title: WEB-DL endovascular treatment of wide-neck bifurcation aneurysms: short- and midterm results in a European study.

text: BACKGROUND AND PURPOSE Flow disruption with the WEB-DL device has been used safely for the treatment of wide-neck bifurcation aneurysms, but the stability of aneurysm occlusion after this treatment is unknown. This retrospective multicenter European study analyzed short- and midterm data in patients treated with WEB-DL. MATERIALS AND METHODS Twelve European neurointerventional centers participated in the study. Clinical data and pre- and postoperative short- and midterm images were collected. An experienced interventional neuroradiologist independently analyzed the images. Aneurysm occlusion was classified into 4 grades: complete occlusion, opacification of the proximal recess of the device, neck remnant, and aneurysm remnant. RESULTS Forty-five patients (34 women and 11 men) 35-74 years of age (mean, 56.3 ± 9.6 years) with 45 aneurysms treated with the WEB device were included. Aneurysm locations were the middle cerebral artery in 26 patients, the posterior circulation in 13 patients, the anterior communicating artery in 5 patients, and the internal carotid artery terminus in 1 patient. Forty-two aneurysms were unruptured. Good clinical outcome (mRS < 2) was observed in 93.3% of patients at the last follow-up. Adequate occlusion (complete occlusion, opacification of the proximal recess, or neck remnant) was observed in 30/37 patients (81.1%) in short-term follow-up (median, 6 months) and in 26/29 patients (89.7%) in midterm follow-up (median, 13 months). Worsening of the aneurysm occlusion was observed in 2/28 patients (7.1%) at midterm follow-up. CONCLUSIONS The results suggest that the WEB endovascular treatment of wide-neck bifurcation aneurysms offers stable occlusion in a class of aneurysms that are historically unstable. Additionally, our data show that opacification of the WEB recess can be delineated from true neck or aneurysm remnants.


title: Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg.

text: OBJECTIVE Although all intracompartmental pressure (ICP) measurement, magnetic resonance imaging, and near-infrared spectroscopy seem to be useful in confirming the diagnosis of chronic exertional compartment syndrome (CECS), no standard diagnostic procedure is currently universally accepted. We reviewed systematically the relevant published evidence on diagnostic criteria commonly in use for CECS to address 3 main questions: (1) Is there a standard diagnostic method available? (2) What ICP threshold criteria should be used for diagnosing CECS? (3) What are the criteria and options for surgical management? Finally, we made statements on the strength of each diagnostic criterion of ICP based on a rigorous standardized process. DATA SOURCES We searched for studies that investigated ICP measurements in diagnosing CECS in the leg of human subjects, using PubMed, Score, PEDRO, Cochrane, Scopus, SportDiscus, Web of Knowledge, and Google Scholar. Initial searches were performed using the phrase, "chronic exertional compartment syndrome." The phrase "compartment syndrome" was then combined, using Boolean connectors ("OR" and "AND") with the words "diagnosis," "parameters," "levels," "localisation," or "measurement." Data extracted from each study included study design, number of subjects, number of controls, ICP instrument used, compartments measured, limb position during measurements, catheter position, exercise protocol, timing of measurements, mean resting compartment pressures, mean maximal compartment pressures, mean postexercise compartment pressures, diagnostic criteria used, and whether a reference diagnostic standard was used. The quality of studies was assessed based on the approach used by the American Academy of Orthopaedic Surgeons in judging the quality of diagnostic studies, and recommendations were made regarding each ICP diagnostic criteria in the literature by taking into account the quality and quantity of the available studies proposing each criterion. MAIN RESULTS In the review, 32 studies were included. The studies varied in the ICP measurement techniques used; the most commonly measured compartment was the anterior muscle compartment, and the exercise protocol varied between running, walking, and ankle plantarflexion and dorsiflexion exercises. Preexercise, mean values ranged from 7.4 to 50.8 mm Hg for CECS patients, and 5.7 to 12 mm Hg in controls; measurements during exercise showed mean pressure readings ranging from 42 to 150 mm Hg in patients and 28 to 141 mm Hg in controls. No overlap between subjects and controls in mean ICP measurements was found at the 1-minute postexercise timing interval only showing values ranging from 34 to 55.4 mm Hg and 9 to 19 mm Hg in CECS patients and controls, respectively. The quality of the studies was generally not high, and we found the evidence for commonly used ICP criteria in diagnosing CECS to be weak. CONCLUSIONS Studies in which an independent, blinded comparison is made with a valid reference standard among consecutive patients are yet to be undertaken. There should also be an agreed ICP test protocol for diagnosing CECS because the variability here contributes to the large differences in ICP measurements and hence diagnostic thresholds between studies. Current ICP pressure criteria for CECS diagnosis are therefore unreliable, and emphasis should remain on good history. However, clinicians may consider measurements taken at 1 minute after exercise because mean levels at this timing interval only did not overlap between subjects and controls in the studies we analyzed. Levels above the highest reported value for controls here (27.5 mm Hg) along with a good history, should be regarded as highly suggestive of CECS. It is evident that to achieve an objective recommendation for ICP threshold there is a need to set up a multi-center study group to reach an agreed testing protocol and modify the preliminary recommendations we have made.


England's new covid-19 monitoring outfit: the Joint Biosecurity Centre.


title: Subcutaneous placement of lap band port without fascial fixation provides safe and durable access.

text: BACKGROUND Laparoscopic adjustable gastric band access port has been routinely sutured to the anterior fascia of the abdominal wall using nonabsorbable sutures. We present our technique demonstrating that nonfascial fixation with using a mesh allows for a safe and durable placement of the port in the superficial subcutaneous tissue. METHODS Retrospective chart review included 102 consecutive patients who had Lap band surgery performed by single surgeon (EA) from June 2011 until April 2013. The port was sutured to a piece of polypropylene mesh and tunneled in the subcutaneous tissue away from the incision. Patients' demographics were analyzed as well as the following parameters: OR time for port placement, follow-up, port complications requiring revision, difficult access facilitated by fluoroscopy imaging, port infection, and skin erosion. RESULTS The study included 102 consecutive patients (23 males and 79 females), mean age was 49 years old, mean weight was 284.7 lb, mean height was 66.2 in., and mean body mass index (BMI) was 46.3 kg/m(2). The average operative time for port placement was 4 min, mean follow-up was 12 months, port complications occurred in 2 % of the patients while fluoroscopy for difficult port access was required in 3 %. No cases of port infections or skin erosions occurred. CONCLUSIONS Superficial subcutaneous placement of Lap Band Port using mesh fixation without anchoring the port to the fascia provides safe and durable access. Deep incisions to secure the port directly to the fascia might not be necessary.


Definitions of response and remission for the Robarts Histopathology Index.


Opinion: Intercepting pandemics through genomics.


title: Primary care management of the coronavirus (COVID-19).

text: South Africa is in the grip of a novel coronavirus pandemic (COVID-19). Primary care providers are in the frontline. COVID-19 is spread primarily by respiratory droplets contaminating surfaces and hands that then transmit the virus to another person's respiratory system. The incubation period is 2-9 days and the majority of cases are mild. The most common symptoms are fever, cough and shortness of breath. Older people and those with cardiopulmonary co-morbidities or immunological deficiency will be more at risk of severe disease. If people meet the case definition, the primary care provider should immediately adopt infection prevention and control measures. Diagnosis is made by a RT-PCR test using respiratory secretions, usually nasopharyngeal and oropharyngeal swabs. Mild cases can be managed at home with self-isolation, symptomatic treatment and follow-up if the disease worsens. Contact tracing is very important. Observed case fatality is between 0.5% and 4%, but may be overestimated as mild cases are not always counted. Primary care providers must give clear, accurate and consistent messages on infection prevention and control in communities and homes.


Letter: possible association of PPI use and spontaneous bacterial peritonitis--authors' reply.


title: Will there be a silver lining in the end? Lessons from and reflections on the COVID-19 pandemic in Hong Kong and beyond.

text: This article provides an analysis of the psychological and moral transformations as people confront the risk of infection, using Hong Kong as a case example. In the face of an unfamiliar threat, the need for uncertainty reduction gives rise to hasty, uncritical, and oversimplified assumptions about risk reduction, while prejudice against people and nations who do not share similar practices, as well as those symptomatic or at risk of catching the virus, ensue. The pandemic is eroding basic human decency and our compassion for one another while the human race battles a common threat to our destiny. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Pregnancy in a hermaphrodite with a male-predominant mosaic karyotype.

text: OBJECTIVE To report a pregnancy in a hermaphrodite and review of the literature. DESIGN Case report and literature review. SETTING Clinical. PATIENT(S) A patient with male-predominant mosaic karyotype 96% 46XY. INTERVENTION(S) Removal of left ovotestis in combination with a supracervical hysterectomy and bilateral salpingo-oophorectomy. MAIN OUTCOME MEASURE(S) Identification of published cases of pregnancy and hermaphroditism. RESULT(S) The current patient had previous pregnancy and a wedge biopsy of her left gonad, which demonstrated an ovotestis and an area suspicious for a gonadoblastoma. After delivery of her second pregnancy, the patient underwent a hysterectomy and bilateral salpingo-oophorectomy. The histopathologic evaluation following bilateral oophorectomy demonstrated a residual ovotestis without further evidence of a gonadoblastoma. Review of the literature identified 10 other cases of pregnancy in a hermaphrodite patient. CONCLUSION(S) This is the 11th reported case of fertility in a true hermaphrodite and only the second report of a mosaic true hermaphrodite to demonstrate fertility. This is the only case of a pregnancy involving a male-predominant mosaic 96% 46XY and the only case to confirm the genetics of the offspring.


title: The Potency of an Anti-MERS Coronavirus Subunit Vaccine Depends on a Unique Combinatorial Adjuvant Formulation.

text: Vaccination is one of the most successful strategies to prevent human infectious diseases. Combinatorial adjuvants have gained increasing interest as they can stimulate multiple immune pathways and enhance the vaccine efficacy of subunit vaccines. We investigated the adjuvanticity of Aluminum (alum) in combination with rASP-1, a protein adjuvant, using the Middle East respiratory syndrome coronavirus MERS-CoV receptor-binding-domain (RBD) vaccine antigen. A highly enhanced anti-MERS-CoV neutralizing antibody response was induced when mice were immunized with rASP-1 and the alum-adjuvanted RBD vaccine in two separate injection sites as compared to mice immunized with RBD + rASP-1 + alum formulated into a single inoculum. The antibodies produced also significantly inhibited the binding of RBD to its cell-associated receptor. Moreover, immunization with rASP-1 co-administered with the alum-adjuvanted RBD vaccine in separate sites resulted in an enhanced frequency of TfH and GC B cells within the draining lymph nodes, both of which were positively associated with the titers of the neutralizing antibody response related to anti-MERS-CoV protective immunity. Our findings not only indicate that this unique combinatorial adjuvanted RBD vaccine regimen improved the immunogenicity of RBD, but also point to the importance of utilizing combinatorial adjuvants for the induction of synergistic protective immune responses.


title: Large Volumes of Critically Hypoperfused Penumbral Tissue Do Not Preclude Good Outcomes After Complete Endovascular Reperfusion: Redefining Malignant Profile.

text: BACKGROUND AND PURPOSE Acute ischemic stroke patients with large volumes of severe hypoperfusion (Tmax>10 s>100 mL) on magnetic resonance imaging have a higher likelihood of intracranial hemorrhage and poor outcomes after reperfusion. We aim to evaluate the impact of the extent of Tmax>10 s CTP lesions in patients undergoing successful treatment. METHODS Retrospective database review of endovascular acute ischemic stroke treatment between September 2010 and March 2015 for patients with anterior circulation occlusions with baseline RAPID CTP and full reperfusion (mTICI 3). The primary outcome was the impact of the Tmax>10 s lesion spectrum on infarct growth. Secondary safety and efficacy outcomes included parenchymal hematomas and good clinical outcomes (90-day modified Rankin Scale score, 0-2). RESULTS Of 684 treated patients, 113 patients fit the inclusion criteria. Tmax>10 s>100 mL patients (n=37) had significantly higher baseline National Institutes of Health Stroke Scale (20.7±3.8 versus 17.0±5.9; P<0.01), more internal carotid artery terminus occlusions (29% versus 9%; P=0.02), and larger baseline (38.6±29.6 versus 11.7±15.8 mL; P<0.01) and final (60.7±60.0 versus 29.4±33.9 mL; P<0.01) infarct volumes when compared with patients without Tmax>10 s>100 mL (n=76); however, the 2 groups were otherwise well balanced. There were no significant differences in infarct growth (22.1±51.6 versus 17.8±32.4 mL; P=0.78), severe intracranial hemorrhage (PH2: 2% versus 4%; P=0.73), good outcomes (90-day mRS score, 0-2: 56% versus 59%; P=0.83), or 90-day mortality (16% versus 7%; P=0.28). On multivariate analysis, only baseline National Institutes of Health Stroke Scale (odds ratio, 1.19; 95% confidence interval, 1.06-1.34; P<0.01) and baseline infarct core volume (odds ratio, 1.05; 95% confidence interval, 1.02-1.08; P<0.01) were independently associated with Tmax>10 s>100 mL. There was no association between Tmax>10 s>100 mL with any PH, good outcome, or infarct growth. CONCLUSIONS In the setting of limited baseline ischemic cores, large Tmax>10 s lesions on computed tomographic perfusion do not seem to be associated with a higher risk of parenchymal hematomas and do not preclude good outcomes in patients undergoing endovascular reperfusion with contemporary technology.


title: Age-dependent dysregulation of innate immunity.

text: As we age, the innate immune system becomes dysregulated and is characterized by persistent inflammatory responses that involve multiple immune and non-immune cell types and that vary depending on the cell activation state and tissue context. This ageing-associated basal inflammation, particularly in humans, is thought to be induced by several factors, including the reactivation of latent viral infections and the release of endogenous damage-associated ligands of pattern recognition receptors (PRRs). Innate immune cell functions that are required to respond to pathogens or vaccines, such as cell migration and PRR signalling, are also impaired in aged individuals. This immune dysregulation may affect conditions associated with chronic inflammation, such as atherosclerosis and Alzheimer's disease.


title: Effectiveness of a nonpenetrating captive bolt for euthanasia of 3 kg to 9 kg pigs.

text: The objective of this study was to determine the effectiveness of a nonpenetrating captive bolt, Zephyr-E, for euthanasia of suckling and weaned pigs from 3 to 9 kg (5-49 d of age) using signs of insensibility and death as well as postmortem assessment of traumatic brain injury (TBI). The Zephyr-E was used by 15 stock people to euthanize 150 compromised pigs from 4 farrowing and nursery units from commercial farms and 2 research stations. Brainstem reflexes, convulsions, and heartbeat were used to assess insensibility, time of brain death, and cardiac arrest following Zephyr-E application. Skull fracture displacement (FD) was quantified from computed tomography (CT) scans (n = 24), macroscopic scoring was used to assess brain hemorrhage and skull fracture severity (n = 150), and microscopic scoring was used to assess subdural hemorrhage (SDH) and parenchymal hemorrhage within specific brain regions that are responsible for consciousness and vital function (n = 32). The Zephyr-E caused immediate, sustained insensibility until death in 98.6% of pigs. On average, clonic convulsions (CC) ceased in 82.2 s (± 3.4 SE), brain death was achieved in 144.9 s (± 5.4 SE), and cardiac arrest occurred in 226.5 s (± 8.7 SE). Time of brain death and cardiac arrest differed significantly among stock people (P = 0.0225 and P = 0.0369). Age was positively related to the duration of CC (P = 0.0092), time of brain death (P = 0.0025), and cardiac arrest (P = 0.0068) with shorter durations seen in younger pigs. Average FD was 8.3 mm (± 1.0 SE). Macroscopic scores were significantly different among weight classes for subcutaneous (P = 0.0402) and subdural-ventral (P = 0.0037) hemorrhage with the lowest severity hemorrhage found in the 9-kg weight category. Microscopic scores differed among brain sections (P = 0.0070) for SDH with lower scores found in the brainstem compared to the cerebral cortex and midbrain. Parenchymal hemorrhage differed among brain sections (P = 0.0052) and weight categories (P = 0.0128) with the lowest scores in the midbrain and brainstem and the 7- and 9-kg weight categories. The Zephyr-E was highly effective for the euthanasia of pigs up to 9 kg (49 d) based on immediate insensibility sustained until death. Postmortem results confirmed that severe skull fracture and widespread brain hemorrhage were caused by the Zephyr-E nonpenetrating captive bolt.


title: Evidence from the Cochrane Collaboration for Traditional Chinese Medicine therapies.

text: BACKGROUND The Cochrane Collaboration, an international not-for-profit organization that prepares and maintains systematic reviews of randomized trials of health care therapies, has produced reviews summarizing much of the evidence on Traditional Chinese Medicine (TCM). Our objective was to review the evidence base according to Cochrane systematic reviews. METHODS In order to detect reviews focusing on TCM, we searched the titles and abstracts of all reviews in Issue 4, 2008 of the Cochrane Database of Systematic Reviews. For each review, we extracted data on the number of trials included and the total number of participants. We provided an indication of the strength of the review findings by assessing the reviewers' abstract conclusions statement. We supplemented our assessment of the abstract conclusions statements with a listing of the comparisons and outcomes showing statistically significant meta-analyses results. RESULTS We identified 70 Cochrane systematic reviews of TCM, primarily acupuncture (n = 26) and Chinese herbal medicine (n = 42), and 1 each of moxibustion and t'ai chi. Nineteen (19) of 26 acupuncture reviews and 22/42 herbal medicine reviews concluded that there was not enough good quality trial evidence to make any conclusion about the efficacy of the evaluated treatment, while the remaining 7 acupuncture and 20 herbal medicine reviews and each of the moxibustion and t'ai chi reviews indicated a suggestion of benefit, which was qualified by a caveat about the poor quality and quantity of studies. Most reviews included many distinct interventions, controls, outcomes, and populations, and a large number of different comparisons were made, each with a distinct forest plot. CONCLUSIONS Most Cochrane systematic reviews of TCM are inconclusive, due specifically to the poor methodology and heterogeneity of the studies reviewed. Some systematic reviews provide preliminary evidence of Chinese medicine's benefits to certain patient populations, underscoring the importance and appropriateness of further research. These preliminary findings should be considered tentative and need to be confirmed with rigorous randomized controlled trials.


title: Prevalence of medicine use among Brazilian adults: a systematic review.

text: The use of medicine in adults has been assessed by some population-based studies in Brazil, but to date there has been no overall estimate of the prevalence of drug consumption. We therefore aimed to estimate the prevalence of medicine use as measured in previously reported cross-sectional studies among Brazilian adults. We conducted a systematic review of the literature, searching in MEDLINE, Embase among others to a date ending January 2017. Two researchers selected the studies, extracted data and assessed methodological quality of those chosen for inclusion. The consumption prevalence were combined in meta-analyses, the heterogeneity measured by I2 and investigated by subgroup analyses and meta-regression. The search identified 4,005 publications, of which 14 were ultimately included in the study. Most studies (12/14) measured the consumption over the previous 15 days, finding a consumption prevalence of 49.1% (95% CI: 48.5-49.6%, I2 = 100%). The recall period explains part of the heterogeneity found (R2 = 23%, p = 0.048), however the subgroup analysis did not allow for more homogeneous results. The use of medications occurs among almost half of all Brazilian adults. Appropriate pharmaceutical assistance and care are necessary to ensure the rational use of these technologies.


title: A randomized controlled cross-over trial and cost analysis comparing endoscopic ultrasound fine needle aspiration and fine needle biopsy.

text: BACKGROUND AND STUDY AIMS Techniques to optimize endoscopic ultrasound-guided tissue acquisition (EUS-TA) in a variety of lesion types have not yet been established. The primary aim of this study was to compare the diagnostic yield (DY) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for pancreatic and non-pancreatic masses. PATIENTS AND METHODS Consecutive patients referred for EUS-TA underwent randomization to EUS-FNA or EUS-FNB at four tertiary-care medical centers. A maximum of three passes were allowed for the initial method of EUS-TA and patients were crossed over to the other arm based on on-site specimen adequacy. RESULTS A total of 140 patients were enrolled. The overall DY was significantly higher with specimens obtained by EUS-FNB compared to EUS-FNA (90.0 % vs. 67.1 %, P = 0.002). While there was no difference in the DY between the two groups for pancreatic masses (FNB: 91.7 % vs. FNA: 78.4 %, P = 0.19), the DY of EUS-FNB was higher than the EUS-FNA for non-pancreatic lesions (88.2 % vs. 54.5 %, P = 0.006). Specimen adequacy was higher for EUS-FNB compared to EUS-FNA for all lesions (P = 0.006). There was a significant rescue effect of crossover from failed FNA to FNB in 27 out of 28 cases (96.5 %, P = 0.0003). Decision analysis showed that the strategy of EUS-FNB was cost saving compared to EUS-FNA over a wide range of cost and outcome probabilities. CONCLUSIONS RESULTS of this RCT and decision analysis demonstrate superior DY and specimen adequacy for solid mass lesions sampled by EUS-FNB.


title: Micromachined hot-wire thermal conductivity probe for biomedical applications.

text: This paper presents the design, fabrication, numerical simulation, and experimental validation of a micromachined probe that measures thermal conductivity of biological tissues. The probe consists of a pair of resistive line heating elements and resistance temperature detector sensors, which were fabricated by using planar photolithography on a glass substrate. The numerical analysis revealed that the thermal conductivity and diffusivity can be determined by the temperature response induced by the uniform heat flux in the heating elements. After calibrating the probe using a material (agar gel) of known thermal conductivity, the probe was deployed to calculate the thermal conductivity of Crisco. The measured value is in agreement with that determined by the macro-hot-wire probe method to within 3%. Finally, the micro thermal probe was used to investigate the change of thermal conductivity of pig liver before and after RF ablation treatment. The results show an increase in thermal conductivity of liver after the RF ablation.


title: Cognitive testing and revision of the pain quality assessment scale.

text: OBJECTIVE To revise the Pain Quality Assessment Scale (PQAS) using feedback from patients to further increase its validity. METHODS This project involved 3 cognitive interviewing studies. In Study 1, a group of patients with chronic pain (N=20) were asked a series of questions regarding the PQAS's understandability, and invited to make suggestions regarding how the measure could be improved. In Study 2, a second group of patients (N=21) responded to questions about a modified version of the PQAS. The PQAS was further modified on the basis of the findings of Study 2, and in Study 3 the participants were asked to indicate whether the changes made improved the understandability of the PQAS further. RESULTS The participants in Studies 1 and 2 identified portions of the PQAS instructions and some of the PQAS items that could be modified to increase their understandability. Modifications resulted in a revised PQAS that was deemed by patients with chronic pain to be more understandable than the original PQAS by the majority of participants. DISCUSSION testing can be used to improve the understandability of pain measures. The results of cognitive testing with the PQAS indicated that much of the content of the original instructions and items were understandable as written, but that minor changes could be made to make them even clearer to patients with chronic pain. The changes made resulted in a revised PQAS that is more understandable and may therefore be even more useful than with the original PQAS.


docid: xjwrljcg

title: Selection of patients for intra-arterial treatment for acute ischaemic stroke: development and validation of a clinical decision tool in two randomised trials.

text: Objective To improve the selection of patients with acute ischaemic stroke for intra-arterial treatment using a clinical decision tool to predict individual treatment benefit.Design Multivariable regression modelling with data from two randomised controlled clinical trials.Setting 16 hospitals in the Netherlands (derivation cohort) and 58 hospitals in the United States, Canada, Australia, and Europe (validation cohort).Participants 500 patients from the Multicenter Randomised Clinical Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands trial (derivation cohort) and 260 patients with intracranial occlusion from the Interventional Management of Stroke III trial (validation cohort).Main outcome measures The primary outcome was the modified Rankin Scale (mRS) score at 90 days after stroke. We constructed an ordinal logistic regression model to predict outcome and treatment benefit, defined as the difference between the predicted probability of good functional outcome (mRS score 0-2) with and without intra-arterial treatment.Results 11 baseline clinical and radiological characteristics were included in the model. The externally validated C statistic was 0.69 (95% confidence interval 0.64 to 0.73) for the ordinal model and 0.73 (0.67 to 0.79) for the prediction of good functional outcome, indicating moderate discriminative ability. The mean predicted treatment benefit varied between patients in the combined derivation and validation cohort from -2.3% to 24.3%. There was benefit of intra-arterial treatment predicted for some individual patients from groups in which no treatment effect was found in previous subgroup analyses, such as those with no or poor collaterals.Conclusion The proposed clinical decision tool combines multiple baseline clinical and radiological characteristics and shows large variations in treatment benefit between patients. The tool is clinically useful as it aids in distinguishing between individual patients who may experience benefit from intra-arterial treatment for acute ischaemic stroke and those who will not.Trial registration clinicaltrials.gov NCT00359424 (IMS III) and isrctn.com ISRCTN10888758 (MR CLEAN).


title: Evaluation of a newly developed piezo actuator-driven pulsed water jet system for liver resection in a surviving swine animal model.

text: BACKGROUND Preservation of the hepatic vessels while dividing the parenchyma is key to achieving safe liver resection in a timely manner. In this study, we assessed the feasibility of a newly developed, piezo actuator-driven pulsed water jet (ADPJ) for liver resection in a surviving swine model. METHODS Ten domestic pigs underwent liver resection. Parenchymal transection and vessel skeletonization were performed using the ADPJ (group A, n = 5) or an ultrasonic aspirator (group U, n = 5). The water jet was applied at a frequency of 400 Hz and a driving voltage of 80 V. Physiological saline was supplied at a flow rate of 7 ml/min. After 7 days, the animals were killed and their short-term complications were examined and compared between the two groups. RESULTS No significant complications, such as massive bleeding, occurred in either group during the surgical procedures. The transection time per transection area was significantly shorter in group A than in group U (1.5 ± 0.3 vs. 2.3 ± 0.5 min/cm(2), respectively, P = 0.03). Blood loss per transection area was not significantly different between groups A and U (9.3 ± 4.2 vs. 11.7 ± 2.3 ml/cm(2), P = 0.6). All pigs in group A survived for 7 days. No postoperative bleeding or bile leakage was observed in any animal at necropsy. CONCLUSION The present results suggested that the ADPJ reduces transection time without increasing blood loss. ADPJ is a safe and feasible device for liver parenchymal transection.


title: Six feet apart or six feet under: The impact of COVID-19 on the Black community.

text: To date, 110,000+ people in the United States have died from the COVID-19 pandemic. In this paper, the authors will discuss COVID-19 relative to Black people and their overrepresentation among those who are infected and died from the disease. Their dying, death, and grief experiences are explored through a cultural and spiritual lens. The physical distancing, social isolation, misinformation, and restrictive burials and cremations now elicited by this unprecedented pandemic have had diminished familial, cultural, emotional, and economic impacts on the Black community. Implications for public health and Black peoples' involvement in the political process are also addressed.


title: Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA versus PSV.

text: BACKGROUND Prolonged controlled mechanical ventilation depresses diaphragmatic efficiency. Assisted modes of ventilation should improve it. We assessed the impact of pressure support ventilation versus neurally adjusted ventilator assist on diaphragmatic efficiency. METHOD Patients previously ventilated with controlled mechanical ventilation for 72 hours or more were randomized to be ventilated for 48 hours with pressure support ventilation (n =12) or neurally adjusted ventilatory assist (n = 13). Neuro-ventilatory efficiency (tidal volume/diaphragmatic electrical activity) and neuro-mechanical efficiency (pressure generated against the occluded airways/diaphragmatic electrical activity) were measured during three spontaneous breathing trials (0, 24 and 48 hours). Breathing pattern, diaphragmatic electrical activity and pressure time product of the diaphragm were assessed every 4 hours. RESULTS In patients randomized to neurally adjusted ventilator assist, neuro-ventilatory efficiency increased from 27 ± 19 ml/μV at baseline to 62 ± 30 ml/μV at 48 hours (p <0.0001) and neuro-mechanical efficiency increased from 1 ± 0.6 to 2.6 ± 1.1 cmH2O/μV (p = 0.033). In patients randomized to pressure support ventilation, these did not change. Electrical activity of the diaphragm, neural inspiratory time, pressure time product of the diaphragm and variability of the breathing pattern were significantly higher in patients ventilated with neurally adjusted ventilatory assist. The asynchrony index was 9.48 [6.38- 21.73] in patients ventilated with pressure support ventilation and 5.39 [3.78- 8.36] in patients ventilated with neurally adjusted ventilatory assist (p = 0.04). CONCLUSION After prolonged controlled mechanical ventilation, neurally adjusted ventilator assist improves diaphragm efficiency whereas pressure support ventilation does not. TRIAL REGISTRATION ClinicalTrials.gov study registration: NCT02473172, 06/11/2015.


title: Hand-assisted hybrid laparoscopic-robotic total proctocolectomy with ileal pouch--anal anastomosis.

text: PURPOSE Few studies have reported minimally invasive total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We herein report a novel hand-assisted hybrid laparoscopic-robotic technique for patients with FAP and UC. METHODS Between February 2010 and March 2014, six patients underwent hand-assisted hybrid laparoscopic-robotic total proctocolectomy with IPAA. The abdominal colectomy was performed laparoscopically with hand assistance through a transverse suprapubic incision, also used to fashion the ileal pouch. The proctectomy was carried out with the da Vinci Surgical System. The IPAA was hand-sewn through a trans-anal approach. The procedure was complemented by a temporary diverting loop ileostomy. RESULTS The mean hand-assisted laparoscopic surgery (HALS) time was 154.6 (±12.8) min whereas the mean robotic time was 93.6 (±8.1) min. In all cases, a nerve-sparing proctectomy was performed, and no conversion to traditional laparotomy was required. The mean postoperative hospital stay was 13.2 (±7.4) days. No anastomotic leakage was observed. To date, no autonomic neurological disorders have been observed with a mean of 5.8 (±1.3) bowel movements per day. CONCLUSIONS The hand-assisted hybrid laparoscopic-robotic approach to total proctocolectomy with IPAA has not been previously described. Our report shows the feasibility of this hybrid approach, which surpasses most of the limitations of pure laparoscopic and robotic techniques. Further experience is necessary to refine the technique and fully assess its potential advantages.


title: Cross-species virus transmission and the emergence of new epidemic diseases.

text: Host range is a viral property reflecting natural hosts that are infected either as part of a principal transmission cycle or, less commonly, as "spillover" infections into alternative hosts. Rarely, viruses gain the ability to spread efficiently within a new host that was not previously exposed or susceptible. These transfers involve either increased exposure or the acquisition of variations that allow them to overcome barriers to infection of the new hosts. In these cases, devastating outbreaks can result. Steps involved in transfers of viruses to new hosts include contact between the virus and the host, infection of an initial individual leading to amplification and an outbreak, and the generation within the original or new host of viral variants that have the ability to spread efficiently between individuals in populations of the new host. Here we review what is known about host switching leading to viral emergence from known examples, considering the evolutionary mechanisms, virus-host interactions, host range barriers to infection, and processes that allow efficient host-to-host transmission in the new host population.


Virtual Conferences of dermatology during the COVID-19 Pandemic.


title: Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms.

text: BACKGROUND Many general thoracic surgeons are learning robotic pulmonary resection. METHODS We retrospectively compared results of completely portal robot lobectomy with 4 arms (CPRL-4) against propensity-matched controls and results after technical changes to CPRL-4. RESULTS In 14 months, 168 patients underwent robotic pulmonary resection: 7 had metastatic pleural disease, 13 had conversion to open procedures, and 148 had completion robotically (106 lobectomies, 26 wedge resections, 16 segmentectomies). All patients underwent R0 resection and removal of all visible lymph nodes (median of 5 N2, 3 N1 nodal stations, 17 lymph nodes). The 106 patients who underwent CPRL-4 were compared with 318 propensity-matched patients who underwent lobectomy by rib- and nerve-sparing thoracotomy. The robotic group had reduced morbidity (27% vs 38%; P = .05), lower mortality (0% vs 3.1%; P = .11), improved mental quality of life (53 vs 40; P < .001), and shorter hospital stay (2.0 vs 4.0 days; P = .02). Results of CPRL-4 after technical modifications led to reductions in median operative time (3.7 vs 1.9 hours; P < .001) and conversion (12/62 vs 1/106; P < .001). Technical improvements were addition of fourth robotic arm for retraction, vessel loop to guide the stapler, tumor removal above the diaphragm, and carbon dioxide insufflation. CONCLUSIONS The newly refined CPRL-4 is safe and yields an R0 resection with complete lymph node removal. It has lower morbidity, mortality, shorter hospital stay, and better quality of life than rib- and nerve-sparing thoracotomy. Technical advances are possible to shorten and improve the operation.


title: Pembrolizumab monotherapy versus chemotherapy for treatment of advanced urothelial carcinoma with disease progression during or following platinum-containing chemotherapy. A Cochrane Rapid Review.

text: BACKGROUND The use of systemic immunotherapy targets is emerging as an important treatment option for metastatic urothelial carcinoma, particularly for patients who cannot tolerate or who fail cisplatin-based chemotherapy. One such target is the inhibition of the checkpoint protein programmed cell death-1 (PD-1) receptor and its ligand (PD-L1) by monoclonal antibodies. OBJECTIVES To assess the effects of pembrolizumab monotherapy versus chemotherapy for treatment of advanced urothelial carcinoma with disease progression during or following platinum-containing chemotherapy. SEARCH METHODS We performed a Cochrane Rapid Review, limiting our search to published studies in the English language. We searched databases of the medical literature, including the Cochrane Central Register of Controlled Trials and MEDLINE, as well as trial registries including ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). Our search extended from January 2000 to June 2018. SELECTION CRITERIA We included randomised controlled trials except cross-over trials and cluster randomised trials. We excluded all other study designs. Participants included had locally advanced or metastatic urothelial carcinoma of the bladder, with disease progression during or following platinum-containing chemotherapy (synonymous with second-/third-/fourth-line therapy). This review focused on pembrolizumab (synonyms: MK-3475, lambrolizumab, Keytruda). DATA COLLECTION AND ANALYSIS Two review authors independently classified and abstracted data from the included study. The certainty of evidence was rated according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We identified one randomised controlled trial that included 542 participants, which compared the use of pembrolizumab monotherapy versus chemotherapy for the treatment of advanced urothelial carcinoma with disease progression during or following platinum-containing chemotherapy. Results were reported after a median follow-up of 14.1 months (range 9.9 to 22.1 months).Primary outcomesPembrolizumab probably reduces the risk of death from any cause (hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.59 to 0.90; moderate certainty evidence). This corresponds to 115 fewer deaths (191 fewer to 38 fewer) per 1000 participants with pembrolizumab at 12 months. We downgraded the certainty of evidence one level for imprecision.Pembrolizumab may slightly improve quality of life (change from baseline to week 15 assessed with the Core Quality of Life Questionnaire; higher value reflects better quality of life; scale 0 to 100) with a mean difference (MD) of 9.05, 95% CI 4.61 to 13.50; low certainty evidence). We downgraded the certainty of evidence two levels for study limitations and imprecision.Secondary outcomesPembrolizumab may have little or no effect on disease progression (HR 0.98, 95% CI 0.81 to 1.19; low certainty evidence). This corresponds to three fewer patients (42 fewer to 24 more) whose disease progressed per 1000 participants at 12 months. We downgraded the certainty of evidence two levels for study limitations and imprecision.Pembrolizumab probably improves treatment response (based on complete or partial radiologic response) with a risk ratio (RR) of 1.85, 95% CI 1.24 to 2.77; moderate certainty evidence). This corresponds to 97 more respondents (27 more to 202 more) per 1000 participants with pembrolizumab. We downgraded the certainty of evidence one level for imprecision.Pembrolizumab may have little or no effect on treatment-related mortality (RR 0.96, 95% CI 0.24 to 3.79; low certainty evidence). This corresponds to one fewer (12 fewer to 44 more) treatment-related deaths per 1000 participants with pembrolizumab. We downgraded the certainty of evidence two levels for study limitations and imprecision.Pembrolizumab may have little or no effect on discontinuations due to adverse events (RR 0.66, 95% CI 0.39 to 1.10). This corresponds to 54 fewer discontinuations per 1000 participants (95% CI 79 fewer to 7 more). We downgraded the certainty of evidence for study limitations and imprecision.Pembrolizumab may reduce serious adverse events (RR 0.83, 95 CI 0.72 to 0.97; low certainty evidence). This corresponds to 107 fewer serious averse events per 1000 participants (95% CI 19 fewer to 176 fewer). We downgraded two levels for study limitations and imprecision. AUTHORS' CONCLUSIONS The use of pembrolizumab in men with advanced urothelial carcinoma with disease progression during or following platinum-containing chemotherapy probably improves overall survival when compared with chemotherapy alone. At 12 months follow-up about 70% of those in the chemotherapy group had died, compared with 59% of those treated with pembrolizumab. We are very uncertain about the effects of pembolizumab on quality of life. Pembolizumab may also improve treatment response rates, and reduce the risk of serious adverse events, but may make little or no difference to discontinuations of treatment due to adverse events. These conclusions are based on a single trial that was sponsored by the producer of pembrolizumab.


title: Chicago Classification of Esophageal Motility Disorders: Lessons Learned.

text: PURPOSE OF REVIEW High-resolution manometry (HRM) is increasingly performed worldwide, to study esophageal motility. The Chicago classification is subsequently applied to interpret the manometric findings and facilitate a diagnosis of esophageal motility disorders. This review will discuss new insights regarding the diagnosis and management using the Chicago classification. RECENT FINDINGS Recent studies have demonstrated that high-resolution manometry is superior to conventional manometry, and has a higher sensitivity to diagnose achalasia. Furthermore, the subclassification of achalasia as used in the Chicago classification has prognostic value and can be used to direct treatment. Diagnosis of esophageal spasm has been improved by using the distal latency as diagnostic criterion. Recently, criteria for minor disorders of peristalsis have been sharpened, leading to a lower rate of patients with abnormal results, thereby increasing the relevance of a diagnosis. High-resolution manometry is now considered the gold standard for diagnosis of esophageal motility disorders. The Chicago classification provides a standardized approach for analysis and categorization of abnormalities that has led to a significant increase in our knowledge regarding the diagnosis and management of motility disorders. Further refinement of the classification will be required.


Protect Pregnant and Lactating Women with COVID-19 Through Research, Not from Research.


title: Autophagy deficiency in macrophages enhances NLRP3 inflammasome activity and chronic lung disease following silica exposure.

text: Autophagy is an important metabolic mechanism that can promote cellular survival following injury. The specific contribution of autophagy to silica-induced inflammation and disease is not known. The objective of these studies was to determine the effects of silica exposure on the autophagic pathway in macrophages, as well as the general contribution of autophagy in macrophages to inflammation and disease. Silica exposure enhanced autophagic activity in vitro in Bone Marrow derived Macrophages and in vivo in Alveolar Macrophages isolated from silica-exposed mice. Impairment of autophagy in myeloid cells in vivo using Atg5(fl/fl)LysM-Cre(+) mice resulted in enhanced cytotoxicity and inflammation after silica exposure compared to littermate controls, including elevated IL-18 and the alarmin HMGB1 in the whole lavage fluid. Autophagy deficiency caused some spontaneous inflammation and disease. Greater silica-induced acute inflammation in Atg5(fl/fl)LysM-Cre(+) mice correlated with increased fibrosis and chronic lung disease. These studies demonstrate a critical role for autophagy in suppressing silica-induced cytotoxicity and inflammation in disease development. Furthermore, this data highlights the importance of basal autophagy in macrophages and other myeloid cells in maintaining lung homeostasis.


title: Development and field evaluation of a nested RT-PCR kit for detecting Japanese encephalitis virus in mosquitoes.

text: A novel nested reverse transcription-polymerase chain reaction (RT-PCR)-based kit is described for detecting Japanese encephalitis virus (JEV), especially for genotype 1 and 3 strains. The assay consists of a first round RT-PCR and a subsequent nested PCR amplification. It has unique features such as the use of a premix system in which all reagents are lyophilized in reaction tubes and the inclusion of control RNA in each reaction to monitor false negative results. In addition, an automatic tissue homogenizer and a RNA extraction system are used concurrently for assay standardization and increasing throughput. The assay using the kit proved specific for JEV with no amplification of other JEV-related flaviviruses. The detection limits were approximately 0.1 PFU/ml and 1 PFU/ml for JEV genotypes 1 and 3, respectively. The assay protocol has been validated in large-scale field trials in South Korea during the 2008-2009 surveillance seasons. Nineteen of 1136 pools of mosquitoes (54,583 mosquitoes total) were identified as JEV positive. This nested RT-PCR kit combined with control RNA and an automatic RNA extraction system should be suitable for routine JEV surveillance programs.


docid: lbnbkqfh

title: Surgical placement of biologic mesh spacers prior to external beam radiation for retroperitoneal and pelvic tumors.

text: PURPOSE To determine the feasibility of surgical placement of biologic mesh spacers to displace bowel and other radiation-sensitive organs prior to external beam radiation for difficult retroperitoneal and pelvic tumors. METHODS AND MATERIALS Tumors were resected if possible, and intraoperative electron radiation therapy (IOERT) was directed to the tumor or tumor bed in selected patients. Biologic mesh spacers comprised of cadaveric human skin treated to remove cells and preserve extracellular matrix (Alloderm; Lifecell, Branchburg, NJ) were then placed around the tumor or tumor bed. External radiation techniques included proton beam radiation therapy (PBRT) and intensity modulated radiation therapy (IMRT). RESULTS Patients had primary sarcomas (n = 2), radiation-associated sarcomas (n = 1), or isolated metastases (n = 2) in the retroperitoneum or pelvis. One patient received preoperative radiation. Three tumors were marginally resected (R1 resection) while 2 tumors were left in situ, and 3 patients received IOERT (10-17 Gy) to the tumor or tumor bed. Up to 4 sheets of biologic mesh were used as spacers around the tumor or tumor bed to displace small bowel, colon, ureter, bladder, or pancreas. The average distance of the 4 closest organs prior to mesh placement was 1.3-9 mm and after mesh placement was 8.0-23.5 mm. Preoperative or postoperative radiation 36-76 Gy was delivered by IMRT or PBRT. There were no early complications from mesh placement and late complications possibly related to radiation included 1 vertebral body compression fracture and 1 deep vein thrombosis. There were no mesh-related infections and none of the meshes required removal. All 5 patients currently remain free of disease progression after 3-38 months. CONCLUSIONS Biologic mesh spacers can be placed around tumors or tumor beds to displace radiation-sensitive organs and may allow for safer delivery of external beam radiation.


title: Magnetic surgery: first U.S. experience with a novel device.

text: INTRODUCTION Magnet-assisted surgery is a new platform within minimally invasive surgery. The Levita™ Magnetic Surgical System, the first magnetic surgical system to receive Food and Drug Administration (FDA) approval, includes a deployable, magnetic grasper and an external magnet that is used to manipulate the grasper within the peritoneal cavity. This system is currently approved for patients undergoing laparoscopic cholecystectomy with a body mass index (BMI) between 21 and 34 kg/m2. Herein, we detail the first United States experience with the Levita™ Magnetic Surgical System during laparoscopic cholecystectomy. METHODS The Levita™ Magnetic Surgical System was used on consecutive patients undergoing laparoscopic cholecystectomy at our institution from June 2016 through November 2016. Only patients undergoing elective surgery and those with a body mass index (BMI) between 21 and 34 kg/m2 were included. Baseline patient characteristics, operative time, and perioperative details were collected. RESULTS A total of ten patients underwent laparoscopic cholecystectomy with the Levita™ Magnetic Surgical System during the defined study period. The mean age at the time of surgery was 49.0 years and the average BMI of the cohort was 27.6 kg/m2. The average operative time was 64.4 min. There were no perioperative complications. Seven (70.0%) patients were discharged to home on the day of surgery, while the remaining three (30.0%) patients were discharged to home on postoperative day number one. Surgeons reported that the magnetic grasper was easy to use and provided adequate tissue retraction and exposure. CONCLUSIONS The Levita™ Magnetic Surgical System is safe and feasible to use in patients undergoing laparoscopic cholecystectomy. Routine use of this system may facilitate a reduction in the total number of laparoscopic trocars used, leading to less tissue trauma and improved cosmesis. Additional studies are needed to determine the applicability and utility of this system for other general surgery cases.


docid: cpyrnkgu

title: The Nonoperative Instability Severity Index Score (NISIS): A Simple Tool to Guide Operative Versus Nonoperative Treatment of the Unstable Shoulder.

text: BACKGROUND The management of the adolescent athlete after initial shoulder instability remains controversial. HYPOTHESIS Individual risk factors in athletes with shoulder instability who are managed nonoperatively can be integrated into a scoring system that can predict successful return to sport. STUDY DESIGN Retrospective cohort study. LEVEL OF EVIDENCE Level 4. METHODS A total of 57 scholastic athletes with primary anterior shoulder instability who were managed nonoperatively were reviewed. Success was defined as a return to index sport at the same level and playing at least 1 subsequent season without missed time as a result of the shoulder. Patient-specific risk factors were individually evaluated, and odds ratios were calculated. A 10-point Nonoperative Injury Severity Index Score (NISIS) incorporated the risk factors for failure. This score was then retrospectively applied with regression analysis and a chi-square analysis to determine the overall optimal score that predicted failure of nonoperative management. RESULTS In total, 6 risk factors for failure were included in the NISIS: age (>15 years), bone loss, type of instability, type of sport (contact vs noncontact), male sex, and arm dominance. Overall, 79% of patients treated nonoperatively were able to successfully return to sport. Nearly all (97%) low-risk patients (NISIS <7) successfully returned to sport, while only 59% of high-risk patients returned to sport, a relative risk of 12.2 (P = 0.001). High-risk patients with unipolar bone loss successfully returned (100%), but 67% of high-risk patients with bipolar bone loss failed. CONCLUSION The NISIS is a simple and effective clinical tool to determine successful nonoperative management following anterior shoulder instability and may be helpful in guiding decision making when presented with the unstable shoulder in the scholastic athlete.


title: [99mTc(CO)3]+-(HE)3-ZIGF1R:4551, a new Affibody conjugate for visualization of insulin-like growth factor-1 receptor expression in malignant tumours.

text: PURPOSE Radionuclide imaging of insulin-like growth factor type 1 receptor (IGF-1R) expression in tumours might be used for selection of patients who would benefit from IGF-1R-targeted therapy. We have previously shown the feasibility of IGF-1R imaging using the Affibody molecule (111)In-DOTA-His(6)-Z(IGF1R:4551). The use of (99m)Tc instead of (111)In should improve sensitivity and resolution of imaging, and reduce the dose burden to patients. We hypothesized that inclusion of a HEHEHE tag instead of a His(6) tag in Z(IGF1R:4551) would permit its convenient purification using IMAC, enable labelling with [(99m)Tc(CO)(3)](+), and improve its biodistribution. METHODS Z(IGF1R:4551) was expressed with a HEHEHE tag in the N terminus. The resulting (HE)(3)-Z(IGF1R:4551) construct was labelled with [(99m)Tc(CO)(3)](+). Targeting of IGF-1R-expressing cells using [(99m)Tc(CO)(3)](+)-(HE)(3)-Z(IGF1R:4551) was evaluated in vitro and in vivo. RESULTS (HE)(3)-Z(IGF1R:4551) was stably labelled with (99m)Tc with preserved specific binding to IGF-1R-expressing DU-145 prostate cancer cells in vitro. In mice, [(99m)Tc(CO)(3)](+)-(HE)(3)-Z(IGF1R:4551) accumulated in IGF-1R-expressing organs (pancreas, stomach, lung and salivary gland). [(99m)Tc(CO)(3)](+)-(HE)(3)-Z(IGF1R:4551) demonstrated 3.6-fold lower accumulation in the liver and spleen than (111)In-DOTA-Z(IGF1R:4551). In NMRI nu/nu mice with DU-145 prostate cancer xenografts, the tumour uptake was 1.32 ± 0.11 %ID/g and the tumour-to-blood ratio was 4.4 ± 0.3 at 8 h after injection. The xenografts were visualized using a gamma camera 6 h after injection. CONCLUSION (99m)Tc(CO)(3)](+)-(HE)(3)-Z(IGF1R:4551) is a promising candidate for visualization of IGF-1R expression in malignant tumours.


title: Adhesiolysis-Related Challenges for Laparoscopic Procedures after Ventral Hernia Repair with Intraperitoneal Mesh.

text: Background: Laparoscopic procedures in patients with history of abdominal surgery can be challenging due to the unknown risk of postoperative adhesions (POA). The intraperitoneal onlay mesh procedures (IPOM) are frequently used for open or laparoscopic repair for incisional and ventral hernia. The risk of PoA can be increased in these patients, thus, any further laparoscopic exploration might be considered difficult. The aim of our study is to analyze the adhesiolysis-related challenges and complications in patients requiring laparoscopic surgery after IPOM ventral hernia repair. Methods: All the patients who underwent any laparoscopic procedure after open or video-assisted IPOM ventral hernia repair in Ponderas Academic Hospital from May 2011 to December 2018, were retrospectively analyzed. Two trained experts reviewed all video recordings and collected data on surgical history, adhesion location and density, dissection difficulty, interval time to release adhesions from the mesh and complications. Results: Twenty-nine patients were included into the study. There were 17 females, mean age of 58.0 +- 14.5 years, mean BMI of 28.7 +- 7.0 Kg/m2 and a median number of abdominal surgeries of 3/ patient. Risk factors for adhesion formation, other than the mesh itself were found in16 patients. The median time from the last IPOM procedure to the laparoscopic exploration was 26 months and it was related to the hernia repair technique in 21 patients and indicated for other pathologies in 8 patients.Adherences to the mesh were found in the majority of the cases (96%).The mean score of surface adhesion and adhesion tenacity was 4.0 +- 1.7 and 3.0 +- 0.8, respectively. The median time to complete the adhesiolysis to the mesh was 22 minutes. Small bowel was open during the dissection in six patients. Mesh migration was encountered in two. There were three conversions to open surgery and one to robotic surgery. History of peritonitis and septic complications at the last surgery were significantly associated with a higher rate of conversion. One surgical site infection and no mesh infection were encountered. The median postoperative hospital stay was 4 days. The 30-day postoperative mortality was nil. The median postoperative follow-up was 13 months. There are 3 recurrent incisional hernias. Conclusions: The study demonstrates that laparoscopic approach after previous IPOM is feasible but challenging. Adherences to the mesh are expected in the majority of the cases. History of peritonitis, a large number of open abdominal procedures, and septic complication at last surgery correlate with a high difficulty of adhesiolysis.


title: In vitro study of antimicrobial activity on Klebsiella Pneumoniae biofilms in endotracheal tubes.

text: Effective treatment approaches for biofilms in endotracheal tubes (ETTs) are lacking. In this study, we evaluated the in vitro effects of five antimicrobials against biofilms formed by Klebsiella pneumoniae in ETTs. K. pneumoniae was added to minimal mucin medium prior to inoculation in microtiter plates containing ETT fragments. Biofilm susceptibility was assessed by crystal violet staining. At 24 h, the antimicrobials significantly reduced biofilm formation. At 48 h, all of the antimicrobial agents exhibited significant reductions in biofilm formation, even at concentrations above the minimum inhibitory concentration (MIC). Tigecycline and fosfomycin showed the greatest inhibition capacity, with good activity at concentrations twofold greater than the MIC. K. pneumoniae exhibited excellent biofilm formation ability, with formation in the first 24 h and significantly reduced antimicrobial activity. These results contribute to the establishment of new antibiotic breakpoints for the adequate management of infections associated with biofilm formation. Abbreviations ETT Endotracheal tube MIC Minimum inhibitory concentration MBIC Minimum biofilm inhibitory concentration OD Optical density PBS Phosphate-buffered saline VAP Ventilator-associated pneumonia.


title: Chemerin, Inflammatory, and Nitrooxidative Stress Marker Changes Six Months after Sleeve Gastrectomy.

text: Background Chemerin is a chemokine known to be increased in morbidly obese (MO) patients and correlated with markers of inflammation and nitrooxidative stress. We aimed to evaluate the changes of serum chemerin six months after laparoscopic sleeve gastrectomy (SG) and to asses if these changes are accompanied by variations of inflammatory and nitrooxidative stress markers. Material and Methods We investigated the levels of chemerin, high-sensitive C-reactive protein (hsCRP), tumor necrosis factor alpha (TNF-α), nitrite and nitrate (NOx), total oxidant status (TOS), total antioxidant response (TAR), and oxidative stress index (OSI) in a group of 24 MO patients submitted to SG before and six months after surgery. The MO group was compared with 20 controls. Results hsCRP (p < 0.001), NOx (p < 0.001), TOS (p < 0.001), TAR (p = 0.007), and OSI (p = 0.001) were significantly different between the two groups. Six months after surgery, we noticed significant changes (42.28% decrease) of hsCRP (p = 0.044) and OSI (p = 0.041) (31.81% decrease), while no significant changes were observed for chemerin (p = 0.605), TNF-α (p = 0.287), NOx (p = 0.137), TOS (p = 0.158), and TAR (p = 0.563). Conclusions Our study showed no significant changes of chemerin, and except for hsCRP and OSI, no other inflammatory and nitrooxidative stress markers changed six months after surgery.


title: Nocturnal time monitoring behavior ("clock-watching") in patients presenting to a sleep medical center with insomnia and posttraumatic stress symptoms.

text: Time monitoring behavior (TMB) commonly occurs among insomnia patients, often leads to frustration about sleeplessness, and perpetuates insomnia symptoms. Few studies have explored relationships between time monitoring and insomnia, and none have studied the potential relationships between insomnia, TMB, and posttraumatic stress symptoms (PSSs). In this retrospective chart review of 1078 patients seeking care at a sleep medical center, the patients presented with one of three chief sleep complaints (poor sleep quality, 51%; sleep-disordered breathing, 26%; and insomnia, 24%), and 32% reported moderate to severe PSSs. Both insomnia and time monitoring severity were greater in the 350 patients with PSSs compared with the 728 patients with minimal or no such symptoms. Insomnia and time monitoring severity correlated significantly with total posttraumatic stress scores and most strongly with the arousal subscale. Research on interventions to treat TMB may inform relationships between insomnia and posttraumatic stress.


title: Effects of wound dressings on cultured primary keratinocytes.

text: Autologous cell-spray grafting of non-cultured epidermal cells is an innovative approach for the treatment of severe second-degree burns. After treatment, wounds are covered with dressings that are widely used in wound care management; however, little is known about the effects of wound dressings on individually isolated cells. The sprayed cells have to actively attach, spread, proliferate, and migrate in the wound for successful re-epithelialization, during the healing process. It is expected that exposure to wound dressing material might interfere with cell survival, attachment, and expansion. Two experiments were performed to determine whether some dressing materials have a negative impact during the early phases of wound healing. In one experiment, freshly isolated cells were seeded and cultured for one week in combination with eight different wound dressings used during burn care. Cells, which were seeded and cultured with samples of Adaptic(®), Xeroform(®), EZ Derm(®), and Mepilex(®) did not attach, nor did they survive during the first week. Mepitel(®), N-Terface(®), Polyskin(®), and Biobrane(®) dressing samples had no negative effect on cell attachment and cell growth when compared to the controls. In a second experiment, the same dressings were exposed to pre-cultured cells in order to exclude the effects of attachment and spreading. The results confirm the above findings. This study could be of interest for establishing skin cell grafting therapies in burn medicine and also for wound care in general.


title: A Report of the Telepsychiatric Evaluation of SARS-CoV-2 Patients.

text: Objective: During the current coronavirus disease 2019 (COVID-19) pandemic, telemedicine has been brought to the forefront of attention. This report aimed to assess psychiatric comorbidities in COVID-19 patients by utilizing telepsychiatry. Methods: COVID-19 patients admitted in Fasa University Hospital and nonhospitalized outpatients of Fasa city were interviewed by a psychiatrist through video chat for a 1-month period (March-April, 2020). Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Assessment (GAD-7), and Perceived Stress Scale-14 (PSS 14) questionnaires were administered for all patients. Each patient's mental status was recorded, and if any psychiatric problem was diagnosed, supportive psychotherapy, pharmacotherapy, and follow-up visits based on the patient's condition were started. Result: From a total of 82 COVID-19 patients who entered the study, 32 (39.03%) and 50 (60.97%) subjects were inpatients and outpatients, respectively. Moreover, 32 (39.03%) subjects were male and 50 (60.97%) were female. Insomnia seen in 24 (29.3%) patients and adjustment disorder in 13 (15.9%) patients were the most common psychiatric disorders among a total of 33 (40.2%) patients suffering from mental illness. Female and hospitalized patients presented significantly more frequent comorbidities than males and outpatients. Conclusions: Psychiatric disorders were significantly more common in patients with hospital admission than those without and more frequent in female versus male subjects. There were no significant differences between male and female subjects with and without admission according to the PHQ-9, GAD-7, and PSS-14 scores. It was concluded that telepsychiatry in the early stages of mental problems during a catastrophic event like the coronavirus pandemic, can be an efficient instrument for the screening of psychosomatic comorbidities, so that pharmacological treatment (considering possible drug interactions with COVID-19 medications) and psychotherapeutic intervention can be optimized by psychiatrists.


title: Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review.

text: Background Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines. Purpose To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment. Study Design Systematic review; Level of evidence, 4. Methods Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture. Results A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53). Conclusion Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.


Stenting in acute stroke: point.


title: Digital Education in Health Professions: The Need for Overarching Evidence Synthesis.

text: Synthesizing evidence from randomized controlled trials of digital health education poses some challenges. These include a lack of clear categorization of digital health education in the literature; constantly evolving concepts, pedagogies, or theories; and a multitude of methods, features, technologies, or delivery settings. The Digital Health Education Collaboration was established to evaluate the evidence on digital education in health professions; inform policymakers, educators, and students; and ultimately, change the way in which these professionals learn and are taught. The aim of this paper is to present the overarching methodology that we use to synthesize evidence across our digital health education reviews and to discuss challenges related to the process. For our research, we followed Cochrane recommendations for the conduct of systematic reviews; all reviews are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. This included assembling experts in various digital health education fields; identifying gaps in the evidence base; formulating focused research questions, aims, and outcome measures; choosing appropriate search terms and databases; defining inclusion and exclusion criteria; running the searches jointly with librarians and information specialists; managing abstracts; retrieving full-text versions of papers; extracting and storing large datasets, critically appraising the quality of studies; analyzing data; discussing findings; drawing meaningful conclusions; and drafting research papers. The approach used for synthesizing evidence from digital health education trials is commonly regarded as the most rigorous benchmark for conducting systematic reviews. Although we acknowledge the presence of certain biases ingrained in the process, we have clearly highlighted and minimized those biases by strictly adhering to scientific rigor, methodological integrity, and standard operating procedures. This paper will be a valuable asset for researchers and methodologists undertaking systematic reviews in digital health education.


docid: syafijdl

title: Conducting Clinical Trials During the COVID-19 Pandemic.

text: The COVID-19 pandemic has greatly impacted dermatology clinical trial operations due to mandated governmental and institutional shut-downs and newly implemented restrictions. During this unprecedented time, measures should be taken to maintain research conduct compliance while also ensuring the safety of trial staff and participants. Herein, we underscore the challenges facing dermatology trials during the COVID-19 pandemic, and offer strategies to maintain compliant and safe conduct.


title: Cerebellar hemangioblastoma supplied by persistent hypoglossal artery.

text: The authors report a unique case of an intramedullary cerebellar hemangioblastoma that was supplied by a persistent hypoglossal artery. In this case, recognition of the persistent hypoglossal artery through angiographic imaging was crucial in identifying tumor blood supply and in guiding the decision to perform a craniotomy without tumor embolization.


title: Robotic Reoperative Anti-reflux Surgery: Low Perioperative Morbidity and High Symptom Resolution.

text: BACKGROUND Laparoscopic reoperative anti-reflux surgery (ARS) has a significantly higher morbidity than laparoscopic primary ARS; however, it is not known whether the same pattern exists within the robotic approach. We aimed to evaluate the safety and efficacy of robotic reoperative ARS in comparison with primary robotic ARS. METHODS A retrospective review of patients undergoing primary or reoperative robotic ARS at a tertiary referral center between 2012 and 2017 was performed. Perioperative outcomes and long-term symptom resolution were evaluated. RESULTS A total of 200 patients were included (38 reoperative and 162 primary ARS). Baseline characteristics were comparable across groups. Seven (18.4%) of the reoperative patients had two or more prior foregut operations. Patients in the reoperative group had a longer operative time (226 vs. 180 min, p < 0.001). There were no conversions to open technique, and one patient in the reoperative group (2.6%) had an intraoperative perforation. Twenty of the 38 reoperative patients (52.6%) were discharged within 24 h as compared to 109/162 primary patients (64.9%) (p = 0.09). The readmission rate and postoperative complication rates were 6 and 3%, respectively, and did not differ between groups. At a mean follow-up of 1 year, complete or partial resolution of preoperative symptoms was achieved in 97% of primary patients and 100% of reoperative patients (p = 0.4). CONCLUSION The robotic approach allows for minimal morbidity, short length of stay, and excellent functional outcomes in patients undergoing reoperative ARS when compared to patients undergoing primary ARS.


title: Intermediate Muscle Length and Tendon Vibration Optimize Corticospinal Excitability During Knee Extensors Local Vibration.

text: While local vibration (LV) has been recently proposed as a potential modality for neuromuscular conditioning, no practical recommendations to optimize its effects have been published. Because changes in corticospinal excitability may reflect at which degree the neuromuscular function is modulated during LV exposure, this study investigated the effects of muscle length and vibration site on LV-induced on motor evoked potentials (MEPs) changes. Twenty-one subjects participated in a single session in which MEPs were evoked on the relaxed knee extensors (KE) during three conditions, i.e., no vibration (CON), muscle (VIBMU), and tendon vibration (VIBTD). Three muscle lengths were tested for each condition, i.e., short/intermediate/long KE muscle length. Both VIBMU and VIBTD significantly increase MEPs compared to CON. Higher increases (P < 0.001) were found for VIBTD compared to VIBMU for vastus lateralis (mean increases of the three angles: +241% vs.+ 148%), vastus medialis (+273% vs. + 180%) and rectus femoris muscles (+191% vs. +141%). The increase in MEPs amplitude was higher (p < 0.001) at an intermediate (mean pooled increase for VIBTD and VIBMU: +265%, +290%, and +212% for VL, VM, and RF, respectively) compared to short (+136%, + 144%, and + 127%) or long (+ 184%, + 246% and + 160%) muscle lengths. These results suggest that LV should be applied to the tendon at an intermediate muscle length to optimize the acute effects of LV on the KE neuromuscular function.


SARS-CoV-2 and COVID-19: facing the pandemic together as citizens and cardiovascular practitioners.


title: Relationship between roll-off occurrence and spatial distribution of dehydrated tissue during RF ablation with cooled electrodes.

text: PURPOSE To study the relationship between roll-off (sudden increase in impedance) and spatial distribution of dehydrated tissue during RF ablation using a cooled electrode (temperatures around 100°C). METHODS We used a double approach: (1) theoretical modelling based on the finite element method, and (2) 20 ablations using an experimental study on ex vivo excised bovine liver in which we measured impedance progress and temperature at three points close to the electrode surface: 0.5 (T1), 1.5 (T2) and 2.5 (T3) mm from the tip. T2 was located exactly at the centre of the 30 mm long electrode. RESULTS Temperatures at T1 and T3 quickly rose to 100°C (at ≈20 and 40 s, respectively), while at the rise at T2 was somewhat slower, stabilized around 50 s and reached a maximum value of 99°C at about 60 s. Impedance reached a minimum of 65 Ω (plateau), began increasing at 50 s and continued rising throughout the procedure, reaching a value equal to the initial value at 70 s. Likewise, computed impedance dropped to ≈73 Ω (plateau), began increasing at 50 s and reached an impedance value equal to the initial value at ≈78 s, which approximately coincided with the time when the entire zone surrounding the electrode was within the 100°C isotherm. CONCLUSION There is a close relationship between the moment at which roll-off occurs and the time when the entire electrode is completely encircled by the dehydrated tissue. The mid-electrode zone is the last in which tissue desiccation occurs.


title: Blunted cerebral vascular responsiveness to hypercapnia in obese individuals.

text: NEW FINDINGS What is the central question of this study? Is there a difference in the cerebral vascular response to rebreathing-induced hypercapnia between obese and lean individuals? What is the main finding and its importance? The main finding is that obese individuals have an attenuated increase in cerebral vascular conductance during hypercapnia relative to lean individuals. This finding suggests cerebral vascular dysfunction in this population, which might contribute to the greater prevalence of cerebral vascular and neurocognitive disease in this population. Obesity increases the risk of cardiovascular disease by >45%. Furthermore, obesity is a contributory factor to cognitive impairment and Alzheimer's disease. The mechanisms accounting for this increased disease risk have not been clarified. This study tested the hypothesis that the total range of change (a) in cerebral blood velocity (CBV) and cerebral vascular conductance (CVCI) and the maximal (y0) CBV and CVCI achieved during rebreathing-induced hypercapnia would be attenuated in obese individuals. Sixteen lean and 15 obese individuals participated. The magnitude of rebreathing-induced hypercapnia was similar between groups (lean, ∆15 ± 3 mmHg versus obese, ∆15 ± 2 mmHg; P = 0.82). The total range of change in CBV during rebreathing (a; expressed as a percentage) was similar between groups (lean, 91 ± 24% versus obese, 76 ± 19%, P = 0.07), whereas the total range of change in CVCI during rebreathing (a; expressed as a percentage) was attenuated in the obese individuals (lean, 71 ± 20% versus obese, 51 ± 15%, P < 0.01). Likewise, the maximal increase in CBV during rebreathing (y0; expressed as a percentage) was similar between groups (lean, 189 ± 22% versus obese, 179 ± 20%, P = 0.20), whereas the maximal increase in CVCI during rebreathing (y0; expressed as a percentage) was attenuated in the obese individuals (lean, 172 ± 19% versus obese, 155 ± 17 %, P = 0.01). These data indicate that the cerebral vascular response to rebreathing-induced hypercapnia is attenuated in obese individuals. This impairment might be a factor contributing to the elevated cerebral vascular and neurocognitive disease risk in this population.


title: Neurological morbidity and mortality associated with the endovascular treatment of cerebral arteriovenous malformations before and during the Onyx era.

text: OBJECT The widespread implementation of the embolic agent Onyx has changed the endovascular management of cerebral arteriovenous malformations (AVMs). Recent data suggest that outcomes following embolization and resection may have worsened in the Onyx era. It has been hypothesized that there may be increased complications with Onyx embolization and increased surgical aggressiveness in patients treated with Onyx. In this study the authors analyzed their institutional experience with the endovascular treatment of cerebral AVMs prior to and after the introduction of Onyx to determine factors associated with periprocedural neurological morbidity and mortality. METHODS A retrospective review was performed of all patients with cerebral AVMs undergoing embolization at the Barrow Neurological Institute from 1995 to 2012. RESULTS Endovascular treatment of 342 cerebral AVMs was performed over 446 treatment sessions (mean age 37.8 years, range 1-83 years). Clinical presentation included hemorrhage in 47.6%, seizures in 21.9%, headaches in 11.1%, and no symptoms in 10% of cases. The endovascular pretreatment strategy was preoperative in 78.9%, preradiosurgery in 9.1%, palliative in 5.3%, targeted in 4.4%, and curative in 2.3%. The median Spetzler-Martin grade was III. The mean number of arteries embolized was 3.5 (range 0-13 arteries), and the mean number of treatment sessions was 1.3 (range 1-4 sessions). Onyx was used in 105 AVMs (30.7%), and N-butyl cyanoacrylate (NBCA) without Onyx was used in 229 AVMs (67%). AVMs treated with Onyx had a higher mean number of arterial pedicles embolized than did NBCA cases (4.3 ± 2.7 vs 3.2 ± 2.4, respectively; p < 0.001) and a greater number of sessions (1.5 ± 0.7 vs 1.2 ± 0.5, respectively; p < 0.05). Unexpected immediate postprocedural permanent neurological deficits were present in 9.6% of AVMs, while transient deficits were present in 1.8%. There was 1 death (0.3%). Spetzler-Martin grade was not associated with differences in outcome, as permanent neurological deficits were observed in 12%, 9%, 13%, 11%, and 13% of AVMs for Spetzler-Martin Grades I-V, respectively (p = 0.91). The use of Onyx compared with NBCA was not associated with differences in periprocedural morbidity (p = 0.23). This lack of a difference persisted even when controlling for number of arteries and sessions (p = 0.14). Sex was not associated with differences in outcome. CONCLUSIONS Permanent and transient postprocedural neurological deficits were noted in 9.6% and 1.8% of all cases, respectively. AVM grade was not associated with endovascular outcome. Despite the greater number of sessions required and arteries embolized for Onyx cases, there was no statistically significant difference in the risk of neurological deficits following cerebral AVM embolization with Onyx and NBCA.


title: Identification of diverse groups of endogenous gammaretroviruses in mega- and microbats.

text: A previous phylogenetic study suggested that mammalian gammaretroviruses may have originated in bats. Here we report the discovery of RNA transcripts from two putative endogenous gammaretroviruses in frugivorous (Rousettus leschenaultii retrovirus, RlRV) and insectivorous (Megaderma lyra retrovirus, MlRV) bat species. Both genomes possess a large deletion in pol, indicating that they are defective retroviruses. Phylogenetic analysis places RlRV and MlRV within the diversity of mammalian gammaretroviruses, with the former falling closer to porcine endogenous retroviruses and the latter to Mus dunni endogenous virus, koala retrovirus and gibbon ape leukemia virus. Additional genomic mining suggests that both microbat (Myotis lucifugus) and megabat (Pteropus vampyrus) genomes harbour many copies of endogenous retroviral forms related to RlRV and MlRV. Furthermore, phylogenetic analysis reveals the presence of three genetically diverse groups of endogenous gammaretroviruses in bat genomes, with M. lucifugus possessing members of all three groups. Taken together, this study indicates that bats harbour distinct gammaretroviruses and may have played an important role as reservoir hosts during the diversification of mammalian gammaretroviruses.


title: Comparison of remifentanil EC50 for facilitating i-gel and laryngeal mask airway insertion with propofol anesthesia.

text: OBJECTIVE Each supraglottic airway requires different anesthetic depth because it has a specific structure and different compressive force in the oropharyngeal cavity. We designed the study to compare the effect-site concentration (Ce) of remifentanil in 50 % of patients (EC50) for successful insertion of the i-gel second-generation supraglottic airway device with that for laryngeal mask airway (LMA) insertion during target-controlled infusion (TCI) of propofol. METHODS Forty-one female patients were randomized to the i-gel group (n = 20) or the LMA group (n = 21). Anesthesia was induced with propofol Ce of 5 μg/ml and the predetermined remifentanil Ce, and the i-gel or LMA was inserted 5 min later. The remifentanil Ce was estimated by modified Dixon's up-and-down method (initial concentration: 3.0 ng/ml, step size: 0.5 ng/ml). The patient's response to device insertion was classified as either "success (no movement)" or "failure (movement)". RESULTS Using the Dixon's up-and-down method, EC50 of remifentanil Ce for the i-gel (1.58 ± 0.41 ng/ml) was significantly lower than that for LMA (2.25 ± 0.55 ng/ml) (p = 0.038). Using isotonic regression, EC50 (83 % CI) of remifentanil in the i-gel group [1.50 (1.37-1.80) ng/ml] was statistically lower than that in the LMA group [2.00 (1.82-2.34) ng/ml]. EC95 (95 % CI) of remifentanil in the i-gel group [2.38 (1.48-2.50) ng/ml] was statistically lower than that in the LMA group [3.35 (2.58-3.48) ng/ml]. CONCLUSIONS We found that EC50 of remifentanil Ce for i-gel insertion (1.58 ng/ml) was significantly lower than that for LMA insertion (2.25 ng/ml) in female patients during propofol TCI without neuromuscular blockade.


title: Continuous positive airway pressure for bronchiolitis in a general paediatric ward; a feasibility study.

text: BACKGROUND Continuous positive airway pressure (CPAP) is commonly used to relieve respiratory distress in infants with bronchiolitis, but has mostly been studied in an intensive care setting. Our prime aim was to evaluate the feasibility of CPAP for infants with bronchiolitis in a general paediatric ward, and secondary to assess capillary PCO2 (cPCO2) levels before and during treatment. METHODS From May 1(st) 2008 to April 30(th) 2012, infants with bronchiolitis at Stavanger University Hospital were treated with CPAP in a general paediatric ward, but could be referred to an intensive care unit (ICU) when needed, according to in-house guidelines. Levels of cPCO2 were prospectively registered before the start of CPAP and at approximately 4, 12, 24 and 48 hours of treatment as long as CPAP was given. We had a continuous updating program for the nurses and physicians caring for the infants with CPAP. The study was population based. RESULTS 672 infants (3.4%) were hospitalized with bronchiolitis. CPAP was initiated in 53 infants (0.3%; 7.9% of infants with bronchiolitis), and was well tolerated in all but three infants. 46 infants were included in the study, the majority of these (n = 33) were treated in the general ward only. These infants had lower cPCO2 before treatment (8.0; 7.7, 8.6)(median; quartiles) than those treated at the ICU (n = 13) (9.3;8.5, 9.9) (p < 0.001). The level of cPCO2 was significantly reduced after 4 h in both groups; 1.1 kPa (paediatric ward) (p < 0.001) and 1.3 kPa (ICU) (p = 0.002). Two infants on the ICU did not respond to CPAP (increasing cPCO2 and severe apnoe) and were given mechanical ventilation, otherwise no side effects were observed in either group treated with CPAP. CONCLUSION Treatment with CPAP for infants with bronchiolitis may be feasible in a general paediatric ward, providing sufficient staffing and training, and the possibility of referral to an ICU when needed.


title: Laparoscopic extralevator abdominoperineal excision of the rectum: short-term outcomes of a prospective case series.

text: BACKGROUND Laparoscopic approaches for the resection of low rectal cancer and the extralevator technique for abdominoperineal excision are both becoming increasingly popular. There are little published data regarding the combined application of these techniques to the resection of low rectal tumours. The aim of this study was to assess the feasibility of such an approach and to appraise short-term outcomes in a consecutive series of patients undergoing laparoscopic extralevator abdominoperineal excision (ELAPE). METHODS Consecutive patients undergoing laparoscopic ELAPE at our institution between 2008 and 2011 were identified from a prospectively maintained database. The abdominal phase of the operation was performed laparoscopically, and following extralevator resection, the perineum was reconstructed using a biologic mesh. All patients were enrolled in an enhanced recovery programme. RESULTS Of 166 patients undergoing radical resection of rectal cancer at our institution between 2008 and 2011, 28 underwent laparoscopic ELAPE. Median age was 70 years, median body mass index was 27.5 kg/m(2), and 71% were male. The conversion rate to laparotomy was 18%. Three patients (10.8%) had circumferential resection margins <1 mm; no intraoperative tumour perforation occurred. The median length of stay was 7 days, with a 30-day readmission rate of 21% and no 30-day mortality. Post-operative perineal wound complications occurred in 25%. At median 38-month follow-up (range 23-66 months), overall survival was 75%, disease-free survival was 71%, and there were three local recurrences (11%). CONCLUSIONS Laparoscopic extralevator abdominoperineal excision can be safely performed without compromising short-term outcomes.


Metformin for women with hyperandrogenic anovulation.


title: Ultrasound-guided photoacoustic imaging-directed re-endothelialization of acellular vasculature leads to improved vascular performance.

text: UNLABELLED As increasing effort is dedicated to investigating the regenerative capacity of decellularized tissues, research has progressed to recellularizing these tissues prior to implantation. The delivery and support of cells seeded throughout acellular scaffolds are typically conducted through the vascular axis of the tissues. However, it is unclear how cell concentration and injection frequency can affect the distribution of cells throughout the scaffold. Furthermore, what effects re-endothelialization have on vascular patency and function are not well understood. We investigated the use of ultrasound-guided photoacoustic (US/PA) imaging as a technique to visualize the distribution of microvascular endothelial cells within an optimized acellular construct upon re-endothelialization and perfusion conditioning. We also evaluated the vascular performance of the re-endothelialized scaffold using quantitative vascular corrosion casting (qVCC) and whole-blood perfusion. We found US/PA imaging was an effective technique to visualize the distribution of cells. Cellular retention following perfusion conditioning was also detected with US/PA imaging. Finally, we demonstrated that a partial recovery of vascular performance is possible following re-endothelialization-confirmed by fewer extravasations in qVCC and improved blood clearance following whole-blood perfusion. STATEMENT OF SIGNIFICANCE Re-endothelialization is a method that enables decellularized tissue to become useful as a tissue engineering construct by creating a nutrient delivery and waste removal system for the entire construct. Our approach utilizes a decellularization method that retains the basement ECM of a highly vascularized tissue upon which endothelial cells can be injected to form an endothelium. The US/PA method allows for rapid visualization of cells within a construct several cm thick. This approach can be experimentally used to observe changes in cellular distribution over large intervals of time, to help optimize cell seeding parameters, and to verify cell retention within re-endothelialized constructs. This approach has temporal and depth advantages compared to section reconstruction and imaged fluorophores respectively.


title: Sex differences in quality of life after ischemic stroke.

text: OBJECTIVE We aimed to compare quality of life (QOL) in women and men after ischemic stroke or TIA, and to determine the incremental impact of demographic, socioeconomic, clinical, and stroke-specific effects on longitudinal QOL. METHODS We assessed QOL in patients with ischemic stroke or TIA at 3 and 12 months postdischarge in the Adherence eValuation After Ischemic stroke-Longitudinal Registry using the European Quality of Life-5 Dimensions (EQ-5D) instrument. We generated multivariable linear regression models to evaluate the association between sex and EQ-5D while sequentially adjusting for sociodemographic, clinical, and stroke-related variables. We also used a proportional odds model to assess sex differences in the change in EQ-5D scores from 3 to 12 months. RESULTS A total of 1,370 patients were included, 53.7% male, median age 65 years (interquartile range 56-77 years). Women had significantly lower QOL at 3 months (unadjusted EQ-5D 0.81 in women vs 0.84 in men; p < 0.001) and 12 months (0.83 vs men 0.84; p < 0.001) poststroke. After multivariable adjustment for sociodemographic, clinical, and stroke-related factors, women continued to have lower QOL at 3 months (mean difference -0.036; p = 0.003) and at 12 months (mean difference -0.022; p = 0.046). Women fared worse in the dimensions of mobility, pain/discomfort, and anxiety/depression at 3 and 12 months. There were no sex differences in change in EQ-5D score from 3 to 12 months. CONCLUSION Women have worse QOL than men up to 12 months after stroke, even after adjusting for important sociodemographic variables, stroke severity, and disability.


title: Persistent SARS-CoV-2 infection and the risk for cancer.

text: The current SARS-CoV-2 has put significant strain on healthcare services worldwide due to acute COVID-19. However, the potential long-term effects of this infection haven't been extensively discussed. We hypothesize that SARS-CoV-2 may be able to cause persistent infection in some individuals, and should this be the case, that in a few years we may see a rise in cancer incidence due to carcinogenic effects of this coronavirus. Non-retroviral RNA viruses such as Coronaviridae have been shown to cause persistent infection in hosts. Empirical evidence of viral genomic material shedding weeks after apparent clinical and laboratorial resolution of COVID-19 may be an indirect proof for persistent viral infection. Furthermore, tropism towards certain immune-privileged territories may facilitate immune evasion by this virus. Structural homology with SARS-CoV-1 indicates that SARS-CoV-2 may be able to directly impair pRb and p53, which are key gatekeepers with tumor suppressor functions. Additionally, COVID-19 features preeminent inflammatory response with marked oxidative stress, which acts as both as initiator and promotor of carcinogenesis. Should there be a carcinogenic risk associated with SARS-CoV-2, the implications for public health are plenty, as infected patients should be closely watched during long periods of follow-up. Additional investigation to establish or exclude the possibility for persistent infection is paramount to identify and prevent possible complications in the future.


title: Fast left prefrontal rTMS acutely suppresses analgesic effects of perceived controllability on the emotional component of pain experience.

text: The prefrontal cortex may be a promising target for transcranial magnetic stimulation (TMS) in the management of pain. It is not clear how prefrontal TMS affects pain perception, but previous findings suggest that ventral lateral and medial prefrontal circuits may comprise an important part of a circuit of perceived controllability regarding pain, stress, and learned helplessness. Although the left dorsolateral prefrontal cortex is a common TMS target for treating clinical depression as well as modulating pain, little is known about whether TMS over this area may affect perceived controllability. The present study explored the immediate effects of fast TMS over the left dorsolateral prefrontal cortex on the analgesic effects of perceived pain controllability. Twenty-four healthy volunteers underwent a laboratory pain task designed to manipulate perception of pain controllability. Real TMS, compared with sham, suppressed the analgesic benefits of perceived control on the emotional dimension of pain, but not the sensory/discriminatory dimension. Findings suggest that, at least acutely, fast TMS over the left dorsolateral prefrontal cortex may interrupt the perceived-controllability effect on the emotional dimension of pain experience. Although it is not clear whether this cortical area is directly involved with modulating perceived controllability or whether downstream effects are responsible for the present findings, it appears possible that left dorsolateral prefrontal TMS may produce analgesic effects by acting through a cortical perceived-control circuit regulating limbic and brainstem areas of the pain circuit. Despite evidence that prefrontal TMS can have analgesic effects, fast left prefrontal TMS appears to acutely suppress analgesia associated with perceived-control. This effect may be limited to the emotional dimension of pain experience.


Chest CT in coronavirus pandemic. Are there really age based radiological and clinical differences?