title: Laparoscopic fixation of the vaginal cuff to the uterosacral ligaments at the time of hysterectomy.

text: INTRODUCTION AND HYPOTHESIS Transvaginal ipsilateral uterosacral ligament colpopexy for pelvic organ prolapse (POP), which was reported by Shull et al. (Shull's colpopexy) in 2000, is one of the most frequently performed non-mesh pelvic floor reconstructive surgical procedures. Despite its excellent anatomical outcomes, ureteral injury and difficulty in uterosacral ligament detection (especially in patients with severe POP) are typical issues with this procedure. METHOD This video demonstrates the procedure in a 58-year-old woman, gravida 2 para 2, with POP-Q stage II uterine prolapse and stage I cystocele. At the beginning of the operation, the bilateral uterosacral ligaments were confirmed and separated from the ureters after entering the retroperitoneal space. The inferior hypogastric nerve and pelvic nerve plexus were also separated from the uterosacral ligament. After total laparoscopic hysterectomy, three ipsilateral delayed absorbable monofilament sutures were placed between the uterosacral ligament and the vaginal cuff. Retroperitonealization was then performed using a continuous suture with closure of the Douglas pouch. CONCLUSION Laparoscopic Shull's colpopexy for POP is a secure procedure with the advantages of laparoscopy (magnification and sharing the operative field). This may become one of the most useful operations for apical support as native tissue repair.


The COVID-19 (Coronavirus) pandemic: consequences for occupational health.


title: Implementation of a Reference-Scaled Average Bioequivalence Approach for Highly Variable Acetylsalicylic Acid in Fixed-Dose Combination with Clopidogrel Versus Enteric Aspirin in Chinese Subjects Under Fasting Conditions: A Phase 1, Open-Label, Randomized, Crossover Study.

text: INTRODUCTION Dual antiplatelet therapy, aspirin and a P2Y12 inhibitor, is recommended to prevent thrombotic complications of acute coronary syndrome. Clopidogrel plus acetylsalicylic acid combination is the most commonly used dual antiplatelet therapy recommended by international guidelines and in Chinese clinical practice. Poor adherence to dual antiplatelet therapy or premature interruption of dual antiplatelet therapy is an important contributor to cardiovascular mortality and lethal cardiovascular events. Clopidogrel + acetylsalicylic acid fixed-dose combination enhances adherence to dual antiplatelet therapy. Herein, we aimed to evaluate bioequivalence of acetylsalicylic acid and clopidogrel in fixed-dose combination compared with simultaneous administration of their individual formulations in healthy Chinese subjects under fasting conditions. METHODS This was a randomized, single-center, open-label, three-sequence, three-period, two-treatment, crossover study with a washout period of 10 days conducted in healthy Chinese volunteers. Subjects were randomized to receive Co-Plavix® (test formulation- fixed-dose combination of 100 mg acetylsalicylic acid and 75 mg clopidogrel) once and reference formulations (coadministration of individual formulations of 100 mg acetylsalicylic acid and 75 mg clopidogrel) twice during the study period. Pharmacokinetic parameters were analyzed for acetylsalicylic acid, its metabolite salicylic acid, clopidogrel, and its metabolite SR26334. As acetylsalicylic acid shows high intrasubject variability, the reference-scaled average bioequivalence (RSABE) approach was implemented for acetylsalicylic acid analysis, while bioequivalence of clopidogrel was assessed using the average bioequivalence method. Point ratios and confidence intervals (CIs) for AUC, AUClast, and Cmax for acetylsalicylic acid and clopidogrel were calculated. RESULTS In total, 171 healthy subjects were enrolled in this study. Subjects were randomized and 170 subjects were treated with test or reference formulation; 164 subjects completed the study. Regarding acetylsalicylic acid exposure, as reference within-subject standard deviation (SDW) was at least 0.294 for acetylsalicylic acid Cmax, AUClast, and AUC, the RSABE analysis method was used to assess bioequivalence for all three parameters. The point estimates were within the 0.80-1.25 range (1.19, 1.09, and 1.04, respectively), and upper one-sided 95% CIs of scaled average bioequivalence metric were at most 0 (- 0.30, - 0.14, and - 0.10, respectively). Thus, bioequivalence was demonstrated with acetylsalicylic acid. Bioequivalence was also achieved with clopidogrel as the 90% CIs for geometric mean ratios of clopidogrel Cmax, AUClast, and AUC were within the bioequivalence range (0.80-1.25). CONCLUSION Application of the reference-scaled average bioequivalence approach to evaluate bioequivalence of acetylsalicylic acid in Chinese male and female healthy volunteers under fasting conditions demonstrated bioequivalence of test and reference formulations. TRIAL REGISTRATION CTR20181695.


title: Future of robotic surgery in urology.

text: OBJECTIVES To provide a comprehensive overview of the current status of the field of robotic systems for urological surgery and discuss future perspectives. MATERIALS AND METHODS A non-systematic literature review was performed using PubMed/Medline search electronic engines. Existing patents for robotic devices were researched using the Google search engine. Findings were also critically analysed taking into account the personal experience of the authors. RESULTS The relevant patents for the first generation of the da Vinci platform will expire in 2019. New robotic systems are coming onto the stage. These can be classified according to type of console, arrangement of robotic arms, handles and instruments, and other specific features (haptic feedback, eye-tracking). The Telelap ALF-X robot uses an open console with eye-tracking, laparoscopy-like handles with haptic feedback, and arms mounted on separate carts; first clinical trials with this system were reported in 2016. The Medtronic robot provides an open console using three-dimensional high-definition video technology and three arms. The Avatera robot features a closed console with microscope-like oculars, four arms arranged on one cart, and 5-mm instruments with six degrees of freedom. The REVO-I consists of an open console and a four-arm arrangement on one cart; the first experiments with this system were published in 2016. Medicaroid uses a semi-open console and three robot arms attached to the operating table. Clinical trials of the SP 1098-platform using the da Vinci Xi for console-based single-port surgery were reported in 2015. The SPORT robot has been tested in animal experiments for single-port surgery. The SurgiBot represents a bedside solution for single-port surgery providing flexible tube-guided instruments. The Avicenna Roboflex has been developed for robotic flexible ureteroscopy, with promising early clinical results. CONCLUSIONS Several console-based robots for laparoscopic multi- and single-port surgery are expected to come to market within the next 5 years. Future developments in the field of robotic surgery are likely to focus on the specific features of robotic arms, instruments, console, and video technology. The high technical standards of four da Vinci generations have set a high bar for upcoming devices. Ultimately, the implementation of these upcoming systems will depend on their clinical applicability and costs. How these technical developments will facilitate surgery and whether their use will translate into better outcomes for our patients remains to be determined.


title: Flexible endoscopic single-incision extraperitoneal implant and fixation of peritoneal dialysis catheter: proof of concept in the porcine model.

text: BACKGROUND Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation. MATERIALS AND METHODS Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer. RESULTS Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76). CONCLUSIONS Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.


A glimpse into a post-Covid vet future.


docid: pbbiyylp

title: Rapid Scale-Up of Telehealth during the COVID-19 Pandemic and Implications for Subspecialty Care in Rural Areas.


title: Mouth-to-mouth ventilation is superior to mouth-to-pocket mask and bag-valve-mask ventilation during lifeguard CPR: a randomized study.

text: AIM The quality of cardiopulmonary resuscitation (CPR) is a crucial determinant of outcome following cardiac arrest. Interruptions in chest compressions are detrimental. We aimed to compare the effect of mouth-to-mouth ventilation (MMV), mouth-to-pocket mask ventilation (MPV) and bag-valve-mask ventilation (BMV) on the quality of CPR. MATERIALS AND METHODS Surf lifeguards in active service were included in the study. Each surf lifeguard was randomized to perform three sessions of single-rescuer CPR using each of the three ventilation techniques (MMV, MPV and BMV) separated by 5 min of rest. Data were obtained from a resuscitation manikin and video recordings. RESULTS A total of 60 surf lifeguards were included (67% male, 33% female, mean age 25 years). Interruptions in chest compressions were significantly reduced by MMV (8.9 ± 1.6 s) when compared to MPV (10.7 ± 3.0 s, P < 0.001) and BMV (12.5 ± 3.5s, P < 0.001). Significantly more effective ventilations (visible chest rise) were delivered using MMV (91%) when compared to MPV (79%, P < 0.001) and BMV (59%, P < 0.001). The inspiratory time was longer during MMV (0.7 ± 0.2 s) and MPV (0.7 ± 0.2s, P < 0.001 for both) compared to BMV (0.5 ± 0.2s). Tidal volumes were significantly lower using BMV (0.4 ± 0.2L) compared to MMV (0.6 ± 0.2L, P < 0.001) and MPV (0.6 ± 0.3 L, P < 0.001), whereas no differences were observed when comparing MMV and MPV. CONCLUSION MMV reduces interruptions in chest compressions and produces a higher proportion of effective ventilations during lifeguard CPR. This suggests that CPR quality is improved using MMV compared to MPV and BMV.


title: Influence of the site of measurement on the ability of plethysmographic variability index to predict fluid responsiveness.

text: BACKGROUND Plethysmographic variability index (PVI) is an accurate predictor of fluid responsiveness in mechanically ventilated patients. However, the site of measurement of the plethysmographic waveform impacts its morphology and its respiratory variation. The goal of this study was to investigate the ability of PVI to predict fluid responsiveness at three sites of measurement (the forehead, ear, and finger) in mechanically ventilated patients under general anaesthesia. METHODS We studied 28 subjects after induction of general anaesthesia. Subjects were monitored with a pulmonary artery catheter and three pulse oximeter sensors (the finger, ear, and forehead). Pulse pressure variation, central venous pressure, cardiac index (CI), and PVI measured at the forehead, ear, and finger (PVI(forehead), PVI(ear), and PVI(finger)) were recorded before and after fluid loading (FL). Subjects were responders to volume expansion if CI increased >15% after FL. RESULTS Areas under the receiver-operating curves to predict fluid responsiveness were 0.906, 0.880, and 0.836 for PVI(forehead), PVI(ear), and PVI(finger), respectively (P<0.05). PVI(forehead), PVI(ear), and PVI(finger) had a threshold value to predict fluid responsiveness of 15%, 16%, and 12% with sensitivities of 89%, 74%, and 74% and specificities of 78%, 74%, and 67%, respectively. CONCLUSIONS PVI can predict fluid responsiveness in anaesthetized and ventilated subjects at all three sites of measurement. However, the threshold values for predicting fluid responsiveness differ with the site of measurement. These results support the use of this plethysmographic dynamic index in the cephalic region when the finger is inaccessible or during states of low peripheral perfusion.


title: Heightened risk of child maltreatment amid the COVID-19 pandemic can exacerbate mental health problems for the next generation.

text: The spread of the COVID-19 disrupted ecological systems in which children develop, exacerbating threats to their safety and increasing their vulnerability to future psychopathology. Supports to reduce sources of stress for caregivers and protect children from threats to their safety are warranted. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Totally intracorporeal laparoscopic colectomy (TILC) is associated with similar surgical outcomes in high and low operative risk patients.

text: PURPOSE Patients undergoing laparoscopic-assisted colectomy with obesity, high American Society of Anesthesiologists (ASA) grade, and left-sided colon tumors are at high risk for operative conversion and complications. We hypothesized that a completely intracorporeal laparoscopic colectomy would be beneficial for high-risk patients compared with healthy, low-risk patients. METHODS We conducted a retrospective study of 136 consecutive patients undergoing a standardized totally intracorporeal laparoscopic colectomy for neoplasms from February 2004 to September 2011. Patients were stratified into a high-risk group with 1 or more factors: body mass index >30, ASA grade ≥ 3, and left-sided tumors or a low-risk group with no factors. Variables compared were case frequency during the learning curve, body mass index, estimated blood loss, operative time, conversion, 30-day complications, and length of stay. Comparisons between groups were made by χ2 analysis or t test where appropriate. Data are expressed as median ± SD, odds ratio, and significance defined as P<0.05. RESULTS Laparoscopic colectomy was performed in 136 patients with a conversion rate of 4%. There were 86 high-risk patients and 50 low-risk patients. High-risk patients had a significantly (P<0.005) longer operative time (225 ± 66 vs. 186 ± 55 min) but no significant difference in estimated blood loss, conversion rates, learning curve, complications, or length of stay compared with low-risk patients. CONCLUSIONS When laparoscopic colectomy is performed totally intracorporeally, surgical outcomes in high-risk patients with obesity, high ASA grade, and left-sided tumors are equally successful to results achieved for low-risk patients that are thin, healthy, with right-sided lesions.


title: Overcoming barriers to evidence-based patient blood management: a restricted review.

text: BACKGROUND Blood transfusions are associated with a range of adverse patient outcomes, including coagulopathy, immunomodulation and haemolysis, which increase the risk of morbidity and mortality. Consideration of these risks and potential benefits are necessary when deciding to transfuse. Patient blood management (PBM) guidelines exist to assist in clinical decision-making, but they are underutilised. Exploration of barriers to the implementation and utilisation of the PBM guidelines is required. This study aimed to identify common barriers and implementation strategies used to implement PBM guidelines, with a comparison against current expert opinion. METHODS A restricted review approach was used to identify the barriers to PBM guideline implementation as reported by health professionals and to review which implementation strategies have been used. Searches were undertaken in MEDLINE/PubMed, CINAHL, Embase, Scopus and the Cochrane library. The Consolidated Framework for Implementation Research (CFIR) was used to code barriers. The Expert Recommendations for Implementing Change (ERIC) tool was used to code implementation strategies, and subsequently, develop recommendations based on expert opinion. RESULTS We identified 14 studies suitable for inclusion. There was a cluster of barriers commonly reported: access to knowledge and information (n = 7), knowledge and beliefs about the intervention ( = 7) and tension for change (n = 6). Implementation strategies used varied widely (n = 25). Only one study reported the use of an implementation theory, model or framework. Most studies (n = 11) had at least 50% agreement with the ERIC recommendations. CONCLUSIONS There are common barriers experienced by health professionals when trying to implement PBM guidelines. There is currently no conclusive evidence to suggest which implementation strategies are most effective. Further research using validated implementation approaches and improved reporting is required.


title: Resource efficient recovery of critical and precious metals from waste silicon PV panel recycling.

text: Although the amount of waste photovoltaic (PV) panels is expected to grow exponentially in the next decades, little research on the resource efficiency of their recycling has been conducted so far. The article analyses the performance of different processes for the recycling of crystalline silicon PV waste, in a life cycle perspective. The life cycle impacts of the recycling are compared, under different scenarios, to the environmental benefits of secondary raw materials recovered. Base-case recycling has a low efficiency and, in some cases, not even in line with legislative targets. Conversely, high-efficient recycling can meet these targets and allows to recover high quality materials (as silicon, glass and silver) that are generally lost in base-case recycling. The benefits due to the recovery of these materials counterbalance the larger impacts of the high-efficiency recycling process. Considering the full life cycle of the panel, the energy produced by the panel grants the most significant environmental benefits. However, benefits due to high-efficient recycling are relevant for some impact categories, especially for the resource depletion indicator. The article also points out that thermal treatments are generally necessary to grant the high efficiency in the recycling. Nevertheless, these treatments have to be carefully assessed since they can be responsible for the emissions of air pollutants (as hydrogen fluoride potentially released from the combustion of halogenated plastics in the panel's backsheet). The article also identifies and assesses potential modifications to the high-efficiency recycling process, including the delocalisation of some treatments for the optimisation of waste transport and the introduction of pyrolysis in the thermal processing of the waste. Finally, recommendations for product designers, recyclers and policymakers are discussed, in order to improve the resource efficiency of future PV panels.


Coronavirus: origins, signs, prevention and management of patients.


title: The impact of glycosylated hemoglobin and diabetes mellitus on wound-healing complications and infection after foot and ankle surgery.

text: BACKGROUND The relationship between hyperglycemia and adverse outcomes after surgery has been widely documented. Long-term glucose control has been recognized as a risk factor for postoperative complications. In the foot and ankle literature, long-term glycemic control as a potential perioperative risk factor is not well studied. Our goal was to investigate whether hemoglobin A1c (HbA1c) level was independently associated with postoperative complications in a retrospective cohort study. METHODS Three hundred twenty-two patients with a diagnosis of diabetes mellitus were enrolled in the study to assess risk factors associated with postoperative foot and ankle surgery complications. RESULTS Bivariate analyses showed that HbA1c level and having at least one comorbidity were associated with postoperative infections. However, after adjusting for other covariates, the only significant factor was HbA1c level, with each increment of 1% increasing the odds of infection by a factor of 1.59 (95% confidence interval [CI], 1.28-1.99). For postoperative wound-healing complications, bivariate analyses showed that body mass index, having at least one comorbidity, and HbA1c level were significant factors. After adjusting for other covariates, the only significant factors for developing postoperative wound complications were having at least one comorbidity (odds ratio, 2.03; 95% CI, 1.22-3.37) and HbA1c level (each 1% increment) (odds ratio, 1.25; 95% CI, 1.02-1.53). CONCLUSIONS In this retrospective study, HbA1c level had the strongest association with postoperative foot and ankle surgery complications in patients with diabetes.


title: Rotavirus infection induces the unfolded protein response of the cell and controls it through the nonstructural protein NSP3.

text: The unfolded protein response (UPR) is a cellular mechanism that is triggered in order to cope with the stress caused by the accumulation of misfolded proteins in the endoplasmic reticulum (ER). This response is initiated by the endoribonuclease inositol-requiring enzyme 1 (IRE1), activating transcription factor 6 (ATF6), and PKR-like ER kinase, which increase the expression of the genes involved in the folding and degradation processes and decrease the protein input into the ER by inhibiting translation. It has been shown that viruses both induce and manipulate the UPR in order to protect the host cells from an ER stress-mediated death, thus permitting the translation of viral proteins and the efficient replication of the virus. To understand the cellular events that occur during the rotavirus replication cycle, we examined the activation of the three UPR arms following infection, using luciferase reporters driven by promoters of the ER stress-responsive genes and real-time reverse transcription-PCR to determine the levels of the stress-induced mRNAs. Our findings indicated that during rotavirus infection two of the three arms of the UPR (IRE1 and ATF6) become activated; however, these pathways are interrupted at the translational level by the general inhibition of protein synthesis caused by NSP3. This response seems to be triggered by more than one viral protein synthesized during the replication of the virus, but not by the viral double-stranded RNA (dsRNA), since cells transfected with psoralen-inactivated virions, or with naked viral dsRNA, did not induce UPR.


title: EP lessons by Legendary Quartet of "Jackman-Klein-Prystowsky-Stevenson": "A Priceless Opportunity" during the COVID-19 Era.

text: The COVID-19 pandemic has already been declared as modern history's gravest health emergency by many countries(1-3). The rapidly increasing demand on health facilities and health care providers threatens to leave some health systems overstretched and unable to operate effectively. This article is protected by copyright. All rights reserved.


title: Differential proteome analysis of host cells infected with porcine circovirus type 2.

text: Porcine circovirus type 2 (PCV2) is the primary causative agent of postweaning multisystemic wasting syndrome, which is an emerging swine immunosuppressive disease. To uncover cellular protein responses in PCV2-infected PK-15 cells, the comprehensive proteome profiles were analyzed utilizing two-dimensional gel electrophoresis (2-DE) coupled with MALDI-TOF/TOF identification. Multiple comparisons of 2-DE revealed that the majority of changes in protein expression occurred at 48-96 h after PCV2 infection. A total of 34 host-encoded proteins, including 15 up-regulated and 19 down-regulated proteins, were identified by MALDI-TOF/TOF analysis. According to cellular function, the differential expression proteins could be sorted into several groups: cytoskeleton proteins, stress response, macromolecular biosynthesis, energy metabolism, ubiquitin-proteasome pathway, signal transduction, gene regulation. Western blot analysis demonstrated the changes of alpha tubulin, beta actin, and cytokeratin 8 during infection. Colocalization and coimmunoprecipitation analyses confirmed that the cellular alpha tubulin interacts with the Cap protein of PCV2 in the infected PK-15 cells. These identified cellular constituents have important implications for understanding the host interactions with PCV2 and brings us a step closer to defining the cellular requirements for the underlying mechanism of PCV2 replication and pathogenesis.


title: Powered air-purifying respirator use in healthcare: Effects on thermal sensations and comfort.

text: Twelve subjects wore an N95 filtering facepiece respirator (N95 FFR), one tight-fitting full facepiece powered air-purifying respirator (PAPR), two loose-fitting PAPRs, and one elastomeric/PAPR hybrid for 1 hr each during treadmill walking at 5.6 km/hr while undergoing physiological and subjective response monitoring. No significant interaction (p ≥ .05) was noted between the five respirators in heart rate, respiratory rate, oxygen saturation, transcutaneous carbon dioxide, and perceptions of breathing effort or discomfort, exertion, facial heat, and overall body heat. Respirator deadspace heat/humidity were significantly greater for the N95 FFR, whereas tympanic forehead skin temperatures were significantly greater for the hybrid PAPR. Temperature of the facial skin covered by the respirator was equivalent for the N95 FFR and hybrid PAPR, and both were significantly higher than for the other three PAPRs. Perception of eye dryness was significantly greater for a tight-fitting full facepiece PAPR than the N95 FFR and hybrid PAPR. At a low-moderate work rate over 1 hr, effects on cardiopulmonary variables, breathing perceptions, and facial and overall body heat perceptions did not differ significantly between the four PAPRs and a N95 FFR, but the tight-fitting, full facepiece PAPR increased perceptions of eye dryness. The two loose-fitting PAPRs and the full facepiece tight-fitting PAPR ameliorated exercise-induced increases in facial temperature, but this did not translate to improved perception of facial heat and overall body heat.


title: VATS left upper lobectomy after CABG with LIMA-LAD bypass graft.

text: Video-assisted thoracic surgery (VATS) lobectomy has been proven to be a safe operation associated with a low complication rate and good long-term results comparable to those obtained by the thoracotomy approach. During the development of thoracoscopic anatomical lung cancer resections, eligibility criteria for the operation have been gradually extended. Currently, even as complicated cases as bronchial and vascular sleeve resections or pneumonectomies are being performed by VATS. However, minimally invasive surgery after previous coronary artery bypass graft surgery merits special consideration due to the consequences of potential injury to the bypass graft. This is particularly important in the case of VATS left upper lobectomy after left internal mammary artery grafting to the left anterior descending artery bypass.


title: Bronchiolitis obliterans organizing pneumonia after radiofrequency ablation of lung cancer: report of three cases.

text: The present report describes three cases of a bronchiolitis obliterans organizing pneumonia (BOOP)-like reactive pneumonitis following radiofrequency (RF) ablation for lung cancer. The incidence of BOOP-like reactive pneumonitis after RF ablation at the authors' institution was estimated to be approximately 0.4% (three of 840 sessions). The patients presented with nonspecific symptoms. Computed tomography images showed consolidation or ground-glass opacity in a peripheral-dominant distribution and/or patchy air-space opacities. The disease was nonresponsive to antibiotic therapy but responded favorably to pulse therapy of steroids. BOOP-like reactive pneumonitis should be recognized as a complication following lung RF ablation.


title: Mucosal vaccines to prevent porcine reproductive and respiratory syndrome: a new perspective.

text: Porcine reproductive and respiratory syndrome (PRRS) is an economically important infectious disease of swine. Constant emergence of variant strains of PRRS virus (PPRSV) and virus-mediated immune evasion followed by viral persistence result in increased incidence and recurrence of PRRS in swine herds. Current live and killed PRRSV vaccines administered by a parenteral route are ineffective in inducing complete protection. Thus, new approaches in design and delivery of PRRSV vaccines are needed to reduce the disease burden of the swine industry. Induction of an effective mucosal immunity to several respiratory pathogens by direct delivery of a vaccine to mucosal sites has proven to be effective in a mouse model. However, there are challenges in eliciting mucosal immunity to PRRS due to our limited understanding of safe and potent mucosal adjuvants, which could potentiate the mucosal immune response to PRRSV. The purpose of this review is to discuss methods for induction of protective mucosal immune responses in the respiratory tract of pigs. The manuscript also discusses how PRRSV modulates innate, adaptive and immunoregulatory responses at both mucosal and systemic sites of infected and/or vaccinated pigs. This information may help in the design of innovative mucosal vaccines to elicit superior cross-protective immunity against divergent field strains of PRRSV.


title: Ventilator-associated pneumonia in patients admitted to intensive care units, using open or closed endotracheal suctioning.

text: BACKGROUND Critically ill patients under mechanical ventilation require frequent suctioning of airway secretion. Closed suction permits suctioning without disconnection from ventilator; so it might decrease hypoxemia and infection rate. OBJECTIVES This study aimed to evaluate the effect of closed tracheal suction system (CTSS) versus open tracheal suction system (OTSS). PATIENTS AND METHODS This is a prospective randomized study, which was carried on 100 patients in surgical Intensive Care Unit requiring mechanical ventilation for more than 48 hours from June 2012 to November 2013. In two groups, suction was performed based on the patients' need as well as physician's or nurses' decision on tracheal secretions. Patients randomly allocated into two groups (50 patients each): CTSS group and OTSS group. Patients were monitored for developing ventilator-associated pneumonia (VAP) during the study. Throat samples were taken on admission and two times per week from each patient. Tracheal samples were performed during endotracheal intubation, two times per week during mechanical ventilation and during extubation. RESULTS Drainage of subglottic secretions decreased the incidence of VAP (P < 0.05). Also type of the pharmacologic medicine for stress ulcer prophylaxis has significant effect on VAP incidence. Among the patients in OTSS and CTSS groups, 20% and 12% developed VAP, respectively. Use of CTSS compared with OTSS did not show statistically significant effect on VAP incidence in multivariate analysis; however, OR (odds ratio) tended to identify OTSS as an exposure factor for the development of VAP (OR = 1.92; CI = 0.45-8.30; = 0.38) compared with the CTSS. Higher levels of APACHE II score, sinusitis and tracheostomy put the patients at the risk of VAP. However, using heat and moisture exchanger (HME) instead of humidifier decreased this risk. CONCLUSIONS Based on the results obtained from our study, impact of suctioning is similar between CTSS and OTSS regarding the occurrence of VAP. It seems that physicians must consider many factors such as duration of mechanical ventilation, comorbidities, oxygenation parameters, number of required suctioning, and the cost prior to using each type of tracheal suction system.


title: Single-incision laparoscopic appendectomy versus traditional three-port laparoscopic appendectomy: an analysis of outcomes at a single institution.

text: BACKGROUND Questions have emerged as to whether single-incision laparoscopy has reproducible or superior patient outcomes compared with traditional laparoscopy. A retrospective review comparing single-incision laparoscopic (SILS) appendectomy and traditional multiport laparoscopic (MP) appendectomy was conducted to assess the safety and feasibility of the less invasive laparoscopic technique. METHODS All SILS and MP appendectomies performed by three surgeons at a single institution during 43 months were reviewed. Statistical evaluation included descriptive analysis of demographic data including age and gender, as well as bi- and multi-variate analyses of operative outcomes including operative time, conversions, complications, and hospital length of stay. RESULTS The study reviewed 168 patients who underwent SILS appendectomy and 108 patients who underwent MP appendectomy. No statistically significant difference was found between the mean SILS and MP operative times (43.63 vs. 40.95 min; p = 0.29). Additionally, no statistically significant association was noted between surgical approach and length of hospital stay. Although 0.93 % of MP appendectomies and 2.38 % of SILS appendectomies were converted to open procedure, this difference was not statistically significant (p = 0.65, Fisher's exact test). After exclusion of cases converted to open procedure from the study, the findings showed that 3.66 % of SILS cases were converted to multiport laparoscopy. No increase in the overall complication rate was associated with SILS compared with MP appendectomy. The wound complications documented included one incisional hernia for SILS appendectomy and two wound infections for MP appendectomy. CONCLUSION The findings showed SILS appendectomy to be a safe and feasible alternative to traditional MP appendectomy that can be conducted with operative times, lengths of stay, and complication rates similar to those of the standardized technique. This review is a precursor to prospective studies, which are warranted to demonstrate conclusively the equivalence of operative times, complications, and lengths of hospital stay, as well as to elucidate differences in patient-centered outcomes including postoperative pain, cosmesis, and quality of life.


docid: glamvdln

title: Can They Do That?: The Limits of Governmental Power over Medical Treatment.


docid: qukqgeup

title: Advanced Imaging for Barrett's Esophagus and Early Neoplasia: Surface and Subsurface Imaging for Diagnosis and Management.

text: PURPOSE OF REVIEW Esophageal adenocarcinoma bears one of the fastest rising incidence of any cancers and generally arises in the setting of gastroesophageal reflux and Barrett's esophagus. However, early detection of neoplasia can be challenging since most patients are asymptomatic until they progress to more advanced and less curable stages, and early dysplastic lesions can be small, multifocal, and difficult to detect. Clearly, new imaging tools are needed in light of sampling error associated with random biopsies, the current standard of practice. RECENT FINDINGS Advances in endoscopic imaging including virtual chromoendoscopy, confocal laser endomicroscopy, and subsurface imaging with optical coherence tomography have ushered in a new era for detecting subtle neoplastic lesions. Moreover, in light of esophagus-sparing treatments for neoplastic lesions, such tools are likely to guide ablation and follow-up management. While there is no ideal single imaging modality to facilitate improved detection, staging, ablation, and follow-up of patients with dysplastic Barrett's esophagus, new advances in available technology, the potential for multimodal imaging, and the use of computer-aided diagnosis and biomarkers all hold great promise for improving detection and treatment.


title: Impact of the COVID-19 Pandemic on the Management of Head and Neck Malignancies.

text: The impact of the coronavirus disease 2019 (COVID-19) pandemic on the management of head and neck cancer must be addressed. Immediate measures to reduce transmission rates and protect patients and providers take priority and necessitate some delays in care, particularly for patients with mild symptoms or less aggressive cancers. However, strict guidelines have yet to be developed, and many unintentional delays in care are to be expected based on the magnitude of the looming public health crisis. The medical complexity of head and neck cancer management may lead to prolonged delays that worsen treatment outcomes. Therefore, those caring for patients with head and neck cancer must take action to reduce these negative impacts as the country rallies to overcome the challenges posed by this pandemic.


title: Grief loss and the COVID-19 pandemic.

text: The capacity for grief literacy is something we all need to develop in the midst of this pandemic.


Meat plants-a new front line in the covid-19 pandemic.


Covid-19 and Immunity in Aging Populations - A New Research Agenda.


title: Anesthetic Management for Concomitant Correction of Congenital Cardiac Defects and Long "O" Ring Tracheal Stenosis: A Role for Heliox?: Report of 2 Cases.

text: We present 2 infants with the rare association of long congenital tracheal stenosis, ventricular septal defect, and pulmonary hypertension. We describe a step-by-step assessment of the patients and the necessary procedures for a successful concomitant repair of both cardiac and tracheal malformations. The use of a helium-oxygen mixture (heliox) for the induction of anesthesia and pre-cardiopulmonary bypass is discussed.


title: Anterior approach white line advancement: technique and long-term outcomes in the correction of blepharoptosis.

text: PurposeAnterior approach white line advancement presents a novel surgical option for correction of blepharoptosis. The technique draws on several advantages of other approaches. The aim of this study was to present outcomes using this technique at a minimum follow-up of 18 months.Patients and methodsParticipants having undergone anterior approach white line advancement ptosis correction at a single institution were retrospectively recruited at a minimum of 18 months' follow-up. A total of 18 independent eyelid measurements were recorded at final review. Outcomes included long-term rate of surgical success, upper eyelid margin-reflex distance (MRD1) at both early and late post-operative follow-up, inter-eyelid asymmetry, complications, re-operation rate, patient satisfaction, and quality-of-life improvement using the Glasgow Benefit Inventory (GBI). Pre- and post-operative MRD1, as well as inter-eyelid asymmetry, were compared using a two-tailed t-test.ResultsIn total, 82 eyelids of 47 participants were included with a mean follow-up of 2.3 years (range 1.5-3.7). Surgical success was achieved in 91.5%, with a final mean MRD1 of 3.5 mm (95% confidence 3.2-3.7). An increase of 2.4 mm (2.1-2.8) in eyelid height was observed between baseline and long-term follow-up (P<0.0001). No significant change was observed between early and late post-operative follow-up. Pre-operative asymmetry was reduced from 1.0 mm (0.7-1.3) to 0.4 mm (0.3-0.5; P<0.0001). Patient satisfaction was 95.7% with a mean GBI score of +21.8 (13.2-30.3).ConclusionsAnterior approach white line advancement presents an excellent option for patients undergoing ptosis correction with favourable long-term results. Comparisons are made with other techniques with respect to anatomical, functional, and surgical factors.


title: More extensive white matter hyperintensity is linked with higher risk of remote intracerebral hemorrhage after intravenous thrombolysis.

text: BACKGROUND AND PURPOSE Remote intracerebral hemorrhage (rICH) is infrequent after intravenous thrombolysis (IVT) and its mechanism remains poorly understood. We aimed to assess its frequency and possible relationship with the severity of white matter hyperintensity (WMH) in patients with acute ischemic stroke. METHODS We prospectively analyzed data from consecutive patients with acute ischemic stroke with magnetic resonance imaging and IVT. WMH volume was quantitatively measured. rICH was defined as intracranial hemorrhage that appears in brain regions without visible ischemic changes on 24-h follow-up imaging. Unfavorable outcome was defined as a modified Rankin scale score of 3-6 at 3 months. Logistic regression analysis was used to determine the impact of WMH volume on hemorrhage, including rICH and local parenchymal hemorrhage, as well as clinical outcome. RESULTS Of a total of 503 patients analyzed, 17 (3.4%) patients developed rICH. Logistic regression analysis indicated that patients with rICH had significantly larger whole-brain corrected WMH volume (cWMHv) than those without rICH (22.90 vs. 4.42 mL; odds ratio, 1.562/10 mL; 95% confidence interval, 1.215-2.009; P = 0.001). Not only the corrected peri-ventricular WMH volume (P = 0.001), but also the corrected deep WMH volume (P = 0.013) was associated with the occurrence of rICH. cWMHv was also independently associated with local parenchymal hemorrhage (P = 0.025). rICH was not related to unfavorable outcome (P = 0.323), whereas cWMHv (P = 0.006) was associated with unfavorable outcome. CONCLUSION An increased occurrence rate of rICH after IVT is related to more extensive WMH, which may suggest underlying whole-brain vascular injury in patients with WMH.


Effect of COVID-19 on ocular diseases and ophthalmology residency training program-A developing country's perspective.


title: Fatal influenza A(H1N1) respiratory tract infection in a patient having psoriasis treated with infliximab.

text: BACKGROUND The use of biologic agents represents a remarkable advance for patients with psoriasis and psoriatic arthritis who have experienced an incomplete response to other therapeutic modalities. Decreased mortality and improved quality of life have been reported in patients undergoing treatment with these agents. Increased risk of bacterial, viral, granulomatous, and opportunistic infections also has been associated with the use of these medications. Enhanced patient education, watchful monitoring to promote early detection of infections, discontinuation of the medication when clinical symptoms are identified, and immediate availability of supportive care are advised to balance the benefit of treatment with biologic agents against the potential risk of infection. Herein, we discuss the risk of infection and the monitoring and vaccination guidelines in patients having psoriasis treated with biologic agents. OBSERVATIONS A woman with obesity and psoriasis that had previously been successfully treated with efalizumab (Raptiva) for 3 years was started on a regimen of infliximab (Remicade) to treat a flare. She died 1 week after her first infusion of infliximab and was found to have had influenza A(H1N1). CONCLUSIONS We report the first case to date of a patient with psoriasis who died of influenza A(H1N1) respiratory tract infection while undergoing treatment with infliximab. Further observations are needed to make a causal association.


title: Cortical atrophy and transcallosal diaschisis following isolated subcortical stroke.

text: Following acute ischemic stroke, isolated subcortical lesions induce gray matter atrophy in anatomically connected, yet distant cortical brain regions. We expand on previous studies by analyzing cortical thinning in contralesional, homologous regions indirectly linked to primary stroke lesions via ipsilesional cortical areas. For this purpose, stroke patients were serially studied by magnetic resonance imaging (diffusion tensor imaging and high-resolution anatomical imaging) in the acute (days 3-5) and late chronic stage one year after stroke. We analyzed changes of gray and white matter integrity in 18 stroke patients (median age 68 years) with subcortical stroke. We applied probabilistic fiber tractography to identify brain regions connected to stroke lesions and contralesional homologous areas. Cortical thickness was quantified by semi-automatic measurements, and fractional anisotropy was analyzed. One year after stroke, significant decrease of cortical thickness was detected in areas connected to ischemic lesions (mean -0.15 mm; 95% CI -0.23 to -0.07 mm) as well as homologous contralateral brain regions (mean -0.13 mm; 95% CI -0.07 to -0.19 mm). We detected reduced white matter integrity of inter- and intrahemispheric fiber tracts. There were no significant associations with clinical recovery. Our results indicate that impact of subcortical lesions extends to homologous brain areas via transcallosal diaschisis.


title: Syrian hamsters as a small animal model for SARS-CoV-2 infection and countermeasure development.

text: At the end of 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2; SARS-CoV-2) was detected in Wuhan, China, that spread rapidly around the world, with severe consequences for human health and the global economy. Here, we assessed the replicative ability and pathogenesis of SARS-CoV-2 isolates in Syrian hamsters. SARS-CoV-2 isolates replicated efficiently in the lungs of hamsters, causing severe pathological lung lesions following intranasal infection. In addition, microcomputed tomographic imaging revealed severe lung injury that shared characteristics with SARS-CoV-2-infected human lung, including severe, bilateral, peripherally distributed, multilobular ground glass opacity, and regions of lung consolidation. SARS-CoV-2-infected hamsters mounted neutralizing antibody responses and were protected against subsequent rechallenge with SARS-CoV-2. Moreover, passive transfer of convalescent serum to naïve hamsters efficiently suppressed the replication of the virus in the lungs even when the serum was administrated 2 d postinfection of the serum-treated hamsters. Collectively, these findings demonstrate that this Syrian hamster model will be useful for understanding SARS-CoV-2 pathogenesis and testing vaccines and antiviral drugs.


title: The adaptive immune system in diseases of the central nervous system.

text: Tissues of the CNS, such as the brain, optic nerves, and spinal cord, may be affected by a range of insults including genetic, autoimmune, infectious, or neurodegenerative diseases and cancer. The immune system is involved in the pathogenesis of many of these, either by causing tissue damage or alternatively by responding to disease and contributing to repair. It is clearly vital that cells of the immune system patrol the CNS and protect against infection. However, in contrast to other tissues, damage caused by immune pathology in the CNS can be irreparable. The nervous and immune systems have, therefore, coevolved to permit effective immune surveillance while limiting immune pathology. Here we will consider aspects of adaptive immunity in the CNS and the retina, both in the context of protection from infection as well as cancer and autoimmunity, while focusing on immune responses that compromise health and lead to significant morbidity.


title: Protein phosphatase 1 subunit Ppp1r15a/GADD34 regulates cytokine production in polyinosinic:polycytidylic acid-stimulated dendritic cells.

text: In response to inflammatory stimulation, dendritic cells (DCs) have a remarkable pattern of differentiation that exhibits specific mechanisms to control the immune response. Here we show that in response to polyriboinosinic:polyribocytidylic acid (pI:C), DCs mount a specific integrated stress response during which the transcription factor ATF4 and the growth arrest and DNA damage-inducible protein 34 (GADD34/Ppp1r15a), a phosphatase 1 (PP1) cofactor, are expressed. In agreement with increased GADD34 levels, an extensive dephosphorylation of the translation initiation factor eIF2α was observed during DC activation. Unexpectedly, although DCs display an unusual resistance to protein synthesis inhibition induced in response to cytosolic dsRNA, GADD34 expression did not have a major impact on protein synthesis. GADD34, however, was shown to be required for normal cytokine production both in vitro and in vivo. These observations have important implications in linking further pathogen detection with the integrated stress response pathways.


title: Long-term adherence to a 5 day antibiotic course guideline for treatment of intensive care unit (ICU)-associated Gram-negative infections.

text: OBJECTIVES To determine long-term adherence to a 5 day antibiotic course guideline for treating intensive care unit (ICU)-acquired Gram-negative bacteria (GNB) infections. METHODS Descriptive analysis of patient-level data on all GNB-active antibiotics prescribed from day 3 and all GNB identified in clinical samples in 5350 patients admitted to a 30 bed general ICU between 2002 and 2009. RESULTS Four thousand five hundred and eleven of 5350 (84%) patients were treated with one or more antibiotics active against GNB commenced from day 3. Gentamicin was the most frequently prescribed antibiotic (92.2 days of therapy/1000 patient-days). Only 6% of courses spanned >6 days of therapy and 89% of antibiotic therapy days were with a single antibiotic active against GNB. There was no significant difference between gentamicin and meropenem in the number of first courses in which a resistant GNB was identified in blood cultures [11/1177 (0.9%) versus 5/351 (1.4%); P = 0.43] or respiratory tract specimens [59/951 (6.2%) versus 17/246 (6.9%); P = 0.68] at the time of starting therapy. CONCLUSIONS This study demonstrates long-term adherence to a 5 day course antibiotic guideline for treatment of ICU-associated GNB infections. This guideline is a potential antibiotic-sparing alternative to currently recommended dual empirical courses extending to ≥7 days.


Reply to Kerkhove et al and Oh.


title: Enhancing the fairness of pandemic critical care triage.

text: Historically, the triage of temporarily scarce health resources has served narrow utilitarian ends. The recent H1N1 pandemic experience provided an opportunity for expanding the theoretical foundations/understandings of critical care triage in the context of declared infectious pandemics. This paper briefly explores the ethics-related challenges associated with the development of modern critical care triage protocols and provides descriptions of some 'enhanced fairness' features which were developed through the use of an inclusive deliberative engagement process by a Canadian provincial Department of Health.


title: Quantitative magnetic resonance angiography as a potential predictor for cerebral hyperperfusion syndrome: a preliminary study.

text: OBJECTIVE Cerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk. METHODS In this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors. RESULTS Twenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS. CONCLUSIONS Cerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.


title: Changes in body weight and pulse: outcome events in overweight and obese subjects with cardiovascular disease in the SCOUT trial.

text: BACKGROUND/OBJECTIVES The Sibutramine Cardiovascular OUTcomes (SCOUT) trial showed a significantly increased relative risk of nonfatal cardiovascular events, but not mortality, in overweight and obese subjects receiving long-term sibutramine treatment with diet and exercise. We examined the relationship between early changes (both increases and decreases) in pulse rate, and the impact of these changes on subsequent cardiovascular outcome events in both the placebo and sibutramine groups. SUBJECTS/METHODS 9804 males and females, aged ⩾55 years, with a body mass index of 27-45 kg m(-)(2) were included in this current subanalysis of the SCOUT trial. Subjects were required to have a history of cardiovascular disease and/or type 2 diabetes mellitus with at least one cardiovascular risk factor, to assess cardiovascular outcomes. The primary outcome event (POE) was a composite of nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death. Time-to-event analyses of the POE were performed using Cox regression models. RESULTS During the initial 6-week sibutramine treatment period, the induced pulse rate increase was related to weight change (1.9±7.7 beats per minute (bpm) with weight increase; 1.4±7.3 bpm, 0-5 kg weight loss; 0.6±7.4 bpm, ⩾5 kg weight loss). Throughout the subsequent treatment period, those continuing on sibutramine showed a consistently higher mean pulse rate than the placebo group. There was no difference in POE rates with either an increase or decrease in pulse rate over the lead-in period, or during lead-in baseline to 12 months post randomization. There was also no relationship between pulse rate at lead-in baseline and subsequent cardiovascular events in subjects with or without a cardiac arrhythmia. CONCLUSION Baseline pulse rate and changes in pulse rate may not be an important modifier nor a clinically useful predictor of outcome in an individual elderly cardiovascular obese subject exposed to weight management.


title: Efficacy of endovascular thrombectomy in patients with M2 segment middle cerebral artery occlusions: meta-analysis of data from the HERMES Collaboration.

text: BACKGROUND The Society of Neurointerventional Surgery revised its operational definition of emergent large vessel occlusion (ELVO) recently to include proximal M2 segment middle cerebral artery (MCA) occlusions. We sought to assess the benefit of endovascular thrombectomy (EVT) over best medical care for M2 segment MCA occlusion. METHODS Patient level data from trials in the HERMES Collaboration were included. The HERMES core laboratory identified patients with M2 segment MCA occlusions and further classified them as proximal versus distal, anterior versus posterior division, and dominant versus co-dominant versus non-dominant. Primary outcome was modified Rankin Scale (mRS) score 0-2 at 90 days. Secondary outcomes were modified Thrombolysis in Cerebral Infarction (mTICI) rates at end of procedure, 90-day mRS shift, 90-day mRS 0-1, 24 hours National Institute of Health Stroke Scale (NIHSS) score 0-2, symptomatic intracerebral hemorrhage (ICH), and death. RESULTS 130 patients with M2 MCA (proximal location n=116 vs distal n=14, anterior division n=72 vs posterior n=58, dominant n=73 vs co-dominant n=50 vs non-dominant n=7) were included. Successful reperfusion (mTICI 2b or 3) among those undergoing EVT was seen in 59.2% of patients. Treatment effect favored EVT (adjusted OR 2.39, 95% CI 1.08 to 5.28, p=0.03) for 90-day mRS 0-2 (58.2% EVT vs 39.7% control). Direction of benefit favored EVT for other outcomes. Treatment effect favoring EVT was maximal in patients with proximal M2 segment MCA occlusions (n=116, adjusted OR 2.68, 95% CI 1.13 to 6.37) and in dominant M2 segment MCA occlusions (n=73, adjusted OR 4.08, 95% CI 1.08 to 15.48). No sICH (0%) was observed in patients treated with EVT compared with five (7.9%) in the control arm. CONCLUSION Patients with proximal M2 segment MCA occlusions eligible for EVT trial protocols benefited from EVT.


title: Associations between psychosocial factors and pain intensity, physical functioning, and psychological functioning in patients with chronic pain: a cross-cultural comparison.

text: OBJECTIVE Current models of chronic pain recognize that psychosocial factors influence pain and the effects of pain on daily life. The role of such factors has been widely studied on English-speaking individuals with chronic pain. It is possible that the associations between such factors and adjustment may be influenced by culture. This study sought to evaluate the importance of coping responses, self-efficacy beliefs, and social support to adjust to chronic pain in a sample of Portuguese patients, and discuss the findings with respect to their similarities and differences from findings of studies on English-speaking individuals. MATERIALS AND METHODS Measures of pain intensity and interference, physical and psychological functioning, coping responses, self-efficacy, and satisfaction with social support were administered to a sample of 324 Portuguese patients with chronic musculoskeletal pain. Univariate and multivariate analyses were computed. Findings were interpreted with respect to those from similar studies using English-speaking individuals. RESULTS Coping responses and perceived social support were significantly associated with pain interference and both physical and psychological functioning; self-efficacy beliefs were significantly associated with all criterion variables. All coping responses, except for task persistence, were positively associated with pain interference and negatively associated with physical and psychological functioning, with the strongest associations found for catastrophizing, praying/hoping, guarding, resting, asking for assistance, and relaxation. DISCUSSION The findings provide support for the importance of the psychosocial factors studied in terms of adjustment to chronic pain in Portuguese patients, and also suggest the possibility of some differences in the role of these factors due to culture.


title: Comparison of laparoscopic skills performance between single-site access (SSA) devices and an independent-port SSA approach.

text: BACKGROUND This study compared the performance of validated laparoscopic tasks on four commercially available single-site-access (SSA) devices with the performance of those tasks on an independent-port (IP) SSA setup. METHODS A prospective, randomized comparison of laparoscopic skills performance on four access devices (ADs) (GelPOINT, SILS Port, SSL Access System, TriPort) and one IP-SSA setup was conducted. A laparoscopic trainer box was used to train 18 (2nd- to 4th-year) medical students, four surgical residents, and five attending surgeons to proficiency in multiport laparoscopy using four laparoscopic drills (i.e., peg transfer, bean drop, pattern cutting, extracorporeal suturing). Drills then were performed in random order on each IP-SSA and AD-SSA setup using straight laparoscopic instruments. Repetitions were timed and errors recorded. Data are presented as mean ± standard deviation. Statistical analysis was performed by two-way analysis of variance (ANOVA) with Tukey HSD post hoc tests. RESULTS The attending surgeons had significantly faster total task times than the residents or students (P < 0.001), but the difference between the residents and students was not significant. Pair-wise comparisons showed significantly faster total task times for the IP-SSA setup than for all four AD-SSAs within the student group only (P < 0.05). The total task times for the residents and attending surgeons showed a similar profile, but the differences were not significant. When the data for the three groups were combined, the total task time was less for the IP-SSA setup than for each of the four AD-SSA setups (P < 0.001). Similarly, the IP-SSA setup was significantly faster than three of the four AD-SSA setups for peg transfer, three of the four setups for pattern cutting, and two of the four setups for suturing. No significant differences in error rates between the IP-SSA and AD-SSA setups were detected. CONCLUSIONS Compared with an IP-SSA laparoscopic setup, AD-SSAs are associated with longer task performance times in a trainer box model, independently of the level of training. Task performance was similar across the different SSA devices.


title: Threefold increased bile duct injury rate is associated with less surgeon experience in an insurance claims database: more rigorous training in biliary surgery may be needed.

text: INTRODUCTION Bile duct injury (BDI) remains the dreaded complication of laparoscopic cholecystectomy (LC) over the last two decades. Although the Fundamentals of Laparoscopic Surgery (FLS) certification is now required for new applicants by the American Board of Surgery, the impact of FLS on procedure-specific outcomes is unknown. Moreover, the FLS content centers on fundamental education and not procedure-specific complication reduction such as BDI, magnifying the importance of understanding the educational impact of FLS on specific case types. This study reviewed the impact of FLS certification and other factors on the incidence of bile duct injury in a large insurance claims database. METHODS In total, 53,632 LCs were reviewed from July 2009 to December 2010 from a large private payer claims database. Surgeon National Provider Identifier (NPI), FLS certification status, International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) were available for each event. Each record was analyzed for evidence of any bile duct injury based on associated CPT or ICD-9 data in the claim record. Characteristics of the FLS+ and FLS- surgeon groups were analyzed by a separate reviewer blinded to clinical outcome on a large scale. RESULTS A total of 53,632 LCs were reviewed; 1748 LC were performed by 441 FLS+ surgeons; and 58,870 LCs by 10,851 FLS- surgeons. (Some procedures involved more than one surgeon). Eighty-two BDIs were identified: 8 in the FLS+ and 74 in the FLS- group. The FLS+ group had a higher rate of BDI than the FLS- group (0.47 vs. 0.14 %, p = 0.0013); however, the FLS+ group was also younger (mean age 38.2 FLS+ vs. 50.4 years) and had significantly fewer years in practice (FLS+ = 6.1 vs. FLS- = 20.7, p = 0.0012). No other complications showed differences between the groups. CONCLUSION NPI can be used as a linking intermediary between skills certification and outcomes on claims databases. FLS certification was not associated with a reduction in bile duct injury in this analysis, but FLS+ surgeons were also younger and less experienced overall. Since FLS lacks content specific to BDI, large-scale validated training and assessment programs targeted at BDI prevention are needed to impact the rate of this complication during cholecystectomy.


title: Exosome mimicry by a HAVCR1-NPC1 pathway of endosomal fusion mediates hepatitis A virus infection.

text: Cell-to-cell communication by exosomes controls normal and pathogenic processes1,2. Viruses can spread in exosomes and thereby avoid immune recognition3. While biogenesis, binding and uptake of exosomes are well characterized4,5, delivery of exosome cargo into the cytoplasm is poorly understood3. We report that the phosphatidylserine receptor HAVCR1 (refs. 6,7) and the cholesterol transporter NPC1 (ref. 8) participate in cargo delivery from exosomes of hepatitis A virus (HAV)-infected cells (exo-HAV) by clathrin-mediated endocytosis. Using CRISPR-Cas9 knockout technology, we show that these two lipid receptors, which interact in the late endosome9, are necessary for the membrane fusion and delivery of RNA from exo-HAV into the cytoplasm. The HAVCR1-NPC1 pathway, which Ebola virus exploits to infect cells9, mediates HAV infection by exo-HAV, which indicates that viral infection via this exosome mimicry mechanism does not require an envelope glycoprotein. The capsid-free viral RNA in the exosome lumen, but not the endosomal uncoating of HAV particles contained in the exosomes, is mainly responsible for exo-HAV infectivity as assessed by methylene blue inactivation of non-encapsidated RNA. In contrast to exo-HAV, infectivity of HAV particles is pH-independent and requires HAVCR1 or another as yet unidentified receptor(s) but not NPC1. Our findings show that envelope-glycoprotein-independent fusion mechanisms are shared by exosomes and viruses, and call for a reassessment of the role of envelope glycoproteins in infection.


Efficacy of MSC for steroid-refractory acute GVHD associates with MSC donor age and a defined molecular profile.


title: Acellular dermal matrix in abdominal wall reconstruction.

text: Abdominal wall reconstruction is a complex and challenging surgical undertaking. While permanent prosthetic mesh is considered the gold standard for minimizing hernia recurrence, placement of synthetic mesh is sometimes imprudent due to contamination or risk of infection. Acellular dermal matrices (ADM) offer an exciting biologic alternative. This article provides a historical perspective on the evolution of complex ventral hernia repair leading up to and including the placement of ADM, an explanation of the biology of ADM as it relates to ventral hernia repair, and a description of the current indications, techniques, benefits, and shortcomings of its use in the abdominal wall.


title: 3D imaging and stealth navigation instead of CT guidance for radiofrequency ablation of osteoid osteomas: a series of 52 patients.

text: BACKGROUND Osteoid osteomas are benign bone neoplasms that may cause severe pain and limit function. They are commonly treated by radiofrequency ablation (RFA) through a needle inserted into the nidus of the lesion under CT guidance, which is associated with exposure of young patients to relatively high dose of radiation. The objective of this study was to investigate the amount of radiation, effectiveness and safety of an alternative imaging approach, the 3D image-guided (O-arm) technology and the Stealth navigation. METHODS We retrospectively reviewed 52 electronic medical files of patients (mean age 24.7 years, range 8-59 years) who were treated with thermal ablation of benign osteoid osteomas guided by the navigated O-arm-assisted technique in our institution between 2015 and 2017. Data were extracted on the associated complications, the reduction in pain at 3 months and one year postoperatively, and the amount of radiation administered during the procedure. RESULTS The level of pain on a visual analogue scale decreased from the preoperative average of 7.73 to 0 at the 3-month follow-up. The mean dose-length product was 544.7 mGycm2 compared to the reported radiation exposure of 1971-7946 mGycm2 of CT-guided radio ablations. The one intra-operative complication was a superficial burn in the subcutaneous lesion in a tibia that was treated locally with no major influence on recovery. CONCLUSIONS RFA ablation guided by 3D O-arm stealth navigation is as effective as the traditional CT-guided technique with the advantage of lower radiation exposure. TRIAL REGISTRATION Retrospective study number 0388-17-TLV at Tel Aviv Sourasky Medical Center IRB, approved at 25.10.17.


title: New technologies in ambulatory thyroid surgery.

text: Thyroid operations are increasingly performed in the outpatient setting. In general the essential objectives for thyroidectomy are: sparing the parathyroid glands, avoidance of injury to the laryngeal nerves, an accurate hemostasis and an excellent cosmesis. In the last 10 years major improvements and new technologies have been proposed and applied in thyroid surgery; among these mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, intraoperative neuromonitoring, and PTH assay technology. This paper reviews relevant medical literature published on the influence of these new technologies on quality of thyroid surgery as well as prevention of postoperative morbidity and mortality. Searches were last updated April 2008.


title: Variability in Uremic Control during Continuous Venovenous Hemodiafiltration in Trauma Patients.

text: Introduction. Acute kidney injury (AKI) necessitating continuous renal replacement therapy (CRRT) is a severe complication in trauma patients (TP). We wanted to assess daily duration of CRRT and its impact on uremic control in TP. Material and Methods. We retrospectively reviewed adult TP, with or without rhabdomyolysis, with AKI undergoing CRRT. Data on daily CRRT duration and causes for temporary stops were collected from the first five CRRT days. Uremic control was assessed by daily changes in serum urea (Δurea) and creatinine (Δcreatinine) concentrations. Results. Thirty-six TP were included with a total of 150 CRRT days, 17 (43%) with rhabdomyolysis. The median (interquartile range (IQR)) time per day with CRRT was 19 (15-21) hours. There was a significant correlation between daily CRRT duration and Δurea (r = 0.60, P≤0.001) and Δcreatinine (r = 0.43; P = 0.012). CRRT pauses were caused by filter clotting (54%), therapeutic interventions (25%), catheter related problems (10%), filter timeout (6%), and diagnostic procedures (6%). Rhabdomyolysis did not affect the CRRT data. Conclusions. TP undergoing CRRT had short daily CRRT duration causing reduced uremic control. Clinicians should modify their daily clinical practice to improve technical skills and achieve sufficient dialysis dose.


title: Dual Roles of Group IID Phospholipase A2 in Inflammation and Cancer.

text: Phospholipase A2 enzymes have long been implicated in the promotion of inflammation by mobilizing pro-inflammatory lipid mediators, yet recent evidence suggests that they also contribute to anti-inflammatory or pro-resolving programs. Group IID-secreted phospholipase A2 (sPLA2-IID) is abundantly expressed in dendritic cells in lymphoid tissues and resolves the Th1 immune response by controlling the steady-state levels of anti-inflammatory lipids such as docosahexaenoic acid and its metabolites. Here, we show that psoriasis and contact dermatitis were exacerbated in Pla2g2d-null mice, whereas they were ameliorated in Pla2g2d-overexpressing transgenic mice, relative to littermate wild-type mice. These phenotypes were associated with concomitant alterations in the tissue levels of ω3 polyunsaturated fatty acid (PUFA) metabolites, which had the capacity to reduce the expression of pro-inflammatory and Th1/Th17-type cytokines in dendritic cells or lymph node cells. In the context of cancer, however, Pla2g2d deficiency resulted in marked attenuation of skin carcinogenesis, likely because of the augmented anti-tumor immunity. Altogether, these results underscore a general role of sPLA2-IID as an immunosuppressive sPLA2 that allows the microenvironmental lipid balance toward an anti-inflammatory state, exerting beneficial or detrimental impact depending upon distinct pathophysiological contexts in inflammation and cancer.


Emergency Palliative Care Planning and Support in a COVID-19 Pandemic.


title: CLINICAL AND EPIDEMIOLOGICAL CHARACTERISTICS OF PATIENTS DIAGNOSED WITH COVID-19 IN A TERTIARY CARE CENTER IN MEXICO CITY: A PROSPECTIVE COHORT STUDY.

text: Background Regional information regarding the characteristics of patients with coronavirus disease (COVID)-19 is needed for a better understanding of the pandemic. Objective The objective of the study to describe the clinical features of COVID-19 patients diagnosed in a tertiary-care center in Mexico City and to assess differences according to the treatment setting (ambulatory vs. hospital) and to the need of intensive care (IC). Methods We conducted a prospective cohort, including consecutive patients with COVID-19 from February 26, 2020 to April 11, 2020. Results We identified 309 patients (140 inpatients and 169 outpatients). The median age was 43 years (interquartile range, 33-54), 59.2% men, and 18.6% healthcare workers (12.3% from our center). The median body mass index (BMI) was 29.00 kg/m2 and 39.6% had obesity. Compared to outpatients, inpatients were older, had comorbidities, cough, and dyspnea more frequently. Twenty-nine (20.7%) inpatients required treatment in the IC unit (ICU). History of diabetes (type 1 or 2) and abdominal pain were more common in ICU patients compared to non-ICU patients. ICU patients had higher BMIs, higher respiratory rates, and lower room-air capillary oxygen saturations. ICU patients showed a more severe inflammatory response as assessed by white blood cell count, neutrophil and platelet count, C-reactive protein, ferritin, procalcitonin, and albumin levels. By the end of the study period, 65 inpatients had been discharged because of improvement, 70 continued hospitalized, and five had died. Conclusions Patients with comorbidities, either middle-age obese or elderly complaining of fever, cough, or dyspnea, were more likely to be admitted. At admission, patients with diabetes, high BMI, and clinical or laboratory findings consistent with a severe inflammatory state were more likely to require IC.


Purpose The locoregional interventional oncological treatment approach is an accepted modality for liver neoplasms, especially for hepatocellular carcinoma (HCC) and oligonodular liver metastases. Materials and Methods The main aim of ablation therapies like microwave ablation (MWA) is to eradicate all malignant cells in a minimally invasive technique under imaging guidance while preserving the healthy tissue with a sufficient safety margin (at least 5 mm) surrounding the ablated lesion. Results Ablation therapy can be performed via a percutaneous, laparoscopic or intraoperative approach under ultrasound, MRI or CT guidance for adequate localization and monitoring of the ablation process. Conclusion Ablation is the method of choice for oligonodular HCCs ≤ 3 cm. The technical success rate varies from 88 % to 98 % and progression-free survival (PFS) at 3 years from 27 % to 91.7 %. The same criteria apply to the therapy of liver metastases. Key Points · Careful selection of patients proves to be essential for optimum results of MWA. · Interventionists should be familiar with all aspects of complication and rapid assessment of imaging methods in order to evaluate induced damage by thermal ablation. · MWA seems to have some advantages over radiofrequency ablation, like shorter ablation time, less pain, less heat sink effect; however, scientific proof is needed. Citation Format · Vogl TJ, Nour-Eldin A, Hammerstingl RM et al. Microwave Ablation (MWA): Basics, Technique and Results in Primary and Metastatic Liver Neoplasms - Review Article. Fortschr Röntgenstr 2017; 189: 1055 - 1066.


title: Strategies to overcome host immunity to adenovirus vectors in vaccine development.

text: The first clinical evaluations of adenovirus (Ad)-based vectors for gene therapy were initiated in the mid-1990s and led to great anticipation for future utility. However, excitement surrounding gene therapy, particularly Ad-based therapy, was diminished upon the death of Jesse Gelsinger, and recent discouraging results from the HIV vaccine STEP trial have brought efficacy and safety issues to the forefront again. Even so, Ad vectors are still considered among the safest and most effective vaccine vectors. Innate and pre-existing immunity to Ad mediate much of the acute toxicities and reduced therapeutic efficacies observed following vaccination with this vector. Thus, innovative strategies must continue to be developed to reduce Ad-specific antigenicity and immune recognition. This review provides an overview and critique of the most promising strategies, including results from preclinical trials in mice and nonhuman primates, which aim to revive the future of Ad-based vaccines.


title: Cellular Scale Imaging of Transparent Retinal Structures and Processes Using Adaptive Optics Optical Coherence Tomography.

text: High-resolution retinal imaging is revolutionizing how scientists and clinicians study the retina on the cellular scale. Its exquisite sensitivity enables time-lapse optical biopsies that capture minute changes in the structure and physiological processes of cells in the living eye. This information is increasingly used to detect disease onset and monitor disease progression during early stages, raising the possibility of personalized eye care. Powerful high-resolution imaging tools have been in development for more than two decades; one that has garnered considerable interest in recent years is optical coherence tomography enhanced with adaptive optics. State-of-the-art adaptive optics optical coherence tomography (AO-OCT) makes it possible to visualize even highly transparent cells and measure some of their internal processes at all depths within the retina, permitting reconstruction of a 3D view of the living microscopic retina. In this review, we report current AO-OCT performance and its success in visualizing and quantifying these once-invisible cells in human eyes. Expected final online publication date for the Annual Review of Vision Science, Volume 6 is September 15, 2020. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.


Facing Covid-19 in Italy - Ethics, Logistics, and Therapeutics on the Epidemic's Front Line.


title: "Perioperative Presentation of COVID-19 Disease in a Liver Transplant Recipient".

text: In a recent issue of Hepatology, Drs. Qin and Wang report a case of a 37-year old patient with COVID-19 disease after undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC). While these are interesting data on the course of COVID-19 disease in an immunosuppressed patient, we would like to highlight some particularly important issues related to management of liver disease and post-transplant care.


title: Generation of VSV pseudotypes using recombinant ΔG-VSV for studies on virus entry, identification of entry inhibitors, and immune responses to vaccines.

text: Vesicular stomatitis virus (VSV) is a prototypic enveloped animal virus that has been used extensively to study virus entry, replication and assembly due to its broad host range and robust replication properties in a wide variety of mammalian and insect cells. Studies on VSV assembly led to the creation of a recombinant VSV in which the glycoprotein (G) gene was deleted. This recombinant (rVSV-ΔG) has been used to produce VSV pseudotypes containing the envelope glycoproteins of heterologous viruses, including viruses that require high-level biocontainment; however, because the infectivity of rVSV-ΔG pseudotypes is restricted to a single round of replication the analysis can be performed using biosafety level 2 (BSL-2) containment. As such, rVSV-ΔG pseudotypes have facilitated the analysis of virus entry for numerous viral pathogens without the need for specialized containment facilities. The pseudotypes also provide a robust platform to screen libraries for entry inhibitors and to evaluate the neutralizing antibody responses following vaccination. This manuscript describes methods to produce and titer rVSV-ΔG pseudotypes. Procedures to generate rVSV-ΔG stocks and to quantify virus infectivity are also described. These protocols should allow any laboratory knowledgeable in general virological and cell culture techniques to produce successfully replication-restricted rVSV-ΔG pseudotypes for subsequent analysis.


title: From colorectal cancer pattern to the characterization of individuals at risk: Picture for genetic research in Latin America.

text: Colorectal cancer (CRC) is one of the most common cancers in Latin America and the Caribbean, with the highest rates reported for Uruguay, Brazil and Argentina. We provide a global snapshot of the CRC patterns, how screening is performed, and compared/contrasted to the genetic profile of Lynch syndrome (LS) in the region. From the literature, we find that only nine (20%) of the Latin America and the Caribbean countries have developed guidelines for early detection of CRC, and also with a low adherence. We describe a genetic profile of LS, including a total of 2,685 suspected families, where confirmed LS ranged from 8% in Uruguay and Argentina to 60% in Peru. Among confirmed LS, path_MLH1 variants were most commonly identified in Peru (82%), Mexico (80%), Chile (60%), and path_MSH2/EPCAM variants were most frequently identified in Colombia (80%) and Argentina (47%). Path_MSH6 and path_PMS2 variants were less common, but they showed important presence in Brazil (15%) and Chile (10%), respectively. Important differences exist at identifying LS families in Latin American countries, where the spectrum of path_MLH1 and path_MSH2 variants are those most frequently identified. Our findings have an impact on the evaluation of the patients and their relatives at risk for LS, derived from the gene affected. Although the awareness of hereditary cancer and genetic testing has improved in the last decade, it is remains deficient, with 39%-80% of the families not being identified for LS among those who actually met both the clinical criteria for LS and showed MMR deficiency.


title: Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State.

text: Importance Hydroxychloroquine, with or without azithromycin, has been considered as a possible therapeutic agent for patients with coronavirus disease 2019 (COVID-19). However, there are limited data on efficacy and associated adverse events. Objective To describe the association between use of hydroxychloroquine, with or without azithromycin, and clinical outcomes among hospital inpatients diagnosed with COVID-19. Design, Setting, and Participants Retrospective multicenter cohort study of patients from a random sample of all admitted patients with laboratory-confirmed COVID-19 in 25 hospitals, representing 88.2% of patients with COVID-19 in the New York metropolitan region. Eligible patients were admitted for at least 24 hours between March 15 and 28, 2020. Medications, preexisting conditions, clinical measures on admission, outcomes, and adverse events were abstracted from medical records. The date of final follow-up was April 24, 2020. Exposures Receipt of both hydroxychloroquine and azithromycin, hydroxychloroquine alone, azithromycin alone, or neither. Main Outcomes and Measures Primary outcome was in-hospital mortality. Secondary outcomes were cardiac arrest and abnormal electrocardiogram findings (arrhythmia or QT prolongation). Results Among 1438 hospitalized patients with a diagnosis of COVID-19 (858 [59.7%] male, median age, 63 years), those receiving hydroxychloroquine, azithromycin, or both were more likely than those not receiving either drug to have diabetes, respiratory rate >22/min, abnormal chest imaging findings, O2 saturation lower than 90%, and aspartate aminotransferase greater than 40 U/L. Overall in-hospital mortality was 20.3% (95% CI, 18.2%-22.4%). The probability of death for patients receiving hydroxychloroquine + azithromycin was 189/735 (25.7% [95% CI, 22.3%-28.9%]), hydroxychloroquine alone, 54/271 (19.9% [95% CI, 15.2%-24.7%]), azithromycin alone, 21/211 (10.0% [95% CI, 5.9%-14.0%]), and neither drug, 28/221 (12.7% [95% CI, 8.3%-17.1%]). In adjusted Cox proportional hazards models, compared with patients receiving neither drug, there were no significant differences in mortality for patients receiving hydroxychloroquine + azithromycin (HR, 1.35 [95% CI, 0.76-2.40]), hydroxychloroquine alone (HR, 1.08 [95% CI, 0.63-1.85]), or azithromycin alone (HR, 0.56 [95% CI, 0.26-1.21]). In logistic models, compared with patients receiving neither drug cardiac arrest was significantly more likely in patients receiving hydroxychloroquine + azithromycin (adjusted OR, 2.13 [95% CI, 1.12-4.05]), but not hydroxychloroquine alone (adjusted OR, 1.91 [95% CI, 0.96-3.81]) or azithromycin alone (adjusted OR, 0.64 [95% CI, 0.27-1.56]), . In adjusted logistic regression models, there were no significant differences in the relative likelihood of abnormal electrocardiogram findings. Conclusions and Relevance Among patients hospitalized in metropolitan New York with COVID-19, treatment with hydroxychloroquine, azithromycin, or both, compared with neither treatment, was not significantly associated with differences in in-hospital mortality. However, the interpretation of these findings may be limited by the observational design.


Optimizing the Use Of Teleneurology During the COVID-19 Pandemic.


title: Presenting Features and Early Mortality from SARS-CoV-2 Infection in Cancer Patients during the Initial Stage of the COVID-19 Pandemic in Europe.

text: We describe the outcomes in cancer patients during the initial outbreak of the COVID-19 in Europe from the retrospective, multi-center observational OnCovid study. We identified 204 cancer patients from eight centers in the United Kingdom, Italy, and Spain aged > 18 (mean = 69) and diagnosed with COVID-19 between February 26th and April 1st, 2020. A total of 127 (62%) were male, 184 (91%) had a diagnosis of solid malignancy, and 103 (51%) had non-metastatic disease. A total of 161 (79%) had > 1 co-morbidity. A total of 141 (69%) patients had > 1 COVID-19 complication. A total of 36 (19%) were escalated to high-dependency or intensive care. A total of 59 (29%) died, 53 (26%) were discharged, and 92 (45%) were in-hospital survivors. Mortality was higher in patients aged > 65 (36% versus 16%), in those with > 2 co-morbidities (40% versus 18%) and developing > 1 complication from COVID-19 (38% versus 4%, p = 0.004). Multi-variable analyses confirmed age > 65 and > 2 co-morbidities to predict for patient mortality independent of tumor stage, active malignancy, or anticancer therapy. During the early outbreak of SARS-CoV-2 infection in Europe co-morbid burden and advancing age predicted for adverse disease course in cancer patients. The ongoing OnCovid study will allow us to compare risks and outcomes in cancer patients between the initial and later stages of the COVID-19 pandemic.


title: Diagnosis and management of Budd Chiari syndrome: an update.

text: Imaging plays a crucial role in the early detection and assessment of the extent of disease in Budd Chiari syndrome (BCS). Early diagnosis and intervention to mitigate hepatic congestion is vital to restoring hepatic function and alleviating portal hypertension. Interventional radiology serves a key role in the management of these patients. The interventionist should be knowledgeable of the clinical presentation as well as key imaging findings, which often dictate the approach to treatment. This article concisely reviews the etiology, pathophysiology, and clinical presentation of BCS and provides a detailed description of imaging and treatment options, particularly interventional management.


title: Immunoregulatory Potential of Exosomes Derived from Cancer Stem Cells.

text: Head and neck squamous cell carcinomas (HNSCCs) are malignancies that originate in the mucosal lining of the upper aerodigestive tract. Despite advances in therapeutic interventions, survival rates amongst HNSCC patients have remained static for years. Cancer stem cells (CSCs) are tumor initiating cells that are highly resistant to treatment, and are hypothesized to contribute to a significant fraction of tumor recurrences. Consequently, further investigations of how CSCs mediate recurrence may provide insights into novel druggable targets. A key element of recurrence involves the tumor's ability to evade immunosurveillance. Recent published reports suggest that CSCs possess immunosuppressive properties, however, the underlying mechanism have yet to be fully elucidated. To date, most groups have focused on the role of CSC-derived secretory proteins, such as cytokines and growth factors. Here, we review the established immunoregulatory role of exosomes derived from mixed tumor cell populations, and propose further study of CSC-derived exosomes may be warranted. Such studies may yield novel insights into new druggable targets, or lay the foundation for future exosome-based diagnostics.


title: Transcriptomic analysis reveals a mechanism for a prefibrotic phenotype in STAT1 knockout mice during severe acute respiratory syndrome coronavirus infection.

text: Severe acute respiratory syndrome coronavirus (SARS-CoV) infection can cause the development of severe end-stage lung disease characterized by acute respiratory distress syndrome (ARDS) and pulmonary fibrosis. The mechanisms by which pulmonary lesions and fibrosis are generated during SARS-CoV infection are not known. Using high-throughput mRNA profiling, we examined the transcriptional response of wild-type (WT), type I interferon receptor knockout (IFNAR1-/-), and STAT1 knockout (STAT1-/-) mice infected with a recombinant mouse-adapted SARS-CoV (rMA15) to better understand the contribution of specific gene expression changes to disease progression. Despite a deletion of the type I interferon receptor, strong expression of interferon-stimulated genes was observed in the lungs of IFNAR1-/- mice, contributing to clearance of the virus. In contrast, STAT1-/- mice exhibited a defect in the expression of interferon-stimulated genes and were unable to clear the infection, resulting in a lethal outcome. STAT1-/- mice exhibited dysregulation of T-cell and macrophage differentiation, leading to a TH2-biased immune response and the development of alternatively activated macrophages that mediate a profibrotic environment within the lung. We propose that a combination of impaired viral clearance and T-cell/macrophage dysregulation causes the formation of prefibrotic lesions in the lungs of rMA15-infected STAT1-/- mice.


title: Characteristics and diagnostic profile of patients seeking dementia care in a memory clinic in Hong Kong.

text: BACKGROUND Seeking medical advice for dementia involves an understanding of norms, values and attitudes towards care-giving and inter-dependency, which are culturally bounded. We hypothesize that local culture and socioeconomic structure affect our Chinese patients who present with forgetfulness to our memory clinic. METHODS A retrospective case notes review was undertaken on 454 consecutive patients referred to the memory clinic at Princess Margaret Hospital, Hong Kong. RESULTS 385 patients were diagnosed with dementia and 27 had mild cognitive impairment. Reversible dementia was identified in 24 patients and normal cognition in 18. In patients with dementia, 55.8% had Alzheimer's disease, 26.2% had vascular dementia, 6.0% had other irreversible dementia, 5.2% had dementia with Lewy bodies, 4.9% had undetermined dementia and 1.8% had frontotemporal dementia. The median duration from symptom onset to medical consultation was two years; 66.5% had advanced disease with initial Mini-mental State Examination scores < or = 17. On their first visit, 85% of patients were living in the community; after two years this proportion had fallen to 63%. CONCLUSIONS Dementia patients in Hong Kong apparently enjoy a long subclinical period and only seek medical attention at late stages. Local Chinese culture and socioeconomic backgrounds could be the main reasons that underlie these observations.


title: The Pipeline embolization device for treatment of intracranial aneurysms.

text: Flow diversion is a new endovascular technique developed for treatment of intracranial aneurysms. It is based on stent-induced modification of blood flow within and around an aneurysm inflow zone, leading to gradual intra-aneurysmal thrombosis and subsequent atrophy, while preserving flow into the parent vessel and perforating branches. Flow-diversion technique is well-suited for the treatment of large, giant, wide-necked, and fusiform intracranial aneurysms because it does not rely on endosaccular packing with coils but rather on the strategy of placing a stent across the aneurysm "neck" or across the diseased segment of a vessel in case of a fusiform aneurysm. Over time, neointimal endothelium covers the flow diverter such that it becomes incorporated into the parent vessel wall and occludes the aneurysm from the circulation, effectively repairing the diseased parent vessel segment. This report describes in detail the Pipeline embolization device (ev3-Covidien, Irvine, California, USA), its mechanism of action and deployment technique, and reviews the pertinent literature regarding safety, efficacy and potential risks and complications associated with the use of this flow diverter.


title: End-to-end cervical esophagogastric anastomoses are associated with a higher number of strictures compared with end-to-side anastomoses.

text: BACKGROUND Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses. METHODS A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed. RESULTS The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p = 0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p = 0.04). Moreover, a median of 11 (7-17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2-8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p < 0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p = 0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p = 0.03 and p = 0.01, respectively). CONCLUSION The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.


title: Treating acute anxiety in patients with COVID-19.

text: At present, there are no firm guidelines for the treatment of COVID-19-related emotional distress. The current approach is based on our knowledge of how to manage anxiety in medically ill patients, taking into consideration all associated medical comorbidities, drug-drug interactions, and the patient's specific needs and preexisting mental illness. Interventions should be implemented at the bedside to augment the patient's own resiliency in coping with these stressful events. A targeted combination of psychopharmacology (targeting acute anxiety and panic symptoms) and psychotherapy (relaxation techniques, breathing exercises, and encouragement) is recommended.


title: Mesh fixation in open IPOM procedure with tackers or sutures? A randomized clinical trial with preliminary results.

text: PURPOSE In open intra-peritoneal onlay mesh (IPOM) hernia repair, mesh fixation can be done by tacks, sutures or fibrin glue. There are randomized controlled trials (RCTs) on laparoscopic IPOM procedure, but no RCT so far has examined mesh fixation techniques in open IPOM repair. METHODS In a single-center RCT, 48 patients undergoing open IPOM repair of an abdominal wall hernia were included. After randomization, surgery was performed in a standardized fashion. Hernia size, extent of mesh fixation, and duration of surgery were documented. The primary endpoint was postoperative pain intensity. Secondary endpoints were: complications, length of stay, quality of life, return to work, hernia recurrence. Follow-up was 1 year in all 48 patients. RESULTS After using tacks, mean pain intensity was 16.9, which is slightly lower than after suture fixation (19.6, p = 0.20). The duration of surgery was about the same (83 vs. 85 min). When using tack fixation, significantly more fixation points were applied as compared to sutures (19 vs. 12; p = 0.02), although mesh size was similar. The complication rate was similar (tacks: 6/28 vs. sutures: 3/20). Cost of suture fixation was about 26 €, which is markedly lower than the 180 € associated with tacks. However, surgeons clearly preferred mesh fixation with tacks, because it is more comfortable especially in small hernias. CONCLUSIONS The present study failed to show an advantage of tacks over suture fixation and even there are more severe adverse events. Using tacks significantly increases the costs of hernia repair.