title: Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial.

text: PURPOSE To evaluate the safety and effectiveness of the Pipeline Embolization Device (PED; ev3/Covidien, Irvine, Calif) in the treatment of complex intracranial aneurysms. MATERIALS AND METHODS The Pipeline for Uncoilable or Failed Aneurysms is a multicenter, prospective, interventional, single-arm trial of PED for the treatment of uncoilable or failed aneurysms of the internal carotid artery. Institutional review board approval of the HIPAA-compliant study protocol was obtained from each center. After providing informed consent, 108 patients with recently unruptured large and giant wide-necked aneurysms were enrolled in the study. The primary effectiveness endpoint was angiographic evaluation that demonstrated complete aneurysm occlusion and absence of major stenosis at 180 days. The primary safety endpoint was occurrence of major ipsilateral stroke or neurologic death at 180 days. RESULTS PED placement was technically successful in 107 of 108 patients (99.1%). Mean aneurysm size was 18.2 mm; 22 aneurysms (20.4%) were giant (>25 mm). Of the 106 aneurysms, 78 met the study's primary effectiveness endpoint (73.6%; 95% posterior probability interval: 64.4%-81.0%). Six of the 107 patients in the safety cohort experienced a major ipsilateral stroke or neurologic death (5.6%; 95% posterior probability interval: 2.6%-11.7%). CONCLUSION PED offers a reasonably safe and effective treatment of large or giant intracranial internal carotid artery aneurysms, demonstrated by high rates of complete aneurysm occlusion and low rates of adverse neurologic events; even in aneurysms failing previous alternative treatments.


title: [Application of tracheotomy in the treatment of severe cases of COVID-19].

text: Objective: Todiscuss the the effects, indications and protective measures of tracheotomy for severe cases of 2019 novel corona virus disease(COVID-19)patients. Methods: A retrospectively analyze was conducted to explore the clinical data of ofCOVID-19 patients who received tracheotomy in February to March 2020,descriptive statistics were used to analyze the indication of tracheotomy, particularity of intraoperative treatment and protective measures. Results: A total of 4 cases were included in this article, 3 cases were successfully operated, 1 case of postoperative incision continuous bleeding, there were not other complications and nosocomial infection among the medical staff.the patient's condition was relieved in different degrees after the operation, who remain hospitalized. Conclusion: Tracheotomy for severe cases of COVID-19 can achieve certain curative effect, but the occurrence of tracheotomy related complicationsand nosocomial infection should be effectively controlled, and the risk benefit ratio of tracheotomy should be carefully weighed before surgery.


Editorial commentary: missing the forest for the trees: respiratory viral assays in patients with kawasaki disease.


title: Ecoepidemiology and complete genome comparison of different strains of severe acute respiratory syndrome-related Rhinolophus bat coronavirus in China reveal bats as a reservoir for acute, self-limiting infection that allows recombination events.

text: Despite the identification of severe acute respiratory syndrome-related coronavirus (SARSr-CoV) in Rhinolophus Chinese horseshoe bats (SARSr-Rh-BatCoV) in China, the evolutionary and possible recombination origin of SARSr-CoV remains undetermined. We carried out the first study to investigate the migration pattern and SARSr-Rh-BatCoV genome epidemiology in Chinese horseshoe bats during a 4-year period. Of 1,401 Chinese horseshoe bats from Hong Kong and Guangdong, China, that were sampled, SARSr-Rh-BatCoV was detected in alimentary specimens from 130 (9.3%) bats, with peak activity during spring. A tagging exercise of 511 bats showed migration distances from 1.86 to 17 km. Bats carrying SARSr-Rh-BatCoV appeared healthy, with viral clearance occurring between 2 weeks and 4 months. However, lower body weights were observed in bats positive for SARSr-Rh-BatCoV, but not Rh-BatCoV HKU2. Complete genome sequencing of 10 SARSr-Rh-BatCoV strains showed frequent recombination between different strains. Moreover, recombination was detected between SARSr-Rh-BatCoV Rp3 from Guangxi, China, and Rf1 from Hubei, China, in the possible generation of civet SARSr-CoV SZ3, with a breakpoint at the nsp16/spike region. Molecular clock analysis showed that SARSr-CoVs were newly emerged viruses with the time of the most recent common ancestor (tMRCA) at 1972, which diverged between civet and bat strains in 1995. The present data suggest that SARSr-Rh-BatCoV causes acute, self-limiting infection in horseshoe bats, which serve as a reservoir for recombination between strains from different geographical locations within reachable foraging range. Civet SARSr-CoV is likely a recombinant virus arising from SARSr-CoV strains closely related to SARSr-Rh-BatCoV Rp3 and Rf1. Such frequent recombination, coupled with rapid evolution especially in ORF7b/ORF8 region, in these animals may have accounted for the cross-species transmission and emergence of SARS.


title: High-Volume Practice by a Single Specialized Team Reduces Mortality and Morbidity of Elective and Urgent Aortic Root Replacement.

text: BACKGROUND Elective aortic root replacement (ARR), or the Bentall procedure, is associated with significant mortality and complications. Recent studies have shown that high procedure volume has an inverse association with postoperative mortality. The outcomes of patients undergoing elective/urgent ARR by a single, high-volume surgical team were assessed in this study. METHODS Patients undergoing nonemergency, elective/urgent ARR for non-Marfan aortic root dilatation, from October 2005 to March 2011, were studied. Valve-preserving procedures, extra-anatomic bypass, and arch and descending aortic repairs were excluded. Patient demographics, operative details, and postoperative outcomes were collected prospectively. Surgical techniques included central cannulation and cardiopulmonary bypass (CPB) at 35°C. Following aneurysm excision, a composite valve-conduit reconstruction with coronary button reimplantation was performed. Tissue glue, Teflon pledgets, and blood products were seldom used. Patients were followed locally at 8 weeks, 6 months, and annually thereafter with echocardiography and computed tomographic (CT) scanning. RESULTS From October 2005 to March 2011, 163 ARRs were performed. Of these, 131 (80%) were isolated first time procedures (four in pregnant women), six were redo (4%), and in 26 (16%) ARR was combined with concomitant valve or coronary artery revascularization procedures. Median age was 63 years (range 19-84). Median cross-clamp and CPB times were 73 (range 69-87) and 86 minutes (range 85-126), respectively. There was one in-hospital death (mortality = 0.6%), one patient underwent resternotomy for bleeding, two required hemofiltration, and there were no strokes. Median hospital stay was 6 days (range 5-11). Median follow-up was 2.9 years (range 6 months-4.3 years) with 100% freedom from reoperation. There was no late distal ascending aorta/arch dilatation. There were two late deaths (1.2%) due to pneumonia and stroke. CONCLUSIONS High-volume surgery, with minimal use of hemostatic adjuncts and sustained follow-up, leads to excellent outcomes, with low morbidity and mortality following ARR.


title: The early kinetics of circulating pneumococcal-specific memory B cells following pneumococcal conjugate and plain polysaccharide vaccines in the elderly.

text: In young children, polyvalent pneumococcal polysaccharide conjugate vaccines (PCVs) have been shown to offer advantage over plain polysaccharide vaccines (PPVs) in both immunogenicity and priming for memory responses. In the elderly, the potential benefit of conjugate vaccines is unclear. Here, we explore the early kinetics of serum antibody and circulating plasma and memory B cell responses to pneumococcal capsular polysaccharide (PPS) in older adults (n=37) immunised a PPV vaccine, Pneumovax or a PCV: Prevenar. All individuals had serum evidence of pre-existing serotype-specific immunity. Following immunisation, a day 7 rise in circulating PPS-specific plasma and memory antibody secreting cells (AbSCs) was detected in both vaccine groups and this was sustained to day 28 in some PCV recipients. There was no difference between vaccine groups in serum antibody responses or the kinetics of the early PBMC-derived B cell responses. Although our sample cohort was small, these data are different from profiles in younger individuals at early time points post-immunisation and suggest that pneumococcal conjugate vaccines may not quantitatively enhance the generation of memory responses in the elderly.


title: Dl-3-N-butylphthalide attenuates ischemic reperfusion injury by improving the function of cerebral artery and circulation.

text: Dl-3-N-butylphthalide (NBP) is approved in China for the treatment of ischemic stroke. Previous studies have shown that NBP promotes recovery after stroke via multiple mechanisms. However, the effect of NBP on vascular function and thrombosis remains unclear. Here, we aim to study the effect of NBP on vascular function using a rat model of transient middle cerebral artery occlusion (MCAO) and a state-of-the-art high-resolution synchrotron radiation angiography. Eighty SD rats underwent MCAO surgery. NBP (90 mg/kg) was administrated daily by gavage. Synchrotron radiation angiography was used to evaluate the cerebral vascular perfusion, vasoconstriction, and vasodilation in real-time. Neurological scores, brain infarction and atrophy were evaluated. Real-time PCR was used to assess the expression levels of thrombosis and vasoconstriction-related genes. Results revealed that NBP attenuated thrombosis after MCAO and reduced brain infarct and atrophy volume. NBP administrated at 1 and 4 h after MCAO prevented the vasoconstriction of the artery and maintained its diameter at normal level. Administrated at one week after surgery, NBP functioned as a vasodilator in rats after MCAO while displayed no vasodilating effect in sham group. Our results suggested that NBP attenuates brain injury via increasing the regional blood flow by reducing thrombosis and vasoconstriction.


title: Development and evaluation of a simulation-based continuing medical education course: beyond lectures and credit hours.

text: BACKGROUND The aim of our study was to modify our previously developed laparoscopic ventral hernia (LVH) simulator to increase difficulty and then reassess validity and feasibility for using the simulator in a newly developed simulation-based continuing medical education course. METHODS Participants (N = 30) were practicing surgeons who signed up for a hands-on postgraduate laparoscopic hernia course. An LVH simulator, with prior validity evidence, was modified for the course to increase difficulty. Participants completed 1 of the 3 variations in hernia anatomy: incarcerated omentum, incarcerated bowel, and diffuse adhesions. During the procedure, course faculty and peer observers rated surgeon performance using Global Operative Assessment of Laparoscopic Skills-Incisional Hernia and Global Operative Assessment of Laparoscopic Skills rating scales with prior validity evidence. Rating scale reliability was reassessed for internal consistency. Peer and faculty raters' scores were compared. In addition, quality and completeness of the hernia repairs were rated. RESULTS Internal consistency on the general skills performance (peer α = .96, faculty α = .94) and procedure-specific performance (peer α = .91, faculty α = .88) scores were high. Peers were more lenient than faculty raters on all LVH items in both the procedure-specific skills and general skills ratings. Overall, participants scored poorly on the quality and completeness of their hernia repairs (mean = 3.90/16, standard deviation = 2.72), suggesting a mismatch between course attendees and hernia difficulty and identifying a learning need. CONCLUSIONS Simulation-based continuing medical education courses provide hands-on experiences that can positively affect clinical practice. Although our data appear to show a significant mismatch between clinical skill and simulator difficulty, these findings also underscore significant learning needs in the surgical community.


SARS: a timely reminder.


title: Personal Protective Equipment during the COVID-19 pandemic and operative time in cesarean section: retrospective cohort study.

text: INTRODUCTION The covid-19 pandemic has meant a change in working protocols, as well as in Personal Protective Equipment (PPE). Obstetricians have had to adapt quickly to these changes without knowing how they affected their clinical practice. The aim of the present study was to evaluate how COVID-19 pandemic and PPE can affect operative time, operating room time, transfer into the operating room to delivery time and skin incision to delivery time in cesarean section. METHODS This is a single-center retrospective cohort study. Women with confirmed or suspected SARS-CoV-2 infection having a cesarean section after March 7th, 2020 during the COVID-19 pandemic were included in the study. For each woman with confirmed or suspected SARS-CoV-2 infection, a woman who had a cesarean section for the same indication during the COVID-19 pandemic and with similar clinical history but not affected by SARS-CoV-2 was included. RESULTS 42 cesarean sections were studied. The operating room time was longer in the COVID-19 confirmed or suspected women: 90 (73.0 to 110.0) versus 61 (48.0 to 70.5) minutes; p < .001. The transfer into the operating room to delivery time was longer, but not statistically significant, in urgent cesarean sections in COVID-19 confirmed or suspected women: 25.5 (17.5 to 31.75) versus 18.0 (10.0 to 26.25) minutes; p = .113. CONCLUSIONS There were no significant differences in the operative time, transfer into the operating room to delivery time and skin incision to delivery time when wearing PPE in cesarean section. The COVID-19 pandemic and the use of PPE resulted in a significant increase in operating room time.


title: Systematic review and meta-analysis of second-generation antidepressants for the treatment of older adults with depression: questionable benefit and considerations for frailty.

text: BACKGROUND Frail older adults are commonly prescribed antidepressants. Yet, there is little evidence to determine the efficacy and safety of antidepressants to treat depression with concomitant frailty. To better understand this issue, we examined the efficacy and safety of second-generation antidepressants for the treatment of older adults with depression and then considered implications for frailty. METHODS Due to the absence of therapeutic studies of frail older adults with depression, we conducted a systematic review and meta-analysis of double-blind, randomized controlled trials that compared antidepressants versus placebo for adults with depression, age 65 years or older. We searched PubMed/MEDLINE, Cochrane Library, reference lists from meta-analyses/studies, hand searches of publication lists, and related articles on PubMed. Outcomes included rates of response, remission, and adverse events. After evaluating the data, we applied a frailty-informed framework to consider how the evidence could be applied to frailty. RESULTS Nine trials were included in the meta-analysis (n = 2704). Subjects had moderate to severe depression. For older adults with depression, there was no statistically significant difference in response or remission to second-generation antidepressants compared to placebo. Response occurred in 45.3% of subjects receiving an antidepressant compared to 40.5% receiving placebo (RR 1.15, 95% CI: 0.96 - 1.37, p = 0.12, I2 = 71%). Remission occurred in 33.1% with antidepressant versus 31.3% with placebo (RR 1.10, 95% CI: 0.92 - 1.31, p = 0.30, I2 = 56%) (Figure 2 and 3). There were more withdrawals due to adverse events with antidepressants, 13% versus 5.8% (RR 2.30, 95% CI: 1.45-3.63; p < 0.001; I2 = 61%; NNH 14, 95% CI:10-28). IMPLICATIONS FOR FRAILTY Subjects in the meta-analysis did not have obvious characteristics of frailty. Using framework questions to consider the implications of frailty, we hypothesize that, like older adults, frail individuals with depression may not respond to antidepressants. Further, observational studies suggest that those who are frail may be less responsive to antidepressants compared to the non-frail. Given the vulnerability of frailty, adverse events may be more burdensome. CONCLUSIONS Second-generation antidepressants have uncertain benefit for older adults with depression and cause more adverse events compared to placebo. Until further research clarifies benefit, careful consideration of antidepressant prescribing with frailty is warranted.


title: Radiology Perspective of Coronavirus Disease 2019 (COVID-19): Lessons From Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome.

text: OBJECTIVE. Since the outbreak of the novel coronavirus pulmonary illness coronavirus disease 2019 (COVID-19) in China, more than 79,000 people have contracted the virus worldwide. The virus is rapidly spreading with human-to-human transmission despite imposed precautions. Because similar pulmonary syndromes have been reported from other strains of the coronavirus family, our aim is to review the lessons from imaging studies obtained during severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks. CONCLUSION. The review of experiences with the MERS and SARS outbreaks will help us better understand the role of the radiologist in combating the outbreak of COVID-19. The known imaging manifestations of the novel coronavirus and the possible unknowns will also be discussed.


title: Microbiological detection of bacteria in animal products seized in baggage of international air passengers to Brazil.

text: Airline travel favours the transmission of diseases, given the short time it takes to travel long distances. In this study, animal products without health certificates seized in international air passengers' baggage at Guarulhos (GRU) and Galeão (GIG) airports in Brazil underwent a microbiological evaluation. Analyses (1610) were carried out on 322 seizures to test for the presence of total and thermotolerant coliforms, as well as Staphylococcus aureus counts and the presence of Listeria monocytogenes and Salmonella. Most seizures analysed showed coliform contamination and coliforms were present above acceptable limits in 83.4% (40/48) of the products that had some type of contamination. The second most prevalent microorganism found was L. monocytogenes in 22.9% (11/48) and S. aureus was cultivated in 14.58% (7/48) of seizures. Among the items seized in the present work, Salmonella was found in one seizure of pig sausage. Contamination of animal products with microbiological pathogens of importance to public health and indicators of the bad quality of the food were shown in the present study.


title: Bronchiolitis of Infancy Discharge Study (BIDS): a multicentre, parallel-group, double-blind, randomised controlled, equivalence trial with economic evaluation.

text: BACKGROUND There are no randomised trials of peripheral capillary oxygen saturation (SpO2) targets in acute respiratory infection. Two national guidelines recommended different targets for the management of acute viral bronchiolitis. OBJECTIVES To compare the American Academy of Pediatrics guideline target of SpO2 ≥ 90% with the Scottish Intercollegiate Guidelines Network target of SpO2 ≥ 94%. DESIGN A multicentre, parallel-group, double-blind, randomised controlled, equivalence trial with economic evaluation. SETTING Eight paediatric hospital departments in the UK. PARTICIPANTS Infants > 6 weeks and ≤ 12 months of age (corrected for prematurity) with physician-diagnosed bronchiolitis admitted to hospital from a paediatric emergency assessment area. Follow-up for 6 months by standardised telephone contacts. INTERVENTION Infants were randomised to a target oxygen saturation of ≥ 94% (standard care) or ≥ 90% (modified care) displayed by a pulse saturation oximeter (Masimo Corporation Limited, CA, USA). ROUTINE CARE All infants received routine care in addition to the study intervention. Infants were eligible for discharge when they exhibited a SpO2 of ≥ 94% in room air for 4 hours including a period of sleep and were also feeding adequately (≥ 75% usual volume). PRIMARY OUTCOME A total of 615 infants were recruited, of whom 308 were allocated to the standard care group and 307 to the modified care group. The primary outcome was time to cough resolution. There was equivalence at the prespecified variance of ± 2 days [time to cough resolution: standard care group, 15 days; modified care group, 15 days; median difference 1 day (benefit modified), 95% confidence interval (CI) -1 to 2 days]. SECONDARY RESULTS Return to adequate feeding occurred sooner in infants in the modified care group than in those in the standard care group (19.5 vs. 24.1 hours). This difference was non-equivalent [median difference 2.7 hours (95% CI -0.3 to 7.0 hours) versus prespecified ± 4 hours; post-hoc hazard ratio 1.22 (95% CI 1.04 to 1.44 (p-value = 0.015)]. Parent perspective of the time taken to return to normal was not equivalent, being 12 days in the standard care group compared with 11 days in the modified care group [median difference 1.0 day (95% CI 0.0 to 3.0 days) versus prespecified ± 2 days; post-hoc hazard ratio 1.19 (95% CI 1.00 to 1.41); p-value = 0.043]. At 28 days, SpO2 was equivalent [mean difference 0.11% (95% CI -0.35% to 0.57%), within the 1% prespecified]. The modified care group (55.6%) required oxygen less than the standard care group (73.1%), and for a shorter period (5.7 hours vs. 27.6 hours). Infants in the modified care group were fit for discharge (30.2 hours vs. 44.2 hours, hazard ratio 1.46, 95% CI 1.23 to 1.73; p-value < 0.001) and were discharged (40.9 hours vs. 50.9 hours; hazard ratio 1.28, 95% CI 1.06 to 1.50; p-value < 0.003) sooner than those in the standard care group. There were 35 serious adverse events in the standard care group, compared with 25 in the modified care group. Eight infants in the standard care group and 12 in the modified care group were admitted to a high-dependency unit. By 28 days, 23 infants had been readmitted to hospital in the standard care group and 12 infants in the modified care group. Parents of infants in the modified care group did not experience higher levels of anxiety and, by 14 days, had lost 28% fewer hours to usual activities. NHS costs were £290 lower in the modified care group than in the standard care group, with additional societal costs also being lower in the modified care group. CONCLUSIONS Management of infants to a SpO2 target of ≥ 90% is as clinically effective as ≥ 94%, gives rise to no additional safety concerns, and appears to be cost-effective. Future work could focus on the safety and effectiveness of using intermittent oxygen saturation monitoring in secondary care, and to consider what are safe and effective oxygen saturation targets for children with bronchiolitis managed in primary care. TRIAL REGISTRATION This trial is registered as ISRCTN28405428. FUNDING This project was funded by the NIHR Health Technology Assessment programme. Masimo Corporation Limited, CA, USA, kindly provided oxygen saturation monitors with standard and altered algorithms.


title: Duodenectomy with jejunal advancement and reimplantation of the ampulla of Vater for recurrent right colon cancer: A case report.

text: BACKGROUND Local or regional recurrence of colon or rectal cancer frequently occurs if there is a positive margin of resection or spillage of cancer cells during the operation. METHODS The clinical course of a patient with right colon cancer recurrent within the resection site and on the anterior aspect of the duodenum was reviewed. RESULTS Resection of recurrent right colon cancer was accomplished by subtotal duodenectomy. Reconstruction was with jejunal advancement and reimplantation of the ampulla of Vater. No postoperative complications occurred and palliation was excellent. CONCLUSIONS Prevention of recurrent right colon cancer is an import consideration for primary resection. However, if this duodenum is involved by recurrence, techniques for resection exist.


title: Development and Applications of Portable Biosensors.

text: The significance of microfluidics-based and microelectromechanical systems-based biosensors has been widely acknowledged, and many reviews have explored their potential applications in clinical diagnostics, personalized medicine, global health, drug discovery, food safety, and forensics. Because health care costs are increasing, there is an increasing need to remotely monitor the health condition of patients by point-of-care-testing. The demand for biosensors for detection of biological warfare agents has increased, and research is focused on ways of producing small portable devices that would allow fast, accurate, and on-site detection. In the past decade, the demand for rapid and accurate on-site detection of plant disease diagnosis has increased due to emerging pathogens with resistance to pesticides, increased human mobility, and regulations limiting the application of toxic chemicals to prevent spread of diseases. The portability of biosensors for on-site diagnosis is limited due to various issues, including sample preparation techniques, fluid-handling techniques, the limited lifetime of biological reagents, device packaging, integrating electronics for data collection/analysis, and the requirement of external accessories and power. Many microfluidic, electronic, and biological design strategies, such as handling liquids in biosensors without pumps/valves, the application of droplet-based microfluidics, paper-based microfluidic devices, and wireless networking capabilities for data transmission, are being explored.


title: Vacuum-assisted closure device and skin substitutes for complex Mohs defects.

text: BACKGROUND Soft tissue defects created by excision of dermatologic malignancies may present a significant challenge to the reconstructive surgeon, particularly when tendon, bone, cartilage, or other vital structures are exposed. Although there are several reliable options for regional or free tissue transfer, many patients with skin cancers are poor surgical candidates. Recent literature has described the use of an acellular dermal regeneration template (ADRT) (Integra LifeSciences Corp, Plainsboro, NJ) with split-thickness skin grafting (STSG) as an alternative to the previously mentioned surgical options. OBJECTIVE To use ADRT with negative-pressure wound therapy (NPWT) and STSG to reconstruct complex Mohs defects of the scalp and feet. MATERIALS AND METHODS Two patients underwent wide local excision of squamous cell carcinomas of the skin. ADRT and a NPWT device were applied. The patients were then skin grafted 7 to 10 days later. RESULTS Both patients had take of their skin grafts and completely healed their wounds without local recurrence. Results were both functionally and aesthetically satisfactory. CONCLUSION The use of ADRT with vacuum-assisted closure followed by split-thickness skin grafting is an acceptable alternative to regional or free tissue transfer for reconstruction of complex Mohs defects.


title: Four arms robotic-assisted pulmonary resection-left upper lobectomy: how to do it.

text: Numerous published articles have shown the safety and efficacy of robotic anatomic pulmonary resection, including lobectomy for non-small cell lung cancer. Several techniques have been described to perform a lung lobectomy robotically. Since the beginning of our experience, we adopted a four-arm robotic approach with the da Vinci Si System. More recently we have used the newer Xi model, that offers a simplified and "quicker" set-up and docking time. This article emphases specifically on the technical aspects of how to complete the hilar dissection during four-arm robotic lobectomy.


Coronavirus rips through Dutch mink farms, triggering culls.


title: Coronaviruses: important emerging human pathogens.

text: The identification of Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 reaffirmed the importance of understanding how coronaviruses emerge, infect, and cause disease. By comparing what is known about severe acute respiratory syndrome coronavirus (SARS-CoV) to what has recently been found for MERS-CoV, researchers are discovering similarities and differences that may be important for pathogenesis. Here we discuss what is known about each virus and what gaps remain in our understanding, especially concerning MERS-CoV.


Imagining a post-pandemic world.


title: Different outcome of COVID-19 in members of a family.

text: We report a family cluster of cases of coronavirus disease 2019 (COVID-19), in which three members of the family were exposed to SARS-CoV-2 at the same time, but the disease manifested differently among the three family members. We describe the clinical manifestations, disease progression, and treatment of wife and husband. We also analyze the daughter who was in close contact with patients with COVID-19 but was not infected.


title: Prediction of Stent-Retriever Thrombectomy Outcomes by Dynamic Multidetector CT Angiography in Patients with Acute Carotid T or MCA Occlusions.

text: BACKGROUND AND PURPOSE The selection of patients for endovascular therapy is an important issue in stroke imaging. The aim of this study was to determine the predictive value of 3 different dynamic CT angiography parameters, occlusion length, collateralization extent, and time delay to maximum enhancement, for latest generation of stent retriever thrombectomy recanalization outcomes in patients with acute ischemic stroke. MATERIALS AND METHODS In this study, subjects were selected from an initial cohort of 2059 consecutive patients who had undergone multiparametric CT, including whole-brain CT perfusion. We included all patients with a complete occlusion of the M1 segment of the MCA or the carotid T and subsequent intra-arterial stent retriever thrombectomy. Dynamic CT angiography was reconstructed from whole-brain CT perfusion raw datasets. Angiographic outcome was scored by using the modified TICI scale; and clinical outcome, by using the modified Rankin Scale. Logistic regression analyses were performed to determine independent predictors of a favorable angiographic (mTICI = 3) and clinical outcome (mRS ≤2). RESULTS Sixty-nine patients (mean age, 68 ± 14 years; 46% men) were included for statistical analysis. In the regression analysis, a short occlusion length was an independent predictor of favorable angiographic outcome (OR, 0.41; P < .05). Both collateralization grade (OR, 1.00; P > .05) and time delay to peak enhancement (OR, 0.90; P > .05) failed to predict a favorable angiographic outcome. None of the dynamic CT angiography predictors were significantly associated with clinical outcome on discharge (OR, 0.664-1.011; P = .330-.953) or at 90 days (OR, 0.779-1.016; P = .130-.845). CONCLUSIONS A short occlusion length as determined by dynamic CT angiography is an independent predictor of a favorable angiographic outcome of stent retriever thrombectomy in patients with ischemic stroke.


docid: sladvfuu

title: A science-based response to COVID-19.

text: The COVID-19 pandemic behaves like many other viruses spread through respiratory routes. This is generally a mild disease for those aged less than 50 years. A complete and prolonged lockdown will reduce COVID-19 mortality but simultaneously lead to a graver public health, social, and economic disaster. The focus has to be based on the reality that exists in an area.


title: Comparative analysis of national legislation in support of the revised international health regulations: potential models for implementation in the United States.

text: In 2005, the World Health Organization adopted the revised International Health Regulations, or IHR (2005), to establish obligations for detecting and responding to public health emergencies of international concern. The success of the IHR (2005) rests on the ability of states to implement the objectives and to execute the regulations in a legal and politically acceptable manner. Implementation of the IHR (2005) may be challenging for federalist nations, where most public health regulatory power lies in local rather than in national governments. We examine the implementation strategies of 4 nations: Australia, Canada, Germany, and India. The methods currently being considered by these nations for executing the IHR (2005) are potentially applicable models for the United States to consider.


Measures of frequency: calculating prevalence and incidence in the era of COVID-19.


title: Free vascularized fibular grafting for patients receiving postoperative corticosteroids.

text: Free vascularized fibular grafting (FVFG) is an effective method to treat corticosteroid-induced osteonecrosis of the femoral head (ONFH). Some patients continued to receive maintenance doses of corticosteroids to treat the primary disease postoperatively. This study was performed to evaluate outcomes of FVFG for corticosteroid-induced ONFH in patients who continued to receive corticosteroids postoperatively. The authors retrospectively reviewed the records of 44 patients (78 hips) who had received corticosteroid treatment for their primary disease after FVFG. They were followed up for at least 2 years (mean, 5.6 years). Demographic details, Harris Hip scores, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and radiographic data were collected and analyzed. The mean Harris Hip score for all hips was 70.9±9.9 points before surgery and increased to 84±12.1 points at the latest follow-up. There were also significant increases (P<.05) in physical component summary score and mental component summary score. According to the latest radiographic evaluation, 49 hips (62.8%) appeared improved, 10 hips (12.8%) appeared unchanged, and only 19 hips (24.4%) appeared worse. Seven hips (9%) underwent total hip arthroplasty during the follow-up period. Therefore, the results showed that FVFG was a viable method of treating corticosteroid-induced ONFH in patients who receive maintenance doses of corticosteroids postoperatively.


title: Influence of variations in systemic blood flow and pressure on cerebral and systemic oxygen saturation in cardiopulmonary bypass patients.

text: BACKGROUND Although both pressure and flow are considered important determinants of regional organ perfusion, the relative importance of each is less established. The aim of the present study was to evaluate the impact of variations in flow, pressure, or both on cerebral and whole-body oxygen saturation. METHODS Thirty-four consenting patients undergoing elective cardiac surgery on cardiopulmonary bypass were included. Using a randomized cross-over design, four different haemodynamic states were simulated: (i) 20% flow decrease, (ii) 20% flow decrease with phenylephrine to restore baseline pressure, (iii) 20% pressure decrease with sodium nitroprusside (SNP) under baseline flow, and (iv) increased flow with baseline pressure. The effect of these changes was evaluated on cerebral (Sc(O₂)) and systemic (Sv(O₂)) oxygen saturation, and on systemic oxygen extraction ratio (OER). Data were assessed by within- and between-group comparisons. RESULTS Decrease in flow was associated with a decrease in [from 63.5 (7.4) to 62.0 (8.5) %, P<0.001]. When arterial pressure was restored with phenylephrine during low flow, Sc(O₂) further decreased from 61.0 (9.7) to 59.2 (10.2) %, P<0.001. Increase in flow was associated with an increase in Sc(O₂) from 62.6 (7.7) to 63.6 (8.9) %, P=0.03, while decreases in pressure with the use of SNP did not affect Sc(O₂). Sv(O₂) was significantly lower (P<0.001) and OER was significantly higher (P<0.001) in the low flow arms. CONCLUSIONS In the present elective cardiac surgery population, Sc(O₂) and Sv(O₂) were significantly lower with lower flow, regardless of systemic arterial pressure. Moreover, phenylephrine administration was associated with a reduced cerebral and systemic oxygen saturation.


Infliximab for severe ulcerative colitis and subsequent SARS-CoV-2 pneumonia: a stone for two birds.


title: Delivery of Compassionate Mental Health Care in a Digital Technology-Driven Age: Scoping Review.

text: BACKGROUND Compassion is a vital component to the achievement of positive health outcomes, particularly in mental health care. The rise of digital technologies may influence the delivery of compassionate care, and thus this relationship between compassion and digital health care needs to be better understood. OBJECTIVE This scoping review aimed to identify existing digital technologies being used by patients and health professionals in the delivery of mental health care, understand how digital technologies are being used in the delivery of compassionate mental health care, and determine the facilitators of and barriers to digital technology use among patients and health professionals in the delivery of compassionate mental health care. METHODS We conducted this scoping review through a search of Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online (MEDLINE), MEDLINE In-Process and EPub Ahead of Print, PsycINFO, and Web of Science for articles published from 1990 to 2019. RESULTS Of the 4472 articles screened, 37 articles were included for data extraction. Telemedicine was the most widely used technology by mental health professionals. Digital technologies were described as facilitating compassionate care and were classified using a conceptual model to identify each digital intersection with compassionate care. Facilitators of and barriers to providing compassionate care through digital technology were identified, including increased safety for providers, health care professional perceptions and abilities, and the use of picture-in-picture feedback to evaluate social cues. CONCLUSIONS Implementing digital technology into mental health care can improve the current delivery of compassionate care and create novel ways to provide compassion. However, as this is a new area of study, mental health professionals and organizations alike should be mindful that compassionate human-centered care is maintained in the delivery of digital health care. Future research could develop tools to facilitate and evaluate the enactment of compassion within digital health care.


title: Key elements of the RNAi pathway are regulated by hepatitis B virus replication and HBx acts as a viral suppressor of RNA silencing.

text: The host-mediated RNAi pathways restrict replication of viruses in plant, invertebrate and vertebrate systems. However, comparatively little is known about the interplay between RNAi and various viral infections in mammalian hosts. We show in the present study that the siRNA-mediated silencing of Drosha, Dicer and Ago2 [argonaute RISC (RNA-induced silencing complex) catalytic component 2] transcripts in Huh7 cells resulted in elevated levels of HBV (hepatitis B virus)-specific RNAs and, conversely, we observed a decrease in mRNA and protein levels of same RNAi components in HepG2 cells infected with HBV. Similar reductions were also detectable in CHB (chronic hepatitis B) patients. Analysis of CHB liver biopsy samples, with high serum HBV DNA load (>log108 IU/ml), revealed a reduced mRNA and protein levels of Drosha, Dicer and Ago2. The low expression levels of key RNAi pathway components in CHB patient samples as well as hepatic cells established a link between HBV replication and RNAi components. The HBV proteins were also examined for RSS (RNA-silencing suppressor) properties. Using GFP-based reversion of silencing assays, in the present study we found that HBx is an RSS protein. Through a series of deletions and substitution mutants, we found that the full-length HBx protein is required for optimum RSS activity. The in vitro dicing assays revealed that the HBx protein inhibited the human Dicer-mediated processing of dsRNAs into siRNAs. Together, our results suggest that the HBx protein might function as RSS to manipulate host RNAi defence, in particular by abrogating the function of Dicer. The present study may have implications in the development of newer strategies to combat HBV infection.


title: Utility of contrast-enhanced ultrasonography with Sonazoid in radiofrequency ablation for hepatocellular carcinoma.

text: BACKGROUND AND AIMS Kupffer imaging in contrast-enhanced ultrasonography (CEUS) with Sonazoid, which lasts for 60 min or longer, may be useful in ultrasound-guided percutaneous tumor ablation. The utility of Sonazoid in radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) was investigated in this study. METHODS We analyzed a total of 716 HCC nodules that were detected on dynamic computed tomography in 316 patients. Detectability of these nodules was compared between CEUS and conventional ultrasonography. The effectiveness in the treatment was assessed by comparing the mean numbers of treatment sessions of RFA in patients treated with CEUS and that in historical controls matched for tumor and background conditions. RESULTS Detectability of tumor nodule was 83.5% in conventional ultrasonography and 93.2% in CEUS (P=0.04). Sixty-nine nodules in 52 patients were additionally detected with CEUS. The number of additionally detected tumor nodules was positively correlated with serum albumin level (P=0.016). The number of RFA sessions was 1.33±0.45 with CEUS as compared to 1.49±0.76 in the historical controls (P=0.0019). CONCLUSIONS CEUS with Sonazoid is useful for HCC detection in patients with a well-conserved liver function reservoir. The decrease in RFA session numbers indicated the utility of Sonazoid in RFA treatment of HCC.


title: Stone formation from nonabsorbable clip migration into the collecting system after robot-assisted partial nephrectomy.

text: We describe a case in which a Weck Hem-o-lok clip (Teleflex, Research Triangle Park, USA) migrated into the collecting system and acted as a nidus for stone formation in a patient after robot-assisted partial nephrectomy. The patient presented 2 years postoperatively with left-sided renal colic. Abdominal computed tomography scan showed a 10 millimeter renal calculus in the left middle pole. After using laser lithotripsy to fragment the overlying renal stone, a Weck Hem-o-lok clip was found to be embedded in the collecting system. A laser fiber through a flexible ureteroscope was used to successfully dislodge the clip from the renal parenchyma, and a stone basket was used to extract the clip.


title: Hyperglycemia enhances pancreatic cancer progression accompanied by elevations in phosphorylated STAT3 and MYC levels.

text: Diabetes mellitus is a well-known risk factor for pancreatic cancer. We focused on hyperglycemia, a main feature of diabetes mellitus, and uncovered its effect on precancerous pancreatic intraepithelial neoplasia (PanIN) progression. In vivo induction of hyperglycemia with 100 mg/kg streptozotocin in KrasLSL G12D Pdx1Cre (KP) mice promoted the PanIN formation and progression. Preconditioning with a high- or low-glucose medium for 28 days showed that a high-glucose environment increased cell viability and sphere formation in PANC-1, a Kras-mutant human pancreatic ductal adenocarcinoma cell line, and mPKC1, a Kras-mutant murine pancreatic cancer cell line. In contrast, no changes were observed in BxPC3, a Kras-wild-type human pancreatic cancer cell line. Orthotopic injection of mPKC1 into the pancreatic tails of BL6/J mice showed that cells maintained in high-glucose medium grew into larger tumors than did those maintained in low-glucose medium. Hyperglycemia strengthened the STAT3 phosphorylation, which was accompanied by elevated MYC expression in Kras-mutant cells. Immunohistochemistry showed stronger phosphorylated STAT3 (pSTAT3) and MYC staining in PanINs from diabetic KP mice than in those from euglycemic counterparts. STAT3 inhibition with 1 μM STAT3 inhibitor STATTIC in Kras-mutant pancreatic cell lines blocked the cell viability- and sphere formation-enhancing effects of the hyperglycemic environment and reversed the elevated pSTAT3 and MYC expression. MYC knockdown did not affect cell viability but did reduce sphere formation. No decrease in pSTAT3 expression was observed upon siMYC treatment. In conclusion, hyperglycemia, on a Kras-mutant background, aggravates the PanIN progression, which is accompanied by elevated pSTAT3 and MYC expression.


title: Recent transmission of a novel alphacoronavirus, bat coronavirus HKU10, from Leschenault's rousettes to pomona leaf-nosed bats: first evidence of interspecies transmission of coronavirus between bats of different suborders.

text: Although coronaviruses are known to infect various animals by adapting to new hosts, interspecies transmission events are still poorly understood. During a surveillance study from 2005 to 2010, a novel alphacoronavirus, BatCoV HKU10, was detected in two very different bat species, Ro-BatCoV HKU10 in Leschenault's rousettes (Rousettus leschenaulti) (fruit bats in the suborder Megachiroptera) in Guangdong and Hi-BatCoV HKU10 in Pomona leaf-nosed bats (Hipposideros pomona) (insectivorous bats in the suborder Microchiroptera) in Hong Kong. Although infected bats appeared to be healthy, Pomona leaf-nosed bats carrying Hi-BatCoV HKU10 had lower body weights than uninfected bats. To investigate possible interspecies transmission between the two bat species, the complete genomes of two Ro-BatCoV HKU10 and six Hi-BatCoV HKU10 strains were sequenced. Genome and phylogenetic analyses showed that Ro-BatCoV HKU10 and Hi-BatCoV HKU10 represented a novel alphacoronavirus species, sharing highly similar genomes except in the genes encoding spike proteins, which had only 60.5% amino acid identities. Evolution of the spike protein was also rapid in Hi-BatCoV HKU10 strains from 2005 to 2006 but stabilized thereafter. Molecular-clock analysis dated the most recent common ancestor of all BatCoV HKU10 strains to 1959 (highest posterior density regions at 95% [HPDs], 1886 to 2002) and that of Hi-BatCoV HKU10 to 1986 (HPDs, 1956 to 2004). The data suggested recent interspecies transmission from Leschenault's rousettes to Pomona leaf-nosed bats in southern China. Notably, the rapid adaptive genetic change in BatCoV HKU10 spike protein by ~40% amino acid divergence after recent interspecies transmission was even greater than the ~20% amino acid divergence between spike proteins of severe acute respiratory syndrome-related Rhinolophus bat coronavirus (SARSr-CoV) in bats and civets. This study provided the first evidence for interspecies transmission of coronavirus between bats of different suborders.


ESPEN disease-specific guideline framework.


title: The effects of acute aerobic exercise on the acquisition and retention of laparoscopic skills.

text: INTRODUCTION Exercise is beneficial to learning. The purpose of this research was to determine whether an episode of aerobic exercise prior to practice improves the acquisition and retention of laparoscopic skills in the fundamentals of laparoscopic surgery (FLS) simulator. METHODS Baseline maximal physical fitness (VO2 max), performance on peg transfer (PT), pattern cut (PC), and intracorporeal suture (ICS) were measured for FLS naïve undergraduates. 2 Weeks later, participants were randomized into exercise (E) and control (C) groups. C did unrelated work for 40 min and then practiced PT and PC for 10 min, and ICS for 15 min. Final scores were recorded. In E, participants ran on a treadmill for 20 min at 60 % of their VO2 max. After a 15 min cool down, they engaged in identical FLS simulator training as group C. Both groups completed the NASA task load index (TLX) to assess workload. Retention was recorded 2 months after the training session. Groups were compared using t tests, χ(2) and Wilcoxon rank tests. p < 0.05 was considered significant. RESULTS There were 52 participants (22 in C; 30 in E) with high physical fitness at baseline. Demographics between the groups were similar at baseline. There were no differences in VO2 max and scores on the three tasks at baseline (all p values NS). There was no statistical significance between the scores of the C and E groups at the training session and retention, except for higher PT scores in the E group after the training session. CONCLUSION In physically fit, surgically naïve students, one bout of aerobic exercise enhanced immediate learning of simple FLS skills but did not have an impact on more complex skills or on retention. The use of exercise in the surgical curriculum, or as a learning tool, warrants further investigation regarding how best to apply it.


title: Radiation Therapy Induces Macrophages to Suppress T-Cell Responses Against Pancreatic Tumors in Mice.

text: BACKGROUND & AIMS The role of radiation therapy in the treatment of patients with pancreatic ductal adenocarcinoma (PDA) is controversial. Randomized controlled trials investigating the efficacy of radiation therapy in patients with locally advanced unresectable PDA have reported mixed results, with effects ranging from modest benefit to worse outcomes compared with control therapies. We investigated whether radiation causes inflammatory cells to acquire an immune-suppressive phenotype that limits the therapeutic effects of radiation on invasive PDAs and accelerates progression of preinvasive foci. METHODS We investigated the effects of radiation therapy in p48(Cre);LSL-Kras(G12D) (KC) and p48(Cre);LSLKras(G12D);LSL-Trp53(R172H) (KPC) mice, as well as in C57BL/6 mice with orthotopic tumors grown from FC1242 cells derived from KPC mice. Some mice were given neutralizing antibodies against macrophage colony-stimulating factor 1 (CSF1 or MCSF) or F4/80. Pancreata were exposed to doses of radiation ranging from 2 to 12 Gy and analyzed by flow cytometry. RESULTS Pancreata of KC mice exposed to radiation had a higher frequency of advanced pancreatic intraepithelial lesions and more foci of invasive cancer than pancreata of unexposed mice (controls); radiation reduced survival time by more than 6 months. A greater proportion of macrophages from radiation treated invasive and preinvasive pancreatic tumors had an immune-suppressive, M2-like phenotype compared with control mice. Pancreata from mice exposed to radiation had fewer CD8(+) T cells than controls, and greater numbers of CD4(+) T cells of T-helper 2 and T-regulatory cell phenotypes. Adoptive transfer of T cells from irradiated PDA to tumors of control mice accelerated tumor growth. Radiation induced production of MCSF by PDA cells. A neutralizing antibody against MCSF prevented radiation from altering the phenotype of macrophages in tumors, increasing the anti-tumor T-cell response and slowing tumor growth. CONCLUSIONS Radiation treatment causes macrophages murine PDA to acquire an immune-suppressive phenotype and disabled T-cell-mediated anti-tumor responses. MCSF blockade negates this effect, allowing radiation to have increased efficacy in slowing tumor growth.


title: Stabilization of the chest wall: autologous and alloplastic reconstructions.

text: The goals of chest wall stabilization include maintenance of a rigid airtight cavity, protection of the thoracic and abdominal contents, optimization of respiration, and, whenever possible, an aesthetic reconstruction. Evidence suggests that bony fixation results in reduced ventilator dependence, a shorter overall hospital stay, and improved upper extremity function. We prefer to accomplish this with autologous tissue alone (such as the pectoralis major, latissimus dorsi, or rectus abdominus muscle flaps) for small to moderate defects. En bloc resection of defects larger than 5 cm or containing four or more ribs will likely benefit from chest wall stabilization. For patients previously treated with radiation, even larger defects may be tolerated owing to fibrosis. For these larger defects, methyl methacrylate composite meshes are used and covered with vascularized tissue. Contaminated wounds are generally reconstructed with bioprosthetic mesh rather than synthetic mesh. Using these principles, the reconstructive plastic surgeon can devise a comprehensive and safe plan to repair tremendous defects of the chest wall.


docid: cbknwgvt

title: Percutaneous ablation of peribiliary tumors with irreversible electroporation.

text: PURPOSE To assess biliary complications after irreversible electroporation (IRE) ablation of hepatic tumors located < 1 cm from major bile ducts. MATERIALS AND METHODS A retrospective review was conducted of all percutaneous IRE ablations of hepatic tumors within 1 cm of the common, left, or right hepatic ducts at a single institution from January 2011 to September 2012. Computed tomography imaging performed before and after treatment was examined for evidence of bile duct dilatation, stricture, or leakage. Serum bilirubin and alkaline phosphatase levels were analyzed for evidence of biliary injury. RESULTS There were 22 hepatic metastases in 11 patients with at least one tumor within 1 cm of the common, left, or right hepatic duct that were treated with IRE ablations in 15 sessions. Median tumor size treated was 3.0 cm (mean, 2.8 cm ± 1.2, range, 1.0-4.7 cm). Laboratory values obtained after IRE were considered abnormal after four treatment sessions in three patients (bilirubin, 2.6-17.6 mg/dL; alkaline phosphatase, 130-1,035 U/L); these abnormal values were transient in two sessions. Two patients had prolonged elevation of values, and one required stent placement; both of these conditions appeared to be secondary to tumor progression rather than bile duct injury. CONCLUSIONS This clinical experience suggests that IRE may be a treatment option for centrally located liver tumors with margins adjacent to major bile ducts where thermal ablation techniques are contraindicated. Further studies with extended follow-up periods are necessary to establish the safety profile of IRE in this setting.


title: Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials.

text: BACKGROUND Debate exists about the efficacy of β-blockers in myocardial infarction and their required duration of usage in contemporary practice. METHODS We conducted a MEDLINE/EMBASE/CENTRAL search for randomized trials evaluating β-blockers in myocardial infarction enrolling at least 100 patients. The primary outcome was all-cause mortality. Analysis was performed stratifying trials into reperfusion-era (> 50% undergoing reperfusion or receiving aspirin/statin) or pre-reperfusion-era trials. RESULTS Sixty trials with 102,003 patients satisfied the inclusion criteria. In the acute myocardial infarction trials, a significant interaction (Pinteraction = .02) was noted such that β-blockers reduced mortality in the pre-reperfusion (incident rate ratio [IRR] 0.86; 95% confidence interval [CI], 0.79-0.94) but not in the reperfusion era (IRR 0.98; 95% CI, 0.92-1.05). In the pre-reperfusion era, β-blockers reduced cardiovascular mortality (IRR 0.87; 95% CI, 0.78-0.98), myocardial infarction (IRR 0.78; 95% CI, 0.62-0.97), and angina (IRR 0.88; 95% CI, 0.82-0.95), with no difference for other outcomes. In the reperfusion era, β-blockers reduced myocardial infarction (IRR 0.72; 95% CI, 0.62-0.83) (number needed to treat to benefit [NNTB] = 209) and angina (IRR 0.80; 95% CI, 0.65-0.98) (NNTB = 26) at the expense of increase in heart failure (IRR 1.10; 95% CI, 1.05-1.16) (number needed to treat to harm [NNTH] = 79), cardiogenic shock (IRR 1.29; 95% CI, 1.18-1.41) (NNTH = 90), and drug discontinuation (IRR 1.64; 95% CI, 1.55-1.73), with no benefit for other outcomes. Benefits for recurrent myocardial infarction and angina in the reperfusion era appeared to be short term (30 days). CONCLUSIONS In contemporary practice of treatment of myocardial infarction, β-blockers have no mortality benefit but reduce recurrent myocardial infarction and angina (short-term) at the expense of increase in heart failure, cardiogenic shock, and drug discontinuation. The guideline authors should reconsider the strength of recommendations for β-blockers post myocardial infarction.


title: Viperin inhibits hepatitis C virus replication by interfering with binding of NS5A to host protein hVAP-33.

text: Viperin is a type-I and -II interferon-inducible intracytoplasmic protein that mediates antiviral activity against several viruses. A previous study has reported that viperin could limit hepatitis C virus (HCV) replication in vitro. However, the underlying mechanism remains elusive. In the present study, we found that overexpression of viperin could inhibit HCV replication in a dose-dependent manner in both the replicon and HCVcc systems. Furthermore, through co-immunoprecipitation and laser confocal microscopic analysis, viperin was found to interact with the host protein hVAP-33. Mutagenesis analysis demonstrated that the anti-HCV activity of viperin was located to its C terminus, which was required for the interaction with the C-terminal domain of hVAP-33. Competitive co-immunoprecipitation analysis showed that viperin could interact competitively with hVAP-33, and could therefore interfere with its interactions with HCV NS5A. In summary, these findings suggest a novel mechanism by which viperin inhibits HCV replication, possibly through binding to host protein hVAP-33 and interfering with its interaction with NS5A.


title: Results in laparoscopic living donor nephrectomy: a multicentric experience.

text: OBJECTIVE Renal transplantation is the most successful therapy to improve survival and quality of life for patients with end-stage renal disease. Living donors have been used as an alternative to reduce the stay on the waiting list. Laparoscopic living donor nephrectomy has become the standard procedure for renal transplantation. Minimally invasive surgery involves less postoperative pain with less analgesic requirements allowing shorter hospital stay for the donor. MATERIAL AND METHODS We retrospectively analyzed demographic and intraoperative data and surgical complications for 46 patients who underwent laparoscopic living donor nephrectomy between March 2001 and March 2011. RESULTS Mean donor age was 41 years. Mean operative time was 170 ± 45 minutes. The average cold ischemic time was 40 minutes and warm ischemic time was 26 minutes. Twenty-one patients were donors for pediatric receptors. Fourty patients underwent left laparoscopic nephrectomy, the other 6 patients underwent right laparoscopic nephrectomy due to vascular anatomic variant. Right laparoscopic nephrectomy was converted in 1 case (2.2%) due to renal vein laceration without donor morbidity and without compromise of graft function. Renal function at the second day post donor nephrectomy was measured using serum creatinine averaged 1.2 mg/dL with a mean increase of 0.4 mg/dL from baseline, with normalization after 30 days. No patient required blood transfusion, and there were no immediate surgical complications, infections, or mortality. One patient developed an incisional hernia in relation to the site of kidney removal. The mean hospital stay was 5 ± 1 days. CONCLUSIONS Laparoscopic nephrectomy in our experience is a safe technique without postoperative morbidity or mortality. It is associated with low levels of pain, early discharge and early return to physical activity and work, good sense of aesthetic results, and long-term graft function comparable to traditional nephrectomy and cadaveric grafts.


title: Effectiveness of treatments for acute and sub-acute mechanical non-specific low back pain: protocol for a systematic review and network meta-analysis.

text: BACKGROUND Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute LBP usually has a good prognosis, with rapid improvement within the first 6 weeks. However, the majority of patients develop chronic LBP and suffer from recurrences. For clinical management, a plethora of treatments is currently available but evidence of the most effective options is lacking. The objective of this study will be to identify the most effective interventions to relieve pain and reduce disability in acute and sub-acute non-specific LBP. METHODS/DESIGN We will search electronic databases (MEDLINE, Embase, CENTRAL) from inception onwards. The eligible population will be individuals with non-specific LBP older than 18 years, both males and females, who experience pain less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Eligible interventions and comparators will include all conservative rehabilitation or pharmacological treatments provided by any health professional; the only eligible study design will be a randomized controlled trial. The primary outcomes will be pain intensity and back-specific functional status. Secondary outcomes will be any adverse events. Studies published in languages other than English will also potentially be included. Two reviewers will independently screen the titles and abstracts retrieved from a literature search, as well as potentially relevant full-text articles. General characteristics, potential effect modifiers, and outcome data will be extracted from the included studies, and the risk of bias will be appraised. Conflicts at all levels of screening and abstraction will be resolved through team discussions. After describing the results of the review, if appropriate, a random effects meta-analysis and network meta-analysis will be conducted in a frequentist setting, assuming equal heterogeneity across all treatment comparisons and accounting for correlations induced by multi-arm studies using a multivariate normal model. DISCUSSION Our systematic review will address the uncertainties in the use of pharmacological or non-pharmacological treatments, and their relative efficacy, for acute and subacute LBP. These findings will be useful for patients, healthcare providers, and policymakers. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018102527.


title: Stroke prevention with rivaroxaban in higher-risk populations with atrial fibrillation.

text: BACKGROUND Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke. Rivaroxaban, an oral factor Xa inhibitor, is approved for the prevention of stroke in patients with non-valvular AF. In the pivotal phase III trial ROCKET AF, rivaroxaban demonstrated non-inferiority compared with warfarin for reducing the risk of stroke or systemic embolism (SE) in patients with AF (intention-to-treat analysis), without an increased risk of major bleeding. Superior efficacy vs. warfarin was achieved while patients were on study medication. Other direct oral factor Xa inhibitors have completed phase III clinical trials in this indication. Compared with warfarin, apixaban (in the ARISTOTLE trial) and edoxaban (in the ENGAGE-AF trial) were shown to be superior or non-inferior, respectively, for reduction in stroke or SE risk in patients with AF. Baseline stroke risk, as indicated by CHADS2 scores, was lower in patients in the ARISTOTLE and ENGAGE-AF trials than in ROCKET AF. OBJECTIVES This review discusses the main findings from ROCKET AF, specifically examining recent subgroup analyses investigating rivaroxaban use across various patient types at high risk for adverse outcomes, including those with prior stroke or transient ischaemic attack, reduced renal function, prior myocardial infarction, peripheral artery disease, heart failure or patients aged ≥ 75 years and those resident in East Asia. CONCLUSIONS These subgroup analyses demonstrate that the treatment effect for rivaroxaban vs. warfarin is broadly consistent across a wide range of patient groups, with respect to both efficacy and safety.


title: Impact of bypass flow rate and catheter position in veno-venous extracorporeal membrane oxygenation on gas exchange in vivo.

text: The clinical use of veno-venous extracorporeal membrane oxygenation (VVECMO) in adult patients with respiratory failure is rapidly increasing. However, recirculation of blood oxygenated by ECMO back into the circuit may occur in VVECMO, resulting in insufficient oxygenation. The cannula position and bypass flow rate are two major factors influencing recirculation, but the relationship and ideal configuration of these factors are not fully understood. In the present study, we attempted to clarify these parameters for effective gas exchange. VVECMO was performed in eight adult goats under general anesthesia. The position of the drainage cannula was fixed in the inferior vena cava (IVC), but the return cannula position was varied between the IVC, right atrium (RA), and superior vena cava (SVC). At each position, the recirculation rates calculated, and the adequacy of oxygen delivery by ECMO in supplying systemic oxygen demand was assessed by measuring the arterial oxygen saturation (SaO2) and pressure (PaO2). Although the recirculation rates increased as the bypass flow rates increased, SaO2 and PaO2 also increased in any position of return cannula. The recirculation rates and PaO2 were 27 ± 2% and 162 ± 16 mmHg, 36 ± 6% and 139 ± 11 mmHg, and 63 ± 6% and 77 ± 9 mmHg in the SVC, RA and IVC position at 4 L/min respectively. In conclusion, the best return cannula position was the SVC, and a high bypass flow rate was advantageous for effective oxygenation. Both the bypass flow rates and cannula position must be considered to achieve effective oxygenation.


title: Interim results of the 5-box thoracoscopic maze procedure.

text: BACKGROUND In accordance with the Cox-Maze paradigm, successful treatment of atrial fibrillation (AF) requires (1) complete posterior left atrial isolation, (2) elimination of corridors for perimitral reentry, (3) elimination of cardiac venous (superior vena cava and coronary sinus) arrhythmogenic foci, (4) complete autonomic denervation, and (5) occlusion or removal of the left atrial appendage. Using a totally thoracoscopic approach, isolation of all left atrial arrhythmogenic substrate is achieved through the creation of 5 discrete but contiguous compartments, thereby enabling unambiguous verification with bidirectional block. Since no previous closed-chest procedure incorporates all these end points, an update on patient outcomes is reported. METHODS One hundred seventy-nine consecutive patients with antiarrhythmic drug-resistant AF (3 paroxysmal, 5 persistent, 171 longstanding persistent cases), known preoperatively for 5.7 (range 0.5 to 25) years, underwent the 5-box thoracoscopic Maze procedure. Only 1 patient suffered a serious procedural complication (sternotomy for pulmonary artery injury). Postoperative rhythm surveillance consisted of 1 week of continuous ambulatory monitoring at 3, 6, 13, and 24 months. Failure was defined as any tachyarrhythmia exceeding 30 seconds beyond the 3-month anniversary. RESULTS Freedom from AF was observed in 137 of 142 patients at 3 months, 115 of 119 patients at 6 months, 75 of 78 patients at 13 months, and 24 of 25 patients at 24 months. Two patients remain in sinus rhythm on low-dose antiarrhythmia therapy. Warfarin is discontinued only after the first monitoring session confirms rhythm stability. CONCLUSIONS Replication of the left atrial Cox-Maze lesion set through a totally thoracoscopic approach isolates virtually all arrhythmogenic substrate. Meticulous verification of compartment integrity allows for outcomes equivalent to the Cox-Maze benchmark.


The mystery of the pandemic's 'happy hypoxia'.


title: Determinants of Diabetes Remission and Glycemic Control After Bariatric Surgery.

text: OBJECTIVE Eligibility criteria for bariatric surgery in diabetes include BMI ≥35 kg/m(2) and poorly controlled glycemia. However, BMI does not predict diabetes remission, and thus, predictors need to be identified. RESEARCH DESIGN AND METHODS Seven hundred twenty-seven patients were included in a database merged from the Swedish Obese Subjects (SOS) study and two randomized controlled studies, with 415 surgical and 312 medical patients in total. Bariatric operations were divided into gastric only (GO) and gastric plus diversion (GD). RESULTS Sixty-four percent of patients in the surgical arm and 15.0% in the medical arm experienced diabetes remission (P < 0.001). GO yielded 60% remission, and GD yielded 76% remission. The best predictors of diabetes remission were lower baseline glycemia and shorter diabetes duration. However, when operation type was considered, GD predicted a higher likelihood of remission and greater weight loss. Patients in remission (responders) lost more weight (25% vs. 17%) and waist circumference (18% vs. 13%) and experienced better insulin sensitivity than nonresponders. CONCLUSIONS Surgery is more effective than medical treatment in achieving diabetes remission and tighter glycemic control. Shorter diabetes duration, lower fasting glycemia before surgery, and GD versus GO procedures independently predict higher rates of remission, whereas baseline HbA1c and waist circumference predict improved glycemic control. The results show the advantage of an early operation together with better controlled glycemia on diabetes remission independently of BMI.


title: Molecular mechanism of sustained inflation in acute respiratory distress syndrome.

text: BACKGROUND The aim of this study was to investigate the effect and the potential molecular mechanism of sustained inflation (SI) recruitment maneuvers in acute respiratory distress syndrome (ARDS) in beagle dog following endotracheal suctioning. METHODS ARDS was induced in 24 beagle dogs with oleic acid. They had mechanical ventilation support. They were randomized into four groups after the establishment of the ARDS model: non-SI-open group where no SI was applied in beagle dogs with ARDS following open endotracheal suctioning; non-SI-closed group where no SI was applied in beagle dogs with ARDS following closed endotracheal suctioning; SI-open group where SI was applied in beagle dogs with ARDS following open endotracheal suctioning; and SI-closed group where SI was applied in beagle dogs with ARDS following closed endotracheal suctioning. Oxygenation, indexes of respiratory mechanics, and hemodynamic indexes were serially measured during the procedure. The serum protein level, or the messenger RNA in the heart and lung, of inflammation-related cytokines was investigated. RESULTS SI in ARDS improved oxygenation, lung compliance, and airway resistance but had no significant effect in the hemodynamic indexes. At molecular level, SI in ARDS neutralized the increases of pro-inflammatory cytokines (tumor necrosis factor α, interleukin 1β [IL-1β], and IL-6), and anti-inflammatory cytokine (IL-10) in the serum. Furthermore, SI in ARDS increased aquaporin 1 and aquaporin 5 messenger RNA in the lung tissue, and decreased IL-6 messenger RNA in the lung and heart tissue. CONCLUSION SI in ARDS could improve oxygenation, lung compliance, and airway resistance, which was related to the improved degree of inflammation and better maintained aquaporins.


title: Endemicity of Yaws and Seroprevalence of Treponema pallidum Antibodies in Nonhuman Primates, Kenya.

text: Human yaws has historically been endemic to Kenya, but current epidemiologic data are lacking. We report seroprevalence for Treponema pallidum antibodies in olive baboons (Papio anubis) and vervet monkeys (Chlorocebus pygerythrus) in Laikipia County, Kenya. Our results suggest endemicity of the yaws bacterium in monkeys, posing a possible zoonotic threat to humans.


COVID-19: Perspectives on the Potential Novel Global Threat.


Addressing racism and disparities in the biomedical sciences.


title: Mental status of patients with chronic insomnia in China during COVID-19 epidemic.

text: AIM To study the sleep and mental health of chronic insomnia patients in China during coronavirus disease in 2019 (COVID-19) epidemic. METHODS A total of 764 patients with chronic insomnia were included in this study. From 17 January 2020 to 24 January 2020, insomnia, anxiety and physical symptoms were evaluated online, and they were followed up for 4 and 8 weeks. Main outcomes and indicators were assessed using the Pittsburgh Sleep Quality Index (PSQI) and each factor score, the General Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-15 (PHQ-15), respectively. In addition, insomnia, anxiety and physical symptoms were assessed at baseline and at the end of fourth and eighth weeks. Wilcoxon signed rank test was used to compare the changes in patients' scale scores at different time points. RESULTS Among the 764 participants, there were 755 and 738 evaluators who completed the fourth and eighth weeks, respectively, and the questionnaire completion rates were 98.82% and 96.60%, respectively. Among them, there are 459 (60.0%) aged 41-60 years old, 546 (71.5%) women, 218 (28.5%) men and 313 (41%) college degrees. After 8 weeks of follow-up, the differences in sleep status, anxiety symptoms and physical symptoms were statistically significant. Among the factors of PSQI, there were differences in subjective sleep quality, sleep latency, sleep duration, sleep disturbance (disorder), sleep efficiency and daytime function. At 4 weeks of follow-up, there was a statistically significant difference in the use of hypnotic drugs; at 8 weeks of follow-up, there was no statistically significant difference in the use of hypnotic drugs. CONCLUSION Under the influence of the COVID-19, the sleep status and anxiety of patients with chronic insomnia are affected by the epidemic.


title: Dabigatran for stroke prevention in atrial fibrillation.

text: Dabigatran is a novel direct thrombin inhibitor that has recently been approved for primary and secondary stroke prevention and prevention of systemic embolism in patients with atrial fibrillation. In the pivotal RE-LY study, dabigatran 110 mg BID was demonstrated to be associated with a stroke rate similar to that observed with warfarin (INR target 2.0 to 3.0), but with a lower rate of major haemorrhage. Dabigatran administered at a dose of 150 mg BID was significantly more effective in stroke prevention than warfarin and showed a similar rate of major hemorrhages. Of note, both dosages resulted in an approximately 60-70% relative risk reduction of haemorrhagic stroke. The dosage of 110 mg BID should be preferably used in patients aged 75-80 years or older as the rate of extracranial bleeding events tends to increase with dabigatran 150 mg BID above this age limit. In RE-LY, myocardial infarcts occurred at a very low incidence. There were numerically more myocardial infarcts in dabigatran-treated patients than in warfarin patients; however, other myocardial ischaemic events were similar in the three treatment arms.


COVID-19 and Parkinson's Disease: Are We Dealing with Short-term Impacts or Something Worse?


title: Cryptic connections illuminate pathogen transmission within community networks.

text: Understanding host interactions that lead to pathogen transmission is fundamental to the prediction and control of epidemics1-5. Although the majority of transmissions often occurs within social groups6-9, the contribution of connections that bridge groups and species to pathogen dynamics is poorly understood10-12. These cryptic connections-which are often indirect or infrequent-provide transmission routes between otherwise disconnected individuals and may have a key role in large-scale outbreaks that span multiple populations or species. Here we quantify the importance of cryptic connections in disease dynamics by simultaneously characterizing social networks and tracing transmission dynamics of surrogate-pathogen epidemics through eight communities of bats. We then compared these data to the invasion of the fungal pathogen that causes white-nose syndrome, a recently emerged disease that is devastating North American bat populations13-15. We found that cryptic connections increased links between individuals and between species by an order of magnitude. Individuals were connected, on average, to less than two per cent of the population through direct contact and to only six per cent through shared groups. However, tracing surrogate-pathogen dynamics showed that each individual was connected to nearly fifteen per cent of the population, and revealed widespread transmission between solitarily roosting individuals as well as extensive contacts among species. Connections estimated from surrogate-pathogen epidemics, which include cryptic connections, explained three times as much variation in the transmission of the fungus that causes white-nose syndrome as did connections based on shared groups. These findings show how cryptic connections facilitate the community-wide spread of pathogens and can lead to explosive epidemics.


title: The next generation HydroCoil: initial clinical experience with the HydroFill embolic coil.

text: BACKGROUND Complete packing of intracranial aneurysms has demonstrated a significant decrease in aneurysm recurrence rates with increased volumetric filling. The HydroCoil Embolization System (HES) was developed to increase volumetric filling within the aneurysm sac to maintain long term occlusion. To further enhance ease of HES deployment, a new next generation embolic coil, the HydroFill coil, was developed. OBJECTIVE To report the first clinical experience with the HydroFill coil, focusing on safety and effectiveness, with immediate and long term follow-up on cases performed at a single institution by a single operator. METHODS Retrospective angiographic and clinical analysis was performed on a non-randomized single arm registry of the first consecutive 11 patients with 14 intracranial saccular aneurysms treated during a 9 month period. RESULTS The immediate angiographic occlusion rate according to the Raymond scale was 100%. Overall packing density of all coils used was 13-135% (mean 64%). The immediate complication rate was 9% (1/11 patients), secondary to a parent vessel occlusion which resolved after intravenous administration of eptifibatide (Integrilin) without neurological sequelae. The angiographic/MR angiography follow-up period for this series was 13-30 months, with an overall complete occlusion rate of 86% (12/14 aneurysms). 2/14 aneurysms (14%) converted from complete occlusion to filling of small neck remnants. Of the two, one (7%) was a cavernous aneurysm that was retreated. CONCLUSIONS Although this initial case series is small, this study demonstrates safe deployment of the HydroFill coil in ruptured and unruptured aneurysms without major complications, and with a high rate of occlusion on long term follow-up.


title: Molecular determinants of enterovirus 71 viral entry: cleft around GLN-172 on VP1 protein interacts with variable region on scavenge receptor B 2.

text: Enterovirus 71 (EV71) is one of the major pathogens that cause hand, foot, and mouth disease outbreaks in young children in the Asia-Pacific region in recent years. Human scavenger receptor class B 2 (SCARB2) is the main cellular receptor for EV71 on target cells. The requirements of the EV71-SCARB2 interaction have not been fully characterized, and it has not been determined whether SCARB2 serves as an uncoating receptor for EV71. Here we compared the efficiency of the receptor from different species including human, horseshoe bat, mouse, and hamster and demonstrated that the residues between 144 and 151 are critical for SCARB2 binding to viral capsid protein VP1 of EV71 and seven residues from the human receptor could convert murine SCARB2, an otherwise inefficient receptor, to an efficient receptor for EV71 viral infection. We also identified that EV71 binds to SCARB2 via a canyon of VP1 around residue Gln-172. Soluble SCARB2 could convert the EV71 virions from 160 S to 135 S particles, indicating that SCARB2 is an uncoating receptor of the virus. The uncoating efficiency of SCARB2 significantly increased in an acidic environment (pH 5.6). These studies elucidated the viral capsid and receptor determinants of enterovirus 71 infection and revealed a possible target for antiviral interventions.


COVID-19: can we learn from encephalitis lethargica?


Insomnia and psychological reactions during the COVID-19 outbreak in China.


The COVID-19 Emergency Response Should Include a Mental Health Component.


docid: mmkekdgv

title: Emergent salvage direct intrahepatic portocaval shunt procedure for acute variceal hemorrhage.

text: PURPOSE To review the safety and effectiveness of direct intrahepatic portocaval shunt (DIPS) creation with variceal embolization for acute variceal hemorrhage after a failed transjugular intrahepatic portosystemic shunt (TIPS) creation attempt or in patients with prohibitive anatomy. MATERIALS AND METHODS Transjugular intrahepatic portosystemic shunt and DIPS procedures performed for variceal hemorrhage between January 2008 and July 2014 were reviewed. The default procedure was TIPS creation, with DIPS creation reserved for patients with unfavorable anatomy or who had technically unsuccessful TIPS creation. Thirteen patients underwent DIPS creation (mean age, 60 y ± 12; Child-Pugh class A/B/C, 8%/62%/30%; Model for End-stage Liver Disease score, 15 ± 5; range, 8-26) and 117 underwent TIPS creation. Four patients underwent a TIPS attempt and were converted to DIPS creation upon technical failure; 9 were treated primarily with DIPS creation because of preprocedural imaging revealing unfavorable anatomy (intrahepatic portal thrombosis, n = 2; venous distortion from prior hepatic resections, n = 2; severely angulated hepatic veins, n = 5). RESULTS Direct intrahepatic portocaval shunt creation with variceal embolization (six gastric or esophageal; seven stomal, duodenal, or rectal) was successful in all patients; 11 also had concomitant variceal sclerotherapy. Mean DIPS procedure time was less than 2 hours. There was 1 major procedural complication. During a mean follow-up of 13.0 months ± 15.5, 1 patient developed DIPS thrombosis and recurrent hemorrhage; 1 patient underwent successful transplantation. Two deaths were observed within 30 days, neither associated with recurrent hemorrhage. CONCLUSIONS Direct intrahepatic portocaval shunt creation appears to be a safe, expedient, and effective treatment for patients with acute variceal hemorrhage who are poor anatomic candidates for TIPS creation or who have undergone unsuccessful TIPS creation attempts.


title: Weight loss after bariatric surgery reverses insulin-induced increases in brain glucose metabolism of the morbidly obese.

text: Obesity and insulin resistance are associated with altered brain glucose metabolism. Here, we studied brain glucose metabolism in 22 morbidly obese patients before and 6 months after bariatric surgery. Seven healthy subjects served as control subjects. Brain glucose metabolism was measured twice per imaging session: with and without insulin stimulation (hyperinsulinemic-euglycemic clamp) using [18F]fluorodeoxyglucose scanning. We found that during fasting, brain glucose metabolism was not different between groups. However, the hyperinsulinemic clamp increased brain glucose metabolism in a widespread manner in the obese but not control subjects, and brain glucose metabolism was significantly higher during clamp in obese than in control subjects. After follow-up, 6 months postoperatively, the increase in glucose metabolism was no longer observed, and this attenuation was coupled with improved peripheral insulin sensitivity after weight loss. We conclude that obesity is associated with increased insulin-stimulated glucose metabolism in the brain and that this abnormality can be reversed by bariatric surgery.


title: The Hajj 2019 Vaccine Requirements and Possible New Challenges.

text: Each year millions of pilgrims perform the annual Hajj from more than 180 countries around the world. This is one of the largest mass gathering events and may result in the occurrence and spread of infectious diseases. As such, there are mandatory vaccinations for the pilgrims such as meningococcal vaccines. The 2019 annual Hajj will take place during August 8-13, 2019. Thus, we review the recommended and mandated vaccinations for the 2019 Hajj and Umrah. The mandatory vaccines required to secure the visa include the quadrivalent meningococcal vaccine for all pilgrims, while yellow fever, and poliomyelitis vaccines are required for pilgrims coming from countries endemic or with disease activity. The recommended vaccines are influenza, pneumococcal, in addition to full compliance with basic vaccines for all pilgrims against diphtheria, tetanus, pertussis, polio, measles, and mumps. It is imperative to continue surveillance for the spread of antimicrobial resistance and occurrence of all infectious diseases causing outbreaks across the globe in the last year, like Zika virus, MDR-Typhoid, Nipah, Ebola, cholera, chikungunya and Middle East Respiratory Syndrome Coronavirus.


title: Robot-assisted versus laparoscopic single-incision cholecystectomy: results of a randomized controlled trial.

text: BACKGROUND Although single-port laparoscopic cholecystectomy (SILC) is safe and effective, inherent surgeons' discomfort has prevented a large-scale adaptation of this technique. Recent advances in robotic technology suggest that da Vinci Single-Site™ cholecystectomy (dVSSC) may overcome this issue by reducing the stress load of the surgeon compared to SILC. However, evidence to objectively assess differences between the two approaches is lacking. METHODS 60 patients [36 women, 24 men (mean age 52 years)] with benign gallbladder disease were randomly assigned to dVSSC (n = 30) or SILC (n = 30) in this single-centre, single-blinded controlled trial. The primary endpoint was surgeon's stress load. Secondary endpoints included operating time, conversion rates, additional trocar placement, blood loss, length of hospital stay, procedure costs, health-related quality of life, cosmesis and complications. Data were collected preoperatively, during the hospital stay, and at 1 and 12 months' follow-up. RESULTS The dVSSC group showed a significant reduction of mental stress load of the surgeon compared to SILC [Subjective Mental Effort Questionnaire (SMEQ) score: median 25.0 (range 8-89) vs. 42.5 (range 13-110) points; p = 0.002] and a trend towards reduced physical stress load [Local Experienced Discomfort (LED) score: median 8 (range 2-27) vs. 12 (range 0-64) points; p = 0.088]. The length of hospital stay was longer in the SILC group [mean 3.06 (median 2; range 1-26) vs. 1.9 (median 2; range 1-4) days, p = 0.034] but overall hospital costs were higher for dVSSC [median 9734 (range 5775-16729) vs. 6900 (range 4156-99977) CHF; p = 0.001]. There were no differences in the rate of postoperative complications that required re-intervention (Dindo-Clavien grade ≥ IIIa; SILC n = 2 vs. dVSSC n = 0, p = 0.492) or other secondary endpoints. CONCLUSIONS Da Vinci Single-Site™ cholecystectomy provides significant benefits over Single-Port Laparoscopic Cholecystectomy in terms of surgeon's stress load, matches the standards of the laparoscopic single-incision approach with regard to patients' outcomes but increases expenses. Clinicaltrials.gov registration-No.: NCT02485392.


title: [Ethical review of clinical study on intervention with traditional Chinese medicine in new public health emergencies].

text: High-quality clinical study on traditional Chinese medicine is of great significance to effectively control new public health emergencies represented by outbreaks of infectious diseases and ensure people's health and safety, but it still faces a series of ethical issues. Based on the seven core values of equity, good deeds, effectiveness, respect for individuals, freedom, reciprocity, and solida-rity proposed in the Guidelines for Management of Ethical Issues in Outbreaks of Infectious Diseases, this article emphasizes the characteristics and laws of clinical studies on traditional Chinese medicine. Main points of ethical review of traditional Chinese medicine were summarized in the aspects of overall concept, syndrome differentiation and treatment, prevention before disease onset, cultural value, and clinical basis. Based on the outbreak of coronavirus disease 2019(COVID-19), we collected relevant registered Chinese medicine clinical studies, summarized the core issues of the ethics review for COVID-19, and further improved the traditional Chinese medicine ethics review system and resources, so as to better serve ethical review and scientific studies in public health emergencies.


title: Autopsy Report with Clinical Pathological Correlation.

text: Since making its debut on the global stage in December 2019, Coronavirus Disease 2019 (COVID-19) has afflicted nearly four million people and caused hundreds of thousands of deaths. Case reports and case series depicting the clinical effects of the causative virus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) have been published, yet few demonstrate the cytopathologic alterations of this disease. We present a clinical-pathological correlation report of a previously healthy Hispanic woman with laboratory-confirmed COVID-19 who had typical features of acute respiratory distress syndrome (ARDS), and also showed cardiac abnormalities thought to represent fulminant viral myocarditis. Congruent with the ARDS clinical impression, autopsy findings were remarkable for extensive and markedly severe acute lung injury consistent with viral pneumonia, characterized by diffuse alveolar damage, pulmonary infarction, severe pulmonary edema, desquamation of pneumocytes with intraalveolar aggregation, and pneumocyte morphological alterations suspicious for viral cytopathic effect. However, there was incongruence between the clinical impression and the cardiovascular pathology findings in that viral myocarditis was not detected on histopathologic evaluation. This case highlights the importance of pathologic corroboration of the clinical impression and, in addition, illuminates the key role autopsy plays during a pandemic by providing valuable insight into viral pathology in tissues.


title: Perioperative anesthesia care for patients with confirmed or suspected COVID-19.

text: The operating room environment is very dynamic with many unique challenges for anesthesia teams caring for patients with confirmed or suspected COVID-19. Specific recommendations by national organizations and institution specific step-by-step guidelines and education materials are required to maintain safety for both patients and caregivers perioperatively, with transport, and medication management.


title: Stability of ischemic core volume during the initial hours of acute large vessel ischemic stroke in a subgroup of mechanically revascularized patients.

text: INTRODUCTION This study aimed to relate growth of the infarct core with time to recanalization in patients receiving mechanical recanalization in whom the time of recanalization is known. METHODS We analyzed data from patients with anterior circulation acute ischemic stroke who underwent mechanical recanalization. Demographic and angiographic characteristics, initial apparent diffusion coefficient (ADC) infarct volume, time-to-peak defect volume, revascularization grade, 24-48 h nonenhanced computed tomography (CT) infarct volume, symptom onset to recanalization time, diffusion-weighted imaging to recanalization time, and discharge National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores were compared between minimal and substantial infarct growth groups. Substantial infarct growth was defined as an increase of infarct volume >10 cm(3) assessed by subtracting initial ADC infarct core volume from infarct volume at 24-48 h CT. RESULTS Of 25 patients, 9 had minimal infarct growth (median 0 cm(3), interquartile range (IQR) -3 to 5 cm(3)) and 16 had substantial infarct growth (median 103 cm(3), IQR 48-132 cm(3)). Patients with minimal infarct growth had a median time from symptom onset to recanalization of 329 min (IQR 314-412 min) and a median time from imaging to recanalization of 231 min (IQR 198-309 min). On univariate analysis, minimal infarct growth was related to male gender (p = 0.04), smaller initial ADC volume (p = 0.04), higher recanalization grade (p < 0.001), and lower discharge NIHSS (p = 0.04) and mRS grades (p = 0.04). CONCLUSION There was no or minimal infarct core growth in at least one third of patients despite an exceptionally long median time from magnetic resonance imaging to recanalization of almost 4 h.


title: Macromolecular crowding extended to a heptameric system: the Co-chaperonin protein 10.

text: Experiments on monomeric proteins have shown that macromolecular crowding can stabilize toward heat perturbation and also modulate native-state structure. To assess the effects of macromolecular crowding on unfolding of an oligomeric protein, we here tested the effects of the synthetic crowding agent Ficoll 70 on human cpn10 (GroES in E. coli), a heptameric protein consisting of seven identical β-barrel subunits assembling into a ring. Using far-UV circular dichroism (CD), tyrosine fluorescence, nuclear magnetic resonance (NMR), and cross-linking experiments, we investigated thermal and chemical stability, as well as the heptamer-monomer dissociation constant, without and with crowding agent. We find that crowding shifts the heptamer-monomer equilibrium constant in the direction of the heptamer. The cpn10 heptamer is both thermally and thermodynamically stabilized in 300 mg/mL Ficoll 70 as compared to regular buffer conditions. Kinetic unfolding experiments show that the increased stability in crowded conditions, in part, is explained by slower unfolding rates. A thermodynamic cycle reveals that in presence of 300 mg/mL Ficoll the thermodynamic stability of each cpn10 monomer increases by over 30%, whereas the interfaces are stabilized by less than 10%. We also introduce a new approach to analyze the spectroscopic data that makes use of multiple wavelengths: this provides robust error estimates of thermodynamic parameters.


title: Emerging infectious disease agents and their potential threat to transfusion safety.

text: BACKGROUND Emerging infections have been identified as a continuing threat to human health. Many such infections are known to be transmissible by blood transfusion, while others have properties indicating this potential. There has been no comprehensive review of such infectious agents and their threat to transfusion recipient safety to date. STUDY DESIGN AND METHODS The members of AABB's Transfusion Transmitted Diseases Committee reviewed a large number of information sources in order to identify infectious agents with actual or potential risk of transfusion transmission now or in the future in the US or Canada; with few exceptions, these agents do not have available interventions to reduce the risk of such transmission. Using a group discussion and writing process, key characteristics of each agent were identified, researched, recorded and documented in standardized format. A group process was used to prioritize each agent on the basis of scientific/epidemiologic data and a subjective assessment of public perception and/or concern expressed by regulatory agencies. RESULTS Sixty-eight infectious agents were identified and are described in detail in a single Supplement to TRANSFUSION. Key information will also be provided in web-based form and updated as necessary. The highest priorities were assigned to Babesia species, Dengue virus, and vCJD. CONCLUSION The information is expected to support the needs of clinicians and transfusion medicine experts in the recognition and management of emerging infections among blood donors and blood recipients.


title: Transcaval embolization as the preferred approach.

text: The management of type II endoleaks that develop after endovascular repair of aortic aneurysms now includes the transcaval approach. We reviewed the safety and efficacy of this technique in 10 consecutive patients (82 ± 7 years old; 80% male) who presented with a mean sac enlargement of 1.2 ± 0.7 cm and documented flow within the aortic sac. Patients presented a mean of 5.5 ± 3.1 years after endovascular aneurysm repair, and five (50%) patients had prior attempts at endovascular repair of the documented endoleak. Patients underwent a percutaneous transcaval approach to the aorta with use of the Rösch-Uchida Transjugular Liver Access Kit (Cook Medical, Bloomington, Ind) through an 8F sheath in a biplane angiography room. Coil embolization of the sac and lumbar arteries and occasional use of gelatin granules and human thrombin slurry allowed obliteration of the endoleak. No complications developed. Nine patients (90%) were noted to have a decreased sac diameter on the postprocedure study, and only one (10%) had persistent (but markedly diminished) flow noted on the follow-up ultrasound examination. Follow-up is early and extends to 6 months without recurrence of the endoleaks. The ability to safely access the aortic sac through the vena cava is a potentially efficient, safe, and useful technique to treat aortic endoleaks.


title: Chronic Living in a Communicable World.

text: By April 2020, COVID-19 lockdowns had restricted the movements of over half the world's population. As health authorities advise people living with chronic conditions to self-isolate because they are at particular risk of serious complications and death, the epidemiological split between communicable and noncommunicable disease is tenuous. We argue that much more is at stake for people living with (multiple) medical conditions than being "at risk" of infection of coronavirus. We emphasize the need to attend to the long-term effects of COVID-19, but also the importance of the continued care of people living with other lifelong medical conditions.