title: An integrated anaerobic system for on-site treatment of wastewater from food waste disposer.

text: In this study, an integrated system of siphon-driven self-agitated anaerobic reactor (SDSAR) and anaerobic fixed bed reactor (AFBR) was conducted for the treatment of wastewater from food waste disposer (FWD), and the effect of influent total solids (TS) concentration on the process performance was evaluated. When the influent TS concentration increased from 7.04 to 15.5 g/L, the methane gas production rate increased from 0.45 to 0.92 L-CH4/L/day. However, with the influent TS concentration of food waste (FW) further increased to 23.5 g/L, a large amount of scum formed and accumulated in the SDSAR. According to the result of chemical oxygen demand (COD) recovery, the proportion of COD remained in the effluent at different TS concentrations was only around 2%. On the other hand, with an increase in TS concentration, the proportion of COD remained in the reactors increased significantly. Our results demonstrated that effluent from the integrated system can meet the water quality requirements recommended by Japan Sewage Works Association (JSWA) for wastewater from FWD. In addition, to enhance the process stability, the influent TS concentration should be maintained below 15.5 g/L.


title: Emerging viral STIs among HIV-positive men who have sex with men: the era of hepatitis C virus and human papillomavirus.

text: The number of infectious disease outbreaks and the number of unique pathogens responsible have significantly increased since the 1980s. HIV-positive men who have sex with men (MSM) are a vulnerable population with regards to the introduction, spread and clinical consequences of (newly introduced) STIs. After the introduction of combination antiretroviral treatment (cART), the incidence of sexually acquired hepatitis C virus (HCV) infection and human papillomavirus (HPV)-induced anal cancers have significantly increased among HIV-positive MSM. The introduction and expansion of HCV is the result of increased sexual risk behaviour and sexually acquired mucosal trauma within large interconnected networks of HIV-positive MSM in particular. With the availability of cART, postexposure and pre-exposure prophylaxis (PEP and PrEP) and direct-acting antivirals (DAAs) for HCV, less concern for HIV and HCV might require a new approach to develop effective behavioural intervention strategies among MSM. The marked rise in HPV-induced anal cancers can be ascribed to the long-term immunologic defects in an ageing population affected by HIV. More evidence with regards to effective treatment options for anal dysplastic lesions and the usefulness of anal malignancy screening programmes is urgently needed. Most anal cancers in the future generation of HIV-positive MSM could be prevented with the inclusion of boys in addition to girls in current HPV vaccination programmes.


title: Utility of chest CT in diagnosis of COVID-19 pneumonia.

text: PURPOSE We aimed to explore the imaging findings of computed tomography (CT) in diagnosing coronavirus disease 2019 (COVID-19) and its clinical value for further evaluation of suspected cases. METHODS Files of 155 patients visiting the fever clinics at our hospital and affiliated hospitals from January 20th to February 9th, 2020 were searched. Among them, 140 cases (including 82 males and 58 females) were included as suspected COVID-19 cases based on clinical and epidemiological history; the CT image features of 70 cases with suggestive findings on CT, confirmed by positive nucleic acid test were analyzed and evaluated. The sensitivity and specificity of CT in diagnosing COVID-19 were evaluated in patients with epidemiological history. RESULTS Of the 70 patients, 84.3% showed bilateral lung involvement on CT; 27 cases (38.6%) showed ground-glass opacity (GGO), which was mostly distributed in the subpleural area (55.7%), and this sign was mainly observed in early COVID-19 patients. In addition, 41 cases (58.6%) manifested GGO combined with focal consolidation opacity, 2 (2.8%) had flake-like consolidation opacity, with involvements of the periphery of lung field and the central zone (44.3%), and this sign was mostly observed in severe or critical patients. Concomitant signs such as pleural effusion and mediastinal lymph node enlargement were rare. Among patients with epidemiological history, the sensitivity of CT in diagnosing COVID-19 was 89.7% (70/78), and the specificity was 88.7% (55/62). CONCLUSION CT shows high sensitivity and specificity in diagnosing COVID-19. CT is an important examination method in evaluation of suspected cases and assessment of disease severity.


Rift Valley Fever: scientific pathways toward public health prevention and response.


title: Initial Clinical Experience with AView-A Clinical Computational Platform for Intracranial Aneurysm Morphology, Hemodynamics, and Treatment Management.

text: BACKGROUND The management of intracranial aneurysm (IA) is challenging. Clinicians often rely on varied and intuitively disparate ways of evaluating rupture risk that may only partially take into account complex hemodynamic and morphologic factors. We developed a prototype of a clinically oriented, streamlined, computational platform, AView, for rapid assessment of hemodynamics and morphometrics in clinical settings. To show the potential clinical utility of AView, we report our initial multicenter experience highlighting the possible advantages of morphologic and hemodynamic analysis of IAs. METHODS AView software was deployed across 8 medical centers (6 in the United States, 2 in Japan). Eight clinicians were trained and used the AView software between September 2012 and January 2013. RESULTS We present 12 illustrative cases that show the potential clinical utility of AView. For all, morphology and hemodynamics, flow visualization, and rupture resemblance score (a surrogate for rupture risk) were provided. In 3 cases, AView could confirm the clinicians' decision to treat; in 3 cases, it could suggest which aneurysms may be at greater risk among multiple aneurysms; in 5 cases, AView could provide additional information for use during treatment decisions for ambiguous situations. In one stent-assisted coiling case, flow visualization predicted that the intuitive choice for stent placement could have resulted in sacrifice of an anterior cerebral artery due to blockage by coils and led clinicians to reconsider treatment plans. CONCLUSIONS AView has the potential to confirm decisions to treat IAs, suggest which among multiple aneurysms to treat, and guide treatment decisions. Furthermore, the flow visualization it affords can inform aneurysm treatment planning and potentially avoid poor outcomes.


title: Is There a Case for Quarantine? Perspectives from SARS to Ebola.

text: Quarantine has been used for centuries in an effort to prevent the introduction, transmission, and spread of communicable diseases. While backed by legal authority, the public and even the health care worker community's understanding of the term is murky at best and scientific evidence to support the use of quarantine is frequently lacking. The multiple interpretations and references to quarantine, the inconsistent application of public health quarantine laws across jurisdictional boundaries, and reports of ineffectiveness are further complicated by associated infringement of civil liberties and human rights abuses. Given the need to balance public safety with human rights, we must be more precise about the meaning of quarantine and consider the efficacy and negative secondary effects resulting from its implementation. This article explains quarantine terminology and then uses a case study from Taiwan during the 2002-2003 severe acute respiratory syndrome (SARS) outbreak to illustrate the key principles associated with quarantine measures taken during the 2014 Ebola outbreak and the potential hazards that can arise from quarantines. Finally, we provide a quarantine and isolation decision tree to assist policy makers and public health officials in applying medically defensible, outcomes-based data and legal authorities to optimize management of emerging infectious diseases.


title: Transabdominal supra-diaphragmatic self-attached mesh for recurrent type IV diaphragmatic hernia on emergency setting: Case report.

text: INTRODUCTION Adult diaphragmatic hernia is a rare case and usually present with various clinical manifestations. Surgery can be done by thoracic and abdominal approaches. In emergency cases, mostly performed by abdominal approach. The use of mesh to close the defect is currently emerging as a viable option. PRESENTATION OF CASE We report a case of 70-year-old woman with complaints of shortness of breath and abdominal pain. The patient had a history of laparoscopic surgery with the installation of an anti-adhesive mesh for diaphragmatic hernia seven months before admission. Chest X-ray and Computed Tomography (CT) scan found recurrence of diaphragmatic hernia. The patient then received laparotomy showing diaphragmatic hernia with contents in the form of transverse colon, ileum, gastric and omentum. The self-attached mesh was placed on the supra-diaphragm with abdominal approach. The patient was hospitalised four days after surgery. At two weeks and six months follow-up, no complaints were found. CT scan and chest X-ray were within normal limits. DISCUSSION We did a modified technique in managing the recurrence and adhesion of the diaphragmatic hernia using the hernia mesh attached onto the superior side of the diaphragm to minimise the complications and recurrences. CONCLUSIONS Transabdominal supradiaphragmatic self-attached mesh for recurrent diaphragmatic hernia can be considered to be an alternative treatment for recurrent diaphragmatic hernia in an emergency setting because this procedure is relatively easier, safer, causes fewer postoperative complications, and can prevent recurrence.


title: A multi-criteria sustainability assessment framework: development and application in comparing two food waste management options using a UK region as a case study.

text: Preventing food wastage is a key element of sustainable resource management. But as food waste is still generated at high volumes, priority is placed on its proper management as a resource, maximising sustainability benefits. This study, by integrating a multi-criteria decision analysis with a sustainability assessment approach, develops a screening and decision support framework for comparing the sustainability performance of food waste management options. A structured process for selecting criteria based on the consideration of environmental, economic and social aspects related to region-specific food waste system planning, policy and management has been developed. Two food waste management options, namely the use of food waste disposal units, which grind food waste at the household's kitchen sink and discharge it to the sewer, and the anaerobic co-digestion of separately collected food waste with sewage sludge, were selected for comparison due to their potential to create synergies between local authorities, waste and water companies, with local circumstances determining which of the two options to adopt. A simplified process used for assessing and comparing the two food waste management options in the Anglian region in the UK, indicated that there are benefits in using the framework as a screening tool for identifying which option may be the most sustainable. To support decision-making, a detailed analysis that incorporates stakeholders' perspectives is required. An additional use of the framework can be in providing recommendations for optimising food waste management options in a specific region, maximising their sustainability performance.


title: Changes in leg cycling muscle synergies after training augmented by functional electrical stimulation in subacute stroke survivors: a pilot study.

text: BACKGROUND Muscle synergies analysis can provide a deep understanding of motor impairment after stroke and of changes after rehabilitation. In this study, the neuro-mechanical analysis of leg cycling was used to longitudinally investigate the motor recovery process coupled with cycling training augmented by Functional Electrical Stimulation (FES) in subacute stroke survivors. METHODS Subjects with ischemic subacute stroke participated in a 3-week training of FES-cycling with visual biofeedback plus usual care. Participants were evaluated before and after the intervention through clinical scales, gait spatio-temporal parameters derived from an instrumented mat, and a voluntary pedaling test. Biomechanical metrics (work produced by the two legs, mechanical effectiveness and symmetry indexes) and bilateral electromyography from 9 leg muscles were acquired during the voluntary pedaling test. To extract muscles synergies, the Weighted Nonnegative Matrix Factorization algorithm was applied to the normalized EMG envelopes. Synergy complexity was measured by the number of synergies required to explain more than 90% of the total variance of the normalized EMG envelopes and variance accounted for by one synergy. Regardless the inter-subject differences in the number of extracted synergies, 4 synergies were extracted from each patient and the cosine-similarity between patients and healthy weight vectors was computed. RESULTS Nine patients (median age of 75 years and median time post-stroke of 2 weeks) were recruited. Significant improvements in terms of clinical scales, gait parameters and work produced by the affected leg were obtained after training. Synergy complexity well correlated to the level of motor impairment at baseline, but it did not change after training. We found a significant improvement in the similarity of the synergy responsible of the knee flexion during the pulling phase of the pedaling cycle, which was the mostly compromised at baseline. This improvement may indicate the re-learning of a more physiological motor strategy. CONCLUSIONS Our findings support the use of the neuro-mechanical analysis of cycling as a method to assess motor recovery after stroke, mainly in an early phase, when gait evaluation is not yet possible. The improvement in the modular coordination of pedaling correlated with the improvement in motor functions and walking ability achieved at the end of the intervention support the role of FES-cycling in enhancing motor re-learning after stroke but need to be confirmed in a controlled study with a larger sample size. TRIAL REGISTRATION ClinicalTrial.gov, NCT02439515. Registered on May 8, 2015, .


title: Challenges and opportunities for telehealth during the COVID-19 pandemic: ideas on spaces and initiatives in the Brazilian context.

text: COVID-19 has created enormous challenges for health systems worldwide, with the rapidly growing number of deaths and critical patients with pneumonia requiring ventilatory support. Alternative methods to control the spread of the disease such as social isolation, extreme quarantine measures, and contact tracing have been used around the world. However, these measures may not be totally effective to fight COVID-19, in step with the necessary national preparations to meet the new patient care demands. A wide range of digital technologies can be used to enhance these public health strategies, and the pandemic has sparked increasing use of telehealth. This field has grown considerably in Brazil in recent years. Still, despite the intense proliferation of recommendations and rules, until the current pandemic the country still lacked a fully consolidated regulatory framework. The emergence of COVID-19 marks a key moment in the expansion of applications and use of telehealth for improving the health system's response to the current crisis. The article discusses telehealth's contribution to the fight against COVID-19 and the recent initiatives triggered in Brazil as opportunities for the consolidation of telemedicine and improvement of the Brazilian Unified National Health System. The authors conclude that telehealth offers capabilities for remote screening, care and treatment, and assists monitoring, surveillance, detection, prevention, and mitigation of the impacts on healthcare indirectly related to COVID-19. The initiatives triggered in this process can reshape the future space of telemedicine in health services in the territory.


title: Our Results of Laparoscopic Partial Nephrectomies Without Pedicle Dissection: Possible Advantages and Disadvantages.

text: OBJECTIVES This study aimed to document the surgical and oncologic results of nephron sparing of non-ischemic laparoscopic partial nephrectomy without the step of hilus controlling and even without dissecting to expose the main renal vascularity and directly focusing on mass removal. MATERIALS & METHODS The records of the patients who underwent our modified laparoscopic partial nephrectomy technique were evaluated retrospectively. The patients' medical records, including tumor complexity calculated via R.E.N.A.L nephrometry scores, operation time, estimated blood loss, blood transfusions, hospital stay, pre- and postoperative serum creatinine levels, complications via the Clavien classification system, pathological status of surgical margin, and follow-up times, were documented. RESULTS The data of 55 patients with 58 renal units were evaluated. Almost all tumors were in the low complex group (91%), with a mean size of 31.74 ± 7.38 mm (range: 12-46 mm). Mean operation time, estimated blood loss, and transfusion rates were 138.62 ± 38.45 minutes (range: 90-240 min), 242.24 ± 107.12 mL (range: 100-500 mL), and 19%, respectively. The hemoglobin level decreased by a mean of 2.05 ± 0.87 g/dL. Whereas the perioperative complications were Clavien grades I, II, and III (74%, 23%, and 3%, respectively), mean hospital stay and follow-up time were 4.05 ± 1.97 and 19.67 ± 13.57 (ranges: 2-10 days and 1-44 months), respectively. CONCLUSION Present un-controlled results pointed that tumor-focusing nephron-sparing non-ischemic partial laparoscopic nephrectomy may be preferable for small-sized, low-complex renal masses.


Case 17-2020: A 68-Year-Old Man with Covid-19 and Acute Kidney Injury.


title: Warm hands, cold heart: progressive whole-body cooling increases warm thermosensitivity of human hands and feet in a dose-dependent fashion.

text: NEW FINDINGS What is the central question of this study? Investigations on inhibitory/facilitatory modulation of vision, touch and pain show that conditioning stimuli outside the receptive field of testing stimuli modulate the central processing of visual, touch and painful stimuli. We asked whether contextual modulation also exists in human temperature integration. What is the main finding and its importance? Progressive decreases in whole-body mean skin temperature (the conditioning stimulus) significantly increased local thermosensitivity to skin warming but not cooling (the testing stimuli) in a dose-dependent fashion. In resembling the central mechanisms underlying endogenous analgesia, our findings point to the existence of an endogenous thermosensory system in humans that could modulate local skin thermal sensitivity to facilitate thermal behaviour. Although inhibitory/facilitatory central modulation of vision and pain has been investigated, contextual modulation of skin temperature integration has not been explored. Hence, we tested whether progressive decreases in whole-body mean skin temperature (Tsk ; a large conditioning stimulus) alter the magnitude estimation of local warming and cooling stimuli applied to hairy and glabrous skin. On four separate occasions, eight men (27 ± 5 years old) underwent a 30 min whole-body cooling protocol (water-perfused suit; temperature, 5°C), during which a quantitative thermosensory test, consisting of reporting the perceived magnitude of warming and cooling stimuli (±8°C from 30°C baseline) applied to the hand (palm/dorsum) and foot (sole/dorsum), was performed before cooling and every 10 min thereafter. The cooling protocol resulted in large progressive reductions in Tsk [10 min, -3.36°C (95% confidence interval -2.62 to -4.10); 20 min, -5.21°C (-4.47 to -5.95); and 30 min, -6.32°C (-5.58 to -7.05); P < 0.001], with minimal changes (∼0.08°C) in rectal temperature. While thermosensitivity to local skin cooling remained unchanged (P = 0.831), sensitivity to skin warming increased significantly at each level of Tsk for all skin regions [10 min, +4.9% (-1.1 to +11.0); 20 min, +6.1% (+0.1-12.2); and 30 min, +7.9% (+1.9-13.9); P = 0.009]. Linear regression indicated a 1.2% °C-1 increase in warm thermosensitivity with whole-body skin cooling. Overall, large decreases in Tsk significantly facilitated warm but not cold sensory processing of local thermal stimuli, in a dose-dependent fashion. In highlighting a novel feature of human temperature integration, these findings point to the existence of an endogenous thermosensory system that could modulate local skin thermal sensitivity in relationship to whole-body thermal states.


title: COVID-19 Lung Injury is Not High Altitude Pulmonary Edema.

text: Not applicable.


Do you know how COVID-19 is changing general practice/family medicine education?


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title: Use of a new soft and long coil reduces the number of coils to embolize a small aneurysm.

text: BACKGROUND In embolizing a cerebral aneurysm, achievement of a high-volume embolization ratio (VER: volume of inserted coils / aneurysm volume) is important because it may prevent coil compaction and recanalization. The goal of the study is to examine whether use of softer and longer coils gives an adequate VER with fewer coils, particularly for small aneurysms. METHODS Aneurysm volumes, VERs, and numbers of inserted coils were investigated in 23 cases of small aneurysms embolized using Infini coils, a long soft coil with a primary diameter of 0.010 inches (Infini group). An aneurysm volume- and VER-matched control (non-Infini) group of 59 cases was selected from patients treated at our facility. Data were also compared between subgroups of patients (n = 18 and n = 34 in the Infini and non-Infini groups, respectively) who were not treated with thicker coils with primary diameters of 0.0135-0.015 inches (18-type coils), since these coils affect the number of coils by increasing VER rapidly. RESULTS Average aneurysm volumes and VERs did not differ significantly between the Infini and non-Infini groups. Significantly fewer coils were used per 0.1 ml aneurysm volume in the Infini group (4.08 coils in average) compared with the non-Infini group (5.67) (p < 0.001). In the non-18-type subgroups, the number of coils used remained significantly smaller in the Infini group (4.49) compared with the non-Infini group (6.72), (p < 0.001). CONCLUSION To achieve VER ≥20%, use of Infini coils significantly decreased the number of coils required per unit volume of a small aneurysm.


title: Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients.

text: BACKGROUND Optimal thromboprophylaxis for patients at risk of bleeding remains uncertain. This meta-analysis assessed whether intermittent pneumatic compression (IPC) of the lower limbs was effective in reducing venous thromboembolism and whether combining pharmacological thromboprophylaxis with IPC would enhance its effectiveness. METHODS AND RESULTS Two reviewers searched MEDLINE, EMBASE, and the Cochrane controlled trial register (1966-February 2013) for randomized, controlled trials and assessed the outcomes and quality of the trials independently. Trials comparing IPC with pharmacological thromboprophylaxis, thromboembolic deterrent stockings, no prophylaxis, and a combination of IPC and pharmacological thromboprophylaxis were considered. Trials that used IPC <24 hours or compared different types of IPC were excluded. A total of 16 164 hospitalized patients from 70 trials met the inclusion criteria and were subjected to meta-analysis. IPC was more effective than no IPC prophylaxis in reducing deep vein thrombosis (7.3% versus 16.7%; absolute risk reduction, 9.4%; 95% confidence interval [CI], 7.9-10.9; relative risk, 0.43; 95% CI, 0.36-0.52; P<0.01; I(2)=34%) and pulmonary embolism (1.2% versus 2.8%; absolute risk reduction, 1.6%; 95% CI, 0.9-2.3; relative risk, 0.48; 95% CI, 0.33-0.69; P<0.01; I(2)=0%). IPC was also more effective than thromboembolic deterrent stockings in reducing deep vein thrombosis and appeared to be as effective as pharmacological thromboprophylaxis but with a reduced risk of bleeding (relative risk, 0.41; 95% CI, 0.25-0.65; P<0.01; I(2)=0%). Adding pharmacological thromboprophylaxis to IPC further reduced the risk of deep vein thrombosis (relative risk, 0.54; 95% CI, 0.32-0.91; P=0.02; I(2)=0%) compared with IPC alone. CONCLUSIONS IPC was effective in reducing venous thromboembolism, and combining pharmacological thromboprophylaxis with IPC was more effective than using IPC alone.


Lopinavir-ritonavir in severe COVID-19.


title: Detection of feline coronavirus mutations in paraffin-embedded tissues in cats with feline infectious peritonitis and controls.

text: OBJECTIVES The amino acid substitutions M1058L and S1060A in the spike protein of feline coronavirus (FCoV) have been postulated to be responsible for the development of the pathogenic feline infectious peritonitis virus (FIPV), which causes feline infectious peritonitis (FIP). The aim of the following study was to investigate the presence of mutated virus in tissue samples of cats with and without FIP. METHODS The study population consisted of 64 cats, 34 of which were diagnosed with FIP and 30 control cats. All cases underwent autopsy, histopathology and immunohistochemistry (IHC) for FCoV. Furthermore, a genotype-discriminating quantitative reverse transcriptase PCR (RT-qPCR) was performed on shavings of paraffin-embedded tissues to discriminate between cats with FIP and controls, and the sensitivity and specificity of this discriminating RT-qPCR were calculated using 95% confidence intervals (CIs). RESULTS Specificity of genotype-discriminating RT-qPCR was 100.0% (95% CI 88.4-100.0), and sensitivity was 70.6% (95% CI 52.5-84.9). In cats with FIP, 24/34 tested positive for FIPV. In samples of three control cats and in seven cats with FIP, FCoV was found, but genotyping was not possible owing to low FCoV RNA concentrations. Out of the positive samples, 23 showed the amino acid substitution M1058L in the spike protein and none the substitution S1060A. One sample in a cat with FIP revealed a mixed population of non-mutated FCoV and FIPV (mixed genotype). For one sample genotyping was not possible despite high viral load, and two samples were negative for FCoV. CONCLUSIONS AND RELEVANCE As none of the control animals showed FCoV amino acid substitutions previously demonstrated in cats with FIP, it can be presumed that the substitution M1058L correlates with the presence of FIP. FCoV was detected in low concentration in tissues of control animals, confirming the ability of FCoV to spread systemically. The fact that no negative controls were included in the IHC protocol could potentially lead to an underestimation of the sensitivity of the RT-qPCR.


title: Primary inflammatory myofibroblastic tumor of the stomach in an adult woman: a case report and review of the literature.

text: Inflammatory myofibroblastic tumor has been defined as a histologically distinctive lesion with uncertain behaviour. The term inflammatory myofibroblastic tumor more commonly referred to as "pseudostumor ", denotes a pseudosarcomatous inflammatory lesion that contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes. It exhibits a variable biological behavior that ranges from frequently benign lesions to more aggressive variants. Inflammatory myofibroblastic tumor mostly occurs in the soft tissue of children and young adults, and the lungs are the most commonly affected site, but it has been recognized that any anatomic localization can be involved. Inflammatory myofibroblastic tumors in adults are very rare, especially in the stomach. We present a case of a 43-year old woman with primary inflammatory myofibiroblastic tumor in the stomach and a review of the literature.


title: Biomechanical evaluation of potential damage to hernia repair materials due to fixation with helical titanium tacks.

text: BACKGROUND This study aimed to determine whether the strength and extensibility of hernia repair materials are negatively influenced by the application of helical titanium tacks. METHODS This study evaluated 14 meshes including bare polypropylene, macroporous polytetrafluoroethylene, absorbable barrier, partially absorbable mesh, and expanded polytetrafluoroethylene materials. Each mesh provided 15 specimens, which were prepared in 7.5 × 7.5-cm squares. Of these, 5 "undamaged" specimens were subjected to ball-burst testing to determine their biomechanical properties before application of helical titanium tacks (ProTack). To 10 "damaged" specimens 7 tacks were applied 1 cm apart in a 3.5-cm-diameter circle using a tacking force of 25 to 28 N. The tacks were removed from five of the specimens before ball-burst testing and left intact in the remaining five specimens. RESULTS The application of tacks had no effect on the tensile strength of Dualmesh, ProLite Ultra, Infinit, Ultrapro, C-QUR Lite (<6 in.), Prolene Soft, or Physiomesh, but the tensile strengths were reduced for Bard Mesh, C-QUR, ProLite, and C-QUR Lite (>6 in.). Most of the meshes did not exhibit significantly different tensile strengths between removal of tacks and tacks left intact. Exceptions included C-QUR, Prolene, Ultrapro, and Bard Soft Mesh, which were weaker with removal of tacks than with tacks left intact during the test. Damage due to the application of helical titanium tacks also caused increased strain at a stress of 16 N/cm for all the meshes except C-QUR Lite (>6 in.) and Physiomesh. CONCLUSIONS Many of the meshes evaluated in this study exhibited damage in the form of reduced tensile strength and increased extensibility after the application of tacks compared with the corresponding "undamaged" meshes. Meshes with smaller interstices and larger filaments were influenced negatively by the application of helical titanium tacks, whereas mesh designs with larger interstices and smaller filaments tended to maintain their baseline mechanical properties.


title: Post operative capnostream monitoring in patients with obstructive sleep apnoea symptoms - Case series.

text: Obstructive sleep apnoea (OSA) patients on opioid analgesic have an increased incidence of postoperative respiratory complications; prevention of these may be possible with appropriate post-operative monitoring. We recruited 4 OSA patients who had general anaesthesia for orthopaedic and septoplasty surgery. They required Patient Controlled Analgesia (PCA) or oral opioids in the post-operative period, hence continuous Saturation of Oxygen (Spo2), End Tidal Carbon dioxide (EtCo2) monitoring on Capnostream monitor with Integrated Pulmonary Index (IPI) was organized in high dependency unit. Overnight data was collected every 30 s which included pulse rate, respiratory rate, EtCo2, Spo2, and IPI. The nursing staff was also asked to document if any intervention was carried out due to altered IPI. For first two patient events occurred during various hours but there were no significant events in early night even though increased opioid use at that time. During the period of desaturation nurse intervention required to increase the O2 flow in the first patient but corrected spontaneously in the second patient. IPI index improved over a period of 2 min in most of the events. The duration of desaturation did not correspond with the IPI in only once, remaining period the clinical symptoms were consistent with fall in O2 saturation. The microstream capnography with IPI may provide complete respiratory status of the patient because of its comprehensive parameters on one screen. Main limitation was duration of monitoring was limited to overnight. Capnostream monitoring with IPI may have a role in patients monitoring with OSA on PCA in the postoperative ward but more trials are necessary.


title: Lessons of the month 1: A case of rhombencephalitis as a rare complication of acute COVID-19 infection.

text: A 40-year-old man developed acute brainstem dysfunction 3 days after hospital admission with symptoms of the novel SARS-CoV-2 infection (COVID-19). Magnetic resonance imaging showed changes in keeping with inflammation of the brainstem and the upper cervical cord, leading to a diagnosis of rhombencephalitis. No other cause explained the patient's abnormal neurological findings. He was managed conservatively with rapid spontaneous improvement in some of his neurological signs and was discharged home with continued neurology follow up.


Covid-19: diabetes clinicians set up social media account to help alleviate patients' fears.


title: Promoting Motor Cortical Plasticity with Acute Aerobic Exercise: A Role for Cerebellar Circuits.

text: Acute aerobic exercise facilitated long-term potentiation-like plasticity in the human primary motor cortex (M1). Here, we investigated the effect of acute aerobic exercise on cerebellar circuits, and their potential contribution to altered M1 plasticity in healthy individuals (age: 24.8 ± 4.1 years). In Experiment 1, acute aerobic exercise reduced cerebellar inhibition (CBI) (n = 10, p = 0.01), elicited by dual-coil paired-pulse transcranial magnetic stimulation. In Experiment 2, we evaluated the facilitatory effects of aerobic exercise on responses to paired associative stimulation, delivered with a 25 ms (PAS25) or 21 ms (PAS21) interstimulus interval (n = 16 per group). Increased M1 excitability evoked by PAS25, but not PAS21, relies on trans-cerebellar sensory pathways. The magnitude of the aerobic exercise effect on PAS response was not significantly different between PAS protocols (interaction effect: p = 0.30); however, planned comparisons indicated that, relative to a period of rest, acute aerobic exercise enhanced the excitatory response to PAS25 (p = 0.02), but not PAS21 (p = 0.30). Thus, the results of these planned comparisons indirectly provide modest evidence that modulation of cerebellar circuits may contribute to exercise-induced increases in M1 plasticity. The findings have implications for developing aerobic exercise strategies to "prime" M1 plasticity for enhanced motor skill learning in applied settings.


title: Coronavirus anxiety scale: A brief mental health screener for COVID-19 related anxiety.

text: Mental health concerns of people impacted by the coronavirus pandemic have not been adequately addressed. The objective of this study was to develop and evaluate the properties of the Coronavirus Anxiety Scale (CAS), which is a brief mental health screener to identify probable cases of dysfunctional anxiety associated with the COVID-19 crisis. This 5-item scale, which was based on 775 adults with anxiety over the coronavirus, demonstrated solid reliability and validity. Elevated CAS scores were found to be associated with coronavirus diagnosis, impairment, alcohol/drug coping, negative religious coping, extreme hopelessness, suicidal ideation, as well as attitudes toward President Trump and Chinese products. The CAS discriminates well between persons with and without dysfunctional anxiety using an optimized cut score of ≥ 9 (90% sensitivity and 85% specificity). These results support the CAS as an efficient and valid tool for clinical research and practice.


title: Laparoscopic left hepatectomy with prior vascular control.

text: BACKGROUND Laparoscopic major resections remain a challenge for liver surgeons. This video illustrates, step by step, our laparoscopic technique for left hepatectomy. METHODS The control of vascular inflow and outflow as well as the division of the left hepatic duct were carried out extraparenchymally before liver transection. Between 2002 and 2008, 11 left hepatectomies were performed by laparoscopy: 7 for liver tumor and 4 for localized Caroli's disease. RESULTS Mean duration of surgery was 248 +/- 25 min. Mean operative blood loss was 129 +/- 42 ml. Intraoperative blood transfusion or conversion to laparotomy were never required. One postoperative biliary collection occurred and was drained percutaneously. None of the patients died. Mean hospital stay was 7.6 +/- 2.2 days. CONCLUSIONS This technique has proved to be safe and easily reproducible.


title: Mechanisms and methods in ecoimmunology: integrating within-organism and between-organism processes.

text: Ecoimmunology utilizes techniques from traditionally laboratory-based disciplines--for example, immunology, genomics, proteomics, neuroendocrinology, and cell biology--to reveal how the immune systems of wild organisms both shape and respond to ecological and evolutionary pressures. Immunological phenotypes are embedded within a mechanistic pathway leading from genotype through physiology to shape higher-order biological phenomena. As such, "mechanisms" in ecoimmunology can refer to both the within-host processes that shape immunological phenotypes, or it can refer the ways in which different immunological phenotypes alter between-organism processes at ecological and evolutionary scales. The mechanistic questions ecoimmunologists can ask, both within-organisms and between-organisms, however, often have been limited by techniques that do not easily transfer to wild, non-model systems. Thus, a major focus in ecoimmunology has been developing and refining the available toolkit. Recently, this toolkit has been expanding at an unprecedented rate, bringing new challenges to choosing techniques and standardizing protocols across studies. By confronting these challenges, we will be able to enhance ecoimmunological inquiries into the physiological basis of life-history trade-offs; the development of low-cost biomarkers for susceptibility to disease; and the investigation of the ecophysiological underpinnings of disease ecology, behavior, and the coevolution of host-parasite systems. The technical advances in, and crossover technologies from, disciplines associated with ecoimmunology and how these advances can help us understand the mechanistic basis of immunological variability in wild species were the focus of the symposium, Methods and Mechanisms in Ecoimmunology.


title: Dynamic Evaluation of Liver Volume and Function in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy.

text: BACKGROUND Despite a fast and potent growth of the future liver remnant (FLR), patients operated with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are at risk of developing posthepatectomy liver failure. In this study, the relation between liver volume and function in ALPPS was studied using a multimodal assessment. METHODS Nine patients with colorectal liver metastases treated with neoadjuvant chemotherapy and operated with ALPPS were studied with hepatobiliary scintigraphy, computed tomography, indocyanine green clearance test, and serum liver function tests. A comparison between liver volume and function was conducted. RESULTS The preoperative FLR volume of 19.5% underestimated the preoperative FLR function of 25.3% (p = 0.011). The increase in FLR volume exceeded the increase in function at day 6 after stage 1 (FLR volume increase 56.7% versus FLR function increase 28.2%, p = 0.021), meaning that the increase in function was 50% of the increase in volume. After stage 2, functional increase exceeded the volume increase, resulting in similar values 28 days after stage 2. CONCLUSIONS In the inter-stage period of ALPPS, the high volume increase is not paralleled by a corresponding functional increase. This may in part explain the high morbidity and mortality rates associated with ALPPS. Functional assessment of the FLR is advised.


title: Hypoxemia after single-shot anesthesia in common marmosets.

text: BACKGROUND It remains unknown how single-shot anesthesia influences physical parameters, especially respiratory function and blood oxygen level of common marmosets (Callithrix jacchus) which came to be used for laboratory research. METHODS We measured blood oxygen levels, both before and after oxygenation, in 13 common marmosets under two single-shot anesthesia conditions: ketamine/xylazine/atropine and alphaxalone. RESULTS AND CONCLUSIONS We found that SpO2 values decreased to about 80% in the ketamine/xylazine/atropine protocol and fell just below 90% in the alphaxalone protocol. We observed a clear decrease in PaO2 values under the anesthetized condition compared to the awake condition. Our data indicate that single-shot anesthesia may cause hypoxemia in marmosets. Previous studies on other non-human primate have reported no SpO2 decrease and hypoxemia; thus, our experiment suggests that marmosets may have a more fragile respiratory system and require intensive veterinary care during anesthesia.


title: Usefulness of the extracted-overlay function in CT/MR-ultrasonography fusion imaging for radiofrequency ablation of hepatocellular carcinoma.

text: OBJECTIVES We developed a novel technique of the extracted-overlay function in CT/MR-ultrasonography (US) fusion imaging for radiofrequency ablation (RFA), in which only a tumor extracted from CT/MR images with a virtual ablative margin of arbitrary thickness is overlaid on US. The usefulness of this function is investigated in this preliminary report. METHODS The volume data of the extracted tumor with a virtual ablative margin were created on an image-processing workstation, and transported into a US unit equipped with a CT/MR-US fusion imaging system. After the positional registration of US and transported images, the extracted tumor with an ablative margin could be overlaid on US. In RFA, using this function, an electrode was inserted targeting the overlaid tumor with an ablative safety margin of 5 mm on US, and the treatment effect was evaluated by dynamic CT. Treatment results of 23 consecutive hepatocellular carcinomas (HCCs) that underwent RFA using this function were retrospectively analyzed. RESULTS Complete tumor ablation was achieved in 22 (95.7%) and 1 (4.3%) HCCs in 1 and 2 treatment sessions, respectively. CONCLUSIONS Due to the visualization of an extracted tumor with an ablative safety margin on a US image, even during and after ablation, this function is useful for treatment planning and guidance of RFA.


Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation.


title: Relationship between time to target temperature and outcome in patients treated with therapeutic hypothermia after cardiac arrest.

text: INTRODUCTION Our purpose was to study whether the time to target temperature correlates with neurologic outcome in patients after cardiac arrest with restoration of spontaneous circulation treated with therapeutic mild hypothermia in an academic emergency department. METHODS Temperature data between April 1995 and June 2008 were collected from 588 patients and analyzed in a retrospective cohort study by observers blinded to outcome. The time needed to achieve an esophageal temperature of less than 34°C was recorded. Survival and neurological outcomes were determined within six months after cardiac arrest. RESULTS The median time from restoration of spontaneous circulation to reaching a temperature of less than 34°C was 209 minutes (interquartile range [IQR]: 130-302) in patients with favorable neurological outcomes compared to 158 min (IQR: 101-230) (P < 0.01) in patients with unfavorable neurological outcomes. The adjusted odds ratio for a favorable neurological outcome with a longer time to target temperature was 1.86 (95% CI 1.03 to 3.38, P = 0.04). CONCLUSIONS In comatose cardiac arrest patients treated with therapeutic hypothermia after return of spontaneous circulation, a faster decline in body temperature to the 34°C target appears to predict an unfavorable neurologic outcome.


title: A Postpartum Death Due to Coronavirus Disease 2019 (COVID-19) in the United States.

text: BACKGROUND Limited U.S. reports of pregnant women with coronavirus disease 2019 (COVID-19) infection describe a few critical cases and no maternal mortality. CASE A 36-year-old patient at 37 weeks of gestation presented with shortness of breath, fever, cough, and sore throat for 1 week. Within 3 hours of admission, she experienced respiratory distress, required intubation, and underwent cesarean delivery and transfer to the intensive care unit. She subsequently decompensated, with multiorgan failure, sepsis, and cardiopulmonary arrest within 36 hours, despite aggressive supportive care and investigational therapies. CONCLUSION A pregnant patient with COVID-19 infection can experience a rapid onset of critical complications that may prove fatal, despite an indolent presentation. The pathogenesis leading to rapid deterioration is unknown.


title: Interaction of the porcine reproductive and respiratory syndrome virus nucleocapsid protein with the inhibitor of MyoD family-a domain-containing protein.

text: Porcine reproductive and respiratory syndrome (PRRS) virus is an RNA virus that replicates in the cytoplasm, but the viral nucleocapsid (N) protein localizes specifically in the nucleus and nucleolus of virus-infected cells. Nuclear localization of N is non-essential for PRRSV replication in cultured cells but has been shown to modulate the pathogenesis of virus in pigs, suggesting that N plays an accessory role in the nucleus during infection. We identified by yeast two-hybrid screening the inhibitor of MyoD family-a (I-mfa) domain-containing protein (HIC) as a cellular partner for PRRS virus (PRRSV) N protein. This protein is a homolog of human HIC, a recently identified cellular transcription factor. The specific interaction of PRRSV N with HIC was confirmed in cells by mammalian two-hybrid assay and co-immunoprecipitation and in vitro by GST pull-down assay. HIC is a zinc-binding protein and confocal microscopy demonstrated co-localization of N with the HIC-p40 isomer in the nucleus and nucleolus, and in the cytoplasm with HIC-p32, which is the N-terminal truncation of HIC-p40. The porcine homolog of HIC is universally expressed in pig tissues including alveolar macrophages. The interaction of viral capsid with the cellular transcription factor implicates a possible regulation of host cell gene expression by the N protein during PRRSV infection.


Children's Hospital ICU Resource Allocation in an Adult Pandemic.


title: Feasibility of transanal minimally invasive surgery for mid-rectal lesions.

text: BACKGROUND Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery. We assessed the feasibility of TAMIS for lesions located in the mid rectum. METHODS From July 2010 to October 2011, 16 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, pneumorectum was established with a laparoscopic device, followed by transanal excision with conventional laparoscopic instruments, including graspers, monopolar electrocautery, and needle drivers. Clinicopathological findings, surgical procedure results, and perioperative outcomes were determined prospectively. RESULTS Of the 16 patients, 11 had rectal cancers (3 T1 lesions and 8 after preoperative chemoradiotherapy), 4 had neuroendocrine tumors, and 1 had a mucocele. The median length of the lesions from anal verge was 7.5 cm (range 4-10 cm). All procedures were completed laparoscopically without conversion to conventional transanal approach. The median operating time was 86 min (range 33-160 min), and the median estimated blood loss was 15 ml (range 0-150 ml) with no patient requiring intraoperative transfusions. There was no surgical morbidity or mortality, but one patient died during follow-up due to synchronous advanced gastric cancer. The median postoperative hospital stay was 3 days (range 2-6 days). CONCLUSIONS TAMIS seems to be a feasible and safe treatment option for lesions located in the mid rectum.


title: Telemedicine During the COVID-19 Pandemic: Impact on Care for Rare Cancers.

text: PURPOSE Many patients with cancer, often those with rare cancers such as sarcomas, travel long distances to access expert care. The COVID-19 pandemic necessitated widespread changes in delivery of cancer care, including rapid adoption of telemedicine-based care. We aimed to evaluate the impact of telemedicine on patients, clinicians, and care delivery at the Royal Marsden Hospital (RMH) Sarcoma Unit during the pandemic. METHODS Data were extracted from patient records for all planned outpatient appointments at the RMH Sarcoma Unit from March 23 to April 24, 2020. Patients and clinicians completed separate questionnaires to understand their experiences. RESULTS Of 379 planned face-to-face appointments, 283 (75%) were converted to telemedicine. Face-to-face appointments remained for patients who needed urgent start of therapy or performance status assessment. Patients lived on average > 1.5 hours from RMH. Patient satisfaction (n = 108) with telemedicine was high (mean, 9/10), and only 48% (n = 52/108) would not want to hear bad news using telemedicine. Clinicians found telemedicine efficient, with no associated increased workload, compared with face-to-face appointments. Clinicians indicated lack of physical examination did not often affect care provision when using telemedicine. Most clinicians (n = 17; 94%) believed telemedicine use was practice changing; congruently, 80% (n = 86/108) of patients desired some telemedicine as part of their future care, citing reduced cost and travel time. CONCLUSION Telemedicine can revolutionize delivery of cancer care, particularly for patients with rare cancers who often live far away from expert centers. Our study demonstrates important patient and clinician benefits; assessment of longer-term impact on patient outcomes and health care systems is needed.


title: Does central fatigue explain reduced cycling after complete sleep deprivation?

text: PURPOSE Sleep deprivation (SD) is characterized by reduced cognitive capabilities and endurance exercise performance and increased perceived exertion (RPE) during exercise. The combined effects of SD and exercise-induced changes in neuromuscular function and cognition are unknown. This study aimed to determine whether central fatigue is greater with SD, and if so, whether this corresponds to diminished cognitive and physical responses. METHODS Twelve active males performed two 2-d conditions (SD and control (CO)). On day 1, subjects performed baseline cognitive and neuromuscular testing. After one night of SD or normal sleep, subjects repeated day 1 testing and then performed 40-min submaximal cycling and a cycling test to task failure. Neuromuscular and cognitive functions were evaluated during the cycling protocol and at task failure. RESULTS After SD, exercise time to task failure was shorter (1137 ± 253 vs 1236 ± 282 s, P = 0.013) and RPE during 40 min submaximal cycling was greater (P = 0.009) than that in CO. Maximal peripheral voluntary activation decreased by 7% (P = 0.003) and cortical voluntary activation tended to decrease by 5% (P = 0.059) with exercise. No other differences in neuromuscular function or cognitive control were observed between conditions. After SD, mean reaction time was 8% longer (P = 0.011) and cognitive response omission rate before cycling was higher (P < 0.05) than that in CO. Acute submaximal exercise counteracted cognitive performance deterioration in SD. CONCLUSIONS One night of complete SD resulted in decreased time to task failure and cognitive performance and higher RPE compared with the control condition. The lack of difference in neuromuscular function between CO and SD indicates that decreased SD exercise performance was probably not caused by increased muscular or central fatigue.


title: [Evaluation of the effectiveness of ARVI treatment regimen including etiotropic (enisamium iodide) and symptomatic treatment].

text: AIM To assess the effectiveness of the use of the antiviral drug enisamium iodide in the complex treatment of acute respiratory viral infections (ARVI) caused by various pathogens in routine clinical practice. MATERIALS AND METHODS А prospective randomized study included 134 patients who were treated in the epidemic season of influenza and ARVI in 20182019. All patients were examined for the presence of influenza A and B viruses, respiratory syncytial virus, human metapneumovirus, parainfluenza virus, coronaviruses, rhinoviruses, adenoviruses in nasopharyngeal swabs by PCR. Patients of the main group received enisamium iodide along with symptomatic therapy, the control group received only symptomatic therapy. The primary parameter of the effectiveness of therapy was evaluated on the scale of the general severity of the manifestations of ARVI (Total Symptom Score TSS) from the 2nd to the 4th day and by the secondary criteria of effectiveness: assessment of the duration of ARVI, the severity of fever, the proportion of patients with normal body temperature, the duration of the main clinical symptoms of acute respiratory viral infections, the proportion of patients in whom complications requiring antibiotics were noted, the dynamics of interferon status on the 6th day. To conduct a statistical analysis, depending on the efficiency parameter, the ANCOVA method with a fixed group factor and an initial score on the TSS severity scale was used as covariates, a criterion for comparing quantitative indicators in two independent groups. RESULTS According to the results of the analysis of the primary efficacy parameter, the median (interquartile range) of the average score on the scale of the general severity of ARVI manifestations in the main group was 4.33 (3.675.83), in the comparison group 6.00 (4.677.25; p0.001). The duration of systemic and local manifestations of acute respiratory viral infections was statistically significantly less in the main group (p=0.002 and p=0.019, respectively). Prescription of additional therapy was required in 2 (2.9%) patients of the main group (patients taking enisamium iodide), compared with 8 (11.9%) patients in the control group. Serum levels of interferon  and interferon  on the last day of treatment were statistically significantly higher in patients of the main group compared with the control group (p0.001). Treatment (excellent) was evaluated by 42 (62.7%) patients, while in the control group only 17 (25.8%) patients gave similar ratings. Both patients (p0.001) and doctors (p0.002) rated therapy tolerance better in the study group. CONCLUSION The results confirmed the safety and effectiveness of enisamium iodide as a treatment for ARVI and influenza. The antiviral, interferonogenic and anti-inflammatory properties of the drug are involved in the formation of an antiviral response and reduce the risk of complications, which makes it possible to reduce the number of symptomatic agents used.


title: Remote Monitoring of Patients in Quarantine in the Era of SARS-CoV-2 Pandemic.

text: The aim of our study is to propose a remote patient monitoring solution through a smart phone application (Smart Patient) collecting health data to support diagnosis, monitoring and predicting poor outcome in asymptomatic/mild cases of COVID-19, including signs and symptoms, risk factors, comorbidities, medications and vital signs such as body temperature, respiratory rate, heart rate and oxygen saturation. By continuous daily recording of suspected cases and patients, family doctors in the community will be able to follow up cases and intervene promptly when deterioration in vital signs and symptoms takes place referring the patient to the hospital.


title: Silicon carbide as a heat-enhancing agent in microwave ablation: in vitro experiments.

text: PURPOSE Silicon carbide (SiC) is an inert compound material with excellent microwave absorption and heat-conducting properties. The aim of our study was to investigate the heat-enhancing effects of SiC in microwave ablation in an in vitro setting. MATERIALS AND METHODS Different concentrations of SiC powder were mixed with 2% gelatin, producing a 20-ml mixture that was then heated with a clinical microwave ablation system (5 min/45 W). Temperature was measured continuously fiberoptically. Additional heating properties were assessed for the most heatable concentrations at different energy settings (10, 20, and 30 W). As reference, 2% gelatin without SiC was heated. Statistical evaluation by analysis of variance with post hoc Student-Newman-Keuls testing was performed. RESULTS For the different SiC concentrations, maximum temperatures measured were 45.7 ± 1.2°C (0% SiC, control), 50.4 ± 3.6°C (2% SiC), 60.8 ± 1.8°C (10% SiC), 74.9 ± 2.6°C (20% SiC), and 83.4 ± 2.5°C (50% SiC). Differences between all data points were significant (P < 0.05). Maximum temperatures that used 20% SiC were 36.3 ± 2.76°C (10 W), 48.7 ± 4.18°C (20 W), and 50.6 ± 0.68°C (30 W). The use of 50% SiC maximum temperatures resulted in values of 46.2 ± 2.52°C (10 W), 70.1 ± 0.64°C (20 W), and 83.0 ± 4.69°C (30 W). With 20% SiC and 50% SiC mixtures, the 10 W maximum temperatures were significantly lower than at all other power levels, and maximum temperatures with 20 and 30 W were significantly lower when compared with 45 W (P < 0.05). CONCLUSIONS SiC is a nontoxic, highly effective substance for enhancing microwave-induced heating with a microwave ablation system in vitro. These data suggest its usefulness for enhancement of ablative effects in percutaneous tumor therapy. Further investigations need to be performed to evaluate the ex vivo and in vivo ablation effects and the possible methods for administration of SiC particles.


title: Robot-assisted low anterior resection after aluminum potassium sulfate and tannic acid sclerosing therapy for internal hemorrhoids.

text: BACKGROUND Internal hemorrhoids are the most common anal diseases. Aluminum potassium sulfate and tannic acid (ALTA) injection is a new sclerosing therapy for the treatment of internal hemorrhoids. Although ALTA injection has been widely used, there are no previous reports of rectal cancer patients who underwent robot-assisted low anterior resection (Rob-LAR) after ALTA injection to treat internal hemorrhoids. CASE PRESENTATION A 70-year-old man with rectal cancer was presented to our hospital. He had an ALTA injection 2 months before presentation at a clinic due to hematochezia with internal hemorrhoids. The rectal tumor was located 7 cm above the anal verge, and Rob-LAR with the da Vinci Xi system was performed. The patient had sclerosis on the stump of the anal side, which made it difficult to transect the rectum with linear staplers. This required multiple repeats of compression through the SmartClamp feedback. After anastomosis with the double-stapling technique, we constructed a diverting ileostomy. CONCLUSION Although ALTA injection is a promising strategy for internal hemorrhoids, rectal cancer should be excluded before the sclerosing therapy.


title: Totally intracorporeal delta-shaped B-I anastomosis following laparoscopic distal gastrectomy using the Tri-Staple™ reloads on the manual Ultra handle: a prospective cohort study with historical controls.

text: BACKGROUND A delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy could be performed easily and sufficiently using only laparoscopic linear staplers. However, the restricted maneuverability and severe blurring of these staplers along with their limited hemostability induced strain. In this study, we determined the feasibility and safety of performing delta-shaped anastomosis using the Endo GIA™ Reloads with Tri-Staple™ Technology combined with Endo GIA™ Ultra Universal stapler (Tri-Staple) with a particular focus on short-term surgical outcomes. METHODS We performed a single-institutional prospective interventional study (UMIN 000008014). The Tri-Staple was prospectively used on 23 consecutive patients who underwent a curative totally laparoscopic Billroth I gastrectomy with delta-shaped anastomosis. These patients were matched with the 19 patients previously treated using the ENDOPATH(®) ETS Articulating Linear Cutters (ETS) on clinical and demographic characteristics. RESULTS There were no differences between the groups in anastomosis-related local complications, morbidity, non-anastomosis-related local complications, total systemic complications, and short-term outcomes with the exception of significantly reduced blood loss in the Tri-Staple group (ETS vs. Tri-Staple: 37 [10-306] vs. 15 [5-210] mL, p = 0.02). Intraoperative bleeding from the staple line was significantly reduced in the Tri-Staple group. The postoperative drain indwelling period (ETS vs. Tri-Staple, 6 [4-10] vs. 4 [2-43] days, p = 0.032), fasting period (5 [3-7] vs. 3 [3-24] days, p = 0.022), and hospital stay (14 [10-47] vs. 11 [6-58] days, p = 0.025) were significantly shorter in the Tri-Staple group. There was no mortality in this series. Acceleration assessed as indices of blurring of stapler tip might have a significant adverse influence on staple-line bleeding at stapling sites. CONCLUSION Totally laparoscopic Billroth I distal gastrectomy using Tri-Staple was feasible and safe with favorable short-term surgical outcomes. Reduced blurring while stapling may be a novel endpoint which newly developed stapling devices should target.


title: Viral quasispecies evolution.

text: Evolution of RNA viruses occurs through disequilibria of collections of closely related mutant spectra or mutant clouds termed viral quasispecies. Here we review the origin of the quasispecies concept and some biological implications of quasispecies dynamics. Two main aspects are addressed: (i) mutant clouds as reservoirs of phenotypic variants for virus adaptability and (ii) the internal interactions that are established within mutant spectra that render a virus ensemble the unit of selection. The understanding of viruses as quasispecies has led to new antiviral designs, such as lethal mutagenesis, whose aim is to drive viruses toward low fitness values with limited chances of fitness recovery. The impact of quasispecies for three salient human pathogens, human immunodeficiency virus and the hepatitis B and C viruses, is reviewed, with emphasis on antiviral treatment strategies. Finally, extensions of quasispecies to nonviral systems are briefly mentioned to emphasize the broad applicability of quasispecies theory.


title: Single-incision laparoscopic surgery using an articulating monopolar for juvenile cystic adenomyoma.

text: We demonstrate the feasibility of single-incision laparoscopic surgery (SILS) by using a novel monopolar cautery and a technique based on conventional multiport laparoscopic surgery in a patient with Juvenile cystic adenomyoma (JCA). A 20-year-old woman with severe dysmenorrhea, and a 3-cm uterine lesion was diagnosed with JCA. 70 cm of absorbable string tied to the tumor parenchyma was used to extract the tumor. The ends of the strings were positioned extracorporeally and the intra-abdominal parts of the strings adjacent to the anchored tumor were grasped by a laparoscopic needle holder for clarifying the incision line surrounding the tumor. The lesion was completely excised using a single-use articulating hook with monopolar cautery, and the hysterotomy site was sutured using barbed string. No complications occurred intraoperatively, and dysmenorrhea had significantly improved three months after surgery. SILS for JCA is a feasible and minimally invasive surgery for women desiring esthetic benefit.


title: Endovascular Treatment of a Dissected Celiac Trunk Aneurysm Complicated with Consequent Pseudoaneurysm: Primary Treatment and Treatment Relapse after 5 Years.

text: We report on an asymptomatic 56-year-old male with incidental diagnosis of celiac trunk aneurysm, diagnosed during an ultrasound scan performed to control polycystic kidney disease. The CT scan revealed a 3.8 cm saccular aneurysm of the celiac artery dissected in the superior wall with a consequent 4.3 cm pseudoaneurysm; we adopted an endovascular approach to exclude the lesion by catheterizing the celiac trunk and positioning a vascular plug in the common hepatic artery and a covered stent in the splenic artery; finally we fulfilled the aneurysm sac with Onyx. 30-day control CT scan revealed procedural success. Five years later he came back to our department for an aneurysm relapse in the common hepatic artery. We performed a second endovascular approach with a superselective catheterization of the pancreaticoduodenal arcade in order to exclude the lesion with Onyx and microcoils. Nowadays the patient is in good clinical conditions. Endovascular approach is a valuable method to treat visceral aneurysms; however, long-term imaging follow-up is essential to monitor the risk of relapse.


title: Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease.

text: AIM Management of fistulating perianal Crohn's disease (fpCD) is a significant challenge for a colorectal surgeon. A recent survey of surgical practice in this condition showed variation in management approaches. As a result we set out to devise recommendations for practice for UK colorectal surgeons. METHOD Results from a national survey were used to devise a set of potential consensus statements. Consultant colorectal surgeons were invited to participate in the exercise via the previous survey and the mailing list of the professional society. Iterative voting was performed on each statement using a five-point Likert scale and electronic voting, with opportunity for discussion and refinement between each vote. Consensus was defined as > 80% agreement. RESULTS Seventeen surgeons and two patient representatives voted upon 51 statements. Consensus was achieved on 39 items. Participants advocated a patient-centred approach by a colorectal specialist, within strong multidisciplinary teamworking. The use of anti-TNFα therapy is advocated. Where definitive surgical techniques are considered they should be carefully selected to avoid adverse impact on function. Ano/rectovaginal fistulas should be managed by specialists in fistulating disease. Stoma or proctectomy could be discussed earlier in a patient's treatment pathway to improve choice, as they may improve quality of life. CONCLUSION This consensus provides principles and guidance for best practice in managing patients with fpCD.


title: Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass.

text: BACKGROUND Robotic surgery is a complex technology offering technical advantages over conventional methods. Still, clinical outcomes and financial issues have been subjects of debate. Several studies have demonstrated higher costs for robotic surgery when compared to laparoscopy or open surgery. However, other studies showed fewer costly anastomotic complications after robotic Roux-en-Y gastric bypass (RYGBP) when compared to laparoscopy. METHODS We collected data for our gastric bypass patients who underwent open, laparoscopic, or robotic surgery from June 1997 to July 2010. Demographic data, BMI, complications, mortality, intensive care unit stay, hospitalization, and operating room (OR) costs were analyzed and a cost projection completed. Sensitivity analyses were performed for varied leak rates during laparoscopy, number of robotic cases per month, number of additional staplers during robotic surgery, and varied OR times for robotic cases. RESULTS Nine-hundred ninety patients underwent gastric bypass surgery at the University Hospital Geneva from June 1997 to July 2010. There were 524 open, 323 laparoscopic, and 143 robotic cases. Significantly fewer anastomotic complications occurred after open and robotic RYGBP when compared to laparoscopy. OR material costs were slightly less for robotic surgery (USD 5,427) than for laparoscopy (USD 5,494), but more than for the open procedure (USD 2,251). Overall, robotic gastric bypass (USD 19,363) was cheaper when compared to laparoscopy (USD 21,697) and open surgery (USD 23,000). CONCLUSIONS Robotic RYGBP can be cost effective due to balancing greater robotic overhead costs with the savings associated with avoiding stapler use and costly anastomotic complications.


What the SWIFT and TREVO II trials tell us about the role of endovascular therapy for acute stroke.


title: The association of stroke severity with health-related quality of life in survivors of acute cerebrovascular disease and their informal caregivers during the first year post stroke: a survey study.

text: PURPOSE To describe the health-related quality of life (HRQoL) of caregivers and survivors of transient ischaemic attack (TIA) and stroke during one year post discharge in comparison to age- and sex-matched population norms; and to analyse the association of initial stroke severity, measured by a routinely used stroke-specific scale, on subsequent HRQoL of caregivers and survivors. METHODS Cohort of hospitalized patients with TIA and stroke discharged alive from a large university hospital in Norway, and their informal caregivers. Questionnaires at 3 and 12 months post discharge were filled out by caregivers (n = 320 and n = 326, respectively) and survivors (n = 368 and n = 383, respectively). Multivariable linear regression analyses tested associations between initial stroke severity (National Institutes of Health Stroke Scale, NIHSS) and HRQoL (EQ-5D-3L) in caregivers and survivors. RESULTS Caregivers of survivors with TIA or stroke did not report lower HRQoL than matched norms. There was some evidence of an association of the NIHSS with caregiver HRQoL at 3 months only (age-sex-adjusted coefficient - 0.01, p = 0.008), however, this was attenuated after additional adjustments. Survivors with stroke, but not TIA, reported lower HRQoL than population norms at both time points. There was a negative association between higher NIHSS scores and survivors' HRQoL; fully adjusted coefficient - 0.01 at both time points (p = 0.001). CONCLUSION The informal caregivers and survivors with TIA did not report lower than expected HRQoL. Increasing stroke severity was associated with decreasing HRQoL among survivors, but had limited predictive value among caregivers. Other factors may therefore be better indicators of 'at risk' caregivers.


title: Microvascular anatomy of spinal dural arteriovenous fistulas: arteriovenous connections and their relationships with the dura mater.

text: OBJECT The microvascular anatomy of spinal dural arteriovenous fistulas (AVFs), especially the relationships of the vessels with the dura mater, has yet to be angiographically demonstrated in detail and proven histologically. METHODS From January 2012 through April 2014, a total of 7 patients with spinal dural AVFs in the thoracic region underwent open microsurgical obliteration at Tokyo Metropolitan Neurological Hospital. The microvascular anatomy of spinal dural AVFs was comprehensively assessed by using advanced microangiography, including 3D computer graphics and intraoperative indocyanine green video angiography, and by histological findings. RESULTS The 2 microangiography techniques revealed the spatial course and in vivo blood flow of the meningeal vessels and their relationships with the dura mater in sufficient detail. The meningeal branch of the intercostal artery split into multiple meningeal vessels on the outer dural surface adjacent to the root sleeve. After crossing the dura mater to the inner dural surface, these vessels gathered and joined a single intradural draining vessel. On the inner dural surface, the single draining vessel was fed by the surrounding multiple meningeal vessels, which appeared to be caput medusae. Histological findings revealed that the structure of the meningeal branch of the intercostal artery corresponded to that of a normal artery. The structure of intradural draining vessels corresponded to that of a vein modified by retrograde arterial inflow. On the inner dural surface, more than 1 meningeal artery gathered and joined with the proximal radiculomedullary vein. CONCLUSIONS Spinal dural AVFs are located on the inner dural surface, where multiple direct AV connections between more than 1 meningeal feeding artery and a single proximal radiculomedullary vein occur at the site where the vein connects to the dura mater.


title: Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study.

text: BACKGROUND The endovascular treatment of middle cerebral artery (MCA) aneurysms with unfavorable anatomy (wide neck, unfavorable morphology) is frequently challenging. Flow disruption with the WEB is a potentially interesting endovascular treatment for this type of aneurysm. OBJECTIVE To report in a multicenter series the preliminary treatment experience of MCA aneurysms with flow disruption by the WEB. METHODS Thirty-three patients with 34 MCA aneurysms were treated with the WEB in 5 European centers. The ability to successfully deploy the WEB, procedure- and device-related adverse events, morbidity and mortality of the treatment, and short-term angiographic follow-up results were analyzed. RESULTS Most treated aneurysms were unruptured (85.3%) and were between 5 and 10 mm (85.3%) with a neck size ≥ 4 mm (88.2%). The treatment failed in 1 of the 34 aneurysms (2.9%) owing to a lack of appropriate device size. Treatment was performed exclusively with the WEB in 29 of 33 aneurysms (87.9%). Additional treatment (coiling and/or stenting) was used in 4 of 33 aneurysms (12.1%). Mortality of the treatment was 0.0% and morbidity was 3.1% (intraoperative rupture with modified Rankin Scale score of 3 at the 1-month follow-up). In short-term follow-up (range, 2-12 months), adequate occlusion (total occlusion or neck remnant) was observed in 83.3% of aneurysms. CONCLUSION WEB flow disruption seems to be a promising technique for the treatment of complex MCA aneurysms, particularly those with a wide neck or unfavorable dome-to-neck ratio.


title: Our Next Pandemic Ethics Challenge? Allocating "Normal" Health Care Services.

text: The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.


title: Pure transvaginal umbilical hernia repair.

text: BACKGROUND Transvaginal natural orifice transluminal endoscopic surgery (NOTES) procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain [1, 2]. Most transvaginal procedures are performed as hybrid procedures [3]. To our knowledge, this is the first video depiction of a pure transvaginal umbilical hernia repair in a human. METHODS This is a 38-year-old woman, body mass index 36.4 kg/m(2), with a symptomatic port site hernia in the umbilical region after a previous laparoscopic cholecystectomy. The patient was positioned in stirrups in a steep Trendelenburg position. Sterilization of vaginal cavity was performed with 10 % povidone-iodine solution. A 2 cm transverse incision at the posterior fornix was made, and a SILS port (Covidien, North Haven, CT) was introduced. One 12 mm trocar and two 5 mm trocars were placed through SILS port. Standard straight laparoscopic instruments were used. A 12 cm round Parietex mesh (Covidien) was placed in a specimen retrieval bag and deployed into the peritoneal cavity. The mesh was extracted, unfolded in the abdominal cavity, and circumferentially fixated to the abdominal wall with an AbsorbaTack device (Covidien). The colpotomy incision was closed with a running absorbable suture. RESULTS The procedure lasted 103 min and was performed on an outpatient basis. No intraoperative complications occurred. The patient was doing well and had no pain or recurrence at 2, 6, and 9 months' follow-up. CONCLUSIONS Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible and safe. This approach may improve cosmesis and decrease the risk of future ventral hernias. Potential cons may include a longer operative time, mesh infection, and risk of visceral injury with a pure transvaginal approach. As transvaginal surgery evolves, techniques and devices will become increasingly refined to tackle these challenges.


The Surgical Health Services Research Agenda for the COVID-19 Pandemic.


docid: bhfqxwee

title: Gain-of-function research: unknown risks.


title: Genetic diversity of novel circular ssDNA viruses in bats in China.

text: Novel circular ssDNA genomes have recently been detected in animals and in the environment using metagenomic and high-throughput sequencing approaches. In this study, five full-length circular ssDNA genomes were recovered from bat faecal samples using inverse PCR with sequences designed based on circovirus-related sequences obtained from Solexa sequencing data derived from a random amplification method. These five sequences shared a similar genomic organization to circovirus or the recently proposed cyclovirus of the family Circoviridae. The newly obtained circovirus/cyclovirus-like genomes ranged from 1741 to 2177 bp, and each consisted of two major ORFs, ORF1 and ORF2, encoding putative replicase (Rep) and capsid (Cap) proteins, respectively. The potential stem-loop region was predicted in all five genomes, and three of them had the typical conserved nonanucleotide motif of cycloviruses. A set of primers targeting the conserved Rep region was designed and used to detect the prevalence of circovirus/cyclovirus sequences in individual bats. Among 199 samples tested, 47 were positive (23.6%) for the circovirus genome and two (1.0%) were positive for the cyclovirus genome. In total, 48 partial Rep sequences plus the five full-length genomes were obtained in this study. Detailed analysis indicated that these sequences are distantly related to known circovirus/cyclovirus genomes and may represent 22 novel species that belong to the family Circoviridae.


title: Exercise-Based Strategies to Prevent Muscle Injury in Elite Footballers: A Systematic Review and Best Evidence Synthesis.

text: BACKGROUND Exercise-based strategies are used to prevent muscle injuries in football and studies on different competitive-level populations may provide different results. OBJECTIVES To evaluate the effectiveness of exercise-based muscle injury prevention strategies in adult elite football. METHODS A systematic search was conducted in PubMed (MEDLINE), Web of Science, Cochrane Library, and SPORTDiscuss (EBSCO). We considered only elite adult (> 16 year-old) football players with no distinction for gender; the intervention to be any exercise/s performed with the target to prevent lower-limb muscle injuries; the comparison to be no injury prevention exercise undertaken; the outcome to be the number of injuries, injury incidence, and severity. We searched systematic reviews, randomized-controlled trials (RCTs), and non-randomized-controlled trials (NRCTs), limited for English language. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool, the Cochrane Collaboration's Tool for assessing risk of bias in RCTs, and the Risk of Bias in NRCTs of Interventions tool. RESULTS 15 studies were included. Three systematic reviews showed inconsistent results, with one supporting (high risk of bias) and two showing insufficient evidence (low risk of bias) to support exercise-based strategies to prevent muscle injuries in elite players. Five RCTs and seven NRCTs support eccentric exercise, proprioception exercises, and a multi-dimensional component to an injury prevention program; however, all were deemed to be at high/critical risk of bias. Only one RCT was found at low risk of bias and supported eccentric exercise for preventing groin problems. CONCLUSION We found limited scientific evidence to support exercise-based strategies to prevent muscle injury in elite footballers. TRIAL REGISTRATION NUMBER PROSPERO CRD42017077705.


docid: geysmyfv

title: Characteristics of missed or interval colorectal cancer and patient survival: a population-based study.

text: BACKGROUND & AIMS Colorectal cancers (CRCs) diagnosed within a few years after an index colonoscopy can arise from missed lesions or the development of a new tumor. We investigated the proportion, characteristics, and factors that predict interval CRCs that develop within 6-60 months of colonoscopy. METHODS We performed a population-based cohort study of Utah residents who underwent colonoscopy examinations from 1995 through 2009 at Intermountain Healthcare or the University of Utah Health System, which provide care to more than 85% of state residents. Colonoscopy results were linked with cancer histories from the Utah Population Database to identify patients who underwent colonoscopy 6-60 months before a diagnosis of CRC (interval cancer). Logistic regression was performed to identify risk factors associated with interval cancers. RESULTS Of 126,851 patients who underwent colonoscopies, 2659 were diagnosed with CRC; 6% of these CRCs (159 of 2659) developed within 6 to 60 months of a colonoscopy. Sex and age were not associated with interval CRCs. A higher percentage of patients with interval CRC were found to have adenomas at their index colonoscopy (57.2%), compared with patients found to have CRC detected at colonoscopy (36%) or patients who did not develop cancer (26%) (P < .001). Interval CRCs tended to be earlier-stage tumors than those detected at index colonoscopy, and to be proximally located (odds ratio, 2.24; P < .001). Patients with interval CRC were more likely to have a family history of CRC (odds ratio, 2.27; P = .008) and had a lower risk of death than patients found to have CRC at their index colonoscopy (hazard ratio, 0.63; P < .001). CONCLUSIONS In a population-based study in Utah, 6% of all patients with CRC had interval cancers (cancer that developed within 6 to 60 months of a colonoscopy). Interval CRCs were associated with the proximal colon, earlier-stage cancer, lower risk of death, higher rate of adenoma, and family history of CRC. These findings indicate that interval colorectal tumors may arise as the result of distinct biologic features and/or suboptimal management of polyps at colonoscopy.


title: The free descending branch muscle-sparing latissimus dorsi flap: vascular anatomy and clinical applications.

text: BACKGROUND Increasing focus on reducing morbidity from latissimus dorsi flaps has led to the evolution of muscle-sparing variants and perforator-based flaps. This study aimed to investigate the vascular anatomy of the muscle-sparing variant and to describe its application as a free flap based on the descending branch of the thoracodorsal artery. METHODS Twelve fresh cadavers underwent anatomical dissection and angiographic injection studies of the thoracodorsal arterial system. The musculocutaneous territories of the descending and transverse branches to the latissimus dorsi muscle were identified and assessed using three-dimensional reconstruction software of computed tomography imaging results. In the clinical study, five patients underwent reconstruction of a variety of defects using the free descending branch muscle-sparing latissimus dorsi flap. RESULTS Three- and four-dimensional (computed tomography) angiography demonstrated perfusion of the latissimus dorsi muscle by the transverse and descending branches, with overlap of vascular territories via cross-linking vessels. The descending branch supplied a slightly greater cutaneous area overlying the muscle, although differences between both branches were not significant (p = 0.76). In the clinical study, the free muscle-sparing latissimus dorsi flap provided excellent coverage with no flap complications or seroma. CONCLUSIONS The free muscle-sparing latissimus dorsi flap based on the descending branch of the thoracodorsal artery is a viable reconstructive option. Significant collateral flow between vessels allows for larger flap harvest than would be expected. The flap is technically simple to harvest, provides a large perfusion area, and is a reliable variant of the full latissimus dorsi flap. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.


Metabolic Surgery for Type 2 Diabetes: Changing the Landscape of Diabetes Care.


title: Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection following standardization--a preliminary study.

text: BACKGROUND Laparoscopy-assisted distal gastrectomy (LADG) with standard D2 dissection is a complex procedure usually performed only by experienced surgeons, and the feasibility of this procedure still remains unclear. METHOD Patients who underwent LADG at the Cancer Institute Hospital between April 2006 and October 2008 were recruited for this study. Early surgical outcomes were compared between patients who underwent complete D2 dissection (complete D2 group; n = 42) and those who underwent D1 + beta dissection (D1 + beta group; n = 179) to determine the feasibility of laparoscopic D2 lymph node dissection. RESULTS In complete D2 group, the operation time was longer (253 +/- 10 vs 224 +/- 4 min; P = 0.005), and the number of retrieved lymph nodes was larger (41 +/- 2 vs 35 +/- 1; P = 0.002) compared with those in D1 + beta group. The other early surgical outcomes monitored for the two groups were not different between groups. CONCLUSIONS LADG with complete D2 lymph node dissection can be performed safely if the procedure is standardized and an experienced laparoscopic surgeon performs the surgery. To be accepted as a standard treatment for advanced gastric cancer, well-designed prospective trial is necessary.


title: Viscosity of iodinated contrast agents during renal excretion.

text: OBJECTIVE Modern iodinated non-ionic contrast agents (CAs) can be classified based on their molecular structure into monomeric and dimeric CAs and have at comparable iodine concentrations a different viscosity and osmolality. During their renal excretion, CAs are concentrated in the renal tubuli which might enhance the viscosity difference between monomeric and dimeric CAs. The viscosity of a CA might have an underestimated importance for renal safety, as suggested by recent publications. In this study, we investigated the viscosities of CAs at the concentrations expected to be present in renal tubules. This concentration process was simulated in vitro using dialysis. Furthermore, we investigated urine viscosity and urine flow in rodents after administration of several non-ionic monomeric and dimeric CAs. MATERIALS AND METHODS To estimate the viscosity of the CAs in vivo, we performed an in vitro dialysis of monomeric and dimeric CAs at various physiological osmolalities of the renal tubulus (290, 400, 500, 700 and 1000 mOsm/kg H2O). Following the dialysis, the iodine concentrations and the viscosities of the CAs were determined. Furthermore, to investigate the concentration process in vivo, we measured the urine viscosity and the urine flow in Han Wister rats after the administration of Iopromide, Iohexol, Ioversol, Iomeprol, Iodixanol, and Iosimenol at comparable iodine concentrations. As a control, saline was injected at the same volume. RESULTS In vitro dialysis of the dimeric CA increased the iodine concentration and strongly increased the viscosity at all tested osmolalities. In contrast, for the monomeric agents an increase in concentration and viscosity was observed only at 700 as well 1000 mOsm/kg H2O but to a lesser extent. In summary, dialysis strongly enhanced the viscosity differences between the non-ionic monomeric and dimeric CAs. The administration of dimeric CAs leads to a strong increase in urine viscosity; this was not observed for the monomeric CAs. In contrast, a significantly higher urine flow was measured after the administration of the monomeric CAs as compared to the dimeric CAs. CONCLUSION We demonstrated that the viscosity differences between monomeric and dimeric CAs are strongly enhanced due to a concentration process of the CAs upon increasing osmolalities, a process which is likely to take place in a similar manner in the tubular system. This result suggests that the viscosity of the dimeric agents increases dramatically in vivo and gives a plausible explanation for measured enhancement of urine viscosity upon dimeric CA administration. On the other hand, the higher osmolality of the monomeric agents causes an osmodiuresis, indicated by a higher urine flow, which leads to a faster elimination of the CAs from the kidney.


title: Urologic surgery in a safe hospital during the COVID-19 pandemic scenario.

text: The COVID-19 pandemic induced a global emergency that overwhelmed most hospitals around the world. Access to Hospitals has been restricted to selective oncological and urgent patients to minimize surgeries requiring Intensive Care Unit care. All other kind of non- urgent and benign surgeries have been rescheduled. The burden of oncological and urgent cases on the healthcare system has increased. We have been asked to become the referral center for major oncological and urgent urological surgeries, increasing our surgical volume. Through meticulous hospital protocols on PPE, use of nasopharyngeal swabs, controlled hospital access and the prompt management of suspected/positive cases, we were able to perform 31% more urological surgical procedures during the COVID-19 pandemic compared to the same period in 2019. We observed a 72% increase in oncological surgical procedures and 150% in urgent procedures. Our experience shows how the management of oncological and urgent cases can be maintained during unexpected, global emergencies, such as COVID-19.


title: Design of polymeric nanoparticles for biomedical delivery applications.

text: Polymeric nanoparticles-based therapeutics show great promise in the treatment of a wide range of diseases, due to the flexibility in which their structures can be modified, with intricate definition over their compositions, structures and properties. Advances in polymerization chemistries and the application of reactive, efficient and orthogonal chemical modification reactions have enabled the engineering of multifunctional polymeric nanoparticles with precise control over the architectures of the individual polymer components, to direct their assembly and subsequent transformations into nanoparticles of selective overall shapes, sizes, internal morphologies, external surface charges and functionalizations. In addition, incorporation of certain functionalities can modulate the responsiveness of these nanostructures to specific stimuli through the use of remote activation. Furthermore, they can be equipped with smart components to allow their delivery beyond certain biological barriers, such as skin, mucus, blood, extracellular matrix, cellular and subcellular organelles. This tutorial review highlights the importance of well-defined chemistries, with detailed ties to specific biological hurdles and opportunities, in the design of nanostructures for various biomedical delivery applications.


title: Keeping Patients With Cancer Exercising in the Age of COVID-19.

text: The novel 2019 coronavirus disease (COVID-19) pandemic is a global public health emergency. To date, physical distancing and good personal hygiene have been the only effective measures to limit spread. The pandemic has altered routine cancer care, including allied health and supportive care interventions. Clinicians must adapt and find ways to continue to deliver optimal patient care at this time. The prescription of exercise to people with cancer has been demonstrated to have meaningful benefits for both physical and mental health and quality of life, and may even enhance survival. Such exercise interventions provide the largest benefit to patients when delivered in a supervised, group, clinic-based setting. In the age of COVID-19, group-based exercise in communal facilities presents risks for both aerosol and surface transmission of the virus among people exercising, necessitating a pivot from the usual methods of exercise delivery to home-based exercise programs. In this article, we discuss the challenges that need to be overcome in moving to a home-based program for patients with cancer while maintaining the benefits of targeted and high-fidelity exercise medicine. We provide practical recommendations for how home-based exercise can be supported and nurtured by qualified exercise professionals who treat people living with cancer, as well as pointing to resources that are available online to assist practitioners. Despite the challenges faced during this pandemic, we believe that it is important for people to continue to benefit from exercise in a safe environment with the support of exercise specialists.


docid: xgcfcwxe

title: 18F-FDG PET as novel imaging biomarker for disease progression after ablation therapy in colorectal liver metastases.

text: PURPOSE Recurrent disease following thermal ablation therapy is a frequently reported problem. Preoperative identification of patients with high risk of recurrent disease might enable individualized treatment based on patients' risk profile. The aim of the present work was to investigate the role of metabolic parameters derived from the pre-ablation 18F-FDG PET/CT as imaging biomarkers for recurrent disease in patients with colorectal liver metastases (CLM). METHODS Included in this retrospective study were all consecutive patients with CLM treated with percutaneous or open thermal ablation therapy who had a pre-treatment baseline 18F-FDG PET/CT available. Multivariable cox regression for survival analysis was performed using different models for the metabolic parameters (SULpeak, SULmean, SULmax, partial volume corrected SULmean (cSULmean), and total lesion glycolysis (TLG)) corrected for tumour and procedure characteristics. The study endpoints were defined as local tumour progression free survival (LTP-FS), new intrahepatic recurrence free survival (NHR-FS) and extrahepatic recurrence free survival (EHR-FS). Clinical and imaging follow-up data was used as the reference standard. RESULTS Fifty-four patients with 90 lesions were selected. Univariable cox regression analysis resulted in eight models. Multivariable analysis revealed that after adjusting for lesion size and the approach of the procedure, none of the metabolic parameters were associated with LTP-FS or EHR-FS. Percutaneous approach was significantly associated with a shorter LTP-FS. It was demonstrated that lower values of SULpeak, SULmax, SULmean , and cSULmean are associated with a significant better NHR-FS, independent of the lesion size and number and prior chemotherapy. CONCLUSION We found no association between the metabolic parameters on pre-ablation 18F-FDG PET/CT and the LTP-FS. However, low values of the metabolic parameters were significantly associated with improved NHR-FS. The clinical implication of these findings might be the identification of high-risk patients who might benefit most from adjuvant or combined treatment strategies.


Collaboration in TB and COVID-19 control in Moscow.


title: First case report of single port video-assisted thoracoscopic middle lobectomy for the treatment of pulmonary aspergilloma in a pediatric patient.

text: We present the case of an 11-year-old girl with pulmonary aspergilloma secondary to a hematologic disease successfully treated with a single port video-assisted thoracoscopic lobectomy. This surgical procedure was not previously reported. We consider this approach to be a safe and appropriate procedure for lung resection, in children or adults requiring minimal intervention and early recovery.


title: Uncertainty and agreement regarding the role of flow diversion in the management of difficult aneurysms.

text: BACKGROUND AND PURPOSE The role of flow diversion in the management of aneurysms remains unknown. We sought to evaluate the community agreement regarding indications for flow diversion. MATERIALS AND METHODS A portfolio of 35 difficult aneurysm cases was sent to 40 clinicians with varying backgrounds and experience. Responders were asked whether they considered flow diversion a treatment option, whether other options were possible, whether recruitment in a randomized trial would be considered, and to select their final choice. Agreement was studied by using κ statistics. RESULTS Decisions for flow diversion were more frequent (n = 300, 39%) than decisions to coil (n = 163, 21.2%), to observe (n = 121, 15.7%), to occlude the parent vessel (n = 102, 13.2%), or to clip (n = 66, 8.6%). Sidewall aneurysm morphology was associated with flow diversion as the final choice (P = .001). Interjudge agreement was fair at best (κ <0.3) for all cases and all judges, despite high certainty levels (range, 7.2-8.9 ± 2.0 on a 0-10 scale). Agreement was no better within specialties or with more experience. All patients were judged to have other treatment options. Judges were willing to offer trial participation in 417 of 741 (56.3%) scenarios, more frequently when the aneurysm was sidewall (P = .001) or in the anterior circulation (P = .028). CONCLUSIONS Individuals did not agree regarding the indications for flow diversion. There is sufficient uncertainty to justify trials designed to protect patients from the potential risks of premature adoption of an innovation.


Novel Coronavirus 2019 (Sars-CoV2): a global emergency that needs new approaches?


Clinical Correlation of Anatomical Location of Nonthrombotic Iliac Vein Lesion.