theory (TMT). According to TMT, reminders of one's mortality are an essential part of humans' daily experience and have the potential to awake paralyzing fear and anxiety. In order to cope with death concerns, people typically activate an anxiety-buffering system centered on their cultural worldview and self-esteem. Recent ABDT research shows that individuals with post-traumatic stress disorder are unable to activate such anxiety buffering defenses. In line with these results, we hypothesized that the burnout syndrome may have similar effects, and that individuals with higher levels of burnout will be less likely to activate an anxiety buffering response when their mortality is made salient. Participants were 418 nurses, who completed a questionnaire including: a mortality salience (MS) manipulation, a delay manipulation, and measures of burnout, work-related self-efficacy, and representation of oneself as a valuable caregiver. Nurses are daily exposed both to the risk of burnout and to mortality reminders, and thus constituted an ideal population for this study. In line with an anxiety buffer disruption hypothesis, we found a significant three-way interaction between burnout, MS and delay. Participants with lower levels of burnout reported higher levels of self-efficacy and a more positive representation as caregivers in the MS condition compared to the control condition, when there was a delay between MS manipulation and the assessment of the dependent measures. The difference was non-significant for participants with higher levels of burnout. Theoretical and practical implications of findings are discussed.


title: Epidemic and pandemic viral infections: impact on tuberculosis and the lung. A consensus by the World Association for Infectious Diseases and Immunological Disorders (WAidid), Global Tuberculosis Network (GTN) and members# of ESCMID Study Group for Mycobacterial Infections (ESGMYC).

text: Major epidemics including some that qualify as pandemics, such as Severe Acute Respiratory Syndrome (SARS), Middle-Eastern Respiratory Syndrome (MERS), Human Immunodeficiency Virus, pandemic H1N1/09 and most recently COVID-19 affect the lung. Tuberculosis (TB) remains the top infectious disease killer but apart from the TB-HIV syndemic, little is known regarding the interaction of viral epidemics and pandemics with TB. The aim of this consensus-based document is to describe the effects of the viral infections resulting in epidemics and pandemics that affect the lung (MERS, SARS, HIV, influenza A (H1N1)pdm/09 and COVID-19) and their interactions with TB. A search of the scientific literature was performed. A writing committee of international experts including the European Centre for Disease Prevention and Control Public Health Emergency (ECDC PHE) team, the World Association for Infectious Diseases and Immunological Disorders (WAidid), the Global Tuberculosis Network (GTN) and members of ESCMID Study Group for Mycobacterial Infections (ESGMYC) was established. Consensus was achieved after multiple rounds of revisions between the writing committee and a larger expert group. A Delphi process involving the core group of authors, excluding the ECDC PHE team identified the areas requiring review/consensus, followed by a second round to refine the definitive consensus elements. The epidemiology, immunology of these viral infections and their interactions with TB are discussed with implications on diagnosis, treatment and prevention of airborne infections (infection control, viral containment and workplace safety). This consensus document represents a rapid and comprehensive summary on what is known on the topic.


docid: uhgrfdxb

title: Donor and Transplant Candidate Selection for Solid Organ Transplantation during the COVID-19 Pandemic.

text: SARS-CoV-2, a novel coronavirus responsible for a worldwide pandemic has forced drastic changes in medical practice in an alarmingly short period of time. Caregivers must modify their strategies as well as optimize the utilization of resources to ensure public and patient safety. For organ transplantation, in particular, the loss of life-saving organs for transplantation could lead to increased waitlist mortality. The priority is to select uninfected donors to transplant uninfected recipients while maintaining safety for healthcare systems in the backdrop of a virulent pandemic. We do not yet have a standard approach to evaluating donors and recipients with possible SARS-CoV-2 infection. Our current communication shares a protocol for donor and transplant recipient selection during the COVID-19 pandemic to continue life-saving solid organ transplantation for heart, lung, liver and kidney recipients. The initial results using this protocol are presented here and meant to encourage dialogue between providers, offering ideas to improve safety in solid organ transplantation with limited health care resources. This protocol was created utilizing the guidelines of various organizations and from the clinical experience of the authors and will continue to evolve as more is understood about SARS-CoV-2 and how it affects organ donors and transplant recipients.


title: The effect of transcutaneous spinal direct current stimulation on corticospinal excitability in chronic incomplete spinal cord injury.

text: OBJECTIVES This study investigated the feasibility of modulating bilateral corticospinal excitability with different polarities of transcutaneous spinal direct current stimulation (tsDCS) in chronic, incomplete spinal cord injury (SCI). METHODS Six subjects with chronic incomplete SCI (>12 months post injury) participated in this crossover study. Intervention consisted of 3 sessions, separated by at least 1 week, in which each subject received the conditions cathodal, anodal, and sham tsDCS. Stimulation was delivered at 2.5 mA for 20 minutes with the active electrode positioned over the spinous processes of T10-T11 and the reference electrode over left deltoid. To measure the effects of tsDCS on corticospinal excitability, motor evoked potentials (MEPs) from transcranial magnetic stimulation were measured bilaterally from soleus before and after tsDCS. RESULTS Five subjects completed all 3 sessions. One subject withdrew after 2 sessions due to complications unrelated to the study. MEPs were measurable in 5 subjects. No significant differences in change of MEP amplitudes were found between the 3 conditions. However, there were trends that indicated laterality of response, particularly with cathodal tsDCS increasing corticospinal excitability contralateral to the reference electrode and decreasing corticospinal excitability ipsilateral to the reference electrode. CONCLUSION Corticospinal excitability may be modulated with laterality by tsDCS in individuals with chronic, incomplete SCI. Further research is needed to 1) determine whether different placement of the reference electrode can lead to uniform modulation bilaterally, and 2) reveal whether these alterations in corticospinal excitability can lead to improved movement function in individuals with chronic, incomplete SCI.


title: Robotic surgery for rectal cancer: initial experience from 30 consecutive patients.

text: BACKGROUND Robotic surgery offers 3D visualization and the advantage of the usage of multi-articulated instruments with superior dexterity. Theoretically, it can overcome many limitations of laparoscopic rectal surgery in the narrow pelvis. MATERIALS AND METHODS Between January 2010 and January 2011, the patients who underwent robotic rectal resection for cancer were retrospectively evaluated in terms of demographics, operative data, complications, the duration of hospital stay, and histopathological data. RESULTS Thirty consecutive patients made up of 13 female and 17 male patients underwent robotic rectal resection. Sphincter-saving mesorectal excision was performed in 27 patients. Of these, there were 19 total and 8 partial mesorectal excisions. The mean operative time was 270 min (175-480 min). The median postoperative hospital stay was 4 days (4-20 days). No operation was converted. The complication rate was 13.3%. One patient died due to colonic necrosis caused by Drummond artery deficiency (3.3%). The median number of harvested lymph nodes was 15 (3-38), and the distal resection margin was 4 cm (2-8). Histopathological evaluation revealed that the mesorectum resection was complete in all patients. CONCLUSION Robotic rectal surgery (hybrid or totally robotic) is a safe and feasible procedure when performed by experienced laparoscopic surgeons.


title: Maternal and neonatal data collection systems in low- and middle-income countries: scoping review protocol.

text: Background: Pregnant women and neonates represent one of the most vulnerable groups, especially in low- and middle-income countries (LMICs). A recent analysis reported that most vaccine pharmacovigilance systems in LMICs consist of spontaneous (passive) adverse event reporting. Thus, LMICs need effective active surveillance approaches, such as pregnancy registries. We intend to identify currently active maternal and neonatal data collection systems in LMICs, with the potential to inform active safety electronic surveillance for novel vaccines using standardized definitions. Methods: A scoping review will be conducted based on established methodology. Multiple databases of indexed and grey literature will be searched with a specific focus on existing electronic and paper-electronic systems in LMICs that collect continuous, prospective, and individual-level data from antenatal care, delivery, neonatal care (up to 28 days), and postpartum (up to 42 days) at the facility and community level, at the national and district level, and at large hospitals. Also, experts will be contacted to identify unpublished information on relevant data collection systems. General and specific descriptions of Health Information Systems (HIS) extracted from the different sources will be combined and duplicated HIS will be removed, producing a list of unique statements. We will present a final list of Maternal, Newborn, and Child Health systems considered flexible enough to be updated with necessary improvements to detect, assess and respond to safety concerns during the introduction of vaccines and other maternal health interventions. Selected experts will participate in an in-person consultation meeting to select up to three systems to be further explored in situ. Results and knowledge gaps will be synthesized after expert consultation.


title: Immunogenicity and structures of a rationally designed prefusion MERS-CoV spike antigen.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) is a lineage C betacoronavirus that since its emergence in 2012 has caused outbreaks in human populations with case-fatality rates of ∼36%. As in other coronaviruses, the spike (S) glycoprotein of MERS-CoV mediates receptor recognition and membrane fusion and is the primary target of the humoral immune response during infection. Here we use structure-based design to develop a generalizable strategy for retaining coronavirus S proteins in the antigenically optimal prefusion conformation and demonstrate that our engineered immunogen is able to elicit high neutralizing antibody titers against MERS-CoV. We also determined high-resolution structures of the trimeric MERS-CoV S ectodomain in complex with G4, a stem-directed neutralizing antibody. The structures reveal that G4 recognizes a glycosylated loop that is variable among coronaviruses and they define four conformational states of the trimer wherein each receptor-binding domain is either tightly packed at the membrane-distal apex or rotated into a receptor-accessible conformation. Our studies suggest a potential mechanism for fusion initiation through sequential receptor-binding events and provide a foundation for the structure-based design of coronavirus vaccines.


title: Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions.

text: OBJECTIVE Endovascular abdominal aortic repair requires an adequate sealing zone. The chimney graft (CG) technique may be the only option for urgent high-risk patients who are unfit for open repair and have no adequate sealing zone. This single-center experience provides long-term results of CGs with endovascular repair for urgent and complex aortic lesions. METHODS Between July 2006 and October 2012, 51 patients (16 women) with a median age of 77 years (interquartile range, 72-81 years), were treated urgently (within 24 hours [61%]) or semiurgently (within 3 days [39%]) with endovascular aortic repair and visceral CGs (n = 73). Median follow-up was 2.3 years (interquartile range, 0.8-5.0 years) for the whole cohort, 3 years for 30-day survivors, and 4.8 years for patients who are still alive. RESULTS Five patients (10%) died within 30 days. All of them had a sacrificed kidney. All-cause mortality was 57% (n = 29), but the chimney- and procedure-related mortality was 6% (n = 3) and 16% (n = 8), respectively. Chimney-related death was due to bleeding, infection, renal failure, and multiple organ failure. There were two postoperative ruptures; both were fatal although not related to the treated disease. The primary and secondary long-term CG patencies were 89% (65 of 73) and 93% (68 of 73), respectively. Primary type I endoleak (EL-I) occurred in 10% (5 of 51) of the patients, and only one patient had recurrent EL-I (2%; 1 of 51). No secondary endoleak was observed. Chimney-related reintervention was required in 16% (8 of 51) of the patients because of EL-I (n = 3), visceral ischemia (n = 4), and bleeding (n = 2). The reinterventions included stenting (n = 5), embolization (n = 3), and laparotomy (n = 2). Thirty-one visceral branches were sacrificed (9 celiac trunks, 9 right, and 13 left renal arteries). Among the 30-day survivors, 8 of 17 patients (47%) with a sacrificed kidney required permanent dialysis; of these, seven underwent an urgent index operation. The aneurysm sac shrank in 63% (29 of 46) of cases. CONCLUSIONS The 6% chimney-related mortality and 93% long-term patency seem promising in urgent, complex aortic lesions of a high-risk population and may justify a continued yet restrictive applicability of this technique. Most endoleaks could be sealed endovascularly. However, sacrifice of a kidney in this elderly cohort was associated with permanent dialysis in 47% of patients.