title: Re-irradiation after gross total resection of recurrent glioblastoma : Spatial pattern of recurrence and a review of the literature as a basis for target volume definition.

text: BACKGROUND Currently, patients with gross total resection (GTR) of recurrent glioblastoma (rGBM) undergo adjuvant chemotherapy or are followed up until progression. Re-irradiation, as one of the most effective treatments in macroscopic rGBM, is withheld in this situation, as uncertainties about the pattern of re-recurrence, the target volume, and also the efficacy of early re-irradiation after GTR exist. METHODS Imaging and clinical data from 26 consecutive patients with GTR of rGBM were analyzed. The spatial pattern of recurrences was analyzed according to the RANO-HGG criteria ("response assessment in neuro-oncology criteria for high-grade gliomas"). Progression-free (PFS) and overall survival (OS) were analyzed by the Kaplan-Meier method. Furthermore, a systematic review was performed in PubMed. RESULTS All but 4 patients underwent adjuvant chemotherapy after GTR. Progression was diagnosed in 20 of 26 patients and 70% of recurrent tumors occurred adjacent to the resection cavity. The median extension beyond the edge of the resection cavity was 20 mm. Median PFS was 6 months; OS was 12.8 months. We propose a target volume containing the resection cavity and every contrast enhancing lesion as the gross tumor volume (GTV), a spherical margin of 5-10 mm to generate the clinical target volume (CTV), and a margin of 1-3 mm to generate the planning target volume (PTV). Re-irradiation of this volume is deemed to be safe and likely to prolong PFS. CONCLUSION Re-irradiation is worth considering also after GTR, as the volumes that need to be treated are limited and re-irradiation has already proven to be a safe treatment option in general. The strategy of early re-irradiation is currently being tested within the GlioCave/NOA 17/Aro 2016/03 trial.


title: Increased risk of intraoperative awareness in patients with a history of awareness.

text: BACKGROUND Patients with a history of intraoperative awareness with explicit recall (AWR) are hypothesized to be at higher risk for AWR than the general surgical population. In this study, the authors assessed whether patients with a history of AWR (1) are actually at higher risk for AWR; (2) receive different anesthetic management; and (3) are relatively resistant to the hypnotic actions of volatile anesthetics. METHODS Patients with a history of AWR and matched controls from three randomized clinical trials investigating prevention of AWR were compared for relative risk of AWR. Anesthetic management was compared with the use of the Hotelling's T statistic. A linear mixed model, including previously identified covariates, assessed the effects of a history of AWR on the relationship between end-tidal anesthetic concentration and bispectral index. RESULTS The incidence of AWR was 1.7% (4 of 241) in patients with a history of AWR and 0.3% (4 of 1,205) in control patients (relative risk = 5.0; 95% CI, 1.3-19.9). Anesthetic management did not differ between cohorts, but there was a significant effect of a history of AWR on the end-tidal anesthetic concentration versus bispectral index relationship. CONCLUSIONS Surgical patients with a history of AWR are five times more likely to experience AWR than similar patients without a history of AWR. Further consideration should be given to modifying perioperative care and postoperative evaluation of patients with a history of AWR.


title: Rectal mesh exposure after laparoscopic sacrocolpopexy.

text: Herein we report the case of a 68-year-old woman who had rectal bleeding 13 days after laparoscopic sacrocolpopexy. Clinical examination and rectoscopy revealed rectal exposure of the posterior polyester mesh placed during the surgery. Endorectal surgery was performed to remove the exposed mesh and repair the rectal erosion. No further complications occurred during follow-up. Although vaginal erosions are a well-known complication of synthetic implants after surgery to repair pelvic organ prolapse, one must keep in mind the possibility of more uncommon types of mesh exposure.


title: Weight loss and weight regain-5-year follow-up for circular- vs. linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass.

text: BACKGROUND Weight regain (WR) occurs in some patients after laparoscopic Roux-en-Y gastric bypass (LRYGBP). Loss of restriction due to dilation of the gastrojejunostomy (GJS) or the gastric pouch might be the main cause for WR. With different techniques available for the establishment of the GJS, the surgical technique might influence long-term success. METHODS We present a 5-year follow-up for weight loss and WR of a matched-pair study comparing circular stapled (CSA) to linear stapled (LSA) GJS in a series of 150 patients who underwent primary antecolic antegastric LRYGBP. Complete 5-year follow-up was obtained for 79 % of the patients. RESULTS Excess BMI loss (EBL) at 3 months was better with the CSA (p = 0.02) and comparable thereafter. The 5-year %EBL was 67.3 ± 23.2 vs. 73.3 ± 24.3 % (CSA vs. LSA, p = 0.19) WR of > 10 kg from nadir was found in 24 patients (16 %) with higher incidence in CSA than in LSA patients (20 % vs. 12 %). The %WR was comparable for both groups, 16 ± 13 vs. 15 ± 19 % (CSA vs. LSA, p = 0.345). Eleven patients underwent surgical re-intervention for WR by placement of a non-adjustable band (n = 2), adjustable band (n = 7) and conversion to distal gastric bypass (n = 2). CONCLUSIONS CSA and LSA lead to comparable weight loss in this 5-year follow-up. More patients in the CSA group had WR. Weight regain of more than 10 kg was found in one out of seven patients within 5 years postoperatively.


title: The Positive Effects of the Human Amniotic Membrane on the Healing of Staple Line After Sleeve Gastrectomy Applied Long-Evans Rat Model.

text: BACKGROUND The staple line leakage is a dangerous complication of sleeve gastrectomy. Various strategies have been tried to reduce the leakage risk. The amniotic membrane (AmM) is the inner layer of the placental membranes and has anti-inflammatory, anti-fibrosis, and anti-scarring effects, and it also has lower immune characteristics which are another essential characteristic of AmM concerning its utility for grafting. In this study, we aimed to investigate the impact of AmM on the staple line healing process of sleeve gastrectomy model in rats. MATERIALS AND METHODS We used twenty-eight Long-Evans rats in this study. Sleeve gastrectomy was performed with tristapler. Fourteen rats served as controls, AmM was applied staple line of the other fourteen. Fourteen animals were sacrificed (seven from the AmM applied group and the other seven from the control group) on the third postoperative day. And, the other fourteen animals were sacrificed (seven from the AmM applied group and seven from the control group) on the seventh postoperative day. The tissue around the staple line was evaluated microscopically and macroscopically, bursting pressures and hydroxyproline levels were also measured. RESULTS The bursting pressure and hydroxyproline measurements of the AmM applied group was significantly higher on the seventh postoperative day (p = 0.015, p = 0.012) Fibroblast activity and neoangiogenesis of the AmM applied group was also significantly higher on the seventh postoperative day (p = 0.004, p = 0.002). CONCLUSION This study showed that covering of staple line of sleeve gastrectomy model in rats significantly provided higher bursting pressures and increased hydroxyproline levels, fibroblast activity, and neoangiogenesis which may potentially lead a better staple line healing. We think further investigations are needed on this issue.


title: Comparison of robotic and laparoendoscopic single-site surgery systems in a suturing and knot tying task.

text: BACKGROUND Laparoendoscopic single-site (LESS) surgery has been established for various procedures. Shortcomings of LESS surgery include loss of triangulation, instrument collisions, and poor ergonomics, making advanced laparoscopic tasks especially challenging. We compared a LESS system with a robotic single-site surgery platform in performance of a suturing and knot-tying task under clinically simulated conditions. METHODS Each of five volunteer minimally invasive surgeons was tasked with suturing a 5 cm longitudinal enterotomy in porcine small intestine with square knots at either end, using a laparoendoscopic or da Vinci robotic single-site surgery platform, within a 20 min time limit. A saline leak test was then performed. Each surgeon performed the task twice using each system. The time to completion of the task and presence of a leak were noted. Fisher's exact test was used to compare the overall completion rate within the defined time limit, and a Wilcoxon rank test was used to compare the specific times to complete the task. A p value of <0.05 was considered significant. RESULTS All surgeons were able to complete the task on the first try within 20 min using the robot system; 60% of surgeons were able to complete it after two attempts using the LESS surgery system. Time to completion using the robot system was significantly shorter than the time using the standard LESS system (p < 0.0001). There were no leaks after closure with the robot system; the leak rate following the standard LESS system was 90%. CONCLUSIONS Surgeons demonstrated significantly better suturing and knot-tying capabilities using the robot single-site system compared to a standard LESS system. The robotic system has the potential to expand single-site surgery to more complex tasks.


title: Graft dysfunction immediately after reperfusion predicts short-term outcomes in living-donor lobar lung transplantation but not in cadaveric lung transplantation.

text: OBJECTIVES Primary graft dysfunction (PGD) is a major cause of early morbidity and mortality after cadaveric lung transplantation (CLT). This study examined the incidence, time course and predictive value of PGD after living-donor lobar lung transplantation (LDLLT). METHODS We retrospectively investigated 75 patients (42 with LDLLT and 33 with CLT) who underwent lung transplantation from January 2008 to December 2013. Patients were assigned PGD grades at six time points, as defined by the International Society for Heart and Lung Transplantation: immediately after final reperfusion, upon arrival at the intensive care unit (ICU), and 12, 24, 48 and 72 h after ICU admission. RESULTS The incidence of severe (Grade 3) PGD at 48 or 72 h after ICU admission was similar for LDLLT and CLT patients (16.7 vs 12.1%; P = 0.581). The majority of the LDLLT patients having severe PGD first developed PGD immediately after reperfusion, whereas more than half of the CLT patients first developed severe PGD upon ICU arrival or later. In LDLLT patients, severe PGD immediately after reperfusion was significantly associated with fewer ventilator-free days during the first 28 postoperative days [median (interquartile range) of 0 (0-10) vs 21 (13-25) days, P = 0.001], prolonged postoperative ICU stay [median (interquartile range) of 20 (16-27) vs 12 (8-14) days, P = 0.005] and increased hospital mortality (27.3 vs 3.2%, P = 0.02). Severe PGD immediately after reperfusion was not associated with ventilator-free days during the first 28 postoperative days, time to discharge from ICU or hospital, or hospital mortality in CLT patients. CONCLUSIONS Postoperative incidence of severe PGD was not significantly different between LDLLT and CLT patients. In LDLLT patients, the onset of severe PGD tended to be earlier than that in CLT patients. Severe PGD immediately after reperfusion was a significant predictor of postoperative morbidity and mortality in LDLLT patients but not in CLT patients.


title: Pharmacogenetics in pain management: the clinical need.

text: Genetic research heralds a new therapeutic approach to pain management. Increasing literature demonstrates individual genetic vulnerabilities to specific pain types and mechanisms, partially explaining differing responses to similar pain stimuli. Furthermore, analgesics demonstrate great variability among polymorphic genotypes. Family history and genotyping promise to play an important role in future pain therapies. As advances continue in the genetics of pain and analgesia, pharmacotherapy will depend more on an individualized, targeted approach and less on empiricism.


title: Delayed endovascular revascularization in a patient with progressive neurological deterioration from bilateral intracranial vertebral artery occlusions: case report.

text: BACKGROUND AND IMPORTANCE This article describes delayed endovascular revascularization in a patient with clinical and radiographic evidence of posterior circulation hemodynamic failure in the setting of intracranial occlusive lesions. CLINICAL PRESENTATION A 48-year-old man presented with a 6-week history of progressive headache, nausea, and ataxia. Bilateral intracranial vertebral artery occlusions and a left posterior inferior cerebellar artery stroke were diagnosed, and the patient began warfarin therapy. Despite these measures, the patient developed dense lower cranial neuropathies, including severe dysarthria, decreased left-sided hearing acuity, and left facial droop. He presented at this point for endovascular evaluation. The patient underwent successful revascularization with intravascular Wingspan stents (Boston Scientific, Natick, Massachusetts) in a delayed fashion (approximately 6 weeks after his initial stroke presentation). His neurological syndrome stabilized and began to improve slowly. CONCLUSION Patients with arterial occlusion should be evaluated acutely for potential revascularization. In the posterior circulation, clinical progression may supplant physiological imaging in the assessment of hemodynamic collapse. A subpopulation of patients will present with progressive deficits distinct from extracranial manifestations of vertebrobasilar insufficiency; these patients should be considered for delayed revascularization.


title: Lung volume recruitment in a preterm pig model of lung immaturity.

text: A translational preterm pig model analogous to infants born at 28 wk of gestation revealed that continuous positive airway pressure results in limited lung recruitment but does not prevent respiratory distress syndrome, whereas assist-control + volume guarantee (AC+VG) ventilation improves recruitment but can cause injury, highlighting the need for improved ventilation strategies. We determined whether airway pressure release ventilation (APRV) can be used to recruit the immature lungs of preterm pigs without injury. Spontaneously breathing pigs delivered at 89% of term (model for 28-wk infants) were randomized to 24 h of APRV (n = 9) vs. AC+VG with a tidal volume of 5 ml/kg (n = 10). Control pigs (n = 36) were provided with supplemental oxygen by an open mask. Nutrition and fluid support was provided throughout the 24-h period. All pigs supported with APRV and AC+VG survived 24 h, compared with 62% of control pigs. APRV resulted in improved lung volume recruitment compared with AC+VG based on radiographs, lower Pco2 levels (44 ± 2.9 vs. 53 ± 2.7 mmHg, P = 0.009) and lower inspired oxygen fraction requirements (36 ± 6 vs. 44 ± 11%, P < 0.001), and higher oxygenation index (5.1 ± 1.5 vs. 2.9 ± 1.1, P = 0.001). There were no differences between APRV and AC+VG pigs for heart rate, ratio of wet to dry lung mass, proinflammatory cytokines, or histopathological markers of lung injury. Lung protective ventilation with APRV improved recruitment of alveoli of preterm lungs, enhanced development and maintenance of functional residual capacity without injury, and improved clinical outcomes relative to AC+VG. Long-term consequences of lung volume recruitment by using APRV should be evaluated.


title: Where Have All the Fractures Gone? The Epidemiology of Pediatric Fractures During the COVID-19 Pandemic.

text: BACKGROUND During the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of school and organized sports. A resulting change in pediatric fracture epidemiology is expected. This study examines the impact of the COVID-19 pandemic on fracture incidence and characteristics. METHODS This is a retrospective cohort study comparing acute fractures presenting to a single level I pediatric trauma hospital during the COVID-19 pandemic with fractures during a prepandemic period at the same institution. The "pandemic" cohort was gathered from March 15 to April 15, 2020 and compared with a "prepandemic" cohort from the same time window in 2018 and 2019. RESULTS In total, 1745 patients presenting with acute fractures were included. There was a significant decrease in the incidence of fractures presenting to our practice during the pandemic (22.5±9.1/d vs. 9.6±5.1/d, P<0.001). The presenting age for all fractures decreased during the pandemic (7.5±4.3 vs. 9.4±4.4 y, P<0.001) because of decreased fracture burden among adolescents. There were also a decrease in the number of fractures requiring surgery (2.2±1.8/d vs. 0.8±0.8/d, P<0.001). During the pandemic, there was an increase in the proportion of injuries occurring at home (57.8% vs. 32.5%, P<0.001) or on bicycles (18.3% vs. 8.2%, P<0.001), but a decrease in those related to sports (7.2% vs. 26.0%, P<0.001) or playgrounds (5.2% vs. 9.0%, P<0.001). There was no increase in time-to-presentation. Patients with distal radius torus fractures were more likely to receive a velcro splint during the pandemic (44.2% vs. 25.9%, P=0.010). CONCLUSIONS Pediatric fracture volume has decreased 2.5-fold during the COVID-19 pandemic, partially because of cessation of organized sports and decreased playground use. In endemic regions, lower trauma volume may allow redeployment of orthopaedic surgeons and staff to other clinical arenas. Given the rising proportion of bicycling injuries, an emphasis on basic safety precautions could improve public health. An observed increase in the prescription of velcro splints for distal radius fractures highlights an opportunity for simplified patient care during the pandemic. LEVEL OF EVIDENCE Level III.


title: [Management of coronavirus disease 2019 (COVID-19): experiences from imported malaria control in China].

text: Currently, the local transmission of coronavirus disease 2019 (COVID-19) has been effectively contained in China; however, the epidemic situation of this highly infectious disease is more and more serious outside of China. Importation of COVID-19 cases from other countries and territories is therefore becoming a new challenge for the control of COVID-19 in China. Malaria was once widely epidemic in China. Nevertheless, the local transmission of this parasitic disease has been interrupted in China since the launch of the national malaria elimination programme in 2010, and great successes have been achieved in the management of appropriately 3 thousand malaria cases imported from other countries and territories annually. Hereby, the epidemiological characteristics and current epidemic situation of COVID-19 in China were analyzed and compared with malaria. Based on the successful experiences from the management of overseas imported malaria in China, the strategy and countermeasures for COVID-19 control were proposed, so as to provide insights into the response to the importation of COVID-19 from other countries and territories and the consolidation of the control achievements in China.


The mathematical strategy that could transform coronavirus testing.


Universities will never be the same after the coronavirus crisis.


title: Tissue-engineered biological dressing accelerates skin wound healing in mice via formation of provisional connective tissue.

text: Despite recent advances in bioengineered therapies, wound healing remains a serious clinical problem. In acute full-thickness wounds, it is desirable to replace both the damaged dermis and epidermis in a single procedure. This approach requires appropriate properties of tissue-engineered dressings to support simultaneous regenerative processes in the dermis and epidermis while they are temporally separated in the natural wound healing process. In this study, a collagen-based scaffold inhabited by skin cells was employed. Its ability to stimulate the skin repair of full-thickness excisional splinting wounds in a murine model was evaluated in comparison with that of acellular collagen and commercially available gelatin porous sponge Spongostan®. The study showed that cell-based skin equivalent promoted the immediate filling of the wound bed and provided simultaneous reorganization of the dermal component into highly vascularized granulation-like tissue and rapid epithelialization, thus improving the quality of healing. Inflammation was delayed and less pronounced. In contrast, acellular collagen and especially Spongostan® failed to demonstrate similar results. The porous structure of Spongostan® prevented effective long-term epithelialization and impeded the formation of an adequate connective tissue at the wound bed.


title: The effects of blood group types on the risk of COVID-19 infection and its clinical outcome.

text: BACKGROUND COVID-19 (Coronavirus Disease of 2019) is an infectious disease outbreak later on declared as a pandemic, caused by the SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2). It spreads very rapidly and can result in severe acute respiratory failure. The clinical studies have shown that advanced age and chronic diseases increase the risk of infection. However, influence of the blood groups on COVID-19 infection and its outcome remains to be confirmed. The aim of this study is to investigate whether there exists a relationship between the blood groups of the patients and risk of SARS-CoV-2 infection and the clinical outcomes in COVID-19 patients. MATERIAL AND METHOD 186 patients with PCR confirmed diagnosis of COVID-19 were included in this study. Age, gender, blood groups, comorbidities, need for intubation and intensive care unit follow up and mortalities of the patients were analyzed retrospectively. 1881 healthy individuals, who presented to the Hacettepe University Blood Bank served as the controls. RESULTS The most frequently detected blood group was blood group A (57%) amongst the COVID-19 patients. This was followed by the blood group O (24.8%). The blood group types did not affect the clinical outcomes. Blood group A was statistically significantly more frequent among those infected with COVID-19 compared to controls (57% vs 38%, p <0.001; OR: 2.1). On the other hand, the frequency of blood group O was significantly lower in the COVID-19 patients, compared to the control group (24.8% vs 37.2%, p: 0.001; OR: 1.8). CONCLUSIONS The results of the present study suggest that while the blood group A might have a role in increased susceptibility to the COVID-19 infection, the blood group O might be somewhat protective. However, once infected, blood group type does not seem to influence clinical outcome.


title: Outcomes in Patients With Transcatheter Aortic Valve Replacement and Left Main Stenting: The TAVR-LM Registry.

text: BACKGROUND A percutaneous approach with transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI) of the left main coronary artery (LM) is frequently used in high-risk patients with coexisting aortic stenosis and LM disease. Outcomes of TAVR plus LM PCI have not been previously reported. OBJECTIVES The primary objective of the TAVR-LM registry is to evaluate clinical outcomes in patients undergoing TAVR plus LM PCI. METHODS Clinical, echocardiographic, computed tomographic, and angiographic characteristics were retrospectively collected in 204 patients undergoing TAVR plus LM PCI. In total, 128 matched patient pairs were generated by performing 1:1 case-control matching between 167 patients with pre-existing LM stents undergoing TAVR and 1,188 control patients undergoing TAVR without LM revascularization. RESULTS One-year mortality (9.4% vs. 10.2%, p = 0.83) was similar between the TAVR plus LM PCI cohort and matched controls. One-year mortality after TAVR plus LM PCI was not different in patients with unprotected compared with protected LMs (7.8% vs. 8.1%, p = 0.88), those undergoing LM PCI within 3 months compared with those with LM PCI greater than 3 months before TAVR (7.4% vs. 8.6%, p = 0.61), and those with ostial versus nonostial LM stents (10.3% vs. 15.6%, p = 0.20). Unplanned LM PCI performed because of TAVR-related coronary complication, compared with planned LM PCI performed for pre-existing LM disease, resulted in increased 30-day (15.8% vs. 3.4%, p = 0.013) and 1-year (21.1% vs. 8.0%, p = 0.071) mortality. CONCLUSIONS Despite the anatomic proximity of the aortic annulus to the LM, TAVR plus LM PCI is safe and technically feasible, with short- and intermediate-term clinical outcomes comparable with those in patients undergoing TAVR alone. These results suggest that TAVR plus LM PCI is a reasonable option for patients who are at high risk for surgery.


title: Technical and operational modifications required for evolving robotic programs performing anatomic pulmonary resection.

text: The objectives of this study are to review the complicated and often confusing technical changes required when converting from the Si robotic system to the Xi when performing pulmonary lobectomy and segmentectomy. We reviewed a prospective database of a consecutive series of patients who intended to undergo robotic lobectomy or segmentectomy by one surgeon. There were 101 lobectomies and 25 segmentectomies performed on the Si robot in 2015-2016, and 95 lobectomies and 28 segmentectomies in 2016 on the Xi robot. The two groups were similar for age, height, weight, pulmonary function, anatomic resections, and co-morbidities. Technical differences in robotic arm numbering, port placement, and instrumentation are shown below. Median docking time was shorter with the Xi robot [7.5 (95% CI 6-8) versus 10 (95% CI 9-12) min, p = 0.003] as was operation duration [114 (95% CI 104-123) versus 119 (95% CI 116-126) min, p = 0.041] and skin closure to room exit [12 (95% CI 10-24) versus 13 (95% CI 12-15) min, p = 0.081]. Anesthesiologists expressed greater comfort with the Xi system, because the patient's head was not covered by the robot. Outcomes for Si and Xi operations such as median blood loss (20 cc versus 20 cc), transfusion rate (0 versus 0), major complication rate (3.2 versus 3.3%), and the 30- and 90-day mortality were no different (one 30-day death in the Si group). The technical changes that are required for robotic Si-to-Xi conversion are shown. The Xi system may offer improved operational efficiency.


title: Induction of immune gene expression and inflammatory mediator release by commonly used surgical suture materials: an experimental in vitro study.

text: BACKGROUND Surgeons have a range of materials to choose from to complete wound closure, yet surprisingly very little is still known about the body's immune response to the suture materials in current use. The growing literature of adverse suture material reactions provided the objective of this study, to use in vitro assays to quantify levels of inflammation produced by seven commonly used suture materials in surgical procedures. METHODS Human monocyte/macrophage THP-1 cells were exposed to suture materials for 1, 3 and 5 days. Gene expression and protein secretion of six inflammatory cytokines and two cell surface markers were assessed using qPCR and ELISA respectively, with LPS exposure providing a positive control. Furthermore, a IL-1β/IL-1RA marker ratio was assessed to determine the balance between pro-/anti-inflammatory expression. RESULTS The findings from our in vitro study suggest that four commonly used suture materials cause upregulation of pro-inflammatory markers indicative of an early foreign body reaction, with no balance from anti-inflammatory markers. CONCLUSIONS As prolonged early pro-inflammation is known to produce delayed wound healing responses, the knowledge produced from this study has potential to improve informed surgical decision making and patient safety. This work has the capability to reduce suture-related adverse immune reactions, and therefore positively affect patient outcomes.


title: Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP).

text: OBJECTIVE To characterize peri-ictal apnea and postictal asystole in generalized convulsive seizures (GCS) of intractable epilepsy. METHODS This was a prospective, multicenter epilepsy monitoring study of autonomic and breathing biomarkers of sudden unexpected death in epilepsy (SUDEP) in patients ≥18 years old with intractable epilepsy and monitored GCS. Video-EEG, thoracoabdominal excursions, nasal airflow, capillary oxygen saturation, and ECG were analyzed. RESULTS We studied 148 GCS in 87 patients. Nineteen patients had generalized epilepsy; 65 had focal epilepsy; 1 had both; and the epileptogenic zone was unknown in 2. Ictal central apnea (ICA) preceded GCS in 49 of 121 (40.4%) seizures in 23 patients, all with focal epilepsy. Postconvulsive central apnea (PCCA) occurred in 31 of 140 (22.1%) seizures in 22 patients, with generalized, focal, or unknown epileptogenic zones. In 2 patients, PCCA occurred concurrently with asystole (near-SUDEP), with an incidence rate of 10.2 per 1,000 patient-years. One patient with PCCA died of probable SUDEP during follow-up, suggesting a SUDEP incidence rate 5.1 per 1,000 patient-years. No cases of laryngospasm were detected. Rhythmic muscle artifact synchronous with breathing was present in 75 of 147 seizures and related to stertorous breathing (odds ratio 3.856, 95% confidence interval 1.395-10.663, p = 0.009). CONCLUSIONS PCCA occurred in both focal and generalized epilepsies, suggesting a different pathophysiology from ICA, which occurred only in focal epilepsy. PCCA was seen in 2 near-SUDEP cases and 1 probable SUDEP case, suggesting that this phenomenon may serve as a clinical biomarker of SUDEP. Larger studies are needed to validate this observation. Rhythmic postictal muscle artifact is suggestive of post-GCS breathing effort rather than a specific biomarker of laryngospasm.


title: A Case of COVID-19 with Acute Myocardial Infarction and Cardiogenic Shock.

text: A 60-year-old male patient with coronavirus disease-2019 showed new onset ST-segment elevation in V1-V2 leads on electrocardiogram and cardiac enzyme elevation in intensive care unit. He had a history of type 2 diabetes mellitus, hypertension, and dyslipidemia. He was receiving mechanical ventilation and veno-venous extracorporeal membrane oxygenation treatment for severe hypoxia. Two-D echocardiogram showed regional wall motion abnormalities. We performed primary percutaneous coronary intervention for acute myocardial infarction complicating cardiogenic shock under hemodynamic support. He expired on the 16th day of admission because of cardiogenic shock and multi-organ failure. Active surveillance and intensive treatment strategy are important for saving lives of COVID-19 patients with acute myocardial infarction.


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title: Endovascular treatment of supraclinoid internal carotid artery aneurysms.

text: Endovascular management of intracranial aneurysms has advanced significantly over the last couple decades and continues to evolve, including aneurysms within the subgroup of supraclinoid internal carotid artery (ophthalmic, superior hypophyseal, posterior communicating, anterior choroidal, dorsal wall/blister, and carotid terminus).


title: Robotic resection of a left brachiocephalic vein aneurysm mimicking thymoma.

text: A 70-year old man was scheduled for the robotic resection of a 21x16x30 mm thymic nodule incidentally detected by a computed tomography scan (CT) for thoracic trauma after a domestic accident. Positron emission tomography (PET) scan confirmed a low [18F]-FDG uptake (SUVmax=1,9). During the surgery the mass showed to be a saccular aneurysm of the left brachiocephalic vein (LBCV). A complete tangential resection of the aneurysm, with the use of EndoGIA stapler (Covidien® Endo GIA™) at its origin was performed. Patient's recovery was uneventful and postoperative CT with contrast administration confirmed the patency of the vein.


title: A review of forensic implications of opioid prescribing with examples from malpractice cases involving opioid-related overdose.

text: OBJECTIVE To provide a forensic overview and trace common threads among malpractice lawsuits involving patients who overdosed while consuming therapeutic opioids. METHODS One of us (LRW) reviewed 35 medical records of patients with chronic pain who overdosed, 20 of them fatally, while consuming therapeutic opioids, leading to lawsuits against physicians for malpractice. The reviews were requested by plaintiff and defense attorneys from across the United States from 2005 to 2009 to ascertain which drug(s) were primarily responsible for each death and whether the death was due to physician error, patient nonadherence, or some other reason. Complaints against pharmaceutical companies were excluded. Cases were examined for common trends, and comment is offered. RESULTS Methadone was responsible for the most deaths at 10 (50%), and hydrocodone was second at four deaths (20%) The most common risk factors found in the medical records of decedents included prescriber error in initiating, converting or titrating doses, patient nonadherence to medical instruction, presence of comorbid mental disorders, toxicological presence of benzodiazepines, middle age, and unrelieved pain. This article focuses on examples of physician errors and how they can be prevented. CONCLUSIONS Common trends emerge from medical records of opioid decedents. Patient actions con-tribute, but physician error, particularly regarding prescribing methadone for pain, is apparent as well. A focused effort to determine the types and causes of common physician errors and how they might be avoided may lead to safer, more effective clinical interventions in the management of pain.


title: Laparoscopic gastrectomy for cancer.

text: Gastric cancer is common worldwide. Tumor location and disease stage differ between Asian and Western countries. Western patients often have higher BMIs and comorbidities that may make laparoscopic resections challenging. Multiple trials from Asian countries demonstrate the benefits of laparoscopic gastrectomy for early gastric cancer while maintaining equivalent short-term and long-term oncologic outcomes compared with open surgery. The outcomes of laparoscopy seem to offer equivalent results to open surgery. In the United States, laparoscopic gastrectomy remains in its infancy and is somewhat controversial. This article summarizes the literature on the epidemiology, operative considerations and approaches, and outcomes for laparoscopic gastrectomy.


title: Caring for patients with cancer in the COVID-19 era.

text: The current COVID-19 pandemic challenges oncologists to profoundly re-organize oncological care in order to dramatically reduce hospital visits and admissions and therapy-induced immune-related complications without compromising cancer outcomes. Since COVID-19 is a novel disease, guidance by scientific evidence is often unavailable, and impactful decisions are inevitably made on the basis of expert opinions. Here we report how the seven comprehensive cancer centers of Cancer Core Europe have organized their healthcare systems at an unprecedented scale and pace to make their operations 'pandemic proof'. We identify and discuss many commonalities, but also important local differences, and pinpoint critical research priorities to enable evidence-based remodeling of cancer care during the COVID-19 pandemic. Also, we discuss how the current situation offers a unique window of opportunity for assessing the effects of de-escalating anticancer regimens, which may fast-forward the development of more-refined and less-toxic treatments. By sharing our joint experiences, we offer a roadmap for proceeding and aim to mobilize the global research community to generate the data that are critically needed to offer the best possible care to patients.


title: Anesthesia for tracheal resection and reconstruction.

text: Tracheal resection and reconstruction (TRR) is the treatment of choice for most patients with tracheal stenosis or tracheal tumors. Anesthesia for TRR offers distinct challenges, especially for the less experienced practitioner. This article explores the preoperative assessment, strategies for induction and emergence from anesthesia, the essential coordination between the surgical and anesthesia teams during airway excision and anastomosis, and postoperative care. The most common complications are reviewed. Targeted readership is practitioners with less extensive experience in managing airway surgery cases. As such, the article focuses first on the most common proximal tracheal resection. Final sections discuss specific considerations for more complicated cases.


title: [New information for the clinical detection of COVID-19 virus infection and options for protection of healthcare workers in the head and neck region].

text: The coronavirus disease (COVID-19), which presumably started in China at the end of 2019 and became a pandemic, affects all segments of the health care system worldwide, including Hungary. As healthcare staff can come into contact with viral infections during many healthcare services, it is essential during the epidemic that Hungarian professionals working in various fields receive up-to-date information about the virus and the aspects of the infection that affect patient care and proposed measures. The present paper is a literature review in which the authors have elaborated on the currently available, relevant references, keeping in mind the epidemiological implications of clinical care. Based on the processed publications, it can be stated that during the interventions primarily affecting the head and neck region, especially in the case of interventions requiring the use of a rotating device, it is essential to fully protect all staff in the room with disposable full clothing, goggles and special masks. Replacement of this equipment and cleaning of the surgery should be done after each intervention and the entire supply team should be prepared for this in advance with training. Strict adherence to occupational health and infection control measures is essential to prevent cross-infections during treatment and infections by professionals. Orv Hetil. 2020; 161 (17): 660-666.


title: A Novel Approach to Combined Vaginal and Laparoscopic Gynecological Surgery.

text: Background and Objectives In this case series, we propose a novel approach to combined vaginal and laparoscopic surgery in which a posterior colpotomy and 2 5-mm abdominal incisions are used to perform benign gynecological procedures. We seek to assess the safety and feasibility of this technique in difficult surgical candidates such as those with obesity or prior laparotomies, as well as to detail intra- and postoperative complications associated with the procedure. Methods We collected demographic, clinical, intra-operative, and postoperative data on 45 women who underwent a combined vaginal and laparoscopic gynecological surgery for benign indications by a single surgeon between February 2013 and August 2017. Results From February 2013 through August 2017, 45 women underwent a combined vaginal and laparoscopic surgery at 2 institutions. Procedures included adnexal surgery (n = 32, 71%), and total hysterectomy (n = 13, 29%). Of patients who underwent adnexal surgery, two had minor postoperative complications. No patients had major complications. In addition, no patients had postoperative vaginal infections or pelvic abscesses, and there were no readmissions within 30 days after the procedures. Conclusion Our proposed combined vaginal and laparoscopic approach to benign gynecological surgery can be utilized in difficult surgical candidates including those with obesity, nulliparous patients, and those with prior abdominal surgery. Our data has shown that this approach is safe and effective.


title: Management of severe acute asthma in the emergency department.

text: PURPOSE OF REVIEW Asthma is one of the most common chronic diseases in most developed countries and control may be elusive. Deterioration in asthma control is common when patients are exposed to airway irritants, viruses, and/or when adherence to chronic anti-inflammatory medications is suboptimal. Acute asthma exacerbations are common, important reasons for presentations to emergency departments, and severe cases may result in hospitalization. Important knowledge gaps exist in what is known and what care is delivered at the bedside. RECENT FINDINGS The literature in asthma is rapidly expanding and recent advances in the care are important to summarize. Systematic reviews, especially high-quality syntheses performed using Cochrane methods, provide the best evidence for busy clinicians to remain current. Management of asthma is based on early recognition of severe disease with aggressive therapy using multimodal interventions that focus on both bronchoconstriction and inflammatory mechanisms. SUMMARY Treatment of severe acute asthma can effectively and safely reduce hospitalizations, airway interventions, and even death. Using the approach outlined herein will enable clinicians to assist patients to rapidly regain asthma control, return to normal activities, and improve their quality of life in the follow-up period.


title: Assessing the functionality of viral entry-associated domains of porcine reproductive and respiratory syndrome virus during inactivation procedures, a potential tool to optimize inactivated vaccines.

text: Porcine reproductive and respiratory syndrome virus (PRRSV) causes severe economic losses in the pig industry worldwide. Currently, vaccines based on inactivated PRRSV provide limited protection of pigs against infection, most likely because viral epitopes associated with the induction of neutralizing antibodies are not or poorly conserved during inactivation. To analyze the effect of inactivation procedures on the interaction of PRRSV with receptors involved in virus entry, a new assay was set up in this study. Viral entry-associated domains are most likely important for the induction of neutralizing antibodies, since neutralizing antibodies block interaction of PRRSV with cellular receptors. To investigate the interaction of PRRSV with the cellular receptors upon different inactivation procedures, attachment to and internalization of inactivated PRRSV into macrophages were monitored. AT-2 could not inactivate PRRSV completely and is therefore not useful for vaccine development. PRRSV inactivated with ultraviolet light, binary ethyleneimine and gamma irradiation, which all mainly have an effect at the genomic level, showed no difference compared to control live virus at all levels of virus entry, whereas PRRSV treated with formaldehyde, glutaraldehyde and pH changes, which all have a modifying effect on proteins, was not able to internalize into macrophages anymore. These results suggest that inactivation with methods with a main effect on the viral genome preserve PRRSV entry-associated domains and are useful for future development of an effective inactivated vaccine against PRRSV. Although PRRSV incubation at 37 degrees C can completely inactivate PRRSV with preservation of entry-associated domains, this method is not recommended for vaccine development, since the mechanism is yet unknown.


title: COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer.

text: INTRODUCTION Total mesorectal excision (TME) is an essential component of surgical management of rectal cancer. Both open and laparoscopic TME have been proven to be oncologically safe. However, it remains a challenge to achieve complete TME with clear circumferential resections margin (CRM) with the conventional transabdominal approach, particularly in mid and low rectal tumours. Transanal TME (TaTME) was developed to improve oncological and functional outcomes of patients with mid and low rectal cancer. METHODS An international, multicentre, superiority, randomised trial was designed to compare TaTME and conventional laparoscopic TME as the surgical treatment of mid and low rectal carcinomas. The primary endpoint is involved CRM. Secondary endpoints include completeness of mesorectum, residual mesorectum, morbidity and mortality, local recurrence, disease-free and overall survival, percentage of sphincter-saving procedures, functional outcome and quality of life. A Quality Assurance Protocol including centralised MRI review, histopathology re-evaluation, standardisation of surgical techniques, and monitoring and assessment of surgical quality will be conducted. DISCUSSION The difference in involvement of CRM between the two treatment strategies is thought to be in favour of the TaTME. TaTME is therefore expected to be superior to laparoscopic TME in terms of oncological outcomes in case of mid and low rectal carcinomas.


title: Identification of RNA partners of viral proteins in infected cells.

text: RNA viruses exhibit small-sized genomes encoding few proteins, but still establish complex networks of protein-protein and RNA-protein interactions within a cell to achieve efficient replication and spreading. Deciphering these interactions is essential to reach a comprehensive understanding of the viral infection process. To study RNA-protein complexes directly in infected cells, we developed a new approach based on recombinant viruses expressing tagged viral proteins that were purified together with their specific RNA partners. High-throughput sequencing was then used to identify these RNA molecules. As a proof of principle, this method was applied to measles virus nucleoprotein (MV-N). It revealed that in addition to full-length genomes, MV-N specifically interacted with a unique population of 5' copy-back defective interfering RNA genomes that we characterized. Such RNA molecules were able to induce strong activation of interferon-stimulated response element promoter preferentially via the cytoplasmic pattern recognition receptor RIG-I protein, demonstrating their biological functionality. Thus, this method provides a new platform to explore biologically active RNA-protein networks that viruses establish within infected cells.


Science-ing from home.


title: Long-term follow-up of laparoscopic total extraperitoneal (TEP) repair in inguinal hernia without mesh fixation.

text: PURPOSE From the current evidence, non-fixation of the mesh (NMF) in laparoscopic total extraperitoneal (TEP) repair appears to be a safe alternative for inguinal hernia patients in the short term. This study aims to demonstrate that NMF is as effective in the long term by following up a large number of patients with a mean follow-up of 6 years. The primary outcomes are chronic pain and recurrence rate. METHODS A thorough review of medical records was conducted from a prospectively maintained database of 538 patients who underwent a laparoscopic TEP inguinal hernia repair by a single surgeon working in Sydney from the year 2005 to 2010. Patient demographics, perioperative outcomes, and postoperative complications were extracted from this database. All these patients were then interviewed using a modified questionnaire based on Franneby et al. [10]. RESULT 538 patients had TEP repair between 2005 and 2010. Out of this 11 were excluded as tacks were used for fixation of mesh. Out of the 649 repairs done on 527 patients during this period, 463 hernia repairs in 387 patients could be followed up with a mean follow-up of 6 years and 4 months. The mean age of patients was 63 years. Overall, there were seven (1.5%) recurrences, and the incidence of chronic pain was 1%, however 2.9% patients in total complained of pain. CONCLUSION This is the only study in literature having a long-term follow-up of more than 5 years for the patients having inguinal hernia repair by TEP technique without mesh fixation. It demonstrates that fixation of mesh with tacks or glue is unnecessary for TEP repair of inguinal hernia.


docid: xkndkbhs

title: Pipeline embolization device implantation in large carotid cavernous aneurysm associated with situs inversus totalis.

text: Situs anomalies are a heterogenous class of inborn visceral and vascular abnormalities with a broad range of radiographic characteristics. Situs inversus totalis is characterized by mirror image location of the heart and viscera relative to situs solitus (normal position). Few aberrations involving the neuraxis, and rarely intracranial aneurysms, have been reported in association with situs inversus totalis. We describe the radiological findings and endovascular management of one of the first of its kind: the association of bilateral carotid cavernous aneurysms (one large and the other small-sized) with situs inversus totalis.


title: Using the features of the time and volumetric capnogram for classification and prediction.

text: Quantitative features derived from the time-based and volumetric capnogram such as respiratory rate, end-tidal PCO2, dead space, carbon dioxide production, and qualitative features such as the shape of capnogram are clinical metrics recognized as important for assessing respiratory function. Researchers are increasingly exploring these and other known physiologically relevant quantitative features, as well as new features derived from the time and volumetric capnogram or transformations of these waveforms, for: (a) real-time waveform classification/anomaly detection, (b) classification of a candidate capnogram into one of several disease classes, (c) estimation of the value of an inaccessible or invasively determined physiologic parameter, (d) prediction of the presence or absence of disease condition, (e) guiding the administration of therapy, and (f) prediction of the likely future morbidity or mortality of a patient with a presenting condition. The work to date with respect to these applications will be reviewed, the underlying algorithms and performance highlighted, and opportunities for the future noted.


EUS-guided transgastric upper GI series for the evaluation of the defunctionalized stomach after gastric bypass.


title: Relation Between Chest CT Findings and Clinical Conditions of Coronavirus Disease (COVID-19) Pneumonia: A Multicenter Study.

text: OBJECTIVE. The increasing number of cases of confirmed coronavirus disease (COVID-19) in China is striking. The purpose of this study was to investigate the relation between chest CT findings and the clinical conditions of COVID-19 pneumonia. MATERIALS AND METHODS. Data on 101 cases of COVID-19 pneumonia were retrospectively collected from four institutions in Hunan, China. Basic clinical characteristics and detailed imaging features were evaluated and compared between two groups on the basis of clinical status: nonemergency (mild or common disease) and emergency (severe or fatal disease). RESULTS. Patients 21-50 years old accounted for most (70.2%) of the cohort, and five (5.0%) patients had disease associated with a family outbreak. Most patients (78.2%) had fever as the onset symptom. Most patients with COVID-19 pneumonia had typical imaging features, such as ground-glass opacities (GGO) (87 [86.1%]) or mixed GGO and consolidation (65 [64.4%]), vascular enlargement in the lesion (72 [71.3%]), and traction bronchiectasis (53 [52.5%]). Lesions present on CT images were more likely to have a peripheral distribution (88 [87.1%]) and bilateral involvement (83 [82.2%]) and be lower lung predominant (55 [54.5%]) and multifocal (55 [54.5%]). Patients in the emergency group were older than those in the non-emergency group. Architectural distortion, traction bronchiectasis, and CT involvement score aided in evaluation of the severity and extent of the disease. CONCLUSION. Patients with confirmed COVID-19 pneumonia have typical imaging features that can be helpful in early screening of highly suspected cases and in evaluation of the severity and extent of disease. Most patients with COVID-19 pneumonia have GGO or mixed GGO and consolidation and vascular enlargement in the lesion. Lesions are more likely to have peripheral distribution and bilateral involvement and be lower lung predominant and multifocal. CT involvement score can help in evaluation of the severity and extent of the disease.


title: Examining the efficacy of intravenous administration of predatory bacteria in rats.

text: The proteobacteria Bdellovibrio bacteriovorus and Micavibrio aeruginosavorus are obligate predators of Gram-negative bacteria, and have been proposed to be used to treat multidrug-resistant bacterial infections. The ability of predatory bacteria to reduce bacterial burden in vivo within the lungs of rats has been demonstrated, but it was unknown if predatory bacteria can attenuate systemic bacterial burden administered intravenously. In this study, we first assessed the safety of intravenous inoculation of predatory bacteria in rats. No rat morbidity or adverse histopathology of various organs due to predatory bacteria administration was observed. An increase in proinflammatory cytokines (TNFα and KC/GRO) was observed at two hours post-inoculation; however, cytokines returned to baseline levels by 18 hours. Furthermore, bacterial dissemination analysis demonstrated that predatory bacteria were efficiently cleared from the host by 20 days post-injection. To determine whether predatory bacteria could reduce bacterial burden in vivo, Klebsiella pneumoniae was injected into the tail veins of rats and followed with multiple doses of predatory bacteria over 16 or 24 hours. Predatory bacteria were unable to significantly reduce K. pneumoniae burden in the blood or prevent dissemination to other organs. The results suggest that predatory bacteria may not be effective for treatment of acute blood infections.


title: Therapeutic Potential of B-1a Cells in COVID-19.

text: Coronavirus disease 2019 (COVID-19) is a life-threatening respiratory illness caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Its clinical presentation can vary from the asymptomatic state to acute respiratory distress syndrome (ARDS) and multi-organ dysfunction. Due to our insufficient understanding of its pathophysiology and lack of effective treatment, the morbidity and mortality of severe COVID-19 patients are high. Patients with COVID-19 develop ARDS fueled by exaggerated neutrophil influx into the lungs and cytokine storm. B-1a cells represent a unique subpopulation of B lymphocytes critical for circulating natural antibodies, innate immunity, and immunoregulation. These cells spontaneously produce natural IgM, interleukin (IL)-10, and granulocyte-monocyte colony stimulating factor (GM-CSF). Natural IgM neutralizes viruses and opsonizes bacteria, IL-10 attenuates the cytokine storm, and GM-CSF induces IgM production by B-1a cells in an autocrine manner. Indeed, B-1a cells have been shown to ameliorate influenza virus infection, sepsis, and pneumonia, all of which are similar to COVID-19. The recent discovery of B-1a cells in humans further reinforces their potentially critical role in the immune response against SARS-CoV-2 and their anticipated translational applications against viral and microbial infections. Given that B-1a cells protect against ARDS via immunoglobulin production and the anti-COVID-19 effects of convalescent plasma treatment, we recommend that studies be conducted to further examine the role of B-1a cells in the pathogenesis of COVID-19 and explore their therapeutic potential to treat COVID-19 patients.


title: We Should Expect More out of Our Sewage Sludge.

text: Sewage sludge and biosolids production and management are a central component of water and sanitation engineering. The culmination of previous incremental technologies and regulations aimed at solving a current treatment problem, rather than developing the practice for the higher goals of sustainability have resulted in sludge becoming an economic and social liability. Sludge management practice must shift from treatment of a liability toward recovery of the embedded energy and chemical assets, while continuing to protect the environment and human health. This shift will require new research, treatment technologies and infrastructure and must be guided by the application of green engineering principles to ensure economic, social, and environmental sustainability.


docid: amtkkqqh

title: Prescription Fill Patterns for Commonly Used Drugs During the COVID-19 Pandemic in the United States.


Rise in the incidence of abusive head trauma during the COVID-19 pandemic.


title: Guidelines for Resident Participation in Otolaryngology Telehealth Clinics During the COVID-19 Pandemic.

text: The practice of otolaryngology has changed drastically since the start of the COVID-19 pandemic. To limit exposure and maintain a reserve of caregivers, residency education ceased most clinical activities and shifted to remote lecture consortiums hosted online across the country in lieu of ambulatory and operative experiences. Many practicing university otolaryngologists have transitioned their clinics to telehealth medicine to maintain access to clinical care during the pandemic. The participation of residents in telemedicine visits has not been described. Here we present guidelines and experience-based suggestions for successful resident involvement in telemedicine. While it is unclear what role telehealth medicine may play within the field of otolaryngology beyond the pandemic, our experiences suggest better patient outreach and access. Expanding residents' skill set with telehealth medicine can enhance their education and better prepare them for future practice.


title: Surgical tracheostomy in morbidly obese patients: technical considerations and a two-flap technique for access.

text: OBJECTIVE In an era in which percutaneous tracheostomies are frequently performed in 'suitable' necks, more technically complex cases are referred to the otolaryngologist. We describe the surgical technique used and close cooperation required in securing the airway of a morbidly obese patient. CASE REPORT A 52-year-old, morbidly obese man with significant comorbidities was referred for surgical tracheostomy following spinal fractures. This was complicated by a previous percutaneous dilatational tracheostomy scar. Tension-free skin advancement was not possible with a deeply plunging trachea; a vertical skin incision was dropped inferiorly to the sternum for access. A size 8 Shiley XLT Proximal Extension cuffed tracheostomy tube was inserted successfully. CONCLUSION We describe safe airway surgery in a morbidly obese man, and outline requirements including the use of a specially designed operating table, the need for an elongated proximal limb tracheostomy tube, and the use of a distal two-flap technique for access to a deeply plunging trachea.


title: Sleeve gastrectomy: a new surgical approach for morbid obesity.

text: While obesity and morbid obesity have reached epidemic proportions worldwide, bariatric surgeons continue to develop safer and more efficacious procedures to battle this lethal disease. Sleeve gastrectomy, a relative new surgical approach, was initially conceived as a restrictive component of the biliopancreatic diversion and duodenal switch in the era of open bariatric surgery. With the advent of minimally invasive surgery in the late 1980s, laparoscopic sleeve gastrectomy (LSG) has been proposed as a step procedure in high-risk patients, followed by a second step Roux-en-Y gastric bypass or biliopancreatic diversion and duodenal switch and, recently, as a standalone bariatric approach. This article reviews the literature and reports the results achieved with LSG performed either as the initial operation for high-risk, high body mass index patients followed by a definitive weight loss operation, or used as a final viable alternative to other well-established bariatric procedures. An extensive literature review was conducted and the information currently available surrounding LSG, such as history, indications and contraindications, mechanism of weight loss, technique and outcomes and controversial issues are discussed. LSG is an accepted procedure for the surgical management of morbid obesity. It is gaining popularity as a primary, staged and revisional operation for its proven safety and simplicity, as well as short-term and mid-term efficacy. Excess weight loss and remission of comorbidities have been reported to take place in a frequency comparable with other well-established procedures. Despite all of the above-mentioned factors, long-term results and larger series are pending.


title: Evaluation of a teaching tool to increase the accuracy of pilot balloon palpation for measuring tracheostomy tube cuff pressure.

text: OBJECTIVES/HYPOTHESIS The purpose of this study was to evaluate the efficacy of a novel teaching tool to improve health care providers' ability to inflate tracheostomy tube cuffs to the appropriate pressure. STUDY DESIGN Single-blinded, randomized, controlled trial. METHODS Subjects were randomized to a control and study group. The control group viewed a video about inflating tracheostomy tube cuffs to safe pressure levels. The study group viewed the same video and also got to palpate the pilot balloons of tracheostomy tube cuffs inflated to three different pressures. All subjects inflated tracheostomy tube cuffs to pressures they believed to be appropriate based on palpation of the pilot balloon preintervention, and immediately, 2 weeks, and 3 months postintervention. RESULTS Forty-nine health care providers participated in the study. There was no significant difference in the mean preintervention cuff inflation pressures between the two groups (36 cm H2 O vs. 38 cm H2 O, P = 0.4888), with both initially overinflating. Postintervention, the study group inflated the cuffs to significantly lower pressures than the control group, closer to the ideal of 25 cm H2 O (26 cm H2 O vs. 35 cm H2 O, P = 0.0001). This difference was also observed 2 weeks (28 cm H2 O vs. 37 cm H2 O P <0.0001) and 3 months (28 cm H2 O vs. 36 cm H2 O, P = 0.0002) postintervention. CONCLUSIONS The novel teaching tool evaluated in this study is simple, easily reproducible, and low-cost. Its use leads to long-lasting improvement in health care providers' ability to more accurately inflate tracheostomy tube cuffs to safe pressures.


title: Emerging infections: a tribute to the one medicine, one health concept.

text: Events in the last decade have taught us that we are now, more than ever, vulnerable to fatal zoonotic diseases such as those caused by haemorrhagic fever viruses, influenza, rabies and BSE/vCJD. Future research activities should focus on solutions to these problems arising at the interface between animals and humans. A 4-fold classification of emerging zoonoses was proposed: Type 1: from wild animals to humans (Hanta); Type 1 plus: from wild animals to humans with further human-to-human transmission (AIDS); Type 2: from wild animals to domestic animals to humans (Avian flu) and Type 2 plus: from wild animals to domestic animals to humans, with further human-to-human transmission (Severe Acute Respiratory Syndrome, SARS). The resulting holistic approach to emerging infections links microbiology, veterinary medicine, human medicine, ecology, public health and epidemiology. As emerging 'new' respiratory viruses are identified in many wild and domestic animals, issues of interspecies transmission have become of increasing concern. The development of safe and effective human and veterinary vaccines is a priority. For example, the spread of different influenza viruses has stimulated influenza vaccine development, just as the spread of Ebola and Marburg viruses has led to new approaches to filovirus vaccines. Interdisciplinary collaboration has become essential because of the convergence of human disease, animal disease and a common approach to biosecurity. High containment pathogens pose a significant threat to public health systems, as well as a major research challenge, because of limited experience in case management, lack of appropriate resources in affected areas and a limited number of animal research facilities in developed countries. Animal models that mimic certain diseases are key elements for understanding the underlying mechanisms of disease pathogenesis, as well as for the development and efficacy testing of therapeutics and vaccines. An updated veterinary curriculum is essential to empower future graduates to work in an international environment, applying international standards for disease surveillance, veterinary public health, food safety and animal welfare.


docid: mycgkwei

title: Global financial crisis and surgical practice: the Greek paradigm.

text: Apart from the significant implications of recent financial crisis in overall health indices and mortality rates, the direct effect of health resources redistribution in everyday clinical practice is barely recognized. In the case of Greece, health sector reform and health spending cuts have already had a major impact on costly interventions, particularly in surgical practice. An increase in utilization of public health resources, lack of basic and advanced surgical supplies, salary deductions, and emerging issues in patient management have contributed to serious dysfunction of a public health system unable to sustain current needs. In this context, significant implications arise for the surgeons and patients as proper perioperative management is directly affected by reduced public health funding. The surgical community has expressed concerns about the quality of surgical care and the future of surgical progress in the era of the European Union. Greek surgeons are expected to support reform while maintaining a high level of surgical care to the public. The challenge of cost control in surgical practice provides, nevertheless, an excellent opportunity to reconsider health economics while innovation through a more traditional approach to the surgical patient should not be precluded. A Greek case study on the extent of the current situation is presented with reference to health policy reform, serving as an alarming paradigm for the global community under the pressure of a profound financial recession.


title: Early Clinical and CT Manifestations of Coronavirus Disease 2019 (COVID-19) Pneumonia.

text: OBJECTIVE. The purpose of this study was to investigate early clinical and CT manifestations of coronavirus disease (COVID-19) pneumonia. MATERIALS AND METHODS. Patients with COVID-19 pneumonia confirmed by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid test (reverse transcription-polymerase chain reaction) were enrolled in this retrospective study. The clinical manifestations, laboratory results, and CT findings were evaluated. RESULTS. One hundred eight patients (38 men, 70 women; age range, 21-90 years) were included in the study. The clinical manifestations were fever in 94 of 108 (87%) patients, dry cough in 65 (60%), and fatigue in 42 (39%). The laboratory results were normal WBC count in 97 (90%) patients and normal or reduced lymphocyte count in 65 (60%). High-sensitivity C-reactive protein level was elevated in 107 (99%) patients. The distribution of involved lobes was one lobe in 38 (35%) patients, two or three lobes in 24 (22%), and four or five lobes in 46 (43%). The major involvement was peripheral (97 patients [90%]), and the common lesion shape was patchy (93 patients [86%]). Sixty-five (60%) patients had ground-glass opacity (GGO), and 44 (41%) had GGO with consolidation. The size of lesions varied from smaller than 1 cm (10 patients [9%]) to larger than 3 cm (56 patients [52%]). Vascular thickening (86 patients [80%]), crazy paving pattern (43 patients [40%]), air bronchogram sign (52 patients [48%]), and halo sign (69 [64%]) were also observed in this study. CONCLUSION. The early clinical and laboratory findings of COVID-19 pneumonia are low to midgrade fever, dry cough, and fatigue with normal WBC count, reduced lymphocyte count, and elevated high-sensitivity C-reactive protein level. The early CT findings are patchy GGO with or without consolidation involving multiple lobes, mainly in the peripheral zone, accompanied by halo sign, vascular thickening, crazy paving pattern, or air bronchogram sign.


Experience of 15 years using the 25-mm flexed end to end anastomosis anvil for safe transoral passage during intracorporeal circular-stapling gastrojejunostomy, esophagogastrostomy, and esophagojejunostomy.


title: Endoscopic dilation of benign esophageal anastomotic strictures over 16 mm has a longer lasting effect.

text: BACKGROUND The optimal target of endoscopic dilation of postsurgical esophageal strictures is unknown. Our aim was to compare the dilation-free period of patients who underwent dilation up to 16 mm with patients who were dilated up to 17 or 18 mm. METHODS We retrospectively analyzed adult patients who received bougie/balloon dilation for a benign anastomotic stricture after esophagectomy. An anastomotic stricture was defined as dysphagia in combination with a luminal diameter of ≤13 mm at endoscopy. We analyzed the dilation-free period using Kaplan-Meier and multivariable Cox regression analysis. RESULTS Eighty-eight patients were dilated up to a maximum diameter of 16 mm and 91 patients to a diameter >16 mm. The stricture recurrence rate was 79.5 % in the 16 mm group and 68.1 % in the >16 mm group (p = 0.083). The overall dilation-free period had a median of 41.5 (range 8-3233) days and 92 (range 17-1745) days, respectively (p < 0.001). For patients who developed a stricture recurrence, the median dilation-free period was 28 (range 8-487) days and 63 (range 17-1013) days, respectively (p = 0.001). Cox regression analysis showed a reduced risk of stricture recurrence for patients who were dilated up to >16 mm: crude hazard ratio (HR) 0.57 (95 % confidence interval (CI) 0.41-0.81) and adjusted HR 0.48 (95 % CI 0.33-0.70). CONCLUSIONS Endoscopic dilation over 16 mm resulted in a significant prolongation of the dilation-free period in comparison with dilation up to 16 mm in patients with benign anastomotic strictures after esophagectomy.


title: Predictive factors of psychological disorder development during recovery following SARS outbreak.

text: OBJECTIVE To investigate strategies for broad mass isolation during outbreaks of infectious diseases. DESIGN A survey using a self-administered questionnaire was conducted on 300 printing company workers in Beijing, China, which was under mass isolation following the 2003 SARS outbreak, in the 7-8 months after the isolation was lifted. MAIN OUTCOME MEASURES Individuals with psychological disorders were classified on the basis of scores on the 30-item General Health Questionnaire during the recovery period. Psychological disorders were observed in 49 of 187 respondents (26.2%; 95% CI = 20.2, 32.7). RESULTS The predicting factor with the highest correlation was income reduction, with an odds ratio of 25.0. Other items obtained were gender, range of activities, eating restrictions, restrictions in going out, disinfection of clothing, and infection control, with odds ratios of 3.2, 5.5, 3.9, 3.2, 0.2, and 0.1, respectively, and the contribution ratio was 87.7%. CONCLUSION Securing income is suggested to be important in future strategies.


title: Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study.

text: BACKGROUND AND PURPOSE Laparoendoscopic single-site surgery (LESS), an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions, has been developed recently. Our aim was to compare LESS simple nephrectomy (LESS-SN) and conventional transperitoneal laparoscopic simple nephrectomy (CTL-SN). PATIENTS AND METHODS In this randomized study that was conducted between December 2008 and September 2009, 27 patients who needed simple nephrectomy were randomized to either LESS-SN or CTL-SN. All procedures in both groups were performed by the first author, who is experienced in laparoscopic surgery. Patient characteristics, perioperative details, and time to return to work were recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS There was no difference in median operative time (117.5 vs 114 min, P = 0.52), blood loss (50.71 vs 47.15 mL, P = 0.60), transfusion rates (0% for both), and hospitalization time (2.07 vs 2.11 days, P = 0.74) between the LESS-SN and CTL-SN groups. Time to return to normal activities was shorter in the LESS-SN group compared with the CTL-SN group (10.7 vs 13.5 days, P = 0.001). Both the visual analogue scale and the postoperative use of analgesics were significantly lower during postoperative days 1, 2, and 3 in patients who underwent LESS-SN, compared with patients who underwent CTL-SN. There were no intraoperative or postoperative complications in both groups. Compared with CTL-SN, LESS-SN was more expensive, but all patients undergoing LESS-SN were very pleased with the cosmetic outcome (no visible scars). CONCLUSION The early experience described in this study suggests that LESS-SN is a safe and effective alternative to CTL-SN that provides surgeons with a minimally invasive surgical option and the ability to hide the surgical incision within the umbilicus; however, a larger series is necessary to confirm these findings and to determine if there are any benefits in pain, recovery, or cosmesis.


title: Our Thanks to ALL Healthcare Workers on the Frontlines Caring for Our Most Vulnerable.

text: The Covid-19 pandemic has touched the lives of nearly every person in the world. No person living today has ever witnessed such a crisis. We strongly request that you follow the guidance in your area and be safe in all your activities. We are so thankful and proud of the medical persons and caregivers for diligently carrying out their duties. We hope and pray that you remain strong for those in need, in particular the elderly, those with medical problems, and those with compromised immune systems.


title: A systematic literature review and meta-analysis of the effectiveness of extracorporeal-CPR versus conventional-CPR for adult patients in cardiac arrest.

text: Introduction The probability of surviving a cardiac arrest remains low. International resuscitation guidelines state that extracorporeal cardiopulmonary resuscitation (ECPR) may have a role in selected patients suffering refractory cardiac arrest. Identifying these patients is challenging. This project systematically reviewed the evidence comparing the outcomes of ECPR over conventional-CPR (CCPR), before examining resuscitation-specific parameters to assess which patients might benefit from ECPR. Method Literature searches of studies comparing ECPR to CCPR and the clinical parameters of survivors of ECPR were performed. The primary outcome examined was survival at hospital discharge or 30 days. A secondary analysis examined the resuscitation parameters that may be associated with survival in patients who receive ECPR (no-flow and low-flow intervals, bystander-CPR, initial shockable cardiac rhythm, and witnessed cardiac arrest). Results Seventeen of 948 examined studies were included. ECPR demonstrated improved survival (OR 0.40 (0.27-0.60)) and a better neurological outcome (OR 0.10 (0.04-0.27)) over CCPR during literature review and meta-analysis. Characteristics that were associated with improved survival in patients receiving ECPR included an initial shockable rhythm and a shorter low-flow time. Shorter no-flow, the presence of bystander-CPR and witnessed arrests were not characteristics that were associated with improved survival following meta-analysis, although the quality of input data was low. All data were non-randomised, and hence the potential for bias is high. Conclusion ECPR is a sophisticated treatment option which may improve outcomes in a selected patient population in refractory cardiac arrest. Further comparative research is needed clarify the role of this potential resuscitative therapy.


Pandemic as Teacher - Forcing Clinicians to Inhabit the Experience of Serious Illness.


Infectious Disease Transmission Models to Predict, Evaluate, and Improve Understanding of SARS-COV-2 Trajectory and Interventions.


title: What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS) pathways?

text: PURPOSE The purpose of this narrative review is to provide a framework from which to measure the outcomes of Enhanced Recovery After Surgery (ERAS) programs. PRINCIPLE FINDINGS We define the outcomes of recovery from the perspective of different stakeholders and time frames. There is no single definition of recovery. There are overlapping phases of recovery which are of particular interest to different stakeholders (surgeons, anesthesiologists, nurses, patients and their caregivers), and the primary outcome of interest may vary depending on the phase and the perspective. In the earliest phase (from the end of the surgery to discharge from the postanesthesia care unit [PACU]), biologic and physiologic outcomes are emphasized. In the intermediate phase (from PACU to discharge from the hospital), symptoms related to pain and gastrointestinal function as well as basic activities are important. Studies of ERAS pathways have reported clinical outcomes and symptoms, including complications, hospital stay, mobilization, and gastrointestinal function, largely during hospitalization. Nevertheless, patients define recovery as return to normal functioning, a process that occurs over weeks to months (late phase). Outcomes reflecting functional status (e.g., physical activity, activities of daily living) and overall health (e.g., quality of life) are important in this phase. To date, few studies reporting the effectiveness of ERAS pathways compared with conventional care have included functional status or quality-of-life outcomes, and there is little information about recovery after discharge from hospital. CONCLUSION Recovery after surgery is a complex construct. Different outcomes are important at different phases along the recovery trajectory. Measures for quantifying recovery in hospital and after discharge are available. A consensus-based core set of outcomes with input from multiple stakeholders would facilitate research reporting.


title: A non-canonical di-acidic signal at the C-terminus of Kv1.3 determines anterograde trafficking and surface expression.

text: Impairment of Kv1.3 expression at the cell membrane in leukocytes and sensory neuron contributes to the pathophysiology of autoimmune diseases and sensory syndromes. Molecular mechanisms underlying Kv1.3 channel trafficking to the plasma membrane remain elusive. We report a novel non-canonical di-acidic signal (E483/484) at the C-terminus of Kv1.3 essential for anterograde transport and surface expression. Notably, homologous motifs are conserved in neuronal Kv1 and Shaker channels. Biochemical analysis revealed interactions with the Sec24 subunit of the coat protein complex II. Disruption of this complex retains the channel at the endoplasmic reticulum. A molecular model of the Kv1.3-Sec24a complex suggests salt-bridges between the di-acidic E483/484 motif in Kv1.3 and the di-basic R750/752 sequence in Sec24. These findings identify a previously unrecognized motif of Kv channels essential for their expression on the cell surface. Our results contribute to our understanding of how Kv1 channels target to the cell membrane, and provide new therapeutic strategies for the treatment of pathological conditions.


title: Acute human orthopneumovirus infection in a captive white-handed gibbon.

text: We report herein a fatal case of acute human orthopneumovirus (formerly respiratory syncytial virus) infection in a captive white-handed gibbon (Hylobates lar). Other members of the housing group had mild respiratory signs. Gross examination revealed bilateral pulmonary congestion and froth in the bronchi. Microscopically, the lungs had lymphocytic, neutrophilic infiltration of the interstitium and alveolar walls. There was necrosis of terminal bronchiolar epithelium and terminal bronchioles, and surrounding alveoli contained necrotic and exfoliated epithelial cells admixed with histiocytes and syncytial cells. Additional lesions included nonsuppurative meningoencephalitis, and epidermal hyperkeratosis and hyperplasia with syncytial cell formation. PCR screening for 12 human respiratory viruses was positive for orthopneumovirus in multiple tissues, including lung, and immunohistochemical staining for human orthopneumovirus detected viral antigen within bronchial epithelial cells. IHC and PCR for measles virus on preserved sections were negative. White-handed gibbons have not been previously reported as hosts for human orthopneumovirus, an important respiratory pathogen of both primates and humans.


title: Extensive blooming artifact predicts no recanalization after intravenous thrombolysis.

text: BACKGROUND AND PURPOSE Hemosiderin exhibits a stronger T2 shortening effect than deoxyhemoglobin. The extent of the 'blooming artifact' may therefore reflect a composition of different iron forms. Our aim was to investigate the relationship between extent of susceptibility vessel sign (SVS) width beyond the lumen and middle cerebral artery (MCA) recanalization. METHODS Clinical and imaging data from consecutive acute ischaemic stroke patients with MCA occlusion who underwent susceptibility-weighted imaging (SWI) before intravenous thrombolysis were examined. The source images of magnitude and angiography were used to obtain the width of SVS and MCA at the interface, respectively. RESULTS The presence of MCA SVS was observed in 64 patients on initial SWI scans and recanalization was observed in 30 (46.9%) patients. The overestimation ratio of thrombus width on SWI was an acceptable predictor for no recanalization [odds ratio 1.360 per 0.1; 95% confidence interval (CI) 1.093-1.691; P = 0.006]. The optimal cut-off point was identified at 1.943, and this yielded a sensitivity of 67.6% and a specificity of 86.7%. Extensive blooming artifact, defined as overestimation ratio ≥2, independently predicted no recanalization (odds ratio 9.687, 95% CI 1.974-47.545; P = 0.005) and unfavorable outcome (odds ratio 4.916, 95% CI 1.049-23.051; P = 0.043). CONCLUSIONS The extent of SVS width beyond the lumen might reflect the content of hemosiderin. An extreme overestimation ratio might indicate aged thrombus, which may be resistant to thrombolysis.


title: High EREG Expression Is Predictive of Better Outcomes in Rectal Cancer Patients Receiving Neoadjuvant Concurrent Chemoradiotherapy.

text: BACKGROUND/AIM A great proportion of patients with rectal cancer initially present with locally advanced disease and can potentially benefit from neoadjuvant concurrent chemoradiotherapy (CCRT) for downstaging before surgery. However, risk and clinical outcome stratification remain a great challenge. We aimed to find the potential biomarker to predict the effect of neoadjuvant CCRT on rectal cancer. METHODS We identified epiregulin (EREG) as the most significant predictive marker for neoadjuvant CCRT response from the published rectal cancer transcriptome data set GSE35452. We collected 172 biopsy specimens from rectal cancer patients who received neoadjuvant CCRT followed by radical proctectomy, performed EREG immunohistochemistry, and analyzed the H-scores. We further examined the correlations between the expression level of EREG and clinicopathological features, tumor regression grade, and survival, including disease-specific survival (DSS), locoregional recurrence-free survival (LRFS), and metastasis-free survival (MeFS). RESULTS High EREG expression was significantly related to early pretreatment (pre-Tx) and posttreatment (post-Tx) tumor status (T1, T2, p = 0.047 and p < 0.001), pre-Tx and post-Tx negative nodal status (N0, p < 0.001 and p = 0.004), less vascular and perineurial invasion (p = 0.015 and p = 0.023), and higher tumor regression grade (p < 0.001). In the survival analysis, high EREG expression was significantly associated with better DSS (p < 0.0001), LRFS (p = 0.0004), and MeFS (p < 0.0001). In the multivariate analysis, high EREG expression remained prognostically significant for better DSS (p = 0.003; hazard ratio: 5.599). CONCLUSION These data suggest that EREG is a potential predictive marker and therapeutic target in rectal cancer patients receiving neoadjuvant CCRT.


title: Outpatient Antibiotic Consumption Fluctuations in a View of Unreasonable Antibacterial Therapy.

text: Unreasonable antibacterial therapy is suspected to be the main reason of emergence of multi-resistant bacteria. The connection between seasonal variability of antibiotic use and reasonable antibacterial therapy has been described. We examined the issue basing on the data obtained from the primary care system in Szczecin (Poland) in order to verify the situation in this region of Central Europe. Increase in antibiotic consumption in a viral infection season was proved to be statistically significant. Statistically significant differences in various drug forms dispensation were also observed. Increased consumption of antibiotics in seasons of influenza-like illnesses might be connected with a lack of proper diagnostics or numerous cases of bacterial co-infections.


title: Stent Retriever-Assisted Mechanical Thrombectomy for Acute Basilar Artery Occlusion: Single US Institution Experience.

text: BACKGROUND Acute basilar artery occlusion causes devastating strokes that carry high mortality and morbidity. OBJECTIVE To report the outcomes of mechanical thrombectomy in the posterior circulation with a focus on safety and efficacy of stent retrievers. METHODS We retrospectively reviewed our endovascular database for all patients treated with stent retrievers for posterior circulation stroke between June 2012 and June 2014. Twelve patients were identified. The following data were analyzed: thrombus location, previous stroke or transient ischemic attack, thrombus etiology, comorbidities, time from presentation to initiation of endovascular treatment, time from start of angiography to revascularization, and whether intravenous tissue plasminogen activator was administered pre-thrombectomy. Outcome was considered poor when modified Rankin Scale score was >2. RESULTS Mean patient age was 63.42 years (median, 64.5; range, 28-83 years); 7 were women. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b or 3) was achieved in 11 of 12 patients (91.7%). Mean discharge modified Rankin Scale score was 2.3 (median, 2.0; standard deviation 1.96; range, 0-6), with a favorable discharge outcome in 9 of 12 (75%) patients. Two patients died as inpatients. Mean follow-up modified Rankin Scale score was 1.4 (median, 1.00; standard deviation 1.075; range, 0-4). Good outcome was achieved in 9 of 10 (90%) patients at last follow-up (mean follow-up duration, 132.42 days [median, 90.50; standard deviation 80.2; range, 8-378 days]). CONCLUSION Our single-institution study has shown that good clinical outcomes and successful recanalization with acceptable mortality can be achieved with current stent retrievers.


title: Should Sensory Impairment Be Considered in Frailty Assessment? A Study in the GAZEL Cohort.

text: OBJECTIVES The assessment of sensory difficulties is sometimes included in the screening of frailty in ageing population. This study aimed to compare the prevalence of frailty and associated risk of adverse outcomes depending on whether sensory difficulties participated in the definition of frailty. DESIGN Prospective cohort study - GAZEL cohort. SETTING France. PARTICIPANTS The 13,128 subjects who completed a questionnaire in 2012. MEASUREMENTS According to the Strawbridge questionnaire, subjects were considered frail if they reported difficulties in two domains or more among physical, nutritive, cognitive and sensory domains. The risk of adverse health outcomes was assessed by using logistic regression models (hospitalisations, onset of difficulty in performing movements of everyday life) and multivariate Cox proportional hazards models (mortality). RESULTS Mean age was 66.8 +/- 3.4 years and 73.8% were males. The prevalence of frailty varied from 4.4 to 14.2% depending on whether the sensory domain was excluded or included. During follow-up, 182 deaths (1.4%), 479 hospitalisations (3.6%) and 703 cases of new disability (8.0%) were observed. Both definitions of frailty predicted the onset of difficulties to perform everyday movements, with 2 to 3-fold increase in the risk. The inclusion of the sensory domain in the definition made frailty predictive of hospitalisations (Odds Ratio 1.31 [1.01-1.70]) but the association with mortality was only observed when sensory difficulties were ignored (Hazard Ratio 2.28 [1.32-3.92]). CONCLUSION The inclusion of a sensory domain into a frailty screening instrument has a major impact in terms of prevalence and modifies the risk profile associated with frailty. In order to develop the use of frailty screening instruments in clinical practice, further researches will need to carefully evaluate the impact on risk prediction of the different domains involved.


title: One-Year Angiographic Follow-Up after WEB-SL Endovascular Treatment of Wide-Neck Bifurcation Intracranial Aneurysms.

text: BACKGROUND AND PURPOSE Endovascular coiling of wide-neck intracranial aneurysms is associated with low rates of initial angiographic occlusion and high rates of recurrence. The WEB intrasaccular device has been developed specifically for this indication. To date, there has been no report of the long-term follow-up of a series of patients with aneurysms treated with this type of device, to our knowledge. Our aim was to evaluate a 1-year follow-up of angiographic results in a prospective single-center series of patients treated with the WEB-Single-Layer (SL) device. MATERIALS AND METHODS All patients treated with the WEB-SL device in our center between August 2013 and May 2014 were prospectively included. One-year angiographic outcomes were assessed. Results at follow-up were graded as complete occlusion, neck remnant, or residual aneurysm. RESULTS Eight patients with 8 unruptured wide-neck aneurysms were enrolled in this study. Average dome width was 7.5 mm (range, 5.4-10.7 mm), and average neck size was 4.9 mm (range, 2.6-6.5 mm). One-year angiographic follow-up obtained in all aneurysms included 1 complete aneurysm occlusion (12.5%), 6 neck remnants (75%), and 1 aneurysm remnant (12.5%). Of 8 aneurysms, worsening of aneurysm occlusion was observed in 2 (25%) by compression of the WEB device. There was no angiographic recurrence of initially totally occluded aneurysms. No bleeding was observed during the follow-up period. CONCLUSIONS Endovascular therapy of intracranial aneurysms with the WEB-SL device allows treatment of wide-neck aneurysms with a high rate of neck remnant at 1 year, at least partially explained by WEB compression. Initial size selection and technologic improvements could be an option for optimization of aneurysm occlusion in WEB-SL treatment.


title: Safety and Efficacy of Preoperative Embolization of Intracranial Hemangioblastomas.

text: BACKGROUND Intracranial hemangioblastomas are highly vascular tumors that account for 1% to 2% of all central nervous system tumors. Preoperative embolization has been proposed to limit the often significant intraoperative blood loss associated with resection and potentially make the tumor more soft/necrotic and thus more amenable to gross total resection. The safety and efficacy of preoperative embolization of intracranial hemangioblastomas, however, are not well characterized. OBJECTIVE To evaluate the safety and efficacy of preoperative endovascular embolization of intracranial hemangioblastomas using a variety of embolic agents. METHODS A retrospective review of all surgically resected intracranial hemangioblastomas treated with preoperative embolization between 1999 and 2014 at 2 high-volume centers was performed. Clinical and radiographic criteria, including von Hippel-Lindau status, magnetic resonance imaging tumor characteristics, embolization-related complications, degree of angiographic devascularization, intraoperative blood loss, ability to obtain gross total resection, transfusion requirements, and operative time, were analyzed. RESULTS A total of 54 patients underwent surgery, with 24 undergoing preoperative embolization followed by surgical resection, and 30 patients undergoing surgical resection alone. Embolization-related neurological complications were seen in 6 patients (25%), including 3 hemorrhages when polyvinyl alcohol particles (P = .04) were used and 3 infarctions when liquid embolic agents were used (P = .27). Permanent neurological deficits were seen in 15%. CONCLUSION Preoperative embolization of intracranial hemangioblastomas should be performed with caution, given the potential for neurological morbidity. Further studies are needed to help guide patient and embolic agent selection.


title: Adherence to guideline-recommended therapy is associated with decreased major adverse cardiovascular events and major adverse limb events among patients with peripheral arterial disease.

text: BACKGROUND Current guidelines recommend that patients with peripheral arterial disease (PAD) cease smoking and be treated with aspirin, statin medications, and angiotensin-converting enzyme (ACE) inhibitors. The combined effects of multiple guideline-recommended therapies in patients with symptomatic PAD have not been well characterized. METHODS AND RESULTS We analyzed a comprehensive database of all patients with claudication or critical limb ischemia (CLI) who underwent diagnostic or interventional lower-extremity angiography between June 1, 2006 and May 1, 2013 at a multidisciplinary vascular center. Baseline demographics, clinical data, and long-term outcomes were obtained. Inverse probability of treatment propensity weighting was used to determine the 3-year risk of major adverse cardiovascular or cerebrovascular events (MACE; myocardial infarction, stroke, or death) and major adverse limb events (MALE; major amputation, thrombolysis, or surgical bypass). Among 739 patients with PAD, 325 (44%) had claudication and 414 (56%) had CLI. Guideline-recommended therapies at baseline included use of aspirin in 651 (88%), statin medications in 496 (67%), ACE inhibitors in 445 (60%), and smoking abstention in 528 (71%) patients. A total of 237 (32%) patients met all four guideline-recommended therapies. After adjustment for baseline covariates, patients adhering to all four guideline-recommended therapies had decreased MACE (hazard ratio [HR], 0.64; 95% CI, 0.45 to 0.89; P=0.009), MALE (HR, 0.55; 95% CI, 0.37 to 0.83; P=0.005), and mortality (HR, 0.56; 95% CI, 0.38 to 0.82; P=0.003), compared to patients receiving less than four of the recommended therapies. CONCLUSIONS In patients with claudication or CLI, combination treatment with four guideline-recommended therapies is associated with significant reductions in MACE, MALE, and mortality.


title: Recanalization and clinical outcome of occlusion sites at baseline CT angiography in the Interventional Management of Stroke III trial.

text: PURPOSE To use baseline computed tomographic (CT) angiography to analyze imaging and clinical end points in an Interventional Management of Stroke III cohort to identify patients who would benefit from endovascular stroke therapy. MATERIALS AND METHODS The primary clinical end point was 90-day dichotomized modified Rankin Scale (mRS) score. Secondary end points were 90-day mRS score distribution and 24-hour recanalization. Prespecified subgroup was baseline proximal occlusions (internal carotid, M1, or basilar arteries). Exploratory analyses were subsets with any occlusion and specific sites of occlusion (two-sided α = .01). RESULTS Of 656 subjects, 306 (47%) underwent baseline CT angiography or magnetic resonance angiography. Of 306, 282 (92%) had arterial occlusions. At baseline CT angiography, proximal occlusions (n = 220) demonstrated no difference in primary outcome (41.3% [62 of 150] endovascular vs 38% [27 of 70] intravenous [IV] tissue-plasminogen activator [tPA]; relative risk, 1.07 [99% confidence interval: 0.67, 1.70]; P = .70); however, 24-hour recanalization rate was higher for endovascular treatment (n = 167; 84.3% [97 of 115] endovascular vs 56% [29 of 52] IV tPA; P < .001). Exploratory subgroup analysis for any occlusion at baseline CT angiography did not demonstrate significant differences between endovascular and IV tPA arms for primary outcome (44.7% [85 of 190] vs 38% [35 of 92], P = .29), although ordinal shift analysis of full mRS distribution demonstrated a trend toward more favorable outcome (P = .011). Carotid T- or L-type occlusion (terminal internal carotid artery [ICA] with M1 middle cerebral artery and/or A1 anterior cerebral artery involvement) or tandem (extracranial or intracranial) ICA and M1 occlusion subgroup also showed a trend favoring endovascular treatment over IV tPA alone for primary outcome (26% [12 of 46] vs 4% [one of 23], P = .047). CONCLUSION Significant differences were identified between treatment arms for 24-hour recanalization in proximal occlusions; carotid T- or L-type and tandem ICA and M1 occlusions showed greater recanalization and a trend toward better outcome with endovascular treatment. Vascular imaging should be mandated in future endovascular trials to identify such occlusions. Online supplemental material is available for this article.