title: Chronic cerebrospinal venous insufficiency in multiple sclerosis: diagnostic, pathogenetic, clinical and treatment perspectives.

text: Chronic cerebrospinal venous insufficiency (CCSVI) was recently described in multiple sclerosis patients. CCSVI is characterized by impaired brain venous drainage due to outflow obstruction in the extracranial venous system, mostly related to anomalies in the internal jugular and azygos veins. The current CCSVI diagnosis is based on Doppler sonography of extracranial and transcranial venous hemodynamics criteria. To date, prevalence estimates of CCSVI, provided by different groups using various imaging methods of assessment, vary widely from none to 100%. There is an urgent need to define and validate the spectrum of cranial/extracranial venous anomalies and to establish reliable, diagnostic gold-standard test(s). The potential usefulness of endovascular treatment for CCSVI in multiple sclerosis patients is still unknown.


docid: mszfwdcr

title: CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 13-2016. A 49-Year-Old Woman with Sudden Hemiplegia and Aphasia during a Transatlantic Flight.


Online management of rheumatoid arthritis during COVID-19 pandemic.


title: Monitoring of Brain Hemodynamics Coupling in Neonates using Updated Tensor Decompositions.

text: In this paper we explore the use of updated tensor decompositions for the monitoring of brain hemodynamics in neonates. For this study, we used concomitant measurements of heart rate, mean arterial blood pressure, arterial oxygen saturation, EEG, and brain oxygenation - measured using near-infrared spectroscopy. These measurements were obtained from 22 neonates undergoing an INSURE procedure (INtubation, SURfactant and Extubation) and sedation using propofol. To develop the monitoring framework using tensors, we used radial basis kernel function (RBF) to construct a similarity matrix for consecutive segments of the signals. These matrices were concatenated forming a tensor. Updating canonical polyadic decomposition was used to evaluate the impact of propofol in the coupling between the different signals. Results indicate, as previously reported, a drop in the interaction between signals due to propofol administration. This shows that tensor decompositions can be useful in order to monitor the coupling between different physiological signals.


title: Impact of the preoperative body composition indexes on intraoperative blood loss in patients undergoing pancreatoduodenectomy.

text: PURPOSES This study sought to identify any significant predictors of blood loss during pancreatoduodenectomy (PD) among preoperative variables, including the body composition indexes. METHODS The preoperative data of patients undergoing PD were retrospectively reviewed. The objective variable was the percentage of blood loss during PD to the estimated circulating blood volume (proportional blood loss: PBL). The circulating blood volume was estimated using Nadler's formula. The total psoas area, average Hounsfield units of psoas area (psoas muscle density: PMD), and visceral to subcutaneous adipose tissue area ratio (VSR) were measured at the third vertebra using preoperative plain computed tomography images. A univariate analysis and multiple linear regression analysis for PBL were conducted using the preoperative variables. RESULTS A total of 415 patients were analyzed. The median PBL was 24.5%. The PMD (coefficient - 0.267; 95% CI - 0.518, - 0.015), VSR (coefficient 2.719; 95% CI 0.238, 5.201), serum albumin level (coefficient - 8.458; 95% CI - 13.02, - 3.898), neoadjuvant therapy (coefficient 9.605; 95% CI 1.722, 17.49), and prothrombin time-international normalized ratio (PT-INR, coefficient 38.63; 95% CI 10.94, 66.31) were independently associated with PBL. CONCLUSIONS The preoperative PMD, VSR, serum albumin level, neoadjuvant therapy, and PT-INR independently affected PBL. These factors could therefore be potential targets to reduce blood loss during PD.


Routine laboratory testing before endoscopic procedures.


docid: priiggyi

title: Coronavirus (COVID-19) Infection-Induced Chilblains: A Brisk Perieccrine Inflammatory Response.

text: The varying cutaneous and pathological manifestations of coronavirus 2 (SARS-CoV-2 or COVID-19) may have prognostic implications. Acral ischemic findings present with a hypercoagulable state in critically ill COVID-19 patients. Pathologically confirmed varicella-like exanthem and perniosis COVID-19 cases have correlated with paucisymptomatic and asymptomatic patients in previous reports. We present the second case of biopsy-proven COVID-19 infection-induced chilblains (pernio) in a paucisymptomatic patient with a brisk perieccrine lymphocytic response. Based on an antecedent pathological study, we know coronavirus particles have been seen in the eccrine gland associated with a brisk peri-inflammatory response. The prominent perieccrine inflammation is helpful in the diagnosis of COVID-19 infections. Currently, nonischemic pathological findings correlate with a good prognosis based on the paucisymptomatic or asymptomatic nature of their disease courses. Patients presenting with suspected COVID-19 infection-induced chilblains who are paucisymptomatic or asymptomatic should be isolated and immediately tested with polymerase chain reaction (PCR) testing (as there is a delay in diagnosis based on the poor sensitivity of the current rapid test). We continue to stress the importance of early diagnosis and quarantining to prevent spread to the older and immunocompromised patients.


Heparin-Induced Hyperkalemia in a Dog Receiving Continuous Renal Replacement Treatment.


title: A systematic review of cerebral oxygenation-monitoring devices in cardiac surgery.

text: OBJECTIVE Cerebral oxygenation monitoring via near-infrared spectroscopy (NIRS) during cardiopulmonary bypass (CPB) is increasingly becoming an accepted and valued component of intraoperative monitoring. In recent years, new devices have become available which all make different claims. The purpose of this study is to examine the research on these individual devices to establish the levels of evidence for each and formulate a research path for further evaluation of this technology in cardiac surgery. METHODS This study is a systematic review of published research on cerebral oximetry. We searched PubMed, CINAHL and Scopus for full-length, peer-reviewed articles containing original data resulting from the study of patient neurologic outcomes based on the use of FDA-approved near-infrared spectroscopy devices. The studies were then grouped and classified based on the device used and the levels of evidence each study provided. RESULTS Only a very limited number of high-level clinical evidence research papers are currently available, with nearly all of those papers based on the INVOS system. This is likely due to the different lengths of time each device has been on the market and its availability for use in clinical trials. Challenges to testing include the expense of testing various devices, the lack of a globally accepted gold standard for cerebral oxygenation saturation, the limited availability of patient frontal surface area and the gradual adoption of this technology. Despite these limitations, significant results have been identified in relation to patient outcomes. CONCLUSION At this time, there is limited high-level evidence available for all of the NIRS devices on the market despite significant outcomes found in these studies. Additional prospective randomized studies should be conducted in order to establish the potential role NIRS may play in patient monitoring as well as assessing the efficacy of the multiple devices on the market.


title: Protecting health during COVID-19 and beyond: A global examination of paid sick leave design in 193 countries.

text: Well-designed paid sick leave is critical to ensure workers stay home when sick to prevent the spread of SARS-CoV-2 and other infectious pathogens, both when the economy is open and during an economic shutdown. To assess whether paid sick leave is available in countries around the world, we created and analysed a database of legislative guarantees of paid leave for personal illness in 193 UN member states. Original labour and social security legislation and global information on social security systems for each country were obtained and analysed by a multilingual research team using a common coding framework. While strong models exist across low- middle- and high-income countries, critical gaps that jeopardise health and economic security remain. 27% of countries do not guarantee paid sick leave from the first day of illness, essential to encouraging workers to stay home when they are sick and prevent spread. 58% of countries do not have explicit provisions to ensure self-employed and gig economy workers have access to paid sick leave benefits. Comprehensive paid sick leave policies that cover all workers are urgently needed if we are to reduce the spread of COVID-19, and be ready to respond to threats from new pathogens.


title: Prevalence and clinical characterization of a newly identified human rhinovirus C species in children with acute respiratory tract infections.

text: Human rhinovirus C (HRV-C) is a newly identified genotype of HRV found in patients with respiratory tract infections (RTIs); however, its epidemiological profile and clinical characteristics are not well understood. In this study, Chinese children with RTIs were screened for HRV-C and their epidemiological and clinical characteristics were analyzed. From December 2006 to November 2007, 406 nasopharyngeal aspirates from children younger than 14 years of age with RTIs were screened for HRV and other common respiratory viruses by PCR or reverse transcription-PCR. Two-hundred twenty-four (55.2%) of the specimens were infected with at least one virus, including 53 patients with HRV (13%). HRV-A, HRV-B, and HRV-C were detected in 22, 12, and 19 specimens, respectively. HRV-C was detected mainly from December 2006 to April 2007 and from October to November 2007, with peaks in December and April (10/19). Acute upper respiratory infection and bronchopneumonia were observed in 53 and 37% of the cases, respectively. The most common symptoms were cough (82%), runny nose (53%), and fever (37%). Wheezing and bronchiolitis were less common in patients infected with HRV-C than in those infected with respiratory syncytial virus (RSV). Partial sequencing of the genes coding for VP4 and VP2 revealed that the HRV-C strains were 56 to 62% identical at the amino acid level to HRV-B and HRV-A reference strains and 80 to 99% identical to HRV-C reference strains. In conclusion, HRV-C is an important cause of RTIs in children, and highly diversified strains of HRV-C are prevalent in China. HRV-C may produce different epidemiological features, and patients infected with HRV-C may exhibit different clinical features from patients infected with RSV or HRV-A/B.


docid: bufcuvzd

title: The effect of renal denervation on kidney oxygenation as determined by BOLD MRI in patients with hypertension.

text: OBJECTIVES Renal denervation (RDN) is a promising therapy for resistant hypertension. RDN is assumed to decrease sympathetic activity. Consequently, RDN can potentially increase renal oxygenation. Blood oxygen level-dependent MRI (BOLD-MRI) provides a non-invasive tool to determine renal oxygenation in humans. The aim of the current study was to investigate the effect of RDN on renal oxygenation as determined by BOLD-MRI. METHODS Patients with resistant hypertension or the inability to follow a stable drug regimen due to unacceptable side effects were included. BOLD-MRI was performed before and 12 months after RDN. Twenty-seven patients were imaged on 3 T and 19 on 1.5 T clinical MRI systems. RESULTS Fifty-four patients were included, 46 patients (23 men, mean age 57 years) completed the study. Mean 24-h BP changed from 163(±20)/98(±14) mmHg to 154(±22)/92(±13) mmHg (p = 0.001 and p < 0.001). eGFR did not change after RDN [77(±18) vs. 79(±20) mL/min/1.73 m(2); p = 0.13]. RDN did not affect renal oxygenation [1.5 T: cortical R2*: 12.5(±0.9) vs. 12.5(±0.9), p = 0.94; medullary R2*: 19.6(±1.7) vs. 19.3(1.4), p = 0.40; 3 T: cortical R2*: 18.1(±0.8) vs. 17.8(±1.2), p = 0.47; medullary R2*: 27.4(±1.9) vs. 26.7(±1.8), p = 0.19]. CONCLUSION The current study shows that RDN does not lead to changes in renal oxygenation 1 year after RDN as determined by BOLD-MRI. KEY POINTS • Renal denervation significantly decreased ambulatory blood pressure. • Renal denervation did not change renal oxygenation as determined by BOLD-MRI. • Absence of a change in renal oxygenation might be explained by autoregulation.


In pursuit of open science, open access is not enough.


title: Trans-gastric pancreaticogastrostomy reconstruction after pylorus-preserving robotic Whipple: a proposal for a standardized technique.

text: BACKGROUND A number of technical improvements regarding the pancreatic anastomosis have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) remains is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined. MATERIALS AND METHODS This study is a retrospective review of a prospectively maintained database. Data were collected from all consecutive robot-assisted pancreaticoduodenectomies (RAPD), performed by a single surgeon, at the University of Illinois Hospital & Health Sciences System, between September 2007 and January 2016. RESULTS A total of 28 consecutive patients (16 male and 12 female) who underwent a RAPD were included in this study. Patients had a mean age and mean BMI of 61.5 years (SD = 12.3) and 27 kg/m2 (SD = 4.9), respectively. The mean operative time was 468.2 min (SD = 73.7) and the average estimated blood loss was 216.1 ml (SD = 113.1). The mean length of hospitalization was 13.1 days (SD = 5.4). There was no clinically significant POPF registered. CONCLUSION Trans-gastric pancreaticogastrostomy (TPG) represents a valid and feasible option as a pancreatic digestive reconstruction during RAPD. Initial results showed decreased incidence of POPF with an increased risk of postoperative bleeding. Our experience suggests that TPG might be safer than pancreaticojejunostomy (PJ); further studies are needed in order to confirm.


title: The immediate effect of multiple mechanical impulses on electromyography and pressure pain threshold of lumbar latent trigger points: an experimental study.

text: BACKGROUND Myofascial pain is a common syndrome, which has not been studied extensively in the low back. Despite a variety of manual and instrument assisted interventions available, little work has targeted the possible effects of fast mechanical impulses on myofascial trigger points (MTrPs) on its sensitivity and electrical activity. The purpose of this experimental study was to quantify the immediate effect of one session of mechanical impulses to lumbar latent MTrPs and to normal muscle tissue with pressure pain threshold (PPT) and surface electromyography (sEMG) as outcome measures. METHODS During the autumn of 2009, in 41 asymptomatic subjects between 17-40 years of age the lumbar musculature was searched for a latent MTrP by a trained clinician. Using 3 disposable pre-gelled electrodes bilaterally, sEMG was recorded continuously from muscle containing either latent or no MTrP. Both the trigger point group and control group received the intervention and were blinded to group allocation. The immediate effects of mechanical impulses were assessed by sEMG and PPT before and after intervention using Wilcoxon matched-pairs signed-ranks test, Mann-Whitney U test and paired t-tests. RESULTS The PPT increased significantly across both groups (p < 0.01) after intervention. The proportionate increase (14.6 %) was comparable in both MTrP and control groups. The electrical activity on the MTrP side was not significantly higher in the MTrP group compared to the contralateral side. The decrease of resting electrical activity after intervention was significant in the MTrP group on the side of the latent MTrP (P = 0.001) as well as the contralateral side (p=0.022), and not significant in the control group on either side (p=0.33 and p=0.93). CONCLUSION In this study, the immediate effect of one session of mechanical impulses was associated with a significant increase in PPT for both groups and a significant decrease in the resting electrical activity of the lumbar muscles only in the MTrP group. It is unknown if these effects have clinical significance.


title: Case-matched series of a non-cross-linked biologic versus non-absorbable mesh in laparoscopic ventral rectopexy.

text: PURPOSE Laparoscopic ventral mesh rectopexy (LVR) is an emerging technique for selected patients with rectal prolapse and obstructed defaecation syndrome. Data are insufficient to conclude which type of mesh affords the greatest benefit. Our aim was to compare the outcomes of LVR using a non-cross-linked biologic versus a permanent mesh. METHODS Twenty nine cases of LVR with permanent mesh were matched based on age and surgical indication with an equal number of patients using biologic mesh. Cases were retrospectively reviewed from a prospectively maintained database. Symptom resolution, patient satisfaction and recurrence of prolapse were measured among those who underwent LVR with either a biologic (Biodesign(®), Cook Medical) or polypropylene mesh. RESULTS Age, American Society of Anesthesiologists (ASA) class, surgical indication and primary symptoms were not different between the two groups. After a median follow-up of 15.4 months, all patients reported being either completely or partially satisfied. Rates of complete or partial symptom resolution (p = 0.26) or satisfaction (p = 0.27) did not differ between groups. After LVR, similar rates of additional procedures were performed in the biologic (21 %) and the permanent (28 %) mesh group. Among patients with full-thickness prolapse (n = 33), there were five cases (15 %) of recurrence, one in the biologic group and four in the permanent mesh group (p = 0.37). There were no mesh-related complications in either group. CONCLUSIONS LVR using a non-cross-linked biologic mesh appears to have comparable rates of symptom improvement and patient satisfaction in the short term. Longer follow-up will be required to determine if prolapse recurrence depends on mesh type.


title: Motivational interviewing to promote health outcomes and behaviour change in multiple sclerosis: a systematic review.

text: OBJECTIVE To examine the evidence for motivational interviewing when used to assist individuals with multiple sclerosis manage their healthcare. DATA SOURCES The Cochrane, Embase, PsycINFO and PubMed databases were searched for studies published between 1983 and December 2019. The reference lists of included studies were additionally examined and Scopus citation searches conducted. REVIEW METHODS Study screening and data extraction were independently completed by two reviewers. Randomised controlled trials comparing motivational interviewing interventions for multiple sclerosis to usual care, wait-list or other active intervention controls were examined. Studies were assessed using the Cochrane Risk of Bias tool. Standardised mean differences (Hedges' g), 95% confidence intervals and P values were calculated for all health and behavioural outcomes. RESULTS Ten randomised controlled trials, involving a pooled sample of 987 adults with relapsing-remitting or progressive multiple sclerosis and mild to moderate impairment, were identified. Most trials had a low or unclear risk of methodological bias. Motivational interviewing, when used in conjunction with other counselling or rehabilitation techniques, resulted in significant immediate medium-to-very large improvements in multiple physical, psychological, social and behavioural outcomes (range: g = .34-2.68). Maintenance effects were promising (range: g = .41-1.11), although less frequently assessed (Nstudies = 5) and of limited duration (1-7 months). Individual and group-based interventions, delivered in-person or by telephone, were all effective. CONCLUSIONS Motivational interviewing is a flexible counselling technique that may improve rehabilitation care for multiple sclerosis. However, evidence for persisting benefits to health outcomes and behaviour is currently limited.


title: Autologous fat grafting: use of closed syringe microcannula system for enhanced autologous structural grafting.

text: OBJECTIVES Provide background for use of acquiring autologous adipose tissue as a tissue graft and source of adult progenitor cells for use in cosmetic plastic surgery. Discuss the background and mechanisms of action of closed syringe vacuum lipoaspiration, with emphasis on accessing adipose-derived mesenchymal/stromal cells and the stromal vascular fraction (SVF) for use in aesthetic, structural reconstruction and regenerative applications. Explain a proven protocol for acquiring high-quality autologous fat grafts (AFG) with use of disposable, microcannula systems. DESIGN Explain the components and advantage of use of the patented super luer-lock and microcannulas system for use with the closed-syringe system. A sequential explanation of equipment selection for minimally traumatic lipoaspiration in small volumes is presented, including use of blunt injection cannulas to reduce risk of embolism. RESULTS Thousands of AFG have proven safe and efficacious for lipoaspiration techniques for large and small structural fat grafting procedures. The importance and advantages of gentle harvesting of the adipose tissue complex has become very clear in the past 5 years. The closed-syringe system offers a minimally invasive, gentle system with which to mobilize subdermal fat tissues in a suspension form. Resulting total nuclear counting of undifferentiated cells of the adipose-derived -SVF suggests that the yield achieved is better than use of always-on, constant mechanical pump applied vacuum systems. CONCLUSION Use of a closed-syringe lipoaspiration system featuring disposable microcannulas offers a safe and effective means of harvesting small volumes of nonmanipulated adipose tissues and its accompanying progenitor cells within the SVF. Closed syringes and microcannulas are available as safe, sterile, disposable, compact systems for acquiring high-quality AFG. Presented is a detailed, step-by-step, proven protocol for performing quality autologous structural adipose transplantation.


title: Management of early-stage esophageal neoplasia (MESEN) consensus.

text: BACKGROUND Treatment of esophageal adenocarcinoma often involves surgical resection. Newer technologies in interventional endoscopy have led to a substantial paradigm shift in the management of early-stage neoplasia in Barrett's esophagus comprising high-grade dysplasia (HGD), intramucosal carcinoma, and, in some cases, submucosal carcinoma. However, there has been no consensus regarding the indications for esophageal preservation in these cases. In this work, consensus guidelines were established for the management of early-stage esophageal neoplasia considering clinically relevant aspects (age, comorbidities, and social environment) in each scenario. METHODS Seventeen experts were invited to participate based on their background and clinical expertise at high-volume centers. A questionnaire was created that included four clinical scenarios covering a wide range of situations within HGD and/or early esophageal neoplasia, particularly where controversies are likely to exist. Each of the clinical scenarios was open to discussion subdivided by patient age (20, 50, and 80 s). For each clinical scenario an expert was chosen to defend that position. Each defense triggered a subsequent discussion during a consensus meeting. Conclusions of that discussion together with an accompanying literature analysis allowed experts to confirm or change their original choices and served as the basis for the recommendations stated in this article. RESULTS There was 100 % consensus supporting esophageal preservation in patients with HGD, independent of patient age or Barrett's length. In patients with T1a adenocarcinoma, consensus for preservation was not reached (65 %) for young and middle-aged individuals but was supported for elderly patients (100 %). For T1b adenocarcinoma, consensus was reached for surgical resection (90 %), leaving organ preservation for patients with very low risk of nodal invasion or poor surgical candidates. CONCLUSION Advances in endoscopic imaging and therapy allow for organ preservation in most settings of early-stage neoplasia of the esophagus, provided that the patient understands the implications of this decision.


title: Interferon-stimulated genes: a complex web of host defenses.

text: Interferon-stimulated gene (ISG) products take on a number of diverse roles. Collectively, they are highly effective at resisting and controlling pathogens. In this review, we begin by introducing interferon (IFN) and the JAK-STAT signaling pathway to highlight features that impact ISG production. Next, we describe ways in which ISGs both enhance innate pathogen-sensing capabilities and negatively regulate signaling through the JAK-STAT pathway. Several ISGs that directly inhibit virus infection are described with an emphasis on those that impact early and late stages of the virus life cycle. Finally, we describe ongoing efforts to identify and characterize antiviral ISGs, and we provide a forward-looking perspective on the ISG landscape.


title: [Case report: Aneurysmatic subarachnoid hemorrhage -- complicated course due to coincidental manifestation of an inverted Tako-Tsubo-cardiomyopathy].

text: We report the case of a patient who suffered a serious subarachnoid hemorrhage with a cardialaffection and development of an inverted Tako-Tsubo-cardiomyopathy. To avoid apparent cerebral ischemia due to severe cerebral vasospasm after exhaustion of conservative therapeutic options a temporarily endovascular therapy with continuous intra-arterial application of Nimodipine was necessary. In the overall protracted and complicated course the special challenge were the therapeutic efforts to avoid apparent cerebral ischemia in context to the significant cardial affection.


title: Glycaemic Control Among People with Type 1 Diabetes During Lockdown for the SARS-CoV-2 Outbreak in Italy

text: INTRODUCTION: In late February 2020, due to the spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the Italian Government closed down all educational and sport activities. In March, it introduced further measures to stop the spread of coronavirus disease (COVID-19), placing the country in a state of almost complete lockdown. We report the impact of these restrictions on glucose control among people with type 1 diabetes (T1D). METHODS: Data were collected on 33 individuals with T1D who were monitoring their glucose levels using a flash glucose monitoring device and remotely connected to the diabetes clinic on a cloud platform. We retrieved information on average glucose, standard deviation and percentage time in hypoglycaemia (< 70 mg/dl), glucose range (70–180 mg/dl) and hyperglycaemia (> 180 mg/dl). We compared glycaemic measures collected during lockdown to those collected before the SARS-CoV-2 epidemic and to the periods immediately before lockdown. RESULTS: In 20 patients who had stopped working and were at home as a result of the lockdown, overall glycaemic control improved during the first 7 days of the lockdown as compared to the weeks before the spread of SARS-CoV-2. Average glucose declined from 177 ± 45 mg/dl (week before lockdown) to 160 ± 40 mg/dl (lockdown; p = 0.005) and the standard deviation improved significantly. Time in range increased from 54.4 to 65.2% (p = 0.010), and time in hyperglycaemia decreased from 42.3 to 31.6% (p = 0.016). The number of scans per day remained unchanged. In 13 patients who continued working, none of the measures of glycaemic control changed during lockdown. CONCLUSION: Despite the limited possibility to exercise and the incumbent psychologic stress, glycaemic control improved in patients with T1D who stopped working during the lockdown, suggesting that slowing down routine daily activities can have beneficial effects on T1D management, at least in the short term.


docid: avkfbfnm

title: Time-limited vs unlimited physician certification.


title: Tension Pneumothorax After Percutaneous Tracheostomy.

text: A 76-year-old woman with right mandibular gingival cancer was scheduled for surgery. A percutaneous tracheostomy kit was used for tracheostomy under intravenous sedation. After puncturing the cricothyroid membrane, a dilator was inserted along a guidewire. Bucking was observed at the time of insertion of the dilator, despite intratracheal lidocaine spray applied before insertion. After that, the tracheostomy tube was inserted, but no capnographic waveforms appeared when the tube was connected to the anesthesia circuit. Direct macroscopic observation revealed a perforation extending from the posterior wall of the trachea to the anterior wall of the esophagus, which prompted us to request assistance from a thoracic surgeon for treatment before reinserting the tracheostomy tube. After verifying capnographic waveforms on the monitor, anesthesia was induced. Because arterial oxygen saturation was 96% under the administration of pure oxygen, chest radiography was conducted revealing a right pneumothorax. A chest tube was inserted and the patient transported to a nearby general hospital. We suspect that pneumothorax was induced when the integrity of the mediastinal pleura was compromised by mediastinal emphysema because of the injury to the posterior tracheal wall complicated by bucking at the time of insertion of the dilator.


docid: uidffyqf

title: Comparative Study With Propensity Score Matching Analysis of Two Different Methods of Transection During Hemi-Right Hepatectomy: Ultracision Harmonic Scalpel Versus Cavitron Ultrasonic Surgical Aspirator.

text: BACKGROUND Several devices are available for liver parenchyma transection (LPT). The aim of this study was to compare the Ultracision Harmonic scalpel (UHS) with the Cavitron Ultrasonic Surgical Aspirator (CUSA) among patients who underwent hemi-right hepatectomies (RH) to homogenize transection areas. METHODS From September 2012 to June 2015, 24 patients who underwent the UHS surgery approach were matched with 24 patients who underwent the CUSA transection procedure for RH using propensity score matching. RESULTS Total operative time (TOT) was shorter in the UHS group, 240 minutes (range 172.5-298.8) versus 330 minutes (range 270-400) in the CUSA group ( P = .0002). The occurrence of hepatopathy (odds ratio = 17; 95% confidence interval = 1.02-230) and the use of the CUSA device (odds ratio = 8; 95% confidence interval = 0.98-77) were associated with a TOT exceeding 300 minutes in multivariate analysis ( P = .05). CONCLUSIONS The UHS is a safe and effective method of LPT as compared to the use of the CUSA system. TOT is statistically decreased.


title: Immunohistochemical assessment of respiratory viruses in necropsy samples from lethal non-pandemic seasonal respiratory infections.

text: BACKGROUND/AIM Acute respiratory infections are an important cause of childhood morbidity and mortality throughout the world, and viruses have often been reported to be an aetiological agent. This study aimed to identify respiratory viruses in paraffin-embedded samples of paediatric lung necropsy specimens, using immunohistochemistry on tissue microarray slides. METHODS Retrospective study in 200 lung tissue samples from children who had died from severe respiratory infections during 1985-2005. Immunoperoxidase assay was performed to detect the viruses that were most commonly associated with respiratory tract infections: influenza virus A (FLU A), influenza virus B (FLU B), respiratory syncytial virus (RSV), adenovirus (AdV) and parainfluenza virus (PIV) types 1, 2 and 3. RESULTS Viruses were detected in 71 (35.5%) cases. Most positive cases were observed in children younger than 6 months. In 42.3% of cases, only one virus was detected: 11 (36.7%) RSV; 7 (23.3%) AdV; 4 (13.3%) PIV2; 3 (10%) FLU A; 2 (6.7%) FLU B; 2 (6.7%) PIV3; and 1 (3.3%) PIV1. Co-infection with more than one virus was observed in 41 (57.7%) cases. No positive correlations were observed between the presence of viral antigens and seasonality of the infection, sex, age or histopathological findings. CONCLUSIONS Non-pandemic seasonal respiratory viruses are involved in a significant number of deaths in paediatric patients; these findings highlight the importance of laboratory investigation of these agents in patients hospitalised with severe acute respiratory infections.


title: The Effects of Bed Bathing on Vital Signs and Oxygen Saturation in Children Who Are Connected to Mechanical Ventilation.

text: AIM This study is a quasi-experimental research that was conducted to evaluate the effects of bathing on vital signs and oxygen saturation in intubated children who are connected to mechanical ventilation. METHODS The study sample consisted of children who are treated in the pediatric intensive care unit, University of Istanbul Cerrahpasa Faculty of Medicine Hospital. A total of 60 children who met the criteria of the sample group were included in the study. The children were given bed bathing with plain warm water of 32°C to 38°C on 3 different days. The vital signs and oxygen saturation values of the children were measured before bathing, just after bathing, and 30 minutes after bathing them. RESULTS Most of the children (65%) were on mechanical ventilation because of respiratory system diseases; 91.7% of them were connected to mechanical ventilation with endotracheal tube. The first bed bathing of children was given mean of 1.54 ± 3.57 days after their hospitalization, and bathing durations were mean of 18.3 minutes. The vital signs (pulse, blood pressure, body temperature) were compared before and after bed bathing, and it was observed that the values before bathing, just after bathing, and 30 minutes after bathing had advanced level of difference (P < .001). The lowest values of all signs except body temperature were obtained 30 minutes after bed bathing. When oxygen saturation measurement values before bathing (94.5%) and after bathing were compared, it was found that the highest values (97.3%) were obtained 30 minutes after bed bathing. CONCLUSION The bed bathing positively affected the vital signs and oxygen saturation values in intubated children connected to the mechanical ventilation. Yet, there is still a need for more research to test the effects of bed bathing on respiratory and circulatory function.


A "new normal" after covid-19 for NHS healthcare workers who are also carers?


title: Long-Term Outcomes of Single-Port Laparoscopic Placement of Peritoneal Dialysis Catheter.

text: INTRODUCTION Laparoscopic insertion of peritoneal dialysis (PD) catheter has become a preferred method compared to the traditional open technique for PD catheter insertion. We retrospectively report the outcome of 1-port laparoscopic placement PD catheters in our institution. METHODS A total of 263 patients with end-stage renal disease who underwent single-trocar laparoscopic PD catheter insertion during a recent 6-year period were reviewed. Laparoscopic technique involves introducing a PD catheter over a stiff guidewire into the abdominal cavity through a 10-mm laparoscopic port. Pertinent clinical variables, procedural complications, and follow-up outcome were analyzed. RESULTS There were 182 men and 81 women. The mean age was 56 years. Technical success was 95.8%. Catheter occlusion was the most common early complications (<6 months) that occurred in 4 (1.5%) patients. Late complications (> 6 months) including catheter occlusion, cuff extrusion, catheter leakage, catheter migration, infection, and hernia occurred in 5 patients (1.9%), 2 patients (0.8%), 3 patients (1.1%), 3 patients (1.1%), 6 patients (2.3%), and 4 patients (1.5), respectively. Mean follow-up time was 39 ± 18 months. Catheter survival rate at 1, 2, 3, 4, and 5 years was 96%, 94%, 90%, 85%, and 82%, respectively. CONCLUSION Laparoscopic PD catheter implantation via a single-trocar utilizing a stiff guidewire technique is feasible and safe. This method can result in low complication and high catheter survival rate.


title: Serum cholesterol by morbidly obese patients after laparoscopic sleeve gastrectomy and additional physical activity.

text: BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has shown to be effective in serum triglycerides reduction and HDL cholesterol increase, but with little effect on total cholesterol and LDL cholesterol. Physical activity is recognized as an effective non-pharmacological intervention to reduce body fat mass and hypercholesterolemia. METHODS A prospective observational study of all the patients undergoing LSG as bariatric technique between 2007 and 2012 was performed. All patients completed the Spanish Version of the Modifiable Physical Activity Questionnaire at two time points: baseline (pre-intervention) and 1 year after surgery, both in face-to-face interviews. Lipid profiles were monitored at the same time points. RESULTS A total of 50 patients were included in the study, 44 females (88 %) and six males (12 %) with a mean age of 42.7 ± 10.3 years. Comorbidities included dyslipidemia in 50 % (40 % hypercholesterolemia and 10 % hypertriglyceridemia). Preoperatively, four patients (8 %) reported moderately active physical activity and one patient (2 %) active physical exercise. The rest of the patients were sedentary. One year after surgery, 30 patients (60 %) performed any kind of active physical activity, while the rest were sedentary. Lipid profile 12 months after surgery showed significantly lower total cholesterol levels in the active group (182.8 mg/dl vs 220 mg/dl in the sedentary group; p = 0.003). LDL cholesterol levels were also lower in the active group (103.2 vs 133 mg/dl in the sedentary group; p = 0.015). CONCLUSION The performance of routine moderate physical activity in addition to LSG achieves a significant improvement in all parameters of the lipid profile.


title: Impact on seizure control of surgical resection or radiosurgery for cerebral arteriovenous malformations.

text: BACKGROUND Seizures are a common presenting symptom of arteriovenous malformations (AVMs). However, the impact of treatment modality on seizure control remains unclear. OBJECTIVE To compare seizure control after surgical resection or radiosurgery for AVMs. METHODS We analyzed retrospectively collected information for 378 patients with cerebral AVMs treated at our institution from 1990 to 2010. The application of strict inclusion criteria resulted in a study population of 164 patients. RESULTS In our cohort, 31 patients (20.7%) had Spetzler-Martin grade I AVMs, 51 (34.0%) grade II, 47 (31.3%) grade III, 20 (13.3%) grade IV, and 1 (0.7%) grade V. Of the 49 patients (30%) presenting with seizures, 60.4% experienced seizure persistence after treatment. For these patients, radiosurgery was associated with seizure recurrence (odds ratio: 4.32, 95% confidence interval: 1.24-15.02, P = .021). AVM obliteration was predictive of seizure freedom at last follow-up (P = .002). In contrast, for patients presenting without seizures, 18.4% experienced de novo seizures after treatment, for which surgical resection was identified as an independent risk factor (hazard ratio: 8.65, 95% confidence interval: 3.05-24.5, P < .001). CONCLUSION Although our data suggest that achieving seizure freedom should not be the primary goal of AVM treatment, surgical resection may result in improved seizure control compared with radiosurgery for patients who present with seizures. Conversely, in patients without presenting seizures, surgical resection increases the risk of new-onset seizures compared with radiosurgery, but primarily within the early posttreatment period. Surgical resection and radiosurgery result in divergent seizure control rates depending on seizure presentation.


title: Sexual function after robot-assisted prolapse surgery: a prospective study.

text: INTRODUCTION AND HYPOTHESIS Female pelvic organ prolapse (POP) can severely influence sexual function. Robot-assisted surgery is increasingly used to treat POP, but studies describing its effect on sexual function are limited. The objective of this study was to evaluate sexual function after robot-assisted POP surgery. METHODS This prospective cohort study included all patients who underwent a robot-assisted sacrocolpopexy (RASC) or supracervical hysterectomy with sacrocervicopexy (RSHS). Exclusion criteria were unknown preoperative sexual activity status or concomitant surgery. In sexually active women, sexual function was measured with the translated validated version of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Changes in sexual activity were scored. Prolapse stages were described using the simplified Pelvic Organ Prolapse Quantification (S-POP) system. RESULTS A total of 107 women were included (median follow-up 15.3 months). No difference was found in the total number of sexually active women before and after surgery [63 (58.9%) vs. 61 (63.5%), p = 0.999]. Significantly fewer women avoided sexual intercourse postoperatively compared with preoperatively. Preoperatively, sexual intercourse was avoided due to vaginal bulging (2% vs. 24%, respectively, p = 0.021). Total mean PISQ-12 scores improved significantly 1 year after prolapse correction (33.5 vs. 37.1; p = 0.004), mainly due to improved scores on the physical and behavioral-emotive domain. No significant difference in pre- and postoperative complains of dyspareunia was found. CONCLUSION Robot-assisted middle-compartment surgery improved sexual function 1 year after surgery according to enhanced physical and emotional scores. The total number of sexually active women and complains of dyspareunia before and after surgery did not differ.


title: Frequency of anesthetic overdose with mean alveolar concentration-guided anesthesia at high altitude.

text: This study reported the frequency of anesthetic overdose measured with the bispectral index in a high altitude city (Bogotá-Colombia, 2600 meters above sea level). We assembled a prospective cohort of patients. Preoperative variables were described, and 10 minutes after the surgical incision, bispectral index, mean alveolar concentration, mean arterial pressure, and oxygen saturation were recorded. Bispectral index was classified as superficial (60), adequate (40-60), and deep (> 40). Mean alveolar concentration was classified as low (< 0.8), normal (0.8-1.2), and high (> 1.2). We included 50 patients. The mean age of the patients was 36.3 ± 13.5 years; 48% were male and 78% were categorized as ASA I. Mean values of mean alveolar concentration and bispectral index were 1.14 ± 0.18 and 38.66 ± 6.9, respectively. Frequency of anesthetic overdose measured with bispectral index was 54% and only 20% with mean alveolar concentration. In total, 78% of patients received normal mean alveolar concentration values, and among these patients, 49% had deep bispectral index levels and 51% were adequate. There was no correlation between mean alveolar concentration and bispectral index (Pearson r = 0.161, P = 0.246) or between bispectral index and mean arterial pressure (Pearson r = 0.367, P = 0.08). All patients older than 60 years exhibited deep bispectral index levels, and although we did not identify a correlation between age and bispectral index, a tendency was observed (Pearson r = -0.087, P = 0.538). Safe and effective anesthesia overdose could be a common phenomenon. Bispectral index-guided anesthesia could be a helpful and reliable tool in the assessment and prevention of anesthesia overdose at high altitude. The study was approved by the ethics committee of the Fundación Cardioinfantil-Instituto de cardiología, Bogota, Colombia (approved number: 312017).


title: Human bone marrow-derived mesenchymal cells differentiate and mature into endocrine pancreatic lineage in vivo.

text: BACKGROUND AIMS The scarcity of human islets for transplantation remains a major limitation of cell replacement therapy for diabetes. Bone marrow-derived progenitor cells are of interest because they can be isolated, expanded and offered for such therapy under autologous/allogeneic settings. METHODS We characterized and compared human bone marrow-derived mesenchymal cells (hBMC) obtained from (second trimester), young (1-24 years) and adult (34-81 years) donors. We propose a novel protocol that involves assessment of paracrine factors from regenerating pancreas in differentiation and maturation of hBMC into endocrine pancreatic lineage in vivo. RESULTS We observed that donor age was inversely related to growth potential of hBMC. Following in vitro expansion and exposure to specific growth factors involved in pancreatic development, hBMC migrated and formed islet-like cell aggregates (ICA). ICA show increased abundance of pancreatic transcription factors (Ngn3, Brn4, Nkx6.1, Pax6 and Isl1). Although efficient differentiation was not achieved in vitro, we observed significant maturation and secretion of human c-peptide (insulin) upon transplantation into pancreactomized and Streptozotocin (STZ)-induced diabetic mice. Transplanted ICA responded to glucose and maintained normoglycemia in diabetic mice. CONCLUSIONS Our data demonstrate that hBMC have tremendous in vitro expansion potential and can be differentiated into multiple lineages, including the endocrine pancreatic lineage. Paracrine factors secreted from regenerating pancreas help in efficient differentiation and maturation of hBMC, possibly via recruiting chromatin modulators, to generate glucose-responsive insulin-secreting cells.


Active and Effective Measures for the Care of Patients With Cancer During the COVID-19 Spread in China.


docid: xzdylcwk

title: Psychological needs and response during the COVID-19 pandemic in Lebanon.

text: Lebanon was 1 of the countries to be affected early by the COVID-19 pandemic while in the midst of political upheaval. The stress implicated by this dual challenge allowed for mental health to take a center stage, prompting a nationwide official and informal response. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Estimated treatment effect of ticagrelor versus aspirin by investigator-assessed events compared with judgement by an independent event adjudication committee in the SOCRATES trial.

text: BACKGROUND Adjudication of endpoints is a standard procedure in cardiovascular clinical trials. However, several studies indicate that the benefit of adjudication in estimating treatment effect may be limited. AIMS This post hoc analysis of SOCRATES (NCT01994720) compared the treatment effects and investigated the agreement of clinical event assessment by site investigators and independent adjudicators. METHODS SOCRATES compared ticagrelor and aspirin in 13,199 patients with acute minor stroke or high-risk transient ischemic attack. The primary endpoint was stroke, myocardial infarction, or death. Stroke was the major component of the primary endpoint and a secondary endpoint. The endpoints were adjudicated by a blinded independent committee. We compared the treatment effect on the primary endpoint and stroke alone based on the investigators' and adjudicators' assessments, and investigated the agreement rate on the stroke endpoint and major hemorrhages. RESULTS The hazard ratios (95% confidence interval) for ticagrelor versus aspirin therapy for the primary endpoint were 0.89 (0.78-1.01) when calculated on adjudicator-assessed events and 0.88 (0.78-1.00) for investigator-assessed events. The hazard ratios (95% confidence intervals) for stroke were 0.86 (0.75-0.99) based on the adjudicators' diagnoses and 0.85 (0.75-0.97) based on the investigators' diagnoses. The overall agreement between adjudicator- and investigator-diagnosed stroke was 91%, and for major hemorrhages was 88%. CONCLUSIONS In SOCRATES, there was no clinically meaningful difference in the estimated treatment effect, on either the primary endpoint or stroke, by using investigator- or adjudicator-assessed events. Double-blind treatment outcome studies with stroke endpoints may not benefit from adjudication. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01994720.


title: Intra and postoperative assessment of re-sterilised Ligasure Atlas for orchidectomies in horses: clinical study.

text: Horses (n=35) underwent orchidectomy in a single institution with a re-sterilised LSA as sole means of haemostasis. During the surgery, the gross quality of the seal, the stickiness of the forceps to the tissues, bleeding/oozing from the stump and the need for a subsequent application in already severed spermatic cord were assessed for haemostasis quality. After surgery, physical parameters (appearance of the mucous membranes, quality of the peripheral pulse, heart rate, respiratory rate, rectal temperature and blood dripping from the incisions), haematology or packed cell volume and total protein were monitored to assess signs of bleeding or any other condition. For cleanliness and asepsis assessment, signs of surgical infection were recorded. Complications during surgery were mild degree of sticking of the LSA forceps to the tissues and dulling of the blade. There was no need to reapply LSA a second time except in one horse. This means a haemostasis complication rate of 2.85 per cent of the horses. No postoperative bleeding was detected. Only two horses with fever had associated signs of surgical site infection. This means an infection rate of 5.71 per cent of the horses.


title: Biaxial system using the Benchmark intracranial guide catheter for placement of a Pipeline Embolization Device for intracranial aneurysms.

text: BACKGROUND The Benchmark (Penumbra, Alameda, CA) is a novel intracranial guide catheter that provides optimized proximal stability combined with a hyperflexible and atraumatic tip. We assessed the use of a biaxial catheter system consistent with the Benchmark and Marksman microcatheter for placement of a Pipeline embolization device (PED) for intracranial aneurysms. METHODS We reviewed consecutive patients with aneurysms undergoing Pipeline embolization for an aneurysm using the biaxial system from April to October 2015 at a major academic institution in the United States. Benchmark performance was measured by the number of 90° turns the catheter could safely cross. Landing and final positions of the Benchmark were recorded. RESULTS A total of 26 procedures were performed in 25 patients (mean age 59.5 ± 10.3 years; male:female = 1:4). In one case (3.8%) the biaxial system had to be substituted for a traditional triaxial system. The Benchmark was able to cross one, two, or three 90° turns in 48%, 40%, and 8% of cases, respectively. There was one (3.8%) thromboembolic event and no arterial dissections. In the period from January 2014 to March 2015 and prior to adopting the biaxial system we encountered three thromboembolic events (6.4%) and one (2.1%) dissection potentially related to the triaxial system in 47 PED procedures. CONCLUSION Preliminary experience shows that a biaxial system using the Benchmark is a safe and efficacious alternative to the traditional triaxial guide catheter system for placement of PED and may reduce the complexity and duration of the procedure.


The COVID-19 pandemic.


title: Illuminating allostery in metal sensing transcriptional regulators.

text: The intracellular availability of all biologically required transition metal ions in bacteria, e.g., Zn, Cu, Fe, as well as the detoxification of nonbiological heavy metal pollutants, is controlled at the molecular level by a panel of metalloregulatory or "metal sensor" proteins. Metal sensor proteins are specialized allosteric proteins that regulate the transcription of genes linked to transition metal homeostasis as a result of direct binding of a single metal ion or two closely related metal ions, to the exclusion of all others. In many cases, the binding of the cognate metal ion induces a structural change in a metal sensor oligomer that either activates or inhibits operator DNA binding. A quantitative measure of the degree to which a particular metal drives metalloregulation of transcription is the allosteric coupling-free energy, ΔG(c). In this chapter, we outline detailed spectroscopically derived methods for measuring metal binding affinity, K(Me), as well as ΔG(c) independent of K(Me), presented in the context of a simple coupled equilibrium scheme. Studies carried out in this way provide quantitative insights into the degree to which a particular metal ion is capable of driving allosteric switching, and via ligand substitution, the extent to which individual coordination bonds establish structural linkage of allosteric metal and operator DNA-binding sites.


title: Clinical and functional evaluation of patients with rectocele and mucosal prolapse treated with transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS).

text: BACKGROUND The aim of the present study was to make a preoperative and postoperative clinical and functional evaluation of patients who underwent transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS procedure) as treatment for obstructed defecation syndrome (ODS) caused by rectocele and rectal mucosal prolapse (RMP). METHODS This prospective study included 35 female patients, 34 multiparous and one nulliparous, with an average age of 47.5 years (range 31-67 years), rectocele grade II (n = 13/37.1%) or grade III (n = 22/62.9%), associated with RMP. The study parameters included ODS, constipation, functional continence scores and pre- and postoperative cinedefecographic findings. RESULTS The average preoperative ODS score, the constipation score and the functional continence score were significantly reduced after surgery from 10.63 to 2.91 (p = 0.001), 15.23 to 4.46 (p = 0.001) and 2.77 to 1.71 (p = 0.001), respectively. Between the first and the eighth postoperative day, the average visual analog scale pain score fell from 5.23 to 1.20 (p = 0.001). Satisfaction with treatment outcome was 79.97, 86.54, 87.65 and 88.06 at 1, 3, 6 and 12 months, respectively. Cinedefecography revealed average reductions in rectocele size from 19.23 ± 8.84 mm (3-42) to 6.68 ± 3.65 mm (range 0-7) at rest and from 34.89 ± 12.30 mm (range 20-70) to 10.94 ± 5.97 mm (range 0-25) during evacuation (both P = 0.001). CONCLUSION The TRREMS procedure is a safe and efficient technique associated with satisfactory anatomic and functional results and with a low incidence of postoperative pain and complications.


The Clinical Pharmacology Sections in Drug Package Inserts: Do We Need to Reexamine the Basis?


title: Short-term results of DST EEA 33 stapler and neu@ anoscope for stapled haemorrhoidectomy: a prospective study of 1,118 patients from a single centre.

text: BACKGROUND Stapled haemorrhoidectomy has been performed with different techniques and staplers. We review our initial experience with the new DST EEA 33 stapler and neu@ anoscope. METHODS A review of all patients who underwent stapled haemorrhoidectomy using the DST EEA 33 over a 14-month period was conducted. Short-term outcomes of bleeding, pain and retention of urine requiring admission or strictures requiring surgical intervention were studied. RESULTS There were 1,118 patients operated from August 2007 to October 2008. The median age was 46-year-old (20-82 years) and 51% were females. The median operating time was 15 min (range 5-45 min), and median follow-up was 7 months (range 3-16 months). There were 26 patients (2.3%) who were admitted for inability to pass urine and 20 required catheterisation. Fifty-two patients (4.6%) were admitted for post-operative bleeding. In 32 cases the bleeding stopped spontaneously, while 19 patients required adrenaline injection and packing for hemostasis. Only one patient required surgical hemostasis. Thirty-three patients (2.9%) were admitted for post-operative pain and stayed for a median of 1 day (range 1-4 days). There were 14 patients (1.2%) who developed anorectal strictures requiring surgical intervention. All underwent anoplasty at a median of 3 months post-operatively (range 2-5 months), with good result. There were no recurrent haemorrhoids during follow-up. CONCLUSION Stapled haemorrhoidectomy using the DST EEA 33 stapler is safe. The neu@ anoscope provides good visibility and handling, and is a useful tool in this procedure.


title: Platelet functions and activities as potential hematologic parameters related to Coronavirus Disease 2019 (Covid-19).

text: Coronavirus disease 2019 (COVID-19) is a new infectious disease that currently lacks standardized and established laboratory markers to evaluate its severity. In COVID-19 patients, the number of platelets (PLTs) and dynamic changes of PLT-related parameters are currently a concern. The present paper discusses the potential link between PLT parameters and COVID-19. Several studies have identified a link between severe COVID-19 patients and specific coagulation index, in particular, high D-dimer level, prolonged prothrombin time, and low PLT count. These alterations reflect the hypercoagulable state present in severe COVID-19 patients, which could promote microthrombosis in the lungs, as well as in other organs. Further information and more advanced hematological parameters related to PLTs are needed to better estimate this link, also considering COVID-19 patients at different disease stages and stratified in different cohorts based on preexisting co-morbidity, age, and gender. Increasing the understanding of PLT functions in COVID-19 will undoubtedly improve our knowledge on disease pathogenesis, clinical management, and therapeutic options, but could also lead to the development of more precise therapeutic strategies for COVID-19 patients.


title: A novel way to treat skin tears.

text: Skin tears are one of the most commonly treated wounds in the elderly population. In their most basic form, they are essentially traumatic random pattern flaps. We postulate that the injured blood flow to these skin flaps should be ignored and the tissue should be treated as a skin graft. A case report is presented of an 86-year-old female with an 8 × 3·5 cm skin tear to her right upper extremity after a hip fracture. In addition to conventional wound closure strips re-approximating the tissues, a disposable negative pressure wound therapy device was placed to act as bolster. Upon its removal on day 5, the opposed skin tear tissue was found to be 100% viable. We therefore propose that this update may be an improvement over classical skin tear treatments and should be followed up with a case series.


docid: mmvsqife

title: Banded sleeve gastrectomy using the GaBP ring--surgical technique.

text: Laparoscopic sleeve gastrectomy (LSG) has been described as the first step of a two-step laparoscopic Roux-en-Y gastric bypass (LRYGB) or biliopancreatic diversion with duodenal switch (BPD-DS) in extremely obese patients. It has also been used as an independent bariatric procedure. Recently a banded sleeve gastrectomy using human dermis was published. Gastric sleeve dilatation is one of the unfavorable postoperative courses that may limit weight loss. Our technique of a banded sleeve gastrectomy using the GaBP Ring Autolock(TM) System to calibrate the sleeve and prevent distal sleeve dilatation is described in this article.


title: Single-stage endovascular treatment of subarachnoid hemorrhage related to bilateral vertebral artery dissecting aneurysms.

text: OBJECTIVE Treatment of bilateral vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage remains challenging as bilateral deconstructive procedures may not be feasible. In this case series, we describe our approach to their management and review the pertinent literature. METHOD A retrospective review of our prospectively collected database on aneurysms was performed to identify all patients with acute subarachnoid hemorrhage in the setting of bilateral intradural vertebral artery dissections (VAD) encompassing a period from January 2000 and March 2012. RESULT Four patients (M/F = 2/2; mean age, 51.5 years) were identified. In two cases the site of rupture could be identified by angiographic and cross-sectional features; in these patients deconstructive treatment (proximal obliteration or trapping) of the ruptured site and reconstructive treatment of the unruptured site (using stents and coils) were performed. In the patients in whom the site of hemorrhage could not be determined, bilateral reconstructive treatment was performed. No treatment-related complications were encountered. Modified Rankin scale scores were 0-1 at discharge, and on follow-up (mean 63 months), no recurrence, in-stent thrombosis or new neurological deficits were encountered. CONCLUSION We believe that single-stage treatment in patients with bilateral VAD is indicated: If the site of hemorrhage can be determined, we prefer deconstructive treatment on the affected site and reconstructive treatment on the non-affected site to prevent increased hemodynamic stress on the unruptured but diseased wall. If the site of dissection cannot be determined, we prefer bilateral reconstructive treatment to avoid increasing hemodynamic stress on the potentially untreated acute hemorrhagic dissection.


Zonisamide-induced Acute-on-Chronic Liver Failure: First Report.


Society of NeuroInterventional Surgery recommendations for the care of emergent neurointerventional patients in the setting of covid-19.


title: Ten things your emergency department should consider to prepare for pandemic influenza.

text: Pandemic influenza remains a potential major threat to global public health. It is essential for emergency departments to be involved in planning for the management of such a major event. It is also important for emergency departments to be clear on their internal arrangements for staff and for patient care. This paper outlines 10 suggestions for UK emergency departments based on the recent experience of emergency departments in Hong Kong and elsewhere.


title: The impact of global budgeting on health service utilization, health care expenditures, and quality of care among patients with pneumonia in Taiwan.

text: This study evaluated the effect of global budgeting on health service utilization, health care expenditures, and the quality of care among patients with pneumonia in Taiwan. The National Health Insurance Research Database (NHIRD) was used for analysis. Data on patients diagnosed with pneumonia during 2000-2001 (the prebudget group) were used as the baseline data, and data on patients diagnosed with pneumonia during 2004-2005 (the postbudget group) were used as the postintervention data. The length of stay (LOS), diagnostic costs, drug costs, therapy costs, total costs, risk of readmission within 14 days, and risk of revisiting the Emergency Department (ED) within 3 days of discharge before and after implementing the global budget system were analyzed and compared. Data on 32,535 patients with pneumonia were analyzed. The mean LOS increased from 6.36 ± 0.07 to 10.78 ± 0.09 days after implementing the global budget system. The mean total costs in the prebudget and postbudget groups were 22,697.82 ± 542.40 and 62,016.7 ± 793.19 New Taiwan dollars (NT$), respectively. The mean rate of revisiting the ED within 3 days decreased from 5.5 ± 0.2 % to 4.6 ± 0.1 % in the prebudget and postbudget groups, respectively. The mean rates of readmission within 14 days before were 6.1 ± 0.2 % and 8.2 ± 0.2 % in the prebudget and postbudget groups, respectively. Global budgeting is associated with a significantly longer LOS, higher health care costs, and poorer quality of care among patients with pneumonia.


title: The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery.

text: BACKGROUND Decreased blood perfusion at an intestinal anastomosis may contribute to postoperative anastomotic leak (AL) resulting in substantial morbidity and mortality. Near-infrared (NIR) laparoscopy in conjunction with indocyanine green (ICG) allows for visualization of the microcirculation before formation of the anastomosis, thereby allowing the surgeon to choose the point of transection at an optimally perfused area. METHODS This is a retrospective case-control analysis examining the effectiveness of NIR + ICG in reducing the rate of AL after low anterior resection (LAR) for rectal cancer. Records of patients undergoing robot-assisted LAR for rectal cancer with and without ICG were analyzed for the years 2011 and 2012. RESULTS Among the 40 patients who underwent robotic LAR, NIR + ICG was used in 16 cases (41 %). Male patients accounted for the majority of cases in both groups (74 %). The median level of the anastomosis was 3.5 cm in the NIR + ICG group and 5.5 cm in the control group. There was no difference in the use of diverting ileostomy. In 3 patients (19 %), the use of NIR + ICG resulted in revision of the proximal bowel (colonic) transection point before formation of the anastomosis. The distal transection point was never revised. The rate of AL in the NIR + ICG group was 6 % versus 18 % in control group. CONCLUSIONS ICG fluorescence may play a role in anastomotic tissue perfusion assessment and affect the AL rate. Larger prospective studies are needed to further validate this novel technology.


docid: zgqhmjsu

title: Incidence and clinical implications of carotid branch occlusion following treatment of internal carotid artery aneurysms with the pipeline embolization device.

text: BACKGROUND The use of flow diverters such as the pipeline embolization device (PED) for treatment of intracranial aneurysms carries the risk of side branch occlusion. OBJECTIVE To determine the incidence and clinical outcomes associated with supraclinoid internal carotid artery (ICA) branch occlusion after deployment of PEDs for ICA aneurysms. METHODS We reviewed patients who underwent endovascular treatment with PEDs for ICA aneurysms between June 2011 and March 2013. Forty-nine patients (43 women, mean age 56.3±1.8 years, 68 aneurysms) in whom PEDs traversed the origin of supraclinoid ICA branches (ophthalmic [OA], posterior communicating [PcommA], and anterior choroidal artery [AChA]) were selected for this study. Follow-up angiograms (mean follow-up, 12.8±0.8 months) were studied to determine the location of PEDs and the patency of ICA branches. RESULTS PEDs were placed across the ostia of 49 OAs, 14 PcommAs, and 11 AChAs. Multiple PEDs were deployed in 16 patients. Rate of branch occlusion was 4% (2/49) for the OA, 7.1% (1/14) for the PcommA, and 0% for the AChA. Patients with branch occlusion did not endure new neurological deficits. ICA branch occlusion was not associated with the number of PEDs covering the ostia (P=.76) or the origin of ICA branches from the aneurysm (P=.24). CONCLUSION The incidence of major supraclinoid ICA branch occlusion after treatment with PEDs was low. These events were not associated with new neurological deficits nor were they related to the number of PEDs deployed or the origin of ICA branches from the aneurysm.


title: Rationale, design, and protocol of a randomized controlled trial of the safety and efficacy of dabigatran etexilate versus dose-adjusted warfarin in patients with cerebral venous thrombosis.

text: Rationale To prevent recurrent venous thrombotic events after acute cerebral venous or dural sinus thrombosis, guidelines recommend long-term oral anticoagulation with vitamin K antagonists. Non-vitamin K oral anticoagulant experience in cerebral venous or dural sinus thrombosis is limited to case reports and series. Aim To compare dabigatran with dose-adjusted warfarin in patients with cerebral venous or dural sinus thrombosis for the prevention of recurrent venous thrombotic event. Sample size One hundred and twenty patients. Methods and design This study is a phase III, prospective, randomized, parallel-group, open-label, multicenter, exploratory trial with blinded endpoint adjudication. Patients with acute cerebral venous or dural sinus thrombosis after 5-15 days of treatment with parenteral heparin are randomized to either dabigatran etexilate 150 mg twice daily or dose-adjusted (international normalized ratio 2-3) warfarin (≤24 weeks). Study outcome The primary endpoint is a composite of patients with new venous thrombotic event (recurring cerebral venous or dural sinus thrombosis, deep venous thrombosis of any limb, pulmonary embolism, and major bleeding (International Society on Thrombosis and Hemostasis definition)) during the treatment period. Statistics will be descriptive (number and frequencies). Study timelines Inclusion started in December 2016. Final results are expected by the end of 2018. Discussion This exploratory trial is the first to compare vitamin K with non-vitamin K antagonists in cerebral venous or dural sinus thrombosis. It will provide evidence to guide physicians and patients in choosing oral anticoagulants to prevent venous thrombotic event after acute cerebral venous or dural sinus thrombosis. ClinicalTrials.gov number: NCT02913326.


title: Negative nasopharyngeal swabs early in the course of COVID-19.

text: BACKGROUND The diagnosis of COVID-19 is made by detection of SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR). Studies have shown a percentage of up to 30 % false negative results. CASE PRESENTATION A previously healthy man in his late thirties was admitted to the hospital after 3-5 days of suffering chest pain, dyspnoea and abdominal discomfort. He had hypoxic respiratory failure and required oxygen therapy. The routine nasopharyngeal swab for PCR was negative at days 5 and 7 after onset of symptoms. A specimen obtained from bronchoalveolar lavage on day 8 was positive. INTERPRETATION This case report shows us that even in the early course of SARS-Cov-2 infection, when the viral load in the upper respiratory tract has been shown to be at its highest, there might be false negative tests. It also emphasises the importance of including other clinical measures before discontinuation of isolation.


title: Early Single-Center Experience with Robotic Partial Nephrectomy Using the da Vinci Xi: Comparative Assessment with Conventional Open Partial Nephrectomy.

text: Background The objective of this study was to evaluate our experience with robot-assisted partial nephrectomy (RAPN) in comparison with conventional open partial nephrectomy (OPN). Patients and Methods This study included 37 and 50 patients undergoing OPN and RAPN for small renal masses, respectively. A single surgeon performed RAPN for all 50 cases using the da Vinci Xi. Trifecta was defined as satisfying all of the following 3 criteria: ischemic time of ≤ 25 minutes, negative surgical margin and no major postoperative complications. Results After adjusting patient variables by 1:1 propensity-score matching, 37 patients were included in each group, and no significant differences in major clinicopathological characteristics were noted between these 2 groups. RAPN was significantly superior to OPN with respect to operative time, estimated blood loss and postoperative length of hospital stay. The rate of trifecta achievement was significantly higher in the RAPN group than in the OPN group (91.9 vs. 62.2%). Furthermore, the operative procedure and R.E.N.A.L. nephrometry score were found to be independently associated with trifecta outcome by multivariate analysis of the entire cohort. Conclusions Although this is our early experience with 50 initial cases, RAPN using the da Vinci Xi resulted in more favorable perioperative outcomes than OPN.


Reply to: Utility of Xpert Ultra on Different Respiratory Specimens in Children.


title: Feasibility and efficacy of laparoscopic restaging surgery for women with unexpected ovarian malignancy.

text: OBJECTIVE To evaluate the feasibility, surgical outcomes and complications of laparoscopic restaging surgery for women with unexpected ovarian malignancy. STUDY DESIGN We conducted a retrospective chart review of 14 women with unexpected ovarian malignancy who underwent laparoscopic restaging surgery including peritoneal washing cytology, laparoscopic pelvic and paraaortic lymphadenectomy up to the left renal vein level, omentectomy, and multiple peritoneal biopsies, and hysterectomy except three fertility saving surgery. RESULTS The median age and median body mass index women were 49 years (range, 22-63) and 24.2m/kg(2) (range, 18.9-25.3), respectively. The median operating time was 230min (range, 155-370). The median numbers of harvested pelvic and paraaortic lymph nodes were 26 (range, 6-41) and 18 (range, 2-40), respectively. The median return of bowel activity was 28h (range, 21-79). Four of the women were upstaged from the initial presumed stage. There were two intraoperative complications, laceration of the inferior vena cava and cisterna chyli rupture. There was one postoperative complication, port-site metastasis. There was no conversion to laparotomic surgery. The median follow-up period was 33 months. Thirteen of the patients have no evidence of recurrences, however one patient died after 22 months after the surgery. CONCLUSION Laparoscopic restaging surgery, performed by a specialized laparoscopic oncologist with sufficient laparoscopic experience and a well-trained operating team, is both feasible and effective in the management of unexpected ovarian malignancies.


title: The impact of neurologically deceased donors' blood pressures on clinical outcomes in transplant recipients: a systematic review.

text: PURPOSE We performed a systematic review of the literature to identify the ideal blood pressure (BP) target in neurologically deceased organ donors to optimize outcomes of recipient organ function and survival, and organs transplanted per donor. SOURCE We searched MEDLINE and EMBASE from inception to December 2018 for studies that evaluated BP targets in neurologically deceased organ donors. A two-step review process with three independent reviewers was employed. We assessed the risk of bias and applied Grading of Recommendations Assessment, Development, and Evaluation methodology to evaluate the certainty of the evidence by outcome. PRINCIPAL FINDINGS Twelve cohort studies were included in our final analysis. Seven studies showed that hypotension was associated with worse post-transplant graft function or survival, while three studies found no association between hypotension and post-transplant graft function or survival. Two other studies showed no association between hypotension and organs transplanted per donor. Overall, six of the identified studies had serious risk of bias. CONCLUSION A systolic BP less 90 mmHg may be associated with graft dysfunction in kidney recipients, but this is based on very low certainty in evidence. Although an ideal and universal BP target in neurologically deceased organ donors is not clearly identifiable in the literature, this could reflect the complexity of donor hemodynamics and the need for individualized targets for different organs. Further prospective research is required to address these questions.


title: Effect of rectal indomethacin for preventing post-ERCP pancreatitis depends on difficulties of cannulation: results from a randomized study with sequential biliary intubation.

text: GOALS AND BACKGROUND The greatest challenges for endoscopists performing biliary therapy in endoscopic retrograde cholangiopancreatography (ERCP) are to achieve selective biliary cannulation and prevent post-ERCP pancreatitis (PEP). Nonsteroidal anti-inflammatory drugs have proven prophylactic effect in PEP. However, the patient population that would benefit from this approach has not been defined. STUDY A total of 539 patients undergoing our cannulation protocol with early precut were randomized into a placebo-controlled, prospective, double-blind study to rectally receive either 100 mg indomethacin or placebo. The effect of indomethacin on PEP was stratified based on difficulties of cannulation and analyzed in patients with different risks. RESULTS In 70.3% of patients, biliary intubation was successful in the first 5 atraumatic attempts, PEP rate was low, and indomethacin was ineffective (7.4% in the placebo group and 5.2% in the indomethacin group, P=0.406). In the next phase of intubation using guidewire, the success rate increased up to 83.5%, and PEP rate rose up to 8.7%, the effect of indomethacin was significant (11.9% vs. 5.4%, P=0.018). Applying early precut success rate of biliary cannulation increased up to 98.1% and overall indomethacin diminished the frequency of PEP from 13.8% to 6.7% (P=0.007). Preventive effect of indomethacin was demonstrated in cases with defined procedure-related risk (28.3% vs. 13.8%, P=0.028) and with defined patient-related risk (16.3% vs. 7.0%, P=0.004), but not in patients without risk factors. CONCLUSIONS Rectally administered 100 mg indomethacin results in significantly lower PEP rate, particularly in cases with difficult cannulation and with identifiable patient-related or procedure-related risk factors.


title: Radiofrequency ablation after arterial injection of miriplatin-iodized oil suspension into swine liver: ablative zone size and tissue platinum concentration.

text: PURPOSE To evaluate whether arterial injection of miriplatin-iodized oil suspension facilitates ablative zone expansion by radiofrequency (RF) ablation using a Cool-Tip electrode and to provide effective tissue platinum concentration in the normal swine liver. MATERIALS AND METHODS RF ablation was performed at three sites of each liver. RF ablation alone was performed in two animals (control). Ablation was performed after arterial injection of iodized oil (iodized-oil group) or a miriplatin-iodized oil suspension (miriplatin group) in two animals each. Long- and short-axis diameters of the ablative zone were measured. In the miriplatin group, tissue platinum concentrations were measured in the ablative, surrounding hyperemic rim, and nonablative zones. RESULTS The mean long- and short-axis diameters of ablative zones were 27.0 ± 3.1 and 18.0 ± 0.6 mm in the control. Although the long-axis diameter (30.2 ± 2.8 mm, p = 0.07) showed no significant expansion, the short-axis diameter (20.8 ± 2.6 mm, p = 0.04) was significantly expanded more in the iodized-oil group than in the control. Ablative zone sizes were largest in the miriplatin group. The long-axis diameter (33.5 ± 2.4 mm, p = 0.01) was significantly larger than that in the control. The short-axis diameter (27.2 ± 1.9 mm, p = 0.004) was significantly larger than that of the iodized-oil group. Tissue platinum concentrations showed an effective antitumor effect (≥9 μg/g) in ablative (16.5 ± 5.7 μg/g), surrounding hyperemic rim (18.0 ± 5.1 μg/g), and nonablative zones (mean 22.2 ± 5.7 μg/g) (p = 0.21). CONCLUSION Arterial injection of miriplatin-iodized oil suspension can expand the ablative zone size and provide effective tissue platinum concentration on tumor control in the ablative zones and their surrounding hyperemic rim.


title: The 'Pull' Technique for Removal of Peritoneal Dialysis Catheters: A Call for Re-Evaluation of Practice Standards.

text: ♦ BACKGROUND: The most commonly used peritoneal dialysis (PD) catheters have silicon tubing with attached Dacron cuffs. The current standard of care for PD catheter removal is by complete surgical dissection, withdrawing both the tubing and the cuffs. The intention is to avoid infection of any residual part of the catheter. We retrospectively analyzed our results with the alternative 'pull' technique, by which the silicon tube is pulled out, leaving the Dacron cuffs within the abdominal wall. This technique never gained popularity due to concern that the retained cuffs would get infected. ♦ METHODS: We reviewed our experience from an 18-month period, between January 2014 and June 2015. There were 46 catheter removals in 40 patients. All the catheters were of the double-cuffed coiled Tenckhoff type (Covidien, Dublin, Ireland). ♦ RESULTS: Of the 46 catheter removals by the 'pull' technique, there was only 1 case of retained cuff infection. ♦ CONCLUSIONS: The 'pull' technique is a safe method for Tenckhoff catheter removal with low risk of infection. We strongly recommend it as the procedure of choice.


title: Safety and Prognosis in Percutaneous vs Surgical Tracheostomy in 27 Patients With COVID-19.

text: During the SARS-CoV-2 pandemic, patients in intensive care units who are undergoing long-term intubation may require tracheostomy. There is controversy about indication and health care professionals' safety regarding the conventional or percutaneous technique. We performed a prospective analysis of a series of 27 consecutive patients with COVID-19 comparing both tracheostomy techniques, safety, and prognosis clinical markers. The results show that the techniques are equally safe, without cases of infection in surgeons. The Sequential Organ Failure Assessment score before surgery and the progression in ventilation support during the first 72 hours after tracheostomy are optimal prognostic markers for these patients.


title: Urban scaling of health outcomes: a protocol for a scoping review.

text: INTRODUCTION With most of the world's population living in urban areas, it is important to understand the health effects of city living. Precise descriptions of the relations of city size and growth with population health metrics have not been systematically described. Describing these relationships can provide clues regarding the factors driving differences in health across cities. OBJECTIVE The goal of this scoping review is to map the existing evidence regarding the scaling properties of health outcomes, with a special emphasis on city size and growth. METHOD AND ANALYSIS We will conduct this scoping review based on a structured search of a combination of keywords for the exposures that aim to capture the population growth and size of cities along with degree of urbanisation, for health-related outcomes regardless of their type (incidence or prevalence of diseases and injuries and mortality). We will search the MEDLINE and Latin American & Caribbean Health Sciences Literature databases from inception for studies in English, Spanish or Portuguese and perform manual searches of references and citations in the included studies. The search will be conducted from April 2019 to September 2019. We will report results using the PRISMA-ScR guidelines. This review aims to inform future research on the role of increasing levels of urbanisation on health outcomes, provide clues into what city level factors may drive patterns of urban health and lead to the design and implementation of policies that promote sustainable growth and improved health. ETHICS AND DISSEMINATION This review will not collect any primary data and will rely on published articles. The findings of this review will be published in a peer-reviewed scientific journal.


docid: evaujxap

title: 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary.


title: Topical delivery of nonsteroidal anti-inflammatory drugs for osteoarthritis.

text: Osteoarthritis (OA) is one of the most commonly reported chronic pain syndromes experienced in the United States. Treatment guidelines for OA recommend acetaminophen for first-line pharmacotherapy for these patients; however, this strategy is rarely effective as monotherapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered the next step in therapy and have accumulated a large body of data to support their efficacy for OA. Unfortunately, this class of agents is not without the potential for significant adverse effects. In an effort to capture the efficacy of NSAIDs while decreasing their side effect burden, many clinicians are turning to the topical administration of these agents. Localized pain and smaller, superficial joints may be especially amenable to the topical administration of NSAIDs. Numerous commercially available topical NSAID formulations have been shown to be efficacious in patients with OA. This review focuses on the topical delivery of NSAIDs for the treatment of OA.


docid: nyipwyck

title: Increase of paradoxical excitement response during propofol-induced sedation in hazardous and harmful alcohol drinkers.

text: BACKGROUND Paradoxical excitement response during sedation consists of loss of affective control and abnormal movements. Chronic alcohol abuse has been proposed as a predisposing factor despite lack of supporting evidence. Because alcohol and propofol have a common site of action, we postulated that paradoxical excitement responses during propofol-induced sedation occur more frequently in hazardous and harmful alcohol drinkers than in social or non-drinkers. METHODS One hundred and ninety patients undergoing orthopaedic knee joint surgery were enrolled in this prospective and observational study. Subjects were divided into Group HD (hazardous and harmful drinkers) or Group NHD (no hazardous drinkers) according to the alcohol use disorder identification test (AUDIT). In study 1, propofol infusion was adjusted to achieve the bispectral index at 70-80 using target-controlled infusion. In study 2, the target concentration of propofol was fixed at 0.8 (study 2/Low) or 1.4 μg ml(-1) (study 2/High). Paradoxical excitement responses were categorized by intensity into mild, moderate, or severe. RESULTS The overall incidence of paradoxical excitement response was higher in Group HD than in Group NHD in study 1 (71.4% vs 43.8%; P=0.022) and study 2/High (70.0% vs 34.5%; P=0.006) but not in study 2/Low. The incidence of moderate-to-severe response was significantly higher in Group HD of study 1 (28.6% vs 3.1%; P=0.0005) and study 2/High (23.3% vs 3.4%; P=0.029) with no difference in study 2/Low. Severe excitement response occurred only in Group HD of study 1 and study 2/High. CONCLUSIONS Paradoxical excitement occurred more frequently and severely in hazardous and harmful alcohol drinkers than in social drinkers during propofol-induced moderate-to-deep sedation, but not during light sedation.


title: Alteration of coupling between brain and heart induced by sedation with propofol and midazolam.

text: For a comprehensive understanding of the nervous system, several previous studies have examined the network connections between the brain and the heart in diverse conditions. In this study, we identified coupling between the brain and the heart along the continuum of sedation levels, but not in discrete sedation levels (e. g., wakefulness, conscious sedation, and deep sedation). To identify coupling between the brain and the heart during sedation, we induced several depths of sedation using patient-controlled sedation with propofol and midazolam. We performed electroencephalogram (EEG) spectral analysis and extracted the instantaneous heart rate (HR) from the electrocardiogram (ECG). EEG spectral power dynamics and mean HR were compared along the continuum of sedation levels. We found that EEG sigma power was the parameter most sensitive to changes in the sedation level and was correlated with the mean HR under the effect of sedative agents. Moreover, we calculated the Granger causality (GC) value to quantify brain-heart coupling at each sedation level. Additionally, the GC analysis revealed noticeably different strengths and directions of causality among different sedation levels. In all the sedation levels, GC values from the brain to the heart (GCb→h) were higher than GC values from the heart to the brain (GCh→b). Moreover, the mean GCb→h increased as the sedation became deeper, resulting in higher GCb→h values in deep sedation (1.97 ± 0.18 in propofol, 2.02 ± 0.15 in midazolam) than in pre-sedation (1.71 ± 0.13 in propofol, 1.75 ± 0.11 in midazolam; p < 0.001). These results show that coupling between brain and heart activities becomes stronger as sedation becomes deeper, and that this coupling is more attributable to the brain-heart direction than to the heart-brain direction. These findings provide a better understanding of the relationship between the brain and the heart under specific conditions, namely, different sedation states.


title: Extent and cost of inappropriate use of tumour markers in patients with pulmonary disease: a multicentre retrospective study in Shanghai, China.

text: OBJECTIVES The currently implemented healthcare reform in China requires substantial capital investment. Although overtreatment results in serious waste, inappropriate laboratory use is widespread, and overuse of tumour markers (TMs) has attracted increasing attention. DESIGN Retrospective study. SETTING The respiratory, thoracic surgery and oncology departments of three hospitals in Shanghai from 2014 to 2015. PARTICIPANTS Patients with chronic obstructive pulmonary disease (COPD) and primary bronchogenic lung cancer (PLC). Based on clinical guidelines and physician experience, the criteria of suitability of TM examinations were determined, and the number, cost and proportion of inappropriate TM requests were analysed. RESULTS The area under the receiver operating characteristic curve for carcinoembryonic antigen+cytokeratin fragment 21-1+squamous cell carcinoma antigen+neuron-specific enolase in patients with COPD and PLC was 0.813, in accordance with the cost-effectiveness principle, indicating good clinical and health economics values. In the 2706 patients, 12 496-16 956 (58.27%-79.06%) of TM requests were inappropriate. Furthermore, the involved expense was 650 200-1 014 156 yuan, accounting for 7.69%-12.00% of examination expenses and 1.35%-2.11% of hospitalisation costs. CONCLUSIONS We found that the inappropriate use of TMs was widespread for patients with pulmonary disease. Clinicians should use TMs strictly according to the guidelines to effectively manage laboratory resources and control costs.


Prediction Models - Development, Evaluation, and Clinical Application.


title: Functional analysis of two cavities in flavivirus NS5 polymerase.

text: Flavivirus NS5 protein encodes methyltransferase and RNA-dependent RNA polymerase (RdRp) activities. Structural analysis of flavivirus RdRp domains uncovered two conserved cavities (A and B). Both cavities are located in the thumb subdomains and represent potential targets for development of allosteric inhibitors. In this study, we used dengue virus as a model to analyze the function of the two RdRp cavities. Amino acids from both cavities were subjected to mutagenesis analysis in the context of genome-length RNA and recombinant NS5 protein; residues critical for viral replication were subjected to revertant analysis. For cavity A, we found that only one (Lys-756) of the seven selected amino acids is critical for viral replication. Alanine substitution of Lys-756 did not affect the RdRp activity, suggesting that this residue functions through a nonenzymatic mechanism. For cavity B, all four selected amino acids (Leu-328, Lys-330, Trp-859, and Ile-863) are critical for viral replication. Biochemical and revertant analyses showed that three of the four mutated residues (Leu-328, Trp-859, and Ile-863) function at the step of initiation of RNA synthesis, whereas the fourth residue (Lys-330) functions by interacting with the viral NS3 helicase domain. Collectively, our results have provided direct evidence for the hypothesis that cavity B, but not cavity A, from dengue virus NS5 polymerase could be a target for rational drug design.


title: Injury of the thoracic aorta during laparoscopic esophagectomy.

text: We report an unusual complication of laparoscopic esophagectomy for carcinoma. During posterior transhiatal dissection, massive bleeding occurred from the left side of the supradiaphragmatic thoracic aorta. A small tear was clearly visible and temporary bleeding control by packing and pressure with a grasper through one of the trocars was effective. A median laparotomy was performed and the aorta was sutured using a standard laparoscopic needle holder. The esophagectomy was successfully completed through a right thoracic approach. Injury to the intrathoracic aorta may occur during transhiatal dissection of the lower mediastinum. Use of a laparoscopic needle holder allowed to repair the supradiaphragmatic aorta through a laparotomy without the need of patient repositioning for a transthoracic approach.


title: Percutaneous thermal ablation combined with TACE versus TACE monotherapy in the treatment for liver cancer with hepatic vein tumor thrombus: A retrospective study.

text: PURPOSE To investigate the efficacy of percutaneous thermal ablation combined with transarterial chemoembolization (TACE) versus TACE monotherapy in treating primary liver cancer with hepatic vein tumor thrombus (HVTT), and to identify potential factors of overall survival after combination therapy. MATERIALS AND METHODS Patients with primary liver cancer and HVTT from 2011 to 2016 at our institute were retrospectively identified. They were divided into two groups (group A and group B). Patients in group A underwent TACE with subsequent percutaneous thermal ablation, while patients in group B who were unsuitable for ablation received TACE monotherapy. Characteristics and survival data of the two groups were analyzed and compared. Relevant factors for overall survival (OS) of group A were explored by univariate analysis. RESULTS Twenty-six patients were included and analyzed. The median OS for group A (n = 13) was 18 months, while the 1-, 2- and 3-year survival rates were 58.6%, 46.9% and 46.9%, respectively. The median OS for group B (n = 13) was 6.5 months and the 1-year survival rate was 10.9%. The survival of group A was significantly better than group B (P = 0.02). The following factors were related with overall survival of group A: ablation technique, complete response of tumor and HVTT, Child-pugh grade, pre-operative extrahepatic metastases and lymph node metastases. In group A, patients who achieved complete response had the longest average survival time (42.1 months). CONCLUSION For patients with primary liver cancer and HVTT, percutaneous thermal ablation and TACE present better efficacy than TACE monotherapy. Long-term survival could be achieved in selected patients.


docid: etghuesu

title: Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study.

text: IMPORTANCE Left atrial fibrosis is prominent in patients with atrial fibrillation (AF). Extensive atrial tissue fibrosis identified by delayed enhancement magnetic resonance imaging (MRI) has been associated with poor outcomes of AF catheter ablation. OBJECTIVE To characterize the feasibility of atrial tissue fibrosis estimation by delayed enhancement MRI and its association with subsequent AF ablation outcome. DESIGN, SETTING, AND PARTICIPANTS Multicenter, prospective, observational cohort study of patients diagnosed with paroxysmal and persistent AF (undergoing their first catheter ablation) conducted between August 2010 and August 2011 at 15 centers in the United States, Europe, and Australia. Delayed enhancement MRI images were obtained up to 30 days before ablation. MAIN OUTCOMES AND MEASURES Fibrosis quantification was performed at a core laboratory blinded to the participating center, ablation approach, and procedure outcome. Fibrosis blinded to the treating physicians was categorized as stage 1 (<10% of the atrial wall), 2 (≥10%-<20%), 3 (≥20%-<30%), and 4 (≥30%). Patients were followed up for recurrent arrhythmia per current guidelines using electrocardiography or ambulatory monitor recording and results were analyzed at a core laboratory. Cumulative incidence of recurrence was estimated by stage at days 325 and 475 after a 90-day blanking period (standard time allowed for arrhythmias related to ablation-induced inflammation to subside) and the risk of recurrence was estimated (adjusting for 10 demographic and clinical covariates). RESULTS Atrial tissue fibrosis estimation by delayed enhancement MRI was successfully quantified in 272 of 329 enrolled patients (57 patients [17%] were excluded due to poor MRI quality). There were 260 patients who were followed up after the blanking period (mean [SD] age of 59.1 [10.7] years, 31.5% female, 64.6% with paroxysmal AF). For recurrent arrhythmia, the unadjusted overall hazard ratio per 1% increase in left atrial fibrosis was 1.06 (95% CI, 1.03-1.08; P < .001). Estimated unadjusted cumulative incidence of recurrent arrhythmia by day 325 for stage 1 fibrosis was 15.3% (95% CI, 7.6%-29.6%); stage 2, 32.6% (95% CI, 24.3%-42.9%); stage 3, 45.9% (95% CI, 35.5%-57.5%); and stage 4, 51.1% (95% CI, 32.8%-72.2%) and by day 475 was 15.3% (95% CI, 7.6%-29.6%), 35.8% (95% CI, 26.2%-47.6%), 45.9% (95% CI, 35.6%-57.5%), and 69.4% (95% CI, 48.6%-87.7%), respectively. Similar results were obtained after covariate adjustment. The addition of fibrosis to a recurrence prediction model that includes traditional clinical covariates resulted in an improved predictive accuracy with the C statistic increasing from 0.65 to 0.69 (risk difference of 0.05; 95% CI, 0.01-0.09). CONCLUSIONS AND RELEVANCE Among patients with AF undergoing catheter ablation, atrial tissue fibrosis estimated by delayed enhancement MRI was independently associated with likelihood of recurrent arrhythmia. The clinical implications of this association warrant further investigation.