title: Improving outcomes after laparoscopic appendectomy: a population-based, 12-year trend analysis of 7446 patients.

text: OBJECTIVE Laparoscopic appendectomy for acute appendicitis has become increasingly used over the past decade. The objective of this trend analysis is to assess whether clinical outcomes after laparoscopic appendectomy have improved over the past 12 years. METHODS This analysis is based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. All patients undergoing emergency laparoscopic appendectomy for acute appendicitis from 1995 to 2006 were included. The following outcomes were assessed for each of the 12 years: conversion rates, intraoperative complications, surgical postoperative complications, general postoperative complications, rate of reoperations, and length of hospital stay. Unadjusted and risk-adjusted multivariable analyses were performed. Statistical significance was set at a level of P < 0.05. All statistical tests were 2-sided. RESULTS Data from 7446 patients undergoing laparoscopic appendectomy for acute appendicitis were prospectively collected. Over the period of observation, the conversion rate decreased significantly from 2.2% to 1.2% (P(trend)< 0.001), as did intraoperative complications (from 3.1% to 0.7%; P(trend)< 0.001), surgical postoperative complications (from 6.1% to 1.9%; P(trend)< 0.001), general postoperative complications (from 4.9% to 1.5%; P(trend)< 0.001), and rates of reoperations (from 3.4% to 0.7%; P(trend)< 0.001). Average postoperative length of hospital stay also significantly decreased from 4.9 to 3.5 days (P(trend)< 0.001). CONCLUSIONS Our investigation provides compelling evidence that intraoperative complications, surgical and general postoperative complications, conversion rates, rates of reoperations, and average length of hospital stay have significantly decreased over the past decade in patients undergoing surgery for acute appendicitis. The present trend analysis is the first one in the literature encompassing more than a decade and reporting clinical outcomes after laparoscopic appendectomy for acute appendicitis, which represents an important quality control.


title: Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity.

text: IMPORTANCE Severe obesity (body mass index [BMI] ≥35) is associated with a broad range of health risks. Bariatric surgery induces weight loss and short-term health improvements, but little is known about long-term outcomes of these operations. OBJECTIVE To report 3-year change in weight and select health parameters after common bariatric surgical procedures. DESIGN AND SETTING The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. PARTICIPANTS AND EXPOSURE: Adults undergoing first-time bariatric surgical procedures as part of routine clinical care by participating surgeons were recruited between 2006 and 2009 and followed up until September 2012. Participants completed research assessments prior to surgery and 6 months, 12 months, and then annually after surgery. MAIN OUTCOMES AND MEASURES Three years after Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), we assessed percent weight change from baseline and the percentage of participants with diabetes achieving hemoglobin A1c levels less than 6.5% or fasting plasma glucose values less than 126 mg/dL without pharmacologic therapy. Dyslipidemia and hypertension resolution at 3 years was also assessed. RESULTS At baseline, participants (N = 2458) were 18 to 78 years old, 79% were women, median BMI was 45.9 (IQR, 41.7-51.5), and median weight was 129 kg (IQR, 115-147). For their first bariatric surgical procedure, 1738 participants underwent RYGB, 610 LAGB, and 110 other procedures. At baseline, 774 (33%) had diabetes, 1252 (63%) dyslipidemia, and 1601 (68%) hypertension. Three years after surgery, median actual weight loss for RYGB participants was 41 kg (IQR, 31-52), corresponding to a percentage of baseline weight lost of 31.5% (IQR, 24.6%-38.4%). For LAGB participants, actual weight loss was 20 kg (IQR, 10-29), corresponding to 15.9% (IQR, 7.9%-23.0%). The majority of weight loss was evident 1 year after surgery for both procedures. Five distinct weight change trajectory groups were identified for each procedure. Among participants who had diabetes at baseline, 216 RYGB participants (67.5%) and 28 LAGB participants (28.6%) experienced partial remission at 3 years. The incidence of diabetes was 0.9% after RYGB and 3.2% after LAGB. Dyslipidemia resolved in 237 RYGB participants (61.9%) and 39 LAGB participants (27.1%); remission of hypertension occurred in 269 RYGB participants (38.2%) and 43 LAGB participants (17.4%). CONCLUSIONS AND RELEVANCE Among participants with severe obesity, there was substantial weight loss 3 years after bariatric surgery, with the majority experiencing maximum weight change during the first year. However, there was variability in the amount and trajectories of weight loss and in diabetes, blood pressure, and lipid outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00465829.


Disruptive Effect of COVID-19 on Orthopaedic Daily Practice: A Cross-Sectional Survey.


title: Safety of Intraventricular rt-PA for Pan-Ventricular IVH Caused by a Ruptured AVM: A Case Report.

text: Intraventricular recombinant tissue plasminogen activator (IVT rt-PA) has improved outcomes for intraventricular hemorrhage (IVH). Patients with suspected or untreated arteriovenous malformations (AVMs) have been excluded from clinical trials. We present a patient with IVH secondary to a ruptured AVM safely treated with IVT rt-PA. A 48-year-old Hispanic male with a history of dermatomyositis presented to the emergency department with sudden left-sided weakness. En route to computed tomography (CT), he became lethargic. Computed tomography revealed extensive IVH with acute hydrocephalus, which was treated with the placement of external ventricular drain with clinical improvement. Computed tomography angiogram performed did not reveal AVM. Cerebral digital subtraction angiogram (DSA) was planned due to suspicion of AVM. Prior to DSA, patient became acutely lethargic. Computed tomography imaging revealed worsening hydrocephalus. External ventricular drain was noted to be draining. Repeat CT revealed improved hydrocephalus but with left lateral ventricle dilatation. Risks and benefits of IVT rt-PA were discussed with the family and a decision was made to treat. Three doses of 1 mg IVT rt-PA were administered with resolution of midline blood and lateral ventricular dilatation with clinical improvement. Digital subtraction angiogram revealed early draining vein on right internal carotid artery injection draining into the inferior sagittal sinus representing ruptured AVM without clear nidus. Repeat DSA with possible embolization was planned after discharge. In spite of additional in-hospital complications, the patient gradually improved and was ultimately discharged home. Our case supports the idea that the use of IVT rt-PA following an IVH caused by an underlying AVM could be further explored in carefully designed clinical trials.


title: Ulcerative Colitis: Shifting Sands.

text: Ulcerative colitis (UC) is a chronic inflammatory bowel disease associated with considerable disease burden. We review some current misconceptions about UC in adults with the aim of optimizing care for patients. Although UC and Crohn's disease (CD) are considered discrete diseases, distinctions between them are not always clear-cut and phenotypes may change over time. Patient management should take into account disease manifestations, disease severity and extent, and response to prior treatments. Although disease extent often defines severity, distal UC is not always less disabling than extensive disease as patients can progress to more extensive disease. In addition, severe proctitis can give rise to severe and debilitating symptoms, with a substantial impact on health-related quality of life. UC carries an increased risk of colorectal cancer (CRC) compared with CD; however, more recent data indicate a similar risk of CRC in CD with colonic involvement as with UC. Corticosteroids are widely used to induce remission in UC, and prolonged use of steroids in patients with UC is common, but corticosteroid-free maintenance of remission is an important therapeutic goal. Although biologic therapies provide a valuable treatment option in UC, they are not clinically effective in all patients and are also associated with secondary loss of response.


title: Safety and location analysis of transumbilical endoscopic submucosal dissection with single-basin lymph node dissection in the upper gastric body: a porcine model.

text: BACKGROUND In our previous study, transumbilical endoscopic submucosal dissection (TU-ESD) was revealed to be feasible, but delayed gastric perforation was observed in 30% of ESD sites. In this study, we aimed to verify locations at which it is feasible to perform TU-ESD in the upper gastric body and to demonstrate the safety of TU-ESD in single-basin lymph node dissection (SBLND). METHODS In vitro, TU-ESD was performed at three lesion sites (anterior wall, AW; posterior wall, PW; and lesser curvature, LC) in each porcine stomach using an EASIE-R tray (cases = 10). In vivo, TU-ESD was performed with SBLND in 9 pigs. Seven days after the operation, the pigs were sacrificed and examined. RESULTS In the in vitro feasibility study, the TU-ESD time was significantly faster in the PW group (5.9 ± 2.0 min) than in the LC group (8.5 ± 1.5 min) (p < 0.05) in all 10 cases. In the in vivo survival study, TU-ESD with SBLND was successfully performed without any complications (N = 9). There were no cases of delayed perforation, and healing ulcers were found in all pigs 7 days after the operation. Ulcer size (5.2 ± 3.5 cm2) was approximately 36% smaller than that observed at the ESD operation site (8.1 ± 1.9 cm2) (p = 0.05). Epithelialization in the margin and healing of the gastric ulcers were confirmed by microscopy. CONCLUSIONS TU-ESD with SBLND is a feasible and safe method. The upper posterior gastric body could be the most feasible location for performing TU-ESD, perhaps because of the difference in the subcutaneous dissection time.


title: The 20 Most Important and Most Preventable Health Problems of China: A Delphi Consultation of Chinese Experts.

text: OBJECTIVES To identify the 20 most important and most preventable health problems that should be addressed in the next 20 years in China. METHODS In 2015, we applied a modified electronic Delphi technique to reach consensus from a panel of top Chinese health experts (n = 70), who were requested to identify 20 health problems that, in their judgment, were most important and preventable. We also compared the results with evidences from epidemiological studies on disease-specific mortalities and disability-adjusted life years. RESULTS Consensus was reached after the second-round survey. The final agreed-upon 20 most important and most preventable health problems included 9 noncommunicable diseases, 4 communicable diseases, 2 unhealthy behaviors, and 2 forms of environmental pollution, plus depression, road injury, and contamination of food with pesticides, antibiotics, and hormone residues. The results are supported by relevant epidemiological studies in China. CONCLUSIONS The 20 most important and most preventable health problems in China for the next 20 years, agreed upon by a panel of top Chinese health experts, should be taken into consideration in national policymaking.


Group urges going metric to head off dosing mistakes.


Covid-19: "Steady the front line! There is no retreat from here".


title: New aspects of the renin-angiotensin system: angiotensin-converting enzyme 2 - a potential target for treatment of hypertension and diabetic nephropathy.

text: PURPOSE OF REVIEW Whereas angiotensin-converting enzyme promotes the formation of angiotensin II, angiotensin-converting enzyme 2 promotes the degradation of angiotensin II to angiotensin-(1-7). We review recent studies dealing with angiotensin-converting enzyme 2 in kidney disease and hypertension, and discuss the potential therapeutic benefit of increasing angiotensin-converting enzyme 2 activity in the treatment of these diseases. RECENT FINDINGS In glomeruli from diabetic mice, angiotensin-converting enzyme 2 expression is downregulated, and pharmacological inhibition of angiotensin-converting enzyme 2 leads to worsening of albuminuria, increased mesangial matrix deposition and fibronectin expression. The deletion of the angiotensin-converting enzyme 2 gene in mice leads to worsening of angiotensin II-induced hypertension and has also been shown to cause glomerulosclerosis in aging male mice. SUMMARY Angiotensin-converting enzyme 2 is a key enzyme in the renin-angiotensin system that favors the degradation of angiotensin I and angiotensin II. Angiotensin-converting enzyme 2 inhibition by pharmacological means and by genetic deletion worsens kidney disease in diabetic mice. Strategies geared to increasing angiotensin-converting enzyme 2 activity may provide a novel therapeutic target within the renin-angiotensin system by enhancing angiotensin II degradation that may complement the current approach of inhibiting angiotensin II formation and action. Amplifying angiotensin-converting enzyme 2 activity may have a potential therapeutic role for kidney disease and hypertension.


title: Laparoscopic common bile duct exploration in patients with complicated cholecystitis: a safety and feasibility study.

text: BACKGROUND Laparoscopic cholecystectomy (LC) with common bile duct exploration (LCBDE) is nowadays a preferred one-stage treatment. However, the influence of complicated cholecystitis (CC) on LCBDE has rarely been addressed. In the present study we aimed to verify whether severe gallbladder inflammation would adversely affect the outcome of LCBDE. MATERIAL AND METHODS From 2008 to 2011, all patients undergoing LC and LCBDE at China Medical University Hospital were included. Patients were divided into two groups based on the severity of cholecystitis. Those with unstable hemodynamics and co-morbidities who were deemed unfit for general anesthesia were excluded. Patient demographics, surgical results, and outcome were compared between the groups. RESULTS During the study period, 117 patients diagnosed with cholecystitis were found to have common bile duct (CBD) stones and underwent LC + LCBDE. Of these 117 patients, 87 had uncomplicated cholecystitis (UC) and the remaining 30 patients had CC. There was no demographic difference between the groups, but for patients with CC there were marginally longer operative times (190 vs. 223 min, p = 0.141), more blood loss (10 vs. 150 ml, p < 0.05), and longer postoperative hospital stays (6 vs. 7 days, p < 0.05). The risk of developing major intraoperative complications was not greater for those with CC. Conversion to open cholecystectomy was necessary in a total of 12 cases (10 %) with an overall 1 % mortality rate. CONCLUSIONS Complicated cholecystitis was not a contraindication for LCBDE. Complete stone clearance can be achieved in a substantial number of cases with an acceptable complication rate. Further prospective randomized studies are required to validate its long-term safety.


title: Current tools for norovirus drug discovery.

text: INTRODUCTION Rapid transmission of norovirus often occurs due to its low infectious dosage, high genetic diversity and its short incubation time. The viruses cause acute gastroenteritis and may lead to death. Presently, no effective vaccine or selective drugs accepted by the United States Food and Drug Administration (FDA) are available for the treatment of norovirus. Advances in the development of norovirus replicon cell lines, GII.4-Sydney HuNoV strain human B cells, and murine and gnotobiotic pig norovirus models have facilitated the discovery of effective small molecule inhibitors in vitro and in vivo. AREAS COVERED This review gives a brief discussion of the biology and replication of norovirus before highlighting the discovery of anti-norovirus molecules. The article coverage includes: an overview of the current state of norovirus drug discovery, the targeting of the norovirus life cycle, the inhibition of structural and nonstructural proteins of norovirus such as proteases and polymerase, and the blockage of virus entry into host cells. Finally, anti-norovirus drugs in the clinical development stage are described. EXPERT OPINION The current approach for the counteraction of norovirus focuses on the inhibition of viral RNA polymerase, norovirus 3C-like protease and the structural proteins VP1 as well as the blockade of norovirus entry. Broad-spectrum anti-norovirus molecules, based on the inhibition of 3C-like protease, have been developed. Other host factors and ways to overcome the development of resistance through mutation are also being examined. A dual approach in targeting viral and host factors may lead to an effective counteraction of norovirus infection. Current successes in developing norovirus replicon harboring cells and norovirus infected human cells, as well as murine norovirus models and other animal models such as piglets have facilitated the discovery of effective drugs and helped our understanding of its mechanism of action.


Laparoscopic repair of an isolated congenital bilateral lumbar hernia in an infant.


title: Comparison of single-stapling and hemi-double-stapling methods for intracorporeal esophagojejunostomy using a circular stapler after totally laparoscopic total gastrectomy.

text: BACKGROUND Laparoscopic total gastrectomy is not widely performed because of the difficulty of esophagojejunal reconstruction. This study analyzed complication rates of two different methods for reconstruction by a circular stapler after totally laparoscopic total gastrectomy (TLTG). METHODS Between 2010 and 2014, clinical data of 19 patients who underwent TLTG for gastric adenocarcinoma were collected retrospectively. There were two methods to fix the anvil of a circular stapler into the distal esophagus: In the single-stapling technique (SST) group, Endo-PSI(II) was used for purse-suturing on the distal esophagus for reconstruction, and in the hemi-double-stapling technique (hemi-DST) group, the esophagus was cut by linear stapler with the entry hole of the anvil shaft opened after inserting the anvil tail. In both groups, surgical procedures were the same, except for the reconstruction. RESULTS All TLTGs were performed securely without mortality. Intracorporeal laparoscopic esophagojejunal anastomosis was performed successfully for all the patients. In the hemi-DST group, four patients experienced anastomotic stenosis, three of whom required endoscopic balloon dilation. In contrast, no stenosis was seen in the SST group (p = 0.033). CONCLUSIONS Anastomosis with SST is preferred to that with hemi-DST to minimize postoperative complications.


title: Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy.

text: BACKGROUND Gastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. OBJECTIVE Determine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SETTING University hospital, France, public practice. MATERIAL AND METHODS This study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. RESULTS A total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1-245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0-86). Uniform gastric shape was acquired after 30-32 SG procedures. CONCLUSION Routine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.


title: Predictive value of National Early Warning Score 2 (NEWS2) for intensive care unit admission in patients with SARS-CoV-2 infection.

text: Background: From January 2020, Coronavirus disease 19 (COVID-19) has rapidly spread all over the world. An early assessment of illness severity is important for the stratification of patients. We analysed the predictive value of National Early Warning Score 2 (NEWS2) for intensive care unit admission (ICU) in patients with Severe Acute Respiratory Syndrome- Coronavirus-2 (SARS-CoV-2) infection.Methods: Data of 71 patients with SARS-CoV-2 admitted from 1 March to 20 April 2020, to the Clinic of Infectious Diseases of Perugia Hospital, Italy, were retrospectively reviewed. NEWS2 at hospital admission, demographic, comorbidity and clinical data were collected. Univariate and multivariate analyses were performed to establish the correlation between each variable and ICU admission.Results: Among 68 patients included in the analysis, 27 were admitted to ICU. NEWS2 at hospital admission was a good predictor of ICU admission as shown by an area under the receiver-operating characteristic curve analysis of 0.90 (standard error 0.04; 95% confidence interval 0.82-0.97). In multivariate logistic regression analysis, NEWS2 was significantly related to ICU admission using thresholds of 5 and 7. No other clinical variables included in the model were significantly correlated with ICU admission.A NEWS2 threshold of 5 had higher sensitivity than a threshold of 7 (89% and 63%). Higher specificity, positive likelihood ratio and positive predictive value were found using a threshold of 7 than a threshold of 5.Conclusions: NEWS2 at hospital admission was a good predictor for ICU admission. Patients with severe COVID-19 were correctly and rapidly stratified.


docid: ecuxvfej

title: Effects of methylprednisolone or immunoglobulin when added to standard treatment with intravenous azithromycin for refractory Mycoplasma pneumoniae pneumonia in children.

text: BACKGROUND The prevalence of Mycoplasma pneumoniae pneumonia has increased considerably in recent years. To evaluate the efficacy of combined treatment of azithromycin with intravenous immunoglo-bulin (IVIG) or methylprednisolone in children with refractory Mycoplasma pneumoniae pneumonia (RMPP). METHODS Children with RMPP were randomly allocated to group A [intravenous azithromycin (IA)+ methylprednisolone], group B (IA+IVIG) or group C (IA alone). Following a 7-day treatment, group C patients were randomly separated into two sub-groups: group C1 (IA+methylprednisolone) and group C2 (IA+IVIG). Temperature, respiratory symptoms and signs were examined. The average febrile period after treatment (F2), average total febrile period (F3), infiltration absorption, atelectasis resolution, pleural effusion disappearance were determined. The levels of C-reactive protein (CRP), D-dimer, and lactate dehydrogenase (LDH) were measured. RESULTS Seven days after enrollment, the average F2 after treatment of group A was the shortest. Compared with the control group C, the combined treatment group A and B showed higher rates of infiltration absorption, atelectasis resolution and pleural effusion disappearance, while lower levels of serum CRP, D-dimer and LDH. Fourteen days after enrollment, all children with combined therapy clinically improved, and presented better laboratory results. Group C1 showed shorter F3 and lower levels of CRP and LDH than those of group C2. Overall, group A showed the shortest F3, also has the lowest CRP and LDH. CONCLUSIONS Azithromycin with IVIG or methylprednisolone was better treatment for children with RMPP than azithromycin alone. IVIG treatment may be beneficial, especially when the efficacy of corticosteroids is insecure, thus could be considered as an alternative of primary therapeutic approaches.


title: Utility of feline coronavirus antibody tests.

text: Eight different tests for antibodies to feline coronavirus (FCoV) were evaluated for attributes that are important in situations in veterinary practice. We compared four indirect immunofluorescent antibody tests (IFAT), one enzyme-linked immunosorbent assay (ELISA) (FCoV Immunocomb; Biogal) and three rapid immunochromatographic (RIM) tests against a panel of samples designated by consensus as positive or negative. Specificity was 100% for all but the two IFATs based on transmissible gastroenteritis virus (TGEV), at 83.3% and 97.5%. The IFAT and ELISA tests were best for obtaining an antibody titre and for working in the presence of virus. The RIM tests were the best for obtaining a result quickly (10-15 mins); of these, the Speed F-Corona was the most sensitive, at 92.4%, followed by FASTest feline infectious peritonitis (FIP; 84.6%) and Anigen Rapid FCoV antibody test (64.1%). Sensitivity was 100% for the ELISA, one FCoV IFAT and one TGEV IFAT; and 98.2% for a second TGEV IFA and 96.1% for a second FCoV IFAT. All tests worked with effusions, even when only blood products were stipulated in the instruction manual. The ELISA and Anigen RIM tests were best for small quantities of sample. The most appropriate FCoV antibody test to use depends on the reason for testing: in excluding a diagnosis of FIP, sensitivity, specificity, small sample quantity, rapidity and ability to work in the presence of virus all matter. For FCoV screening, speed and sensitivity are important, and for FCoV elimination antibody titre is essential.


title: Robotic perineal radical prostatectomy and robotic pelvic lymph node dissection via a perineal approach: The Tugcu Bakirkoy Technique.

text: Objective To describe The Tugcu Bakirkoy robotic perineal radical prostatectomy and pelvic lymph node dissection technique, and present the results of seven patients. Material and methods We performed seven robotic perineal radical prostatectomy and pelvic lymph node dissection operation using Da Vinci Xi HD Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, USA) on single Gel-port platform. The operation is completed in 4 stages: stage 1 open perineal dissection and gel port placement, stage 2 robotic perineal radical prostatectomy, stage 3 robotic pelvic lymph node dissection, stage 4 vesico-urethral anastomosis. In addition to describing the operation technique step by step, we aimed to present the perioperative and postoperative findings of the seven patients who underwent The Tugcu Bakirkoy Technique. Results All operations were successfully completed without any complications in fully the robotic procedure by a single surgeon. Demographic data of the patients were as follows: Mean age (62.1±8 years), mean body mass index (28.2±0.7 kg/m2), mean prostate specific antigen value (10.7±3 ng/mL), and mean prostate volume (64.2±15.3 cc). Mean operative time (184.1±20.2 mins), blood loss (64.2±15.3 cc), hospitalization time (2.1±0.6 days), and time to withdrawal of the urethral catheter (7.8±0.8 days) were also estimated. According to the pathology results, lymph node metastasis was detected in 3 patients while the surgical margin was positive in one. Conclusion We demonstrated for the first time that a new The Tugcu Bakirkoy robotic perineal radical prostatectomy technique which was previously tested in a cadaveric model, can be safely applied for the first time in vivo, and presented our results. On the basis of this, for problems that can not be overcome by traditional methods, this method is a good alternative as a way out. In this regard, it is necessary to carry out advanced studies so that this method can be applied to daily practice.


title: [Feasibility of laparoendoscopic single-site surgery in gynecology with conventional laparoscopic instruments].

text: OBJECTIVES To describe the safety and efficacy of single-port access for laparoscopic surgery in gynecology with conventional laparoscopic instruments. PATIENTS AND METHODS In this prospective study, we report our experience with 90 patients who underwent Single Port Access (SPA) laparoscopic surgery for gynecologic pathology with the use of the SILS(®) Port Multiple Instrument Access Port (Covidien(®), Mansfield, MA). RESULTS We realised 15 ovarian cystectomies, 30 salpingo-oophrectomies with 14 one side, 9 lysis of adhesions, 7 distal tubal repairs, 6 salpingectomy, 8 other procedures. The mean surgical time is 47 min (25-120). One conversion to conventional laparoscopy and one in laparotomy were performed. The mean duration stay is 2 days [1-3]. DISCUSSION AND CONCLUSION SPA in gynecology is feasible with conventional laparoscopic instruments. SPA surgery represents the newest frontier in minimally invasive surgery.


title: Case report: a novel method for uterine-sparing hysteropexy.

text: OBJECTIVE The objective of this study was to describe a technique for uterine-sparing hysteropexy. CASE REPORT A 50-year-old multiparous woman with pelvic organ prolapse underwent laparoscopic sacrohysteropexy utilizing polypropylene mesh with good clinical result. CONCLUSIONS Placement of mesh arms medial to the uterine vessels during a laparoscopic sacrohysteropexy can be facilitated by using blunt needles to introduce the mesh arms.


title: Surgical technique: Muscle transfer restores extensor function after failed patella-patellar tendon allograft.

text: BACKGROUND Extensor mechanism allograft provides an effective remedy for severe quadriceps deficiency caused by loss of the patella, patellar tendon, and quadriceps tendon in TKA. Late failure is common, however, and major quadriceps deficiency occurs after removal of the allograft material. DESCRIPTION OF TECHNIQUE Six human cadaver specimens were dissected to evaluate the feasibility of transferring the vastus medialis, vastus lateralis, and medial head of the gastrocnemius muscle to fill the defect caused by loss of the patella and extensor tendon mechanism after failure and removal of allograft material. Transfer of the medial and lateral vastus muscles with their distal attachments into the tibia achieved closure of the defect but did not provide robust tendon material to fill the defect in the anterior knee. The medial gastrocnemius muscle reached easily to the muscular portion of the vastus medialis and lateralis flaps and provided secure closure of the anterior knee and strong attachment of viable muscle and tendon. METHODS Five knees (five patients) with failed patella-patellar tendon allograft between August 2008 and April 2010 were repaired using this technique. RESULTS Mean extensor lag was 47° (range, 35°-62°) before surgery and improved to 12° (range, 5°-15°) 1 year after surgery. CONCLUSIONS These preliminary results suggest that the described muscle transfer technique may provide an approach to salvage the failed extensor mechanism allograft after TKA.


title: TEP and Lichtenstein anatomy: does simulation accelerate acquisition among interns?

text: PURPOSE The anatomy of the inguinal region is notoriously challenging to master. We sought to teach open inguinal hernia (OIH) and totally extraperitoneal (TEP) anatomy with simulation models among general surgery (GS) interns. METHODS Low-fidelity OIH and TEP models were constructed out of cardboard, plastic bins, fabric, and yarn. GS interns (n = 30) participated in a 3-h hernia session including a pretest, anatomy lecture, simulated OIH and TEP hernia repair, and posttest. Pre- and posttest scores were based on a difficult 30-point exam which included didactic questions (10 points), drawing relevant TEP (10 points), and OIH (10 points) anatomy. Participants were surveyed following the session. RESULTS Median pretest scores were 13 % (range 0-60 %). Median posttest scores improved to 47 % (range 20-93 %, p < 0.001). Median number of structures drawn in the TEP image improved from 2 (range 0-14) to 11 (range 1-21, p < 0.001). Median number of structures drawn in the OIH image improved from 3 (range 0-15) to 7 (range 1-19, p < 0.001). 67 % (12/18) demonstrated improvement in knowledge of abdominal wall layers. 23 % (7/30) knew the triangles of pain/doom on the pretest vs. 77 % (23/30) on the posttest. Mean Likert scores favored session enjoyability (4.5), not a waste of training time (4.4), and improved understanding of OIH and TEP anatomy (4.4, 4.2). CONCLUSIONS Low-fidelity simulators can be used to teach and assess knowledge of TEP and OIH anatomy. While enjoyable and useful, one 3-h session does not create master hernia surgeons or expert anatomists out of novice trainees.


title: Balloon-assisted coil embolization and large stent delivery for cerebral aneurysms with a new generation of dual lumen balloons (Copernic 2L).

text: INTRODUCTION Dual coaxial lumen balloon microcatheters through which small stents can be delivered have recently been described. We report a series of a new type of dual lumen balloon catheter with a parallel lumen design enabling enhanced inflation and deflation properties through which larger stents may be deployed, including flow diverters (FD). METHODS All aneurysms that were treated with a Copernic 2L (COP2L) dual lumen balloon catheter at our institution between February 2014 and December 2016 were assessed. Patient demographics, aneurysm characteristics, clinical and angiographic follow-up, as well as adverse events were analyzed. RESULTS A total of 18 aneurysms in 16 patients (14 women) were treated with the COP2L. Mean maximal aneurysm diameter was 6.4 mm, mean neck size was 3.3 mm (min 1; max 6.3), and mean aneurysm height/width was 1.1 (min 0.5; max 2.1). The COP2L was used for balloon-remodeled coiling exclusively in 2 aneurysms; coiling and FD stenting in 8; coiling and braided stent delivery in 3; coiling, braided and FD stenting in 1; and FD stenting without coiling in 4 (stenting alone). The rate of Roy-Raymond 1 (complete occlusion) changed from 22% in the immediate postoperative period to 100% at 3 months (mean imaging follow-up 8.2 months). There were three technical complications (3/16, 18.7%), including a perforation and two thromboembolic asymptomatic events that were rapidly controlled with the COP2L. There was no immediate or delayed morbidity or mortality (modified Rankin Scale score 0-1 in 100% of patients). CONCLUSION The COP2L is a new type of dual lumen balloon catheter that may be useful for balloon and/or stent-assisted coiling of cerebral aneurysms. The same device can be used to deliver stents up to 4.5 mm and to optimize stent/wall apposition or serve as a life-saving tool in case of thromboembolic or hemorrhagic events. Long-term efficacy and safety need to be further assessed with larger case-controlled cohorts.


docid: bkdoihfl

title: Cingulum-Callosal white-matter microstructure associated with emotional dysregulation in children: A diffusion tensor imaging study.

text: Emotional dysregulation symptoms in youth frequently predispose individuals to increased risk for mood disorders and other mental health difficulties. These symptoms are also known as a behavioral risk marker in predicting pediatric mood disorders. The underlying neural mechanism of emotional dysregulation, however, remains unclear. This study used the diffusion tensor imaging (DTI) technique to identify anatomically specific variation in white-matter microstructure that is associated with pediatric emotional dysregulation severity. Thirty-two children (mean age 9.53 years) with varying levels of emotional dysregulation symptoms were recruited by the Massachusetts General Hospital and underwent the DTI scans at Massachusetts Institute of Technology. Emotional dysregulation severity was measured by the empirically-derived Child Behavior Checklist Emotional Dysregulation Profile that includes the Attention, Aggression, and Anxiety/Depression subscales. Whole-brain voxel-wise regression tests revealed significantly increased radial diffusivity (RD) and decreased fractional anisotropy (FA) in the cingulum-callosal regions linked to greater emotional dysregulation in the children. The results suggest that microstructural differences in cingulum-callosal white-matter pathways may manifest as a neurodevelopmental vulnerability for pediatric mood disorders as implicated in the clinical phenotype of pediatric emotional dysregulation. These findings may offer clinically and biologically relevant neural targets for early identification and prevention efforts for pediatric mood disorders.


title: Advanced ultrasonography technologies to assess the effects of radiofrequency ablation on hepatocellular carcinoma.

text: BACKGROUND Radiofrequency ablation (RFA) is a curative therapy for hepatocellular carcinoma (HCC). In RFA, ultrasonography (US) is most commonly used to guide tumor puncture, while its effects are assessed using dynamic computed tomography or magnetic resonance. The differences in modalities used for RFA and assessment of its effects complicate RFA. We developed a method for assessing the effects of RFA on HCC by combining contrast-enhanced (CE) US and real-time virtual sonography with three-dimensional US data. PATIENTS AND METHODS Before RFA, we performed a sweep scan of the target HCC nodule and the surrounding hepatic parenchyma to generate three-dimensional US data. After RFA, we synchronized multi-planar reconstruction images derived from stored three-dimensional US data with real-time US images on the same US monitor and performed CEUS and real-time virtual sonography. Using a marking function, we drew a sphere marker along the target HCC nodule contour on pre-treatment US- multi-planar reconstruction images so that the automatically synchronized sphere marker represented the original HCC nodule contour on post-treatment real-time CEUS images. Ablation was considered sufficient when an avascular area with a margin of several millimeters in all directions surrounded the sphere marker on CEUS. RESULTS This method was feasible and useful for assessing therapeutic effects in 13 consecutive patients with HCC who underwent RFA. In 2 patients who underwent multiple sessions of RFA, HCC-nodule portions requiring additional RFA were easily identified on US images. CONCLUSIONS This method using advanced US technologies will facilitate assessment of the effects of RFA on HCC.


title: Pathogenesis and transmission of SARS-CoV-2 in golden hamsters.

text: SARS-CoV-2, a novel coronavirus with high nucleotide identity to SARS-CoV and SARS-related coronaviruses detected in horseshoe bats, has spread across the world and impacted global healthcare systems and economy1,2. A suitable small animal model is needed to support vaccine and therapy development. We report the pathogenesis and transmissibility of the SARS-CoV-2 in golden Syrian hamsters. Immunohistochemistry demonstrated viral antigens in nasal mucosa, bronchial epithelial cells, and in areas of lung consolidation on days 2 and 5 post-inoculation (dpi), followed by rapid viral clearance and pneumocyte hyperplasia on 7 dpi. Viral antigen was also found in the duodenum epithelial cells with viral RNA detected in feces. Notably, SARS-CoV-2 transmitted efficiently from inoculated hamsters to naïve hamsters by direct contact and via aerosols. Transmission via fomites in soiled cages was less efficient. Although viral RNA was continuously detected in the nasal washes of inoculated hamsters for 14 days, the communicable period was short and correlated with the detection of infectious virus but not viral RNA. Inoculated and naturally-infected hamsters showed apparent weight loss, and all animals recovered with the detection of neutralizing antibodies. Our results suggest that SARS-CoV-2 infection in golden Syrian hamsters resemble features found in humans with mild infections.


title: Effect of COVID-19 on Urology Residency Training: A Nationwide Survey of Program Directors by the Society of Academic Urologists.

text: PURPOSE Coronavirus disease (COVID-19) has profoundly impacted residency training and education. To date, there has not been any broad assessment of urological surgery residency changes and concerns during the COVID-19 pandemic. MATERIALS AND METHODS The Society of Academic Urologists distributed a questionnaire to urology residency program directors on March 30, 2020 exploring residency programs changes related to the COVID-19 pandemic. Descriptive statistics are presented. A qualitative analysis of free response questions was undertaken. A post hoc analysis of differences related to local COVID-19 incidence is described. RESULTS The survey was distributed to 144 residency programs with 65 responses for a 45% response rate. Reserve staffing had started in 80% of programs. Patient-contact time had decreased significantly from 4.7 to 2.1 days per week (P<0.001). Redeployment was reported by 26% of programs. Sixty percent of programs reported concern that residents will not meet case minimums due to COVID-19. Wellness activities centered on increased communication. All programs had begun to use video-conferencing and the majority planned to continue using this. Programs in states with higher incidence of COVID-19 were more likely to report resident redeployment (48% vs 11%, P=0.002) and exposure to COVID-19-positive patients (70% vs 40%, P=0.03) and were less likely to report concerns regarding exposure (78% vs 97%, P=0.02) and personal protective equipment (PPE) availability (62% vs 89%, P=0.02). CONCLUSIONS As of April 1, 2020, the COVID-19 pandemic had resulted in significant changes in urology residency programs. These findings inform a rapidly changing landscape and aid in development of best practices.


title: Structure-modifying effects of chondroitin sulfate in knee osteoarthritis: an updated meta-analysis of randomized placebo-controlled trials of 2-year duration.

text: OBJECTIVE To update a published meta-analysis of double-blind placebo-controlled randomized clinical trials (RCTs) to assess the efficacy of chondroitin sulfate as a structure-modifying drug for knee osteoarthritis (OA). DESIGN A published meta-analysis of randomized controlled trials was updated to include data from one new trial and final data from a second trial both published recently in peer-reviewed literature. This meta-analysis was limited to three RCTs of 2-year duration. Data were pooled using a fixed effects model as there was no evidence of important heterogeneity. RESULTS Pooled results demonstrated a small significant effect of chondroitin sulfate on the reduction in rate of decline in minimum joint space width of 0.13 mm [95% confidence interval (CI) 0.06, 0.19] (P=0.0002) that corresponded to an effect size of 0.23 (95% CI 0.11, 0.35) (P=0.0001). CONCLUSION These results demonstrate that chondroitin sulfate is effective for reducing the rate of decline in minimum joint space width in patients with knee OA.


title: Identification of cardioviruses related to Theiler's murine encephalomyelitis virus in human infections.

text: Cardioviruses comprise a genus of picornaviruses that cause severe illnesses in rodents, but little is known about the prevalence, diversity, or spectrum of disease of such agents among humans. A single cardiovirus isolate, Saffold virus, was cultured in 1981 in stool from an infant with fever. Here, we describe the identification of a group of human cardioviruses that have been cloned directly from patient specimens, the first of which was detected using a pan-viral microarray in respiratory secretions from a child with influenza-like illness. Phylogenetic analysis of the nearly complete viral genome (7961 bp) revealed that this virus belongs to the Theiler's murine encephalomyelitis virus (TMEV) subgroup of cardioviruses and is most closely related to Saffold virus. Subsequent screening by RT-PCR of 719 additional respiratory specimens [637 (89%) from patients with acute respiratory illness] and 400 cerebrospinal fluid specimens from patients with neurological disease (aseptic meningitis, encephalitis, and multiple sclerosis) revealed no evidence of cardiovirus infection. However, screening of 751 stool specimens from 498 individuals in a gastroenteritis cohort resulted in the detection of 6 additional cardioviruses (1.2%). Although all 8 human cardioviruses (including Saffold virus) clustered together by phylogenetic analysis, significant sequence diversity was observed in the VP1 gene (66.9%-100% pairwise amino acid identities). These findings suggest that there exists a diverse group of novel human Theiler's murine encephalomyelitis virus-like cardioviruses that hitherto have gone largely undetected, are found primarily in the gastrointestinal tract, can be shed asymptomatically, and have potential links to enteric and extraintestinal disease.


Where do they go?


title: Economic interventions to ameliorate the impact of COVID-19 on the economy and health: an international comparison.

text: BACKGROUND The COVID-19 pandemic continues to challenge governments and policymakers worldwide. They have rightfully prioritised reducing the spread of the virus through social distancing interventions. However, shuttered business and widespread restrictions on travel and mobility have led to an economic collapse with increasing uncertainty of how quickly recovery will be achieved. METHODS The authors carried out a review of publicly available information on the economic intervention's countries have put in place to ameliorate the impact of COVID-19. RESULTS The strategies and scale of economic interventions have been broad, ranging from 2.5% to a reported 50% of Gross Domestic Product. CONCLUSIONS Numerous countries are beginning to ease lockdown restrictions and restart economies in different ways. There is therefore evolving, real-world data that should be used dynamically by governments and policymakers. The strategies on restarting the economy must be balanced against the uncertainty of a possible second wave of COVID-19. A nuanced approach to easing restrictions needs to take into account not only immediate risk to life but longer-term risks of widening inequalities and falling life expectancy.


title: Beliefs in Conspiracy Theories Following Ostracism.

text: Four studies (total valid N = 643) examined whether ostracism increases people's political conspiracy beliefs through heightened vulnerability and whether self-affirmation intervention counteracts the effect of ostracism on conspiracy beliefs. Compared with their nonostracized counterparts, ostracized participants were more likely to endorse conspiracy beliefs related to different political issues (Studies 1-3). Moreover, heightened vulnerability mediated the link between ostracism and conspiracy beliefs (Studies 1-3). Offering ostracized participants an opportunity to reaffirm values important to them could reduce their political conspiracy beliefs (Study 4). Taken together, our findings highlight the crucial role of vulnerability in understanding when and why ostracism increases conspiracy beliefs and how to ameliorate this relationship. Our findings also provide novel insights into how daily interpersonal interactions influence people's political beliefs and involvement.


title: The involvement of the central nervous system in patients with COVID-19.

text: Coronaviruses disease (COVID-19) has caused major outbreaks. A novel variant, SARS-CoV-2, is responsible for COVID-19 pandemic. Clinical presentations and pathological mechanisms of COVID-19 are broad. The respiratory aspect of the disease has been extensively researched. Emerging studies point out the possibility of the central nervous system (CNS) involvement by COVID-19. Here, we discuss the current evidence for CNS involvement in COVID-19 and highlight that the high pathogenicity of SARS-CoV-2 might be due to its neuroinvasive potential.


title: Salvage robotic transmesenteric off-clamp partial nephrectomy after multiple prior open kidney surgeries.

text: Repeat renal surgery is technically demanding with a high morbidity rate. We describe a novel surgical approach, a salvage robotic transmesenteric off-clamp partial nephrectomy for the management of a renal cell carcinoma in a patient with a history of VHL and multiple prior renal surgeries on the affected kidney. Upon pathological review, the specimen was diagnosed as clear cell RCC, Fuhrman Grade 3, with negative surgical margins. The patient suffered no post-operative complications and had a rapid convalescence. This approach is a feasible and safe alternative in select patients with a significant history of renal surgeries and favorable anatomy.


docid: hntahezz

title: The Effect of Bioactive Glass-Enhanced Orthodontic Bonding Resins on Prevention of Demineralization: A Systematic Review.

text: At present, bioactive glasses (BAGs) are demonstrating promising results in the remineralization of hard tissues. Their bioactive properties can potentially overcome the demineralization effect accompanying orthodontic treatment. This review aimed to evaluate the effectiveness of bioactive glass enhanced orthodontic bonding resins on enamel remineralization, in addition to their antibacterial, ion release and acid neutralization effect. Four databases (PubMed, MEDLINE, Web of Science and Scopus) were searched. Two hundred and fifty-one full-text articles were screened independently, out of which seven studies satisfied the inclusion criteria. Quality appraisal was performed by two independent reviewers. Methodologies used to assess the anti-demineralization effect included Micro-Computed Tomography, Polarized Light Microscopy and Hardness Testing (Knoop and Berkovich). All seven articles confirmed the superior remineralization effect of BAG orthodontic bonding resins compared to their non-BAG counterparts. A proportional relationship was proved between BAG concentrations and increased anti-demineralization effect. The addition of antibacterial agents to BAG does not necessarily improve its anti-demineralization effect. Although studies have confirmed the effectiveness of BAG orthodontic bonding resins on enamel remineralization, there was a degree of heterogeneity across studies due to the lack of an in vitro studies standardized protocol.


title: Early results of the Axium MicroFX for Endovascular Repair of IntraCranial Aneurysm (AMERICA) study: a multicenter prospective observational registry.

text: BACKGROUND Axium MicroFX coils contain polymer (polyglycolic/polylactic acid, PGLA) microfilaments designed to significantly impact intra-aneurysmal flow and to encourage aneurysm thrombosis. To provide preliminary evaluation of the safety and suggested efficacy of the MicroFX design, we performed a multicenter prospective single-arm trial, Axium MicroFX for Endovascular Repair of IntraCranial Aneurysm study (AMERICA). METHODS AMERICA is a prospective multicenter 100 aneurysm observational study evaluating the safety and efficacy of Axium MicroFX PGLA coils. Enrollment was started in April 2010 and completed in October 2012. RESULTS 99 patients underwent treatment for 100 aneurysms at 13 centers. Mean age was 60.2 years, most were women (72%) and 18% of patients had previously undergone treatment for a separate aneurysm. 22% of patients underwent treatment after acute aneurysmal subarachnoid hemorrhage (SAH). Of these patients, all were Hunt and Hess grade 1-3. Pre-procedure modified Rankin score (mRS) was 0-2 in 92% of patients. The majority of aneurysms were anterior circulation (86%), with the most common aneurysm locations being the anterior communicating artery (23%) followed by the supraclinoid internal carotid artery and posterior communicating artery (18% each). The mean maximum diameter was 6.5 mm. Axium MicroFX coils could be placed in all but one treatment (99%). Raymond grade at conclusion of coiling was I (complete) in 52%, II (dog ear or residual neck) in 33% and III (residual aneurysm) in 15%. Discharge mRS was significantly worse in patients with SAH (62% mRS 0-2) compared with electively treated aneurysms (mRS 0-2 in 94%, p<001). Major events were uncommon (6% thromboembolic events, 3% intraoperative vessel or aneurysm rupture) and device-related adverse events (AE) were rare (2% of cases). CONCLUSIONS This prospective study of Axium MicroFX coils demonstrates excellent aneurysm occlusion rates. 52% of aneurysms were completely occluded post-procedure. Within the ruptured aneurysm group, post-procedure occlusion rates were 63.6%. Major AE rates were consistent with historical data.


docid: dmybkkxd

title: Role of antimalarials in COVID-19: observational data from a cohort of rheumatic patients.


title: Nuclear medicine in the first year of life.

text: Nuclear medicine has an important role in the care of newborns and children less than 1 y old. Patients in this age group present with a spectrum of diseases different from those of older children or adults. These patients can benefit from the full range of nuclear medicine studies. In these young children, nuclear medicine studies are more likely to be used to evaluate a wide range of congenital conditions but also can be helpful for evaluating acquired conditions such as infection, cancer, and trauma. This review first will cover the general aspects of nuclear medicine practice with these patients, including the special considerations that can help achieve successful diagnostic imaging. These topics will include clinical indications, imaging technology, instrumentation, software, positioning and immobilization, sedation, local and general anesthesia, radiopharmaceutical doses, radiation risk, and dose reduction. The review then will discuss the specific nuclear medicine studies that typically are obtained in patients in this age group. With extra care and attention to the special needs of this population, nuclear medicine departments can successfully study patients less than 1 y old.


title: The international agreement study on the diagnosis of the septate uterus at office hysteroscopy in infertile patients.

text: OBJECTIVE To assess the international agreement on the hysteroscopic diagnosis of septate uterus. DESIGN Interobserver study. SETTING Eight hysteroscopy recordings were put online on the website of the European Society of Gynaecological Endoscopy. PATIENT(S) Asymptomatic, infertile women indicated for a first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment cycle. INTERVENTION(S) Office hysteroscopy. MAIN OUTCOME MEASURE(S) The interobserver agreement on the uterine shape and necessity to correct the abnormality found. RESULT(S) Seventy-eight observers from 24 different countries assessed 8 hysteroscopy recordings. The interobserver agreement on uterine shape variations septate and arcuate was fair (intraclass correlation coefficient = 0.27). Observers from the same country reached a significantly higher level of agreement. The agreement on the necessity of correction was poor (intraclass correlation coefficient = 0.17). The most distinct features for diagnosing a septate uterus judged to be the extent of endocavitary bulging and the angle of the bulging structure from the fundal area. CONCLUSION(S) The agreement among international experts on the hysteroscopic diagnosis of the septate uterus was found to be poor. This may have implications for the accuracy of screening hysteroscopy for diagnosing uterine cavity abnormalities in infertile patients. Development of consented definitions for the hysteroscopic diagnosis of septate and arcuate uterus is recommended.


Protecting the population with immune individuals.


title: Comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure.

text: IMPORTANCE Outcomes associated with use of high-frequency oscillatory ventilation (HFOV) in children with acute respiratory failure have not been established. OBJECTIVE To compare the outcomes of HFOV with those of conventional mechanical ventilation (CMV) in children with acute respiratory failure. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective, observational study using deidentified data obtained from all consecutive patients receiving mechanical ventilation aged 1 month to 18 years in the Virtual PICU System database from January 1, 2009, through December 31, 2011. The study population was divided into 2 groups: HFOV and CMV. The HFOV group was further divided into early and late HFOV. Propensity score matching was performed as a 1-to-1 match of HFOV and CMV patients. A similar matching process was performed for early HFOV and CMV patients. EXPOSURE High-frequency oscillatory ventilation. MAIN OUTCOMES AND MEASURES Length of mechanical ventilation, intensive care unit (ICU) length of stay, ICU mortality, and standardized mortality ratio (SMR). RESULTS A total of 9177 patients from 98 hospitals qualified for inclusion. Of these, 902 (9.8%) received HFOV, whereas 8275 (90.2%) received CMV. A total of 1764 patients were matched to compare HFOV and CMV, whereas 942 patients were matched to compare early HFOV and CMV. Length of mechanical ventilation (CMV vs HFOV: 14.6 vs 20.3 days, P < .001; CMV vs early HFOV: 14.6 vs 15.9 days, P < .001), ICU length of stay (19.1 vs 24.9 days, P < .001; 19.3 vs 19.5 days, P = .03), and mortality (8.4% vs 17.3%, P < .001; 8.3% vs 18.1%, P < .001) were significantly higher in HFOV and early HFOV patients compared with CMV patients. The SMR in the HFOV group was 2.00 (95% CI, 1.71-2.35) compared with an SMR in the CMV group of 0.85 (95% CI, 0.68-1.07). The SMR in the early HFOV group was 1.62 (95% CI, 1.31-2.01) compared with an SMR in the CMV group of 0.76 (95% CI, 0.62-1.16). CONCLUSIONS AND RELEVANCE Application of HFOV and early HFOV compared with CMV in children with acute respiratory failure is associated with worse outcomes. The results of our study are similar to recently published studies in adults comparing these 2 modalities of ventilation for acute respiratory distress syndrome.


title: Interleukin-15 is associated with disease severity in viral bronchiolitis.

text: Disease severity in viral bronchiolitis in infancy is difficult to predict and has been linked to host innate immunity. The study aimed to investigate the innate cytokine interleukin-15 (IL-15) as a marker of disease severity.A prospective single-centre observational study was conducted in a university-affiliated paediatric teaching hospital, comparing children (0-18 months) hospitalised for viral bronchiolitis, those admitted to the paediatric intensive care unit with severe disease and healthy age-matched controls. IL-15-related parameters were compared between groups. PCR and microRNA (miRNA) sequencing was undertaken on natural killer (NK) cells collected from study participants.Samples from 88 children with viral bronchiolitis and 43 controls enrolled between 2009 and 2012 were analysed. Peripheral blood mononuclear cell (PBMC) IL-15 mRNA expression was significantly higher in those with moderate severity bronchiolitis compared with controls and those with severe disease. Serum IL-15 levels correlated with disease severity. The relative frequency of NK cells in peripheral blood was significantly reduced in participants with bronchiolitis. The NK cell miRNA transcriptome in bronchiolitis was distinct. Targets of de-regulated miRNA were differentially expressed in bronchiolitis, including JAK3, STAT5A and NFKB1 on the IL-15 signalling pathway.IL-15 is associated with disease severity in children hospitalised with viral bronchiolitis.


title: Efficacy of a modified live porcine reproductive and respiratory syndrome virus (PRRSV) vaccine in pigs naturally exposed to a heterologous European (Italian cluster) field strain: Clinical protection and cell-mediated immunity.

text: The purpose of this study was to assess clinical protection in pigs vaccinated with a commercially available attenuated porcine reproductive and respiratory syndrome virus (PRRSV) vaccine (Porcilis) PRRS) and then naturally exposed under field conditions to a heterologous (Italian cluster) strain of virulent PRRSV. A total of 30, 4-week-old pigs seronegative for PRRSV were allocated to 1 of 3 groups (IM, ID, and C groups). At 5 weeks of age, pigs of groups IM (n=10 pigs) and ID (n=10 pigs) were vaccinated intramuscularly and intradermally, respectively, with modified live PRRSV-1 vaccine (Porcilis) PRRS). Pigs of group C (n=10 pigs) were kept as non-vaccinated controls. At post-vaccination (PV) days 0, 7, 14, 28, and 45, blood samples were collected for detection of vaccine virus (PCR) and antibody response (ELISA), identification of changes in lymphocyte subpopulations by cytometry, and IFN-gamma PRRSV-specific secreting cells (SC) by ELISpot. At PV day 45, pigs of A, B, and C groups were moved to a site 3 conventional finishing herd with a history of respiratory disease caused by PRRSV and the most common bacteria to be exposed to a natural challenge. The PRRSV field strain, belonging to the Italian cluster of the PRRSV-1, demonstrated a 84% identity with the vaccine virus (DV strain) at ORF5 sequencing. At 0 (exposure day=45 days PV), 4, 7, 11, 14, 19, 21, 28, and 34 days post-exposure (PE) blood samples were collected for detection and titration of PRRSV and antibody, as well as for lymphocyte and IFN-gamma measurement as described above. Throughout the post-exposure period, all pigs were observed daily for clinical signs. The overall clinical signs were reduced by 68 and 72%, respectively in the intramuscularly and intradermally vaccinated pigs compared to controls. Respiratory signs were reduced by 72 and 80%, respectively in the IM and ID groups. Clinical protection was associated with marked activation of cell-mediated immune response. The highest levels of specific IFN-gamma production at 21-34 days PE were concomitant and associated to changes in natural killer (NK) cells, gamma/delta T, and cytotoxic T lymphocytes in the blood. In our field study, evidences of EU attenuated vaccine-induced clinical protection against natural exposure to a genetically diverse (84% homology) PRRSV-1 isolate (Italian cluster) was demonstrated by the statistically significant reduction in clinical signs in terms of incidence, duration and severity and by a more efficient cell-mediated immune response in the vaccinated pigs as compared to the unvaccinated controls.


title: Live-interactive teledermatology program in Taiwan: One-year experience serving a district hospital in rural Taitung County.

text: BACKGROUND/PURPOSE Population aging and unequal accessibility of health care are increasingly important in developed countries. One strategy to overcome these issues is utilizing telemedicine, which is recently made possible technologically by the advancement of internet speed, high speed zooming cameras, and the information storages. In Taiwan, the telemedicine is granted legally by the amendment for Taiwan's Physician Act in 2018. METHODS Kaohsiung Chang Gung Memorial Hospital (Kaohsiung CGMH) is the first hospital in Taiwan to provide the telemedicine service connecting to Cheng Kung Branch of Taitung Hospital since Nov 2018. Consultation services from Dermatology, ENT, and Ophthalmology have been delivered in the live-interactive and face to face module every week. RESULTS Dermatology consultation comprises the majorities. In the first year, there were totally 426 dermatology consultation services. Eczema, fungal infections, and scabies infestation were the three most common diseases in the beginning. The disease diagnosis became more diverse after several months, including some ready-to-treat diseases pending correct diagnosis, such as pediculosis, psoriasis, and urticaria. Coupled with dermoscopic images, diseases such as hair loss, pediculosis capitis, skin tumor, and scabies, were diagnosed promptly. The subjective patient improvement rate was more than 75% year-round and the case closure rate was more than 85% year-round. CONCLUSION Teledermatology is a promising approach to serve the remote medical-underprivileged regions. The teledermatology is anticipated to help underserved regions, nursing homes, prisons, and in situations with severe pandemic infections, such as COVID-19.


docid: fswycwoj

title: Label-free, electrical detection of the SARS virus N-protein with nanowire biosensors utilizing antibody mimics as capture probes.

text: Antibody mimic proteins (AMPs) are polypeptides that bind to their target analytes with high affinity and specificity, just like conventional antibodies, but are much smaller in size (2-5 nm, less than 10 kDa). In this report, we describe the first application of AMP in the field of nanobiosensors. In(2)O(3) nanowire based biosensors have been configured with an AMP (Fibronectin, Fn) to detect nucleocapsid (N) protein, a biomarker for severe acute respiratory syndrome (SARS). Using these devices, N protein was detected at subnanomolar concentration in the presence of 44 microM bovine serum albumin as a background. Furthermore, the binding constant of the AMP to Fn was determined from the concentration dependence of the response of our biosensors.


title: Development of a novel real-time RT-PCR assay to detect Seneca Valley virus associated with emerging cases of vesicular disease in pigs.

text: Seneca Valley virus (SVV) can cause vesicular disease that is clinically indistinguishable from foot-and-mouth disease, vesicular stomatitis and swine vesicular disease. SVV-associated disease has been identified in pigs in several countries, namely USA, Canada, Brazil and China. Diagnostic tests are required to reliably detect this emerging virus, and this report describes the development and evaluation of a novel real-time reverse-transcription (RT) PCR assay (rRT-PCR), targeting the viral polymerase gene (3D) of SVV. This new assay detected all historical and contemporary SVV-1 isolates examined (n=8), while no cross-reactivity was observed with nucleic acid template prepared from other vesicular disease viruses or common swine pathogens. The analytical sensitivity of the rRT-PCR was 0.79 TCID50/ml and the limit of detect was equivalent using two different RT-PCR master-mixes. The performance of the test was further evaluated using pig nasal (n=25) and rectal swab samples (n=25), where concordant results compared to virus sequencing were generated for 43/50 samples. The availability of this assay, will enable laboratories to rapidly detect SVV in cases of vesicular disease in pigs, negated for notifiable diseases, and could enable existing knowledge gaps to be investigated surrounding the natural epidemiology of SVV.


Endoscopic Abscess Septotomy for Management of Sleeve Gastrectomy Leak.


title: Necrobiotic xanthogranuloma as an unusual cause of refractive chronic bilateral leg ulceration.

text: Necrobiotic xanthogranuloma is a progressive histiocytic granulomatous disease with frequent extracutaneous involvement. We have documented an unusual case of necrobiotic xanthogranuloma in a 58-year-old man with a history of recalcitrant and chronic arm and leg ulcerations in the absence of characteristic periorbital involvement. Our patient demonstrates a therapeutic challenge and may display a new necrobiotic inflammatory disorder not previously characterized.


Program at a glance.


Mental Health and the Covid-19 Pandemic.


title: Short-term outcomes of laparoscopic total mesorectal excision following neoadjuvant chemoradiotherapy.

text: OBJECTIVE To investigate the feasibility of laparoscopic total mesorectal excision (TME) in mid and lower rectal cancers following neoadjuvant chemoradiation (nCRT). BACKGROUND The laparoscopic approach for colon cancer has been widely accepted. A few studies have shown that there are advantages of laparoscopic over open TME surgery for rectal cancer. However, the role of laparoscopy has not been clearly defined specifically in cases following nCRT. METHODS All patients with rectal cancer who underwent nCRT were identified; no operations for rectal carcinoma were performed laparoscopically between 1997 and 2005. The laparoscopic cases were matched to open cases based on gender, procedure, age, and body mass index (BMI). The medical records were reviewed and short-term outcome was compared between these two groups. Statistical analysis was performed using SPSS 15 software. RESULTS Between 2002 and 2008, 64 patients were identified, including 32 patients who underwent laparoscopic surgery and 32 who had a laparotomy. There was no difference between the two groups based on gender, procedure, age, BMI or American Society of Anesthesiologists (ASA) classification. The procedures performed within each group included 8 abdominoperineal resections and 24 anterior resections, which included 20 colonic J-pouch-anal anastomoses and 4 straight coloanal anastomoses. In the laparoscopic group, 12 patients underwent totally laparoscopic operations, 12 were either laparoscopic-assisted or hand-assisted procedures, and 8 were converted to laparotomy. The reasons for conversion included bleeding, splenic injury, and difficult anatomy. There were no differences in comorbidities, tumor location, tumor size, tumor stage or radiation dose between the two groups. Operative time was longer in the laparoscopic group (267 + or - 76 versus 205 + or - 49 min, p < 0.001). Operative blood loss, complication rate, and mortality rate were all similar between the two groups. However, the laparoscopic group benefited from shorter length of stay (6.1 + or - 2.4 versus 7.6 + or - 2.3 days, p = 0.012), earlier first bowel movement (1.9 + or - 1 versus 3.3 + or - 2.4 days, p = 0.006), and shorter time to regular diet (3.9 + or - 2.1 versus 5.8 + or - 2.5 days, p = 0.003). There was no difference in lymph node harvest (both positive node harvest and total lymph node harvest), distal margin or radial margin. CONCLUSIONS In our experience, laparoscopic TME for mid and lower rectal cancer is feasible and safe. Patients benefit from the short-term advantages of laparoscopy, including shorter length of hospital stay, time to tolerating a regular diet, and time to first bowel movement or stoma function. Although there were no short-term differences in oncologic parameters, the long-term oncologic outcome requires further investigation.


Endovascular therapy for stroke: getting to the "heart" of the matter.


title: Positron emission tomography/computed tomography and biomarkers for early treatment response evaluation in metastatic colon cancer.

text: BACKGROUND Treatment options for metastatic colon cancer (mCC) are widening. We prospectively evaluated serial 2-deoxy-2-[18F]fluoro-d-glucose positron-emission tomography/computed tomography (PET/CT) and measurements of tissue inhibitor of metalloproteinases-1 (TIMP-1), carcinoembryonic antigen (CEA), and liberated domain I of urokinase plasminogen activator receptor (uPAR(I)) for early assessment of treatment response in mCC patients. METHODS Thirty-three mCC patients scheduled for first-line chemotherapy with capecitabine and oxaliplatin (CAPOX) and bevacizumab participated; 27 were evaluated by PET/CT before treatment, after one and four treatment series. Morphological and metabolic response was independently assessed according to Response Evaluation Criteria in Solid Tumors and European Organization for Research and Treatment of Cancer PET criteria. Plasma TIMP-1, plasma uPAR(I), and serum CEA were determined. RESULTS Metabolic response after one treatment course predicted the ability of CAPOX and bevacizumab to induce morphological response after four treatment series with a sensitivity of 80%, specificity of 69%, and odds ratio of 13.9 (95% confidence interval [CI] 1.9; 182). Early metabolically stable or progressive disease was associated with shorter progression-free survival (hazard ratio [HR] = 3.2 [CI 1.3; 7.8]). Biomarker levels at early evaluation were associated with shorter OS (TIMP-1 per unit increase on a log-2-transformed ng/mL scale: HR = 2.6 [CI 1.4; 4.9]; uPAR(I) per 25 fmol/mL increase: HR = 1.5 [CI 1.1; 2.1]). CONCLUSION This monocentric study demonstrated predictive value of early metabolic PET response and prognostic value of TIMP-1 and uPAR(I) levels in mCC treated with CAPOX and bevacizumab. Results support investigation of PET/CT, TIMP-1, and uPAR(I) guided early treatment adaptation in mCC.


title: Comparison of performance achievement award recognition with primary stroke center certification for acute ischemic stroke care.

text: BACKGROUND Hospital certification and recognition programs represent 2 independent but commonly used systems to distinguish hospitals, yet they have not been directly compared. This study assessed acute ischemic stroke quality of care measure conformity by hospitals receiving Primary Stroke Center (PSC) certification and those receiving the American Heart Association's Get With The Guidelines-Stroke (GWTG-Stroke) Performance Achievement Award (PAA) recognition. METHODS AND RESULTS The patient and hospital characteristics as well as performance/quality measures for acute ischemic stroke from 1356 hospitals participating in the GWTG-Stroke Program 2010-2012 were compared. Hospitals were classified as PAA+/PSC+ (hospitals n = 410, patients n = 169,302), PAA+/PSC- (n = 415, n = 129,454), PAA-/PSC+ (n = 88, n = 26,386), and PAA-/PSC- (n = 443, n = 75,565). A comprehensive set of stroke measures were compared with adjustment for patient and hospital characteristics. Patient characteristics were similar by PAA and PSC status but PAA-/PSC- hospitals were more likely to be smaller and nonteaching. Measure conformity was highest for PAA+/PSC+ and PAA+/PSC- hospitals, intermediate for PAA-/PSC+ hospitals, and lowest for PAA-/PSC- hospitals (all-or-none care measure 91.2%, 91.2%, 84.3%, and 76.9%, respectively). After adjustment for patient and hospital characteristics, PAA+/PSC+, PAA+/PSC-, and PAA-/PSC+ hospitals had 3.15 (95% CIs 2.86 to 3.47); 3.23 (2.93 to 3.56) and 1.72 (1.47 to 2.00), higher odds for providing all indicated stroke performance measures to patients compared with PAA-/PSC- hospitals. CONCLUSIONS While both PSC certification and GWTG-Stroke PAA recognition identified hospitals providing higher conformity with care measures for patients hospitalized with acute ischemic stroke, PAA recognition was a more robust identifier of hospitals with better performance.


title: Pathophysiology and treatment options in trigeminal meningoceles.

text: Trigeminal meningoceles, lateral to the maxillary nerve (V2), have seldom been reported as underlying pathology for spontaneous rhinoliquorrhea. In contrast to sphenoid meningoceles arising from a persistent lateral craniopharyngeal canal (Sternberg-Cruveilhier, medial to V2), their occurrence seems to be generated by addition of erosive processes to the constitutively thin bony shell underneath the semilunar ganglion, lateral to the round foramen (and V2). The developmental and anatomical relationships of trigeminal meningoceles to the sphenoid bone are depicted, and in a review of the literature we present the different surgical approaches employed for sealing the dura leak. In view of these techniques we discuss an unusual case of therapy-resistant rhinoliquorrhea with left-sided trigeminal meningocele involving the Meckel cave at the lateral sphenoid and reaching the superior orbital fissure and the medial orbital space. In contrast to patients who have lateral sphenoidal meningoceles with a persistent lateral craniopharyngeal canal (Sternberg-Cruveilhier), who can be treated successfully using an endoscopic transsphenoidal approach (recurrence rate 13.7%), the recurrence rate of cerebrospinal fluid (CSF) efflux for trigeminal meningoceles lies much higher (endoscopically 66%, open craniotomy 33%). The surgical strategy thus has to be chosen individually, taking into account specific anatomical situations and eventually preceding operations.


title: SSTR-Mediated Imaging in Breast Cancer: Is There a Role for Radiolabeled Somatostatin Receptor Antagonists?

text: Recent studies have shown enhanced tumor targeting by novel somatostatin receptor (SSTR) antagonists compared with clinically widely used agonists. However, these results have been obtained mostly in neuroendocrine tumors, and only limited data are available for cancer types with lower SSTR expression, including breast cancer (BC). To date, two studies have reported higher binding of the antagonist than the agonist in BC, but in both studies only a limited number of cases were evaluated. In this preclinical study, we further investigated whether the application of an SSTR antagonist can improve SSTR-mediated BC imaging in a large panel of BC specimens. We also generated an in vivo BC mouse model and performed SPECT/MRI and biodistribution studies. Methods: Binding of 111In-DOTA-Tyr3-octreotate (SSTR agonist) and 111In-DOTA-JR11 (SSTR antagonist) to 40 human BC specimens was compared using in vitro autoradiography. SSTR2 immunostaining was performed to confirm SSTR2 expression of the tumor cells. Furthermore, binding of the radiolabeled SSTR agonist and antagonist was analyzed in tissue material from 6 patient-derived xenografts. One patient-derived xenograft, the estrogen receptor-positive model T126, was chosen to generate in vivo mouse models containing orthotopic breast tumors for in vivo SPECT/MRI and biodistribution studies after injection with 177Lu-DOTA-Tyr3-octreotate or 177Lu-DOTA-JR11. Results:111In-DOTA-JR11 binding to human BC tissue was significantly higher than 111In-DOTA-Tyr3-octreotate binding (P < 0.001). The median ratio of antagonist binding versus agonist binding was 3.39 (interquartile range, 2-5). SSTR2 immunostaining confirmed SSTR2 expression on the tumor cells. SPECT/MRI of the mouse model found better tumor visualization with the antagonist. This result was in line with the significantly higher tumor uptake of the radiolabeled antagonist than of the agonist as measured in biodistribution studies 285 min after radiotracer injection (percentage injected dose per gram of tissue: 1.92 ± 0.43 vs. 0.90 ± 0.17; P = 0.002). Conclusion: SSTR antagonists are promising candidates for BC imaging.


title: Uptrend in distress and psychiatric symptomatology in pregnant women during the COVID-19 pandemic.

text: INTRODUCTION Prenatal maternal distress has a negative impact on the course of pregnancy, fetal development, offspring development and later psychopathologies. The study aimed to determine the extent to which the Coronavirus disease 2019 (COVID-19) pandemic may aggravate pregnant women prenatal distress and psychiatric symptomatology. MATERIAL AND METHODS Two cohorts of pregnant volunteer women were evaluated, one that was recruited before the COVID-19 pandemic (n=496) through advertisements in prenatal clinics in Quebec, Canada, from April 2018 to March 2020; the other (n=1258) was recruited online during the pandemic from April 2 to April 13 2020. Prenatal distress and psychiatric symptomatology were measured with the Kessler Distress Scale (K10), Post-traumatic Checklist for DSM-5 (PCL-5), Dissociative Experiences Scale (DES-II) and Positive and Negative Affect Schedule (PANAS). RESULTS The 1754 pregnant women (Mage =29.27, SD=4.23) were between 4 and 41 gestational weeks (M=24.80, SD=9.42), were generally educated (91.3% had post-high school training) and financially well-resourced (85.3% were above the low-income cut-off). A multivariate analysis of covariance controlling for age, gestational age, household income, education and lifetime psychiatric disorders showed a large effect size (ES) in the difference between the two cohorts on psychiatric symptoms (Wilks' λ=0.68, F6,1400 =108.50, p < 0.001, partial η2 = 0.32). According to post-hoc analyses of covariance, the COVID-19 women reported higher levels of depressive and anxiety symptoms (ES=0.57), dissociative symptoms (ES=0.22 and 0.25), symptoms of post-traumatic stress disorder (ES=0.19), negative affectivity (ES = 0.96) and less positive affectivity (ES=0.95) than the pre-COVID-19 cohort. Women from the COVID-19 cohort were more likely than pre-COVID-19 women to present clinically significant levels of depressive and anxiety symptoms [OR=1.94, χ2(1)=10.05, p=.002]. Multiple regression analyses indicated that COVID-19 pregnant women having a previous psychiatric diagnosis or low income would be more prone to elevated distress and psychiatric symptoms. CONCLUSIONS Pregnant women assessed during the COVID-19 pandemic reported more distress and psychiatric symptoms than pregnant women assessed before the pandemic, mainly in the form of depression and anxiety symptoms. Given the harmful consequences of prenatal distress on mothers and offspring, the presently observed upsurge of symptoms in pregnant women calls for special means of clinical surveillance.


title: Airborne exposure patterns from a passenger source in aircraft cabins.

text: Airflow is a critical factor that influences air quality, airborne contaminant distribution, and disease transmission in commercial airliner cabins. The general aircraft-cabin air-contaminant transport effect model seeks to build exposure-spatial relationships between contaminant sources and receptors, quantify the uncertainty, and provide a platform for incorporation of data from a variety of studies. Knowledge of infection risk to flight crews and passengers is needed to form a coherent response to an unfolding epidemic, and infection risk may have an airborne pathogen exposure component. The general aircraf-tcabin air-contaminant transport effect model was applied to datasets from the University of Illinois and Kansas State University and also to case study information from a flight with probable severe acute respiratory syndrome transmission. Data were fit to regression curves, where the dependent variable was contaminant concentration (normalized for source strength and ventilation rate), and the independent variable was distance between source and measurement locations. The data-driven model showed exposure to viable small droplets and post-evaporation nuclei at a source distance of several rows in a mock-up of a twin-aisle airliner with seven seats per row. Similar behavior was observed in tracer gas, particle experiments, and flight infection data for severe acute respiratory syndrome. The study supports the airborne pathway as part of the matrix of possible disease transmission modes in aircraft cabins.


Editorial comment on: complications of laparoscopic and percutaneous renal cryoablation in a single tertiary referral center.


title: Burn wound care.

text: The goals of burn wound care are removal of nonviable tissue, prevention of infection, and facilitation of wound healing, while controlling pain and maximizing outcome. This article reviews the basic pathophysiology of burn wounds; describes the evaluation of the depth, location, and extent of the wound; and discusses the myriad of wound care products on the market including their strengths and weaknesses. This article guides the reader through wound assessment and designing the appropriate treatment plan.


title: Meningioma embolization with the pressure cooker technique using Squid 12.

text: Background Preoperative meningioma embolization may be performed with microparticles or liquid embolic agents. The pressure cooker technique (PCT) has recently been described for the embolization of brain arteriovenous malformations (AVMs). Case We present the case of a 73-year-old woman with a large frontal interhemispheric meningioma that was successfully preoperatively embolized with the PCT using Squid 12, a new ethyl-vinyl alcohol copolymer embolic agent. The PCT presents considerable advantages relative to conventional embolization techniques such as deeper and faster tumor penetration and embolization of tumors with difficult vascular access, and retrograde feeling of pial afferents may be achieved. Conclusions The use of the PCT with Squid 12 may potentially increase the effectiveness of meningioma embolization, increase tumor devascularization and improve outcomes of surgical resection.


title: Thoughts on the alveolar phase of COVID-19.

text: COVID-19 can be divided into three clinical stages, and one can speculate that these stages correlate with where the infection resides. For the asymptomatic phase, the infection mostly resides in the nose where it elicits a minimal innate immune response. For the mildly symptomatic phase, the infection is mostly in the psuedostatified stratified epithelium of the larger airways and is accompanied by a more vigorous innate immune response. In the conducting airways, the epithelium can recover from the infection, because the keratin V basal cells are spared and they are the progenitor cells for the bronchial epithelium. There may be more severe disease in the respiratory bronchioles where the club cells are likely infected. The devastating third phase is in the gas exchange units of the lung, where ACE2 expressing alveolar type II cells and perhaps type I cells are infected. The loss of type II cells results in respiratory insufficiency due to the loss of pulmonary surfactant, alveolar flooding, and loss of normal repair, since type II cells are the progenitors of type I cells. The loss of type I and type II cells will also block normal active resorption of alveolar fluid. Subsequent endothelial damage leads to transudation of plasma proteins, formation of hyaline membranes, and an inflammatory exudate, characteristic of ARDS. Repair might be normal, but if the type II cells are severely damaged, alternative pathways for epithelial repair may be activated, which would result in some residual lung disease.


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title: COVID-19 as a confounding factor in a child submitted to staged surgical palliation of hypoplastic left heart syndrome: One of the first reports of SARS-CoV-2 infection in patients with congenital heart disease.


title: The Effects of Vasoconstriction And Volume Expansion on Veno-Arterial ECMO Flow.

text: BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is gaining widespread use in the treatment of severe cardiorespiratory failure. Blood volume expansion is commonly used to increase ECMO flow (QECMO), with risk of positive fluid balance and worsening prognosis. We studied the effects of vasoconstriction on recruitment of blood volume as an alternative for increasing QECMO, based on the concepts of venous return. METHODS In a closed chest, centrally cannulated porcine preparation (n = 9) in ventricular fibrillation and VA-ECMO with vented left atrium, mean systemic filling pressure (MSFP), and venous return driving pressure (VRdP) were determined in Euvolemia, during Vasoconstriction (norepinephrine 0.05, 0.125, and 0.2 μg/kg/min) and after Volume Expansion (3 boluses of 10 mL/kg Ringer's lactate). Maximum achievable QECMO was examined. RESULTS Vasoconstriction and Volume Expansion both increased maximum achievable QECMO, delivery of oxygen (DO2), and MSFP, but right atrial pressure increased in parallel. VRdP did not change. The vascular elastance curve was shifted to the left by Vasoconstriction, with recruitment of stressed volume. It was shifted to the right by Volume Expansion with direct expansion of stressed volume. Volume Expansion decreased resistance to venous return and pump afterload. CONCLUSIONS In a circulation completely dependent on ECMO support, maximum achievable flow directly depended on the vascular factors governing venous return-i.e., closing conditions, stressed vascular volume and the elastance and resistive properties of the vasculature. Both treatments increased maximum achievable ECMO flow at stable DO2, via increases in stressed volume by different mechanisms. Vascular resistance and pump afterload decreased with Volume Expansion.


title: Gadolinium enhancement on cranial MRI in multiple sclerosis is age dependent.

text: BACKGROUND Epidemiological, pathological and radiological studies suggest that inflammatory demyelination in MS is an age-dependent process, and that the formation of focal inflammatory demyelinating lesions decreases with age. Gadolinium-enhancing lesions are a biomarker of inflammatory disease activity in MS, but little is known about the relation of age and gadolinium enhancement on cranial MRI scans in people with MS. In this study, we investigated the association of age and other risk factors with gadolinium enhancement on cranial MRI in a retrospective cross-sectional clinical MS cohort. METHODS In a cohort including 1543 people with CIS and MS, we investigated the association of the risk factors age, sex, disease course, immunomodulatory drug (IMD) treatment, and disability with gadolinium enhancement on cranial MRI scans using a binary logistic regression model. RESULTS Age was the most important factor associated with gadolinium enhancement, with the odds of gadolinium enhancement decreasing with advancing age. Participants with CIS had lower odds of gadolinium enhancement (odds ratio of 0.42, 95% confidence interval of 0.24-0.72 compared to RRMS). Sex, disease course and IMD treatment were not significantly associated with gadolinium enhancement in our cohort. CONCLUSIONS Our investigation shows that gadolinium enhancement is strongly associated with age. Since gadolinium enhancement is a marker of inflammatory disease activity, our findings suggest that inflammatory disease activity declines with age, and that IMD treatment may be more beneficial in younger and less useful in older people with MS.


title: Jailed Artery Ostia Modifications After Flow-Diverting Stent Deployment at Arterial Bifurcations: A Scanning Electron Microscopy Translational Study.

text: BACKGROUND Even though flow-diverting stents are being increasingly used to treat intracranial aneurysms, the fate of jailed side branches remains controversial, with recent clinical data contradicting finding of earlier animal studies that reported patency. OBJECTIVE To quantify the surface area of the ostia after 3 months of jailing by flow-diverting stents as a more accurate means of patency evaluation. METHODS Ten large white swine were stented by flow-diverting stents placed at common carotid-ascending pharyngeal arterial bifurcation sites. A dual antiplatelet regimen was initiated 72 hours before stenting and maintained during follow-up. Optical coherence tomography was used to search for per-procedural thrombus formation. Selective control digital subtraction angiography was performed 12 weeks post-stenting. Subsequently, the stented arterial segments were harvested en bloc and observed under scanning electron microscopy, photographed, and quantified. RESULTS The absence of per-procedural thrombus formation was confirmed. All ostia were patent at 12 weeks (or 3 months) post stenting, with no angiographic or scanning electron microscopy-evident thrombus formation. The mean initial ostium surface was 2 048 617 ± 731 625 μm. At 3 months, the mean nonendothelialized ostium surface was 229 218 ± 140 172 μm, and mean endothelialized ostium surface was 1 819 399 ± 672 632 μm. A statistically significant difference (reduction) was observed between the initial and 12-week ostium surfaces (P < .001), with an significant statistical power (1.000). CONCLUSION Jailed side branches remained patent after stenting, but the surface quantifications showed significant endothelial coverage, with a significant reduction of patent ostium surfaces at 12 weeks post-stenting. ABBREVIATIONS APhA, ascending pharyngeal arteryCI, confidence interval3DRA, 3-dimensional rotational angiographyDSA, digital subtraction angiographyFDS, flow-diverting stentOCT, optical coherence tomographyOS, ostium surfaceSEM, scanning electron microscopy.


Letter: For Whom the Bell Tolls: Overcoming the Challenges of the COVID Pandemic as a Residency Program.


title: COVID-19 and pulmonary hypertension.

text: Pulmonary hypertension (PH) is a pulmonary vascular disease characterized by pulmonary arterial remodeling and vasoconstriction leading to elevated pulmonary artery pressure and, ultimately, right heart failure. So far, few cases of COVID-19 disease in patients with PH have been reported. Caution is warranted in interpreting this observation as data are evolving and several factors may influence the number of reported cases of PH and COVID-19. Social distancing and quarantine could play a role, especially for patients with chronic diseases who might be more vigilant of their potential for respiratory infection. In addition, PH is a rare disease, and because testing is not universal, we could be underestimating the number of cases. Other hypothetical factors to consider are the underlying pathophysiology of PH and the medications used to treat PH and their implications in COVID-19.


title: Combination of Multicatheter Plus Stent or Balloon for Treatment of Complex Aneurysms.

text: BACKGROUND AND PURPOSE Coiling of complex aneurysms is still difficult even with current adjuvant techniques. This study sought to evaluate the safety and effectiveness of a combination of multicatheter plus stent or balloon for the treatment of complex aneurysms. MATERIALS AND METHODS All complex aneurysms that underwent coiling with the combination technique were identified from prospectively maintained neurointerventional data bases. "Complex aneurysm" was defined as a wide-neck aneurysm with branch incorporation into or a deep lobulation of the sac. The clinical and angiographic outcomes were retrospectively analyzed. RESULTS Sixty-two complex aneurysms (12 ruptured, 50 unruptured) in 62 patients (mean age, 57 years; male/female ratio, 12:50) were treated with a combination technique by using a multicatheter plus stent (n = 42, 3 ruptured) or balloon (n = 20, 9 ruptured). Treatment-related morbidity (grade 3 hemiparesis) occurred in 1 patient (1.6%). Except for 1 patient who had treatment-related morbidity, none of the other patients with unruptured aneurysms developed new neurologic symptoms at discharge. Nine of the 12 patients with ruptured aneurysms had good outcomes (Glasgow Outcome Score, 4 or 5) at the latest follow-up (mean, 32 months; range, 6-72 months), and 1 patient died from an initial SAH. Posttreatment control angiograms revealed complete occlusion in 27, neck remnant in 34, and incomplete occlusion in 1 aneurysm. At least 1 follow-up catheter or MR angiogram was available in 80.6% (n = 50) (mean, 21 months; range, 6-65 months). There were 4 minor and 3 major recurrences (14.0%). CONCLUSIONS In this case series, the combination technique by using multicatheter plus stent or balloon seemed safe and effective for the treatment of complex aneurysms.


Tackling the mental health burden of frontline healthcare staff in the COVID-19 pandemic: China's experiences.


title: Emerging microbiology diagnostics for transplant infections: On the cusp of a paradigm shift.

text: In light of the heightened risk for infection associated with solid organ and hematopoietic stem cell transplantation, rapid and accurate microbiology diagnostics are essential to the practice of transplant clinicians, including infectious diseases specialists. In the last decade, diagnostic microbiology has seen a shift towards culture-independent techniques including single-target and multiplexed molecular testing, mass-spectrometry, and magnetic resonance-based methods which have together greatly expanded the array of pathogens identified, increased processing speed and throughput, allowed for detection of resistance determinants, and ultimately improved the outcomes of infected transplant recipients. More recently, a newer generation of diagnostics with immense potential has emerged, including multiplexed molecular panels directly applicable to blood and blood culture specimens, next-generation metagenomics and gas chromatography mass spectrometry. Though these methods have some recognized drawbacks, many have already demonstrated improved diagnostic sensitivity and a positive impact on clinical outcomes in transplant and immunocompromised patients.