title: Diagnostic challenges and treatment options of a suspected pericardial metallic projectile foreign body in a dog.

text: OBJECTIVE To describe a case of a suspected pericardial metallic projectile foreign body in a dog with a history of trauma to the left shoulder and to review the literature regarding the management of cardiac and intracardiac foreign bodies. CASE SUMMARY A 3-year-old male, neutered Brittany spaniel presented with a 10-day history of decreased activity and partial anorexia. Serial thoracic radiographs identified a migrating pericardial metallic projectile foreign body and an echocardiogram diagnosed pericardial effusion and abdominal ultrasound identified the presence of ascites. Concern for a possible effusive-constrictive pericarditis prompted a subphrenic pericardectomy performed via thoracoscopy. The foreign body was not recovered. Six months postsurgery, the dog remained asymptomatic. NEW OR UNIQUE INFORMATION PROVIDED Considering the high rate of complications that develop in human patients where the foreign bodies are not removed, veterinarians should be aware of risks associated with long standing pericardial foreign bodies even when no clinical signs are present. Guidelines from the human literature may be considered for investigation of, and treatment options for, cardiac and intracardiac metallic projectile foreign bodies in dogs.


title: Current management of liver metastases from gastric cancer: what is common practice? New challenge of EORTC and JCOG.

text: The role of multidisciplinary treatment including surgery for liver metastases from gastric cancer (LMGC) is controversial. Studies to answer this clinical question are increasing in number, but all published data thus far are based on retrospective analyses with limited sample sizes. Thus, the European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Tract Cancer Group (GITCG) and the Japan Clinical Oncology Group (JCOG) Stomach Cancer Study Group (SCSG) initiated a collaboration to develop an optimal treatment strategy for LMGC. Before planning a prospective study, a questionnaire was sent out to the network members of both groups in June 2016 to clarify current common practice in each region. Sixty-seven sites from 17 countries in the EORTC network and 55 sites from Japan responded. According to the survey, for patients with resectable LMGC without extrahepatic metastases, preoperative chemotherapy followed by resection of both primary (if still in place) and liver lesions was the preferred option for both the synchronous and the metachronous setting. For patients with unresectable LMGC, most of the sites recommended chemotherapy only. In this article, the detailed results of this survey are reported, shedding light on current community practice, and a joint EORTC-JCOG strategy of investigation is delineated.


docid: xrgviwby

title: Practical Aspects of Neuroendoscopic Techniques and Complication Avoidance: A Systematic Review.

text: Although endoscopic techniques have many advantages including improved visualization and magnification, they are also associated with limitations. The objective of this review is to discuss the practical aspects that can reduce complications after endoscopic procedures, and their management. The review is based on the personal experience of more than 2000 neuroendoscopic procedures performed by the senior author. Topic search was made on PubMed using Neuroendoscopy, complications and neuroendoscopy, complication avoidance and neuroendoscopy, endoscopic neurosurgery, and minimally invasive neurosurgery. Relevant articles were selected after analyzing abstracts and/or topics. Endoscopic procedures are also associated with limitations such as obstruction in instruments manipulation, steep learning curve, blind area, difficulty in visualization, disorientation, loss of stereoscopic image and others. Neuroendoscopy is distinct from microsurgery and the surgeon has to learn endoscopic skills in addition to microsurgical techniques. Difficulties in controlling bleeding, working in a limited area, higher complication rate during the initial learning curve and longer operative time are some of the limitations. Attending live workshops, practicing on models, and hands on cadaveric workshops can reduce the learning curve. Proper case selection, multidisciplinary team approach, watching operative video, visiting other departments, observing a skillful endoscopic surgeon, lab training, and simulators can improve results and shorten the learning curve. Limitations of this review are that the search is limited to the English literature and personal experience of a single surgeon that may create some bias. Although neuroendoscopic techniques are associated with improved results in some indications, they have many limitations. Neuroendoscopic skills need to be learned to improve results.


title: Cellular radioprotecting potential of glyzyrrhizic acid, silver nanoparticle and their complex.

text: Silver nanoparticles (SN) of particle size of less than 50nm were redispersed in aqueous solution of Pluronic F127 and complexed with the phytoceutical, glyzyrrhizic acid (GLY). Radioprotecting ability of the obtained nanoparticle-glyzyrrhizic acid complex (SN-GLY) was evaluated in an in vivo model using Swiss albino mice. Oral administration of SN-GLY, SN and GLY one hour prior to radiation exposure reduced the radiation induced damage in peripheral blood leucocytes, bone marrow cells and spleen cells of mice as revealed by comet assay. Exposure of mice to whole body gamma irradiation resulted in formation of micronuclei in blood reticulocytes and chromosomal aberrations in bone marrow cells while SN-GLY, SN or GLY administration resulted in reduction in micronucleus formation and chromosomal aberrations indicating radioprotection. In SN-GLY treated mice the cellular DNA was found protected to a greater extent compared to GLY or SN treated mice. The studies, under in vivo radiation exposure conditions, showed effective radiation protection.


title: Determinants of a short convalescence after laparoscopic transabdominal preperitoneal inguinal hernia repair.

text: BACKGROUND Evidence-based recommendations for the expected duration of convalescence after laparoscopic groin hernia repair are not available, and objective reasons for prolonged convalescence are not clear. Our main aim was to establish the expected duration of convalescence using preoperative recommendations to the patient and to identify the limiting factors for early (postoperative) resumption of normal activities after laparoscopic transabdominal preperitoneal inguinal herniorraphy (TAPP). METHODS This was a single-center prospective study. The intervention (the recommendation to the patient) was 1 day for convalescence. Several predefined factors were investigated for their influence on the duration of convalescence and the risk of early postoperative pain. Predefined, clinically justified reasons for not resuming normal activities within the first 3 postoperative days were also registered. RESULTS Between August 2009 and August 2010, 185 consecutive male patients with groin hernia were enrolled prospectively, and 162 patients were available for analysis. Convalescences from work and leisure activities were a median of 5 days (range, 1-40) and 3 days (range, 1-49), respectively (P = .34). Preoperative expectations of convalescence from work (the number of days) was the only factor to explain prolonged convalescence from work (P < .001). Postoperative, self-registered planned sick leave, and complaints of pain and fatigue were the dominant reasons for not resuming normal activities within the first 3 days after operation. Younger age was the only factor found to explain the intensity of postoperative pain (P < .001). CONCLUSION Postoperative convalescence (return to work or normal activities) was between 3 and 5 days after TAPP in patients who were counseled about a 1-day expected convalescence. The expectation of convalescence from work was an important reason for delayed convalescence beyond 1 day.


title: Acknowledgement to Reviewers of IJERPH in 2016.

text: The editors of IJERPH would like to express their sincere gratitude to the following reviewers for assessing manuscripts in 2016.[...].


title: Gastrojejunal Anastomosis Complications and Their Management after Laparoscopic Roux-en-Y Gastric Bypass.

text: BACKGROUND Complications at the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) are challenging in terms of diagnosis, therapy, and prevention. This study aims at identifying these complications and discussing their management. METHODS Data of 228 patients who underwent a LRYGB between October 2008 and December 2011 were reviewed retrospectively to evaluate the frequency and treatment of complications such as stenoses, marginal ulcers, perforated marginal ulcers, or anastomotic leaks related to the operation. RESULTS Follow-up information was available for 209 patients (91.7%) with a median follow-up of 38 months (range 24-62 months). Of these patients 16 patients (7.7%) experienced complications at the gastrojejunostomy. Four patients (1.9%) had stenoses and 12 patients (5.7%) marginal ulcers, one of them with perforation (0.5%). No anastomotic leaks were reported. One case with perforated ulcer and one with recurrent ulcers required surgical revision. CONCLUSION Gastrojejunal anastomotic complications are frequent and occur within the first few days or up to several years after surgery. Stenoses or marginal ulcers are usually successfully treated nonoperatively. Laparoscopic repair, meanwhile, is an appropriate therapeutic option for perforated ulcers.


title: Which interventions work best in a pandemic?

text: We can exploit randomized controlled trials, compartmental models, and spillovers.


title: Covidien micro vascular plug in congenital heart diseases and vascular anomalies: A new kid on the block for premature babies and older patients.

text: OBJECTIVES To evaluate the safety, feasibility, and efficacy of the MVP™ microvascular plug(Covidien) for closure of vascular anomalies in patients with congenital heart diseases (CHD). BACKGROUND The MVP™ is a novel device with PTFE integrated. The device has been recently introduced in the radiological field and reported exclusively for neurological anomalies. METHODS All CHD patients receiving the device from April 2015 until July 2015 were included in the study and followed up clinically as well as by transthoracic echocardiography. Standard safety and follow-up such as vascular complications, embolization rate, and residual shunting were assessed. RESULTS Twelve patients with a median age of 2.6-years (0.03-12.6 years) and a mean weight of 13 kg (2.8-34.2 kg) were included. Devices were delivered from the femoral artery in 10 and from the femoral vein in 2 patients. Devices were used for closure of patent ductus arteriosus (PDA) closure (n = 5), aorto-pulmonary collaterals or Blalock-Taussig shunt (n = 5), veno-venous fistula (n = 1), and coronary fistula (n = 1). One device was retrieved before release due to inappropriate size estimation (PDA spasm). The PDA was successfully closed using a PDA device (Lifetech, Medtronic). Immediate angiographic evaluation showed minimal or no shunt in 90% (10/11 patients) and 100% occlusion rate after a mean follow-up of 3.2-months. There was no device embolization, hemolysis, or any other complication following closure. CONCLUSIONS The delivery of new MVP™ micro vascular plug system (Covidien) is safe and effective in patients with CHD for closure of a variety of vascular abnormalities. The low profile of the device and the sheathless nature of the procedure make it particularly interesting for PDA closure in premature babies. © 2016 Wiley Periodicals, Inc.


title: Single-incision versus multiport laparoscopic right and hand-assisted left colectomy: a case-matched comparison.

text: BACKGROUND New technology for single-incision laparoscopic colectomy is now commercially available, yet advantages of this approach over multiport laparoscopic colectomy have not been demonstrated. OBJECTIVE This study aimed to compare the outcomes of patients who underwent single-incision vs multiport laparoscopic colectomies. DESIGN Consecutive patients who underwent single-incision laparoscopic colectomies were case matched to patients who underwent multiport laparoscopic colectomies by age, operation, surgeon, diagnosis, and body mass index. Data from a prospective database and the medical records of patients treated were reviewed. SETTINGS This study took place at 2 tertiary care hospitals. PATIENTS Forty-six consecutive patients with a body mass index of 24 underwent single-incision laparoscopic colectomies (24 right, 18 sigmoid, 4 low anterior resection). MAIN OUTCOME MEASURES Perioperative outcomes and cosmesis and body image scores at 90 days were compared. RESULTS The largest incision length was significantly shorter for the single-incision group. Two patients with single incisions were converted to hand-assisted laparoscopic surgery and 4 required placement of a 5-mm trocar. A significantly greater portion of the operation was performed by the attending surgeons in the single-incision group. For right colectomies, operative times were similar. For left colectomies, operative time (149 ± 30 vs 126 ± 21 min) was significantly longer for the single-incision group. Time to flatus and bowel movements were significantly shorter for the single-incision group, but length of stay was similar. Cosmetic score was higher for the single-incision group (P = .03). CONCLUSIONS Single incision is equivalent to multiport laparoscopic colectomy with regard to safety and efficacy with smaller incision size and higher cosmetic scores. Operative times were equivalent, although a greater portion of the operation was performed by the attending surgeons in the single-incision group. Further prospective studies are warranted to evaluate the advantages of single-incision laparoscopic colectomy.


title: First-in-human uPAR PET: Imaging of Cancer Aggressiveness.

text: A first-in-human clinical trial with Positron Emission Tomography (PET) imaging of the urokinase-type plasminogen activator receptor (uPAR) in patients with breast, prostate and bladder cancer, is described. uPAR is expressed in many types of human cancers and the expression is predictive of invasion, metastasis and indicates poor prognosis. uPAR PET imaging therefore holds promise to be a new and innovative method for improved cancer diagnosis, staging and individual risk stratification. The uPAR specific peptide AE105 was conjugated to the macrocyclic chelator DOTA and labeled with (64)Cu for targeted molecular imaging with PET. The safety, pharmacokinetic, biodistribution profile and radiation dosimetry after a single intravenous dose of (64)Cu-DOTA-AE105 were assessed by serial PET and computed tomography (CT) in 4 prostate, 3 breast and 3 bladder cancer patients. Safety assessment with laboratory blood screening tests was performed before and after PET ligand injection. In a subgroup of the patients, the in vivo stability of our targeted PET ligand was determined in collected blood and urine. No adverse or clinically detectable side effects in any of the 10 patients were found. The ligand exhibited good in vivo stability and fast clearance from plasma and tissue compartments by renal excretion. In addition, high uptake in both primary tumor lesions and lymph node metastases was seen and paralleled high uPAR expression in excised tumor tissue. Overall, this first-in-human study therefore provides promising evidence for safe use of (64)Cu-DOTA-AE105 for uPAR PET imaging in cancer patients.


title: Telehealth: Synopsis.

text: The COVID-19 pandemic has changed the Australian medical landscape, especially in relation to how we need to provide clinical care in general practice.


title: A schlieren optical study of the human cough with and without wearing masks for aerosol infection control.

text: Various infectious agents are known to be transmitted naturally via respiratory aerosols produced by infected patients. Such aerosols may be produced during normal activities by breathing, talking, coughing and sneezing. The schlieren optical method, previously applied mostly in engineering and physics, can be effectively used here to visualize airflows around human subjects in such indoor situations, non-intrusively and without the need for either tracer gas or airborne particles. It accomplishes this by rendering visible the optical phase gradients owing to real-time changes in air temperature. In this study, schlieren video records are obtained of human volunteers coughing with and without wearing standard surgical and N95 masks. The object is to characterize the exhaled airflows and evaluate the effect of these commonly used masks on the fluid-dynamic mechanisms that spread infection by coughing. Further, a high-speed schlieren video of a single cough is analysed by a computerized method of tracking individual turbulent eddies, demonstrating the non-intrusive velocimetry of the expelled airflow. Results show that human coughing projects a rapid turbulent jet into the surrounding air, but that wearing a surgical or N95 mask thwarts this natural mechanism of transmitting airborne infection, either by blocking the formation of the jet (N95 mask), or by redirecting it in a less harmful direction (surgical mask).


Authors' reply: Outbreak of COVID-19 - an urgent need for good science to silence our fears?


title: Laparoscopic Organopexy with Non-mesh Genital (LONG) Suspension: A Novel Uterine Preservation Procedure for the Treatment of Apical Prolapse.

text: To assess whether our novel uterus-sparing procedure- laparoscopic organopexy with non-mesh genital(LONG) suspension is an effective, safe, and timesaving surgery for the treatment of apical prolapse. Forty consecutive women with main uterine prolapse stage II or greater defined by the POP quantification(POP-Q) staging system were referred for LONG procedures at our hospitals. Clinical evaluations before and 6 months after surgery included pelvic examination, urodynamic study, and a personal interview to evaluate urinary and sexual symptoms with overactive bladder symptom score(OABSS), the short forms of Urogenital Distress Inventory(UDI-6) and Incontinence Impact Questionnaire(IIQ-7), and the Female Sexual Function Index(FSFI). After follow-up time of 12 to 30 months, anatomical cure rate was 85%(34/40), and the success rates for apical, anterior, and posterior vaginal prolapse were 95%(38/40), 85%(34/40), and 97.5%(39/40), respectively. Six recurrences of anterior vaginal wall all suffered from significant cystocele (stage3; Ba>+1) preoperatively. The average operative time was 73.1 ± 30.8 minutes. One bladder injury occurred and was recognized during surgery. The dyspareunia domain and total FSFI scores of the twelve sexually-active premenopausal women improved postoperatively in a significant manner (P < 0.05). The results of our study suggest that LONG suspension is an effective and safe uterus-sparing surgery for the treatment of apical prolapse.


title: An allosteric inhibitor of substrate recognition by the SCF(Cdc4) ubiquitin ligase.

text: The specificity of SCF ubiquitin ligase-mediated protein degradation is determined by F-box proteins. We identified a biplanar dicarboxylic acid compound, called SCF-I2, as an inhibitor of substrate recognition by the yeast F-box protein Cdc4 using a fluorescence polarization screen to monitor the displacement of a fluorescein-labeled phosphodegron peptide. SCF-I2 inhibits the binding and ubiquitination of full-length phosphorylated substrates by SCF(Cdc4). A co-crystal structure reveals that SCF-I2 inserts itself between the beta-strands of blades 5 and 6 of the WD40 propeller domain of Cdc4 at a site that is 25 A away from the substrate binding site. Long-range transmission of SCF-I2 interactions distorts the substrate binding pocket and impedes recognition of key determinants in the Cdc4 phosphodegron. Mutation of the SCF-I2 binding site abrogates its inhibitory effect and explains specificity in the allosteric inhibition mechanism. Mammalian WD40 domain proteins may exhibit similar allosteric responsiveness and hence represent an extensive class of druggable target.


title: Intranasal delivery of an adjuvanted modified live porcine reproductive and respiratory syndrome virus vaccine reduces ROS production.

text: Reactive oxygen species (ROS) are produced predominantly by phagocytic cells in response to microbial infections. When produced at optimal levels ROS have potent antimicrobial properties. However, excessive production of ROS induces apoptosis/necrosis of infected as well as bystander cells, resulting in inflammatory pathology. Previously we showed that vaccination of pigs with a modified live porcine reproductive and respiratory syndrome virus vaccine (PRRS-MLV) administered intranasally with a potent mucosal adjuvant M. tuberculosis whole-cell lysate (Mtb WCL) induces protective immunity against PRRSV challenge. In this study, using bronchoalveolar lavage fluid cells and peripheral blood mononuclear cells harvested from that study were quantified for the levels of ROS produced. Our results indicated that in vaccinated pigs, levels of ROS were lower compared to unvaccinated PRRSV-challenged pigs. In unvaccinated but PRRSV-challenged pigs, the higher ROS production was associated with increased inflammatory lung pathology. In conclusion, our results suggest that intranasal immunization using PRRS-MLV along with a potent mucosal adjuvant protects pigs against both homologous and virulent heterologous PRRSV challenge, which was associated with reduced ROS production and reduced lung pathology compared to control virus-challenged pigs.


title: Impact of Continuous Capnography in Ventilated Neonates: A Randomized, Multicenter Study.

text: OBJECTIVE To compare the time spent within a predefined safe range of CO2 (30-60 mmHg) during conventional ventilation between infants who were monitored with distal end-tidal CO2 (dETCO2, or capnography) and those who were not. STUDY DESIGN For this randomized, controlled multicenter study, ventilated infants with a double-lumen endotracheal tube were randomized to 1 of 2 groups: the open (monitored) group, in which data from the capnograph were recorded, displayed to the medical team, and used for patient care, and the masked group, in which data from the capnograph were recorded. However, the measurements were masked and not available for patient care. dETCO2 was compared with PaCO2 measurements recorded for patient care. RESULTS Fifty-five infants (25 open, 30 masked) participated in the study (median gestational age, 28.6 weeks; range, 23.5-39.0 weeks). The 2 groups were comparable. dETCO2 was in good correlation (r = 0.73; P < .001) and adequate agreement (mean ± SD of the difference, 3.0 ± 8.5 mmHg) with PaCO2. Compared with infants in the masked group, those in the monitored group had significantly (P = .03) less time with an unsafe dETCO2 level (high: 3.8% vs 8.8% or low: 3.8% vs 8.9%). The prevalence of intraventricular hemorrhage or periventricular leukomalacia rate was lower in the monitored group (P = .02) and was significantly (P < .05) associated with the independent factors dETCO2 monitoring and gestational age. CONCLUSION Continuous dETCO2 monitoring improved control of CO2 levels within a safe range during conventional ventilation in a neonatal intensive care unit. TRIAL REGISTRATION ClinicalTrials.gov: NCT01572272.


title: Sexually transmitted infections among high-risk populations that use treatment as prevention or pre-exposure prophylaxis: a protocol for a systematic review.

text: BACKGROUND Among men who have sex with men, pre-exposure prophylaxis (PrEP) reduces the risk of HIV by 95%. Based on the documented benefits, the Centre for Disease Control and Prevention has recommended PrEP as a prevention method for high-risk groups. Moreover, for those HIV-infected individuals, antiretroviral therapy has been shown to serve as both as a treatment and prevention method for HIV. METHODS AND ANALYSIS This systematic review protocol was reported according to the Preferred Reporting Items for Systematic reviews and Analyses (PRISMA) P framework. Medline (1980-present), Embase (1980-present), CINAHL (1980-present), Cochrane Central Register of Controlled Trials and clinicaltrials.gov will be used to identify relevant articles based on a piloted search strategy. Peer-reviewed observational and experimental studies will be included. A narrative style will be used to describe descriptive data. A meta-analysis will be conducted if heterogeneity is not significant. ETHICS AND DISSEMINATION Recent evidence suggests that there is an increased risk of sexually transmitted infections (STIs) among high-risk persons that use PrEP. Furthermore, there is a paucity of data on the relationship of treatment as prevention and incidence of STIs. The findings of this review will assess this emerging public health phenomenon and serve to inform future public health policy. No formal ethical review is required for this protocol. All findings will be published in a peer reviewed journal. PROTOCOL REGISTRATION NUMBER CRD42019128720.


docid: zyogqibi

title: Removal of percutaneous K-wires used in paediatric fracture stabilisation under IV sedation: a cost-effective and timesaving service delivery in the COVID-19 pandemic setting.


title: Dying in the face of the COVID-19 pandemic: Contextual considerations and clinical recommendations.

text: Dying is a natural part of life; however, death is often a fearful, frightening event. Dying in the midst of the COVID-19 pandemic presents challenges that magnify normative fears and may interfere with a healthy grieving process. To maintain a resilient spirit among those who are at risk of losing a loved one or who have lost a family member to COVID-19, it is important that they be provided with the necessary contextually and culturally appropriate skills and resources to facilitate healing in the face of hardship and uncertainty. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


title: Clopidogrel Resistance in Neurovascular Stenting: Correlations between Light Transmission Aggregometry, VerifyNow, and the Multiplate.

text: BACKGROUND AND PURPOSE Clopidogrel resistance is blamed for thromboembolic complications in neurovascular stent placement. Platelet-function assays are weakly standardized. The aim of this study was to correlate the results of 3 different platelet-inhibition measurements (from light transmission aggregometry, the VerifyNow P2Y12 test, and the Multiplate analyzer) and their relation to periprocedural thromboembolic complications in elective neurovascular stent placement. MATERIALS AND METHODS Clopidogrel resistance was determined on the day of the intervention according to predefined platelet reactivity cutoff values. All 3 tests were performed in 103 consecutive neurovascular stent-placement procedures in 97 patients (extracranial, n = 77; intracranial, n = 26). RESULTS The clopidogrel resistance rates were 47.6% (light transmission aggregometry), 50.5% (VerifyNow), and 35.9% (Multiplate). In 67% of the patients, clopidogrel resistance was present according to at least one method. The correlations of qualitative results that classified a patient as responsive or resistant to clopidogrel were 67.9% for light transmission aggregometry with VerifyNow, 77.7% for light transmission aggregometry with the Multiplate, and 66% for VerifyNow with the Multiplate. Periprocedural thromboembolic complications (n = 9) occurred more frequently in patients who were determined by all 3 methods to be clopidogrel resistant. The difference was most pronounced with light transmission aggregometry (complication rates, 14.4% [clopidogrel-resistant patients] vs 3.7% [clopidogrel-responsive patients]). Sensitivity and specificity rates of clopidogrel resistance in relation to embolic complications were, respectively, 78% and 55% for light transmission aggregometry, 67% and 51% for VerifyNow, and 44% and 67% for the Multiplate. CONCLUSIONS Clopidogrel resistance is a frequent finding in patients who undergo neurovascular stent placement. The correlations among the different testing methods are only modest and differ considerably. Light transmission aggregometry results seem to correlate with thromboembolic complications more accurately than with VerifyNow and Multiplate point-of-care methods.


title: Use of Twitter social media activity as a proxy for human mobility to predict the spatiotemporal spread of COVID-19 at global scale.

text: As of February 27, 2020, 82,294 confirmed cases of coronavirus disease (COVID-19) have been reported since December 2019, including 2,804 deaths, with cases reported throughout China, as well as in 45 international locations outside of mainland China. We predict the spatiotemporal spread of reported COVID- 19 cases at the global level during the first few weeks of the current outbreak by analyzing openly available geolocated Twitter social media data. Human mobility patterns were estimated by analyzing geolocated 2013-2015 Twitter data from users who had: i) tweeted at least twice on consecutive days from Wuhan, China, between November 1, 2013, and January 28, 2014, and November 1, 2014, and January 28, 2015; and ii) left Wuhan following their second tweet during the time period under investigation. Publicly available COVID-19 case data were used to investigate the correlation among cases reported during the current outbreak, locations visited by the study cohort of Twitter users, and airports with scheduled flights from Wuhan. Infectious Disease Vulnerability Index (IDVI) data were obtained to identify the capacity of countries receiving travellers from Wuhan to respond to COVID-19. Our study cohort comprised 161 users. Of these users, 133 (82.6%) posted tweets from 157 Chinese cities (1,344 tweets) during the 30 days after leaving Wuhan following their second tweet, with a median of 2 (IQR= 1-3) locations visited and a mean distance of 601 km (IQR= 295.2-834.7 km) traveled. Of our user cohort, 60 (37.2%) traveled abroad to 119 locations in 28 countries. Of the 82 COVID-19 cases reported outside China as of January 30, 2020, 54 cases had known geolocation coordinates and 74.1% (40 cases) were reported less than 15 km (median = 7.4 km, IQR= 2.9-285.5 km) from a location visited by at least one of our study cohort's users. Countries visited by the cohort's users and which have cases reported by January 30, 2020, had a median IDVI equal to 0.74. We show that social media data can be used to predict the spatiotemporal spread of infectious diseases such as COVID-19. Based on our analyses, we anticipate cases to be reported in Saudi Arabia and Indonesia; additionally, countries with a moderate to low IDVI (i.e. ≤0.7) such as Indonesia, Pakistan, and Turkey should be on high alert and develop COVID- 19 response plans as soon as permitting.


title: Etiology and prognosis of acute respiratory failure in patients with primary malignant brain tumors admitted to the intensive care unit.

text: PURPOSE Acute respiratory failure (ARF) is common and potentially fatal in patients with primary malignant brain tumors (PMBT). However, few data are available regarding its precipitating factors and prognosis. We sought to: (1) compare the causes of ARF and the outcome between patients with PMBT and patients with other peripheral solid tumors (PST), (2) identify the factors influencing ICU survival in PMBT patients. METHODS Two-center retrospective case-control study from March 1996 to May 2014. Primary central nervous system lymphomas were also included. RESULTS Eighty-four patients with PMBT and 133 patients with PST were included. Acute infectious pneumonia was more frequent in PMBT than PST patients (77 vs. 36%, p < 0.001). Pulmonary embolism was also more frequent in PMBT patients (13% vs. 5%, p = 0.042), while cardiogenic pulmonary edema and acute-on-chronic respiratory failure were more frequent in PST patients (37 vs. 10%, p < 0.001). Among acute infectious pneumonia, Pneumocystis pneumonia and aspiration pneumonia were more frequent in PMBT patients (19 vs. 2%, p < 0.001 and 19 vs. 8%, p < 0.001, respectively). ICU mortality was similar between PMBT and PST patients (24% vs. 24%, p = 0.966). In multivariate analysis, cancer progression (OR 7.25 95% CI 1.13-46.45, p = 0.034), need for intubation (OR 7.01 95% CI 1.29-38.54, p = 0.022), were independently associated with ICU mortality in PMBT patients. CONCLUSIONS The cause of ARF in patients with PMBT differs significantly than those with PST and up to 50% may have been prevented. Mortality did not differ between the two groups. These results suggest that PMBT alone is not a relevant criterion for ICU recusal.


title: Delayed Laboratory Response to COVID-19 Caused by Molecular Diagnostic Contamination.

text: The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) created an exceptional situation in which numerous laboratories in Europe simultaneously implemented SARS-CoV-2 diagnostics. These laboratories reported in February 2020 that commercial primer and probe batches for SARS-CoV-2 detection were contaminated with synthetic control material, causing delays of regional testing roll-out in various countries.


docid: rlrtrapw

title: Feasibility and safety of pipeline embolization device in patients with ruptured carotid blister aneurysms.

text: BACKGROUND Treatment of internal carotid ruptured blister aneurysms (IC-RBA) presents many challenges to neurosurgeons because of the high propensity for rebleeding during intervention. The role of a Pipeline Embolization Device (PED) in the treatment of this challenging aneurysm subtype remains undefined despite theoretical advantages. OBJECTIVE To present a series of 11 patients treated with a PED and to discuss the management and results of this novel application of flow diverters. METHODS Medical records of patients who presented with IC-RBA from May 2011 to March 2013 were retrospectively reviewed at 6 institutions in the United States. All relevant data were independently compiled. RESULTS A total of 12 IC-RBAs in 11 patients were treated during the study period. Nine (75%) were treated with a single PED; 1 was treated with 2 PEDs; 1 was treated with coils and 1 PED; and 1 was treated with coils and 2 PEDs. Three (27%) had major perioperative complications: middle cerebral artery territory infarction, vision loss, and death. Seven patients demonstrated complete obliteration of the aneurysm in postoperative imaging. Early clinical outcomes were favorable (modified Rankin Scale score, 0-2) in all 10 survivors. CONCLUSION This study demonstrates the feasibility and safety of using the PED to treat IC-RBA with fair initial results. The proper introduction and management of antiplatelet regimen are key for successful results. Bleeding complications related to dual antiplatelet therapy were similar to those in previous studies of stent-assisted coiling for the same population. Larger cohort analysis is needed to define the precise role of flow diverters in the treatment of IC-RBA.


Detection of SARS-CoV-2 in Different Types of Clinical Specimens.


title: An enhanced recovery pathway decreases duration of stay after esophagectomy.

text: PURPOSE Enhanced recovery pathways (ERP) decrease morbidity and duration of stay after colorectal surgery. There is little information about their role in complex procedures, such as esophagectomy. The purpose of this study was to determine the impact of an ERP on duration of stay, complications, and readmissions after esophagectomy. METHODS Patients undergoing esophagectomy for cancer or high-grade dysplasia from June 2009 to December 2011 were identified from a prospectively maintained database. Beginning in June 2010, all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan, indications for intensive care admission, early structured mobilization, and diet and drain management. Short-term (30-day) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway. Data are expressed as median values [interquartile range]. RESULTS We identified 106 patients; 47 underwent esophagectomy before ERP implementation and 59 after. Patients were similar with respect to age, gender, diagnosis, and operative time. Hospital stay was shorter in the ERP group (8 [7-17] vs 10 [9-17] days; P = .01). There were no differences in rates of complications (59% vs 62%) or readmissions (6% vs 5%). CONCLUSION Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay, without an increase in complications or readmissions.


title: Discrete Wavelet Packet Transform Based Discriminant Analysis for Whole Genome Sequences.

text: In recent years, alignment-free methods have been widely applied in comparing genome sequences, as these methods compute efficiently and provide desirable phylogenetic analysis results. These methods have been successfully combined with hierarchical clustering methods for finding phylogenetic trees. However, it may not be suitable to apply these alignment-free methods directly to existing statistical classification methods, because an appropriate statistical classification theory for integrating with the alignment-free representation methods is still lacking. In this article, we propose a discriminant analysis method which uses the discrete wavelet packet transform to classify whole genome sequences. The proposed alignment-free representation statistics of features follow a joint normal distribution asymptotically. The data analysis results indicate that the proposed method provides satisfactory classification results in real time.


title: [Radiofrequency of lung metastases: should initial pneumothorax predict treatment failure?].

text: In the management of lung metastases originating from colorectal cancer, RFA is particularly indicated in case of major comorbidities contraindicating thoracic surgery or recurrent disease after previous ipsilateral resection. The most frequent complication of RFA is pneumothorax, requiring chest tube insertion in 5% of cases. Interestingly, this proportion is very close to the rate of local recurrence, suggesting a possible association. We report a case of RFA followed by intractable pneumothorax requiring surgical management, and leading to the diagnosis of residual tumour. This case report illustrates this association and questions its relevance.


Percutaneous imaging-guided biopsies in patients with COVID-19 positive cancer performed at the peak of the COVID-19 pandemic.


title: Mechanical Thrombectomy with the Embolus Retriever with Interlinked Cages in Acute Ischemic Stroke: ERIC, the New Boy in the Class.

text: BACKGROUND AND PURPOSE The Embolus Retriever with Interlinked Cages (ERIC) device is a novel stent retriever for mechanical thrombectomy. It consists of interlinked cages and could improve procedural benchmarks and clinical outcome compared with classic stent retrievers. This study compares the rates of recanalization, favorable clinical outcome, procedural adverse events, and benchmarks between the ERIC device and classic stent retrievers. MATERIALS AND METHODS From 545 patients treated with thrombectomy between 2012 and 2015, 316 patients were included. The mean age was 69 ±13 years, the mean baseline NIHSS score was 17 ± 5, and 174 (55%) were men. The ERIC was used as the primary thrombectomy device in 59 (19%) patients. In a propensity score matched analysis including the NIHSS score, clot location, delay to groin puncture, neurointerventionalist, and anesthetic management, 57 matched pairs were identified. RESULTS Patients treated with the ERIC device compared with classic stent retrievers showed equal rates of recanalization (86% versus 81%, P = .61), equal favorable 3-month clinical outcome (mRS 0-2: 46% versus 40%, P = .71), and procedural adverse events (28% versus 30%, P = 1.00). However, in patients treated with the ERIC device, thrombectomy procedures were less time-consuming (67 versus 98 minutes, P = .009) and a rescue device was needed less often (18% versus 39%, P = .02) compared with classic stent retrievers. CONCLUSIONS Mechanical thrombectomy with the ERIC device is effective and safe. Rates of favorable procedural and clinical outcomes are at least as good as those with classic stent retrievers. Of note, the ERIC device might be time-saving and decrease the need for rescue devices. These promising results call for replication in larger prospective clinical trials.


title: Platelet-leukocyte rich gel application in the prevention of deep sternal wound problems after cardiac surgery in obese diabetic patients.

text: Background Deep sternal wound problems (DSWP) are a rare, but serious complication following cardiac surgery requiring extensive medical treatment and resulting in increased mortality. Cardiac surgery patients presenting with both obesity and diabetes mellitus type 2 (DM 2) showed an increased incidence of DSWP in our clinic. As platelets upon activation have been shown to excrete growth factors and attractants for tissue stem cells, thus potentially promoting tissue healing, we investigated whether activated platelets could reduce the incidence of DSWP. Methods We applied activated autologous platelet rich plasma (PRP), forming a gel (PLG), between the sternal halves immediately prior to closure in obese [body mass index (BMI) >30] DM 2 cardiac surgery patients. The reference group constituted of all elective patients with a BMI >30 and DM 2 operated upon in the 2-year period before the application of PLG. Results The PLG treated group (n=144) showed a significant decrease in DSWP compared to the reference group (n=118), 6 DSWP vs. 13 DSWP respectively, P=0.03. In these groups the application of PLG was associated with a risk reduction for DSWP from 11% to 4.2%. Conclusions These results suggest PLG application could be beneficial to prevent DSWP following cardiac surgery in a high-risk population.


title: Positive contrast spiral imaging for visualization of commercial nitinol guidewires with reduced heating.

text: BACKGROUND CMR-guidance has the potential to improve tissue visualization during cardiovascular catheterization procedures and to reduce ionizing radiation exposure, but a lack of commercially available CMR guidewires limits widespread adoption. Standard metallic guidewires are considered to be unsafe in CMR due to risks of RF-induced heating. Here, we propose the use of RF-efficient gradient echo (GRE) spiral imaging for reduced guidewire heating (low flip angle, long readout), in combination with positive contrast for guidewire visualization. METHODS A GRE spiral sequence with 8 interleaves was used for imaging. Positive contrast was achieved using through-slice dephasing such that the guidewire appeared bright and the background signal suppressed. Positive contrast images were interleaved with anatomical images, and real-time image processing was used to produce a color overlay of the guidewire on the anatomy. Temperature was measured with a fiber-optic probe attached to the guidewire in an acrylic gel phantom and in vivo. RESULTS Left heart catheterization was performed on swine using the real-time color overlay for procedural guidance with a frame rate of 6.25 frames/second. Using our standard Cartesian real-time imaging (flip angle 60°), temperature increases up to 50 °C (phantom) and 4 °C (in vivo) were observed. In comparison, spiral GRE images (8 interleaves, flip angle 10°) generated negligible heating measuring 0.37 °C (phantom) and 0.06 °C (in vivo). CONCLUSIONS The ability to use commercial metallic guidewires safely during CMR-guided catheterization could potentially expedite clinical translation of these methods.


The researchers taking a gamble with antibody tests for coronavirus.


docid: dbfjbwee

title: Negligible impact of highly patient-specific decision support for potassium-increasing drug-drug interactions - a cluster-randomised controlled trial.

text: BACKGROUND AND OBJECTIVE Clinical decision support (CDS) might improve management of potassium-increasing drug-drug interactions (DDI). We studied CDS with five features intended to increase effectiveness: (i) focus on serious DDIs, (ii) fewer notifications, (iii) presentation of current laboratory results, (iv) timing (when adverse event becomes likelier), (v) removal of notification when appropriate. METHODS We conducted a 1-year, hospital-wide, cluster-randomised controlled trial in the inpatient setting at a large tertiary-care academic medical centre. Three CDS types were implemented: monitoring reminders (unknown potassium, no monitoring ordered), elevated potassium warnings (≥4.9 mEq/l), and hyperkalaemia alerts (≥5.5 mEq/l). The primary endpoint was the frequency of potassium-monitoring intervals >72 h. RESULTS We analysed 15,272 and 18,981 stays with 2804 and 2057 potassium-increasing DDIs in the intervention and control groups, respectively. Patient-specific notifications: displayed were 869 reminders (1 per 3.2 potassium-increasing DDIs), 356 warnings (1:7.9), and 62 alerts (1:45.2). Nevertheless, insufficiently monitored DDIs were not reduced (intervention 451 of 9686 intervals >72 h [4.66%]; control 249 of 6140 [4.06%]). The only secondary outcome improved was the length of potassium monitoring intervals (intervention group mean 22.9 h, control 23.7 h; p <0.001). However, in the intervention group, during 50 of 2804 observed potassium-increasing DDI periods (1.78%) one or more serum potassium values ≥ 5.5mEq/l were measured, in the control group, during 27 of 2057 (1.31%; p = 0.20). CONCLUSIONS A highly patient-specific CDS feature combination had a negligible impact on the management of potentially serious potassium-increasing DDIs and was unable to improve safety among hospitalised patients.


title: Betacoronavirus Genomes: How Genomic Information has been Used to Deal with Past Outbreaks and the COVID-19 Pandemic.

text: In the 21st century, three highly pathogenic betacoronaviruses have emerged, with an alarming rate of human morbidity and case fatality. Genomic information has been widely used to understand the pathogenesis, animal origin and mode of transmission of coronaviruses in the aftermath of the 2002-2003 severe acute respiratory syndrome (SARS) and 2012 Middle East respiratory syndrome (MERS) outbreaks. Furthermore, genome sequencing and bioinformatic analysis have had an unprecedented relevance in the battle against the 2019-2020 coronavirus disease 2019 (COVID-19) pandemic, the newest and most devastating outbreak caused by a coronavirus in the history of mankind. Here, we review how genomic information has been used to tackle outbreaks caused by emerging, highly pathogenic, betacoronavirus strains, emphasizing on SARS-CoV, MERS-CoV and SARS-CoV-2. We focus on shared genomic features of the betacoronaviruses and the application of genomic information to phylogenetic analysis, molecular epidemiology and the design of diagnostic systems, potential drugs and vaccine candidates.


The next epidemic--lessons from Ebola.


Beyond expectations: 40 years of EPI.


title: Injury rates and characteristics in recreational, elite student and professional dancers: A systematic review.

text: The purpose of this study was to systematically review the literature and synthesise the evidence on injury rates and characteristics in recreational, elite student, and professional dancers. Five online databases were searched from inception to January 2018 and screened by two independent reviewers. Primary research studies were eligible for inclusion if they reported injury rates in recreational, elite student, and/or professional dancers of any genre and measured individual dance exposure at the hour, event, or day level. Sixteen studies were included, with only three studies incorporating recreational dancers. Reported injury incidence rates were less than 5 injuries per 1,000 dance hours, however substantially different definitions and methods for measuring injury and dance exposure were used. Based on the current evidence there is not an identifiable difference in injury rate or characteristics between recreational, elite student, and professional dancers. However, there remains a lack of high quality comprehensive data available across levels and genres of dance participation, and greater focus on consistency and completeness of reporting in dance injury research is still required.


title: Interventions designed to improve the safety and quality of therapeutic anticoagulation in an inpatient electronic medical record.

text: IMPORTANCE Anticoagulants are high-risk medications with the potential to cause significant patient harm or death. Digital transformation is occurring in hospital practice and it is essential to implement effective, evidence-based strategies for these medications in an electronic medical record (EMR). OBJECTIVE To systematically appraise the literature to determine which EMR interventions have improved the safety and quality of therapeutic anticoagulation in an inpatient hospital setting. METHODS PubMed, Embase, CINAHL, and the International Pharmaceutical Database were searched for suitable publications. Articles that met eligibility criteria up to September 2018 were included. The review was registered with PROSPERO (CRD42018104899). The web-based software platform Covidence® was used for screening and data extraction. Studies were grouped according to the type of intervention and the outcomes measured. Where relevant, a bias assessment was performed. RESULTS We found 2624 candidate articles and 27 met inclusion criteria. They included 3 randomised controlled trials, 4 cohort studies and 20 pre/post observational studies. There were four major interventions; computerised physician order entry (CPOE) (n = 4 studies), clinical decision support system (CDSS) methods (n = 21), dashboard utilisation (n = 1) and EMR implementation in general (n = 1). Seven outcomes were used to summarise the study results. Most research focused on prescribing or documentation compliance (n = 18). The remaining study outcome measures were: medication errors (n = 9), adverse drug events (n = 5), patient outcomes (morbidity/mortality/length of hospital stay/re-hospitalisation) (n = 5), quality use of anticoagulant (n = 4), end-user acceptance (n = 4), cost effectiveness (n = 1). CONCLUSION Despite the research cited, limited benefits have been demonstrated to date. It appears healthcare organisations are yet to determine optimal, evidence-based-methods to improve EMR utilisation. Further evaluation, collaboration and work are necessary to measure and leverage the potential benefits of digital health systems. Most research evaluating therapeutic anticoagulation management within an EMR focused on prescribing or documentation compliance, with less focus on clinical impact to the patient or cost effectiveness. Evidence suggests that CPOE in conjunction with CDSS is needed to effectively manage therapeutic anticoagulation. Targets for robust research include the integration of 'stealth' alerts, nomograms into digital systems and the use of dashboards within clinical practice.


title: Cost-effectiveness of Extracorporeal Cardiopulmonary Resuscitation after in-hospital cardiac arrest: a Markov decision model.

text: BACKGROUND This study aimed to estimate the cost-effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest treatment. METHODS A decision tree and Markov model were constructed based on current literature. The model was conditional on age, Charlson Comorbidity Index (CCI) and sex. Three treatment strategies were considered: ECPR for patients with an Age-Combined Charlson Comorbidity Index (ACCI) below different thresholds (2 - 4), ECPR for everyone (EALL), and ECPR for no one (NE). Cost-effectiveness was assessed with costs per quality-of-life adjusted life years (QALY). MEASUREMENTS AND MAIN RESULTS Treating eligible patients with an ACCI below 2 points costs 8,394 (95% CI: 4,922 - 14,911) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 3 costs 8,825 (95% CI: 5,192 - 15,777) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 4 costs 9311 (95% CI: 5,478 - 16,690) euro per extra QALY per IHCA patient; treating every eligible patient with ECPR costs 10818 (95% CI: 6,357 - 19,400) euro per extra QALY per IHCA patient. For WTP thresholds of 0 to 9,500 euro, NE has the highest probability of being the most cost-effective strategy. For WTP thresholds between 9,500 and 12,500, treating eligible patients with an ACCI below 4 has the highest probability of being the most cost-effective strategy. For WTP thresholds of 12,500 or higher, EALL was found to have the highest probability of being the most cost-effective strategy. CONCLUSIONS Given that conventional WTP thresholds in Europe and North-America lie between 50,000 - 100,000 euro or U.S. dollars, ECPR can be considered a cost-effective treatment after in-hospital cardiac arrest from a healthcare perspective. More research is necessary to validate the effectiveness of ECPR, with a focus on the long-term effects of complications of ECPR.


title: Protecting American Lungs and Reversing Youth Tobacco Epidemic Act.

text: Annually, the National Association of School Nurses (NASN) sets advocacy goals. The goals include legislative and policy priorities. This article sets forth current NASN legislative priorities and results of advocacy that benefits students. The NASN Board of Directors are instrumental in moving policy priorities forward. In addition, this article shares NASN advocacy during the COVID-19 pandemic.


title: Critically Ill patients with 2009 influenza A(H1N1) in Mexico.

text: CONTEXT In March 2009, novel 2009 influenza A(H1N1) was first reported in the southwestern United States and Mexico. The population and health care system in Mexico City experienced the first and greatest early burden of critical illness. OBJECTIVE To describe baseline characteristics, treatment, and outcomes of consecutive critically ill patients in Mexico hospitals that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1). DESIGN, SETTING, AND PATIENTS Observational study of 58 critically ill patients with 2009 influenza A(H1N1) at 6 hospitals between March 24 and June 1, 2009. Demographic data, symptoms, comorbid conditions, illness progression, treatments, and clinical outcomes were collected using a piloted case report form. MAIN OUTCOME MEASURES The primary outcome measure was mortality. Secondary outcomes included rate of 2009 influenza (A)H1N1-related critical illness and mechanical ventilation as well as intensive care unit (ICU) and hospital length of stay. RESULTS Critical illness occurred in 58 of 899 patients (6.5%) admitted to the hospital with confirmed, probable, or suspected 2009 influenza (A)H1N1. Patients were young (median, 44.0 [range, 10-83] years); all presented with fever and all but 1 with respiratory symptoms. Few patients had comorbid respiratory disorders, but 21 (36%) were obese. Time from hospital to ICU admission was short (median, 1 day [interquartile range {IQR}, 0-3 days]), and all patients but 2 received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia (median day 1 ratio of Pao(2) to fraction of inspired oxygen, 83 [IQR, 59-145] mm Hg). By 60 days, 24 patients had died (41.4%; 95% confidence interval, 28.9%-55.0%). Patients who died had greater initial severity of illness, worse hypoxemia, higher creatine kinase levels, higher creatinine levels, and ongoing organ dysfunction. After adjusting for a reduced opportunity of patients dying early to receive neuraminidase inhibitors, neuraminidase inhibitor treatment (vs no treatment) was associated with improved survival (odds ratio, 8.5; 95% confidence interval, 1.2-62.8). CONCLUSION Critical illness from 2009 influenza A(H1N1) in Mexico occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, and had a high case-fatality rate.


title: Identification of avian RIG-I responsive genes during influenza infection.

text: Ducks can survive infection with highly pathogenic avian influenza viruses that are lethal to chickens. We showed that the influenza detector, RIG-I can initiate antiviral responses in ducks, but this gene is absent in chickens. We can reconstitute this pathway by transfecting chicken DF-1 embryonic fibroblast cells with duck RIG-I, which augments their antiviral response to influenza and decreases viral titer. However, the genes downstream of duck RIG-I that mediate this antiviral response to influenza are not known. Using microarrays, we compared the transcriptional profile of chicken embryonic fibroblasts transfected with duck RIG-I or empty vector, and infected with low or highly pathogenic avian influenza viruses. Transfected duck RIG-I expressed in chicken cells was associated with the marked induction of many antiviral innate immune genes upon infection with both viruses. We used real-time PCR to confirm upregulation of a subset of these antiviral genes including MX1, PKR, IFIT5, OASL, IFNB, and downregulation of the influenza matrix gene. These results provide some insight into the genes induced by duck RIG-I upon influenza infection, and provide evidence that duck RIG-I can function to elicit an interferon-driven, antiviral response against influenza in chicken embryonic fibroblasts.


title: Use of emerging oral anticoagulants in clinical practice: translating results from clinical trials to orthopedic and general surgical patient populations.

text: OBJECTIVE A review of clinical data from oral anticoagulant studies in orthopedic/general surgery and extrapolation to actual clinical practice. SUMMARY BACKGROUND DATA In all surgical patients, there is a risk of postoperative venous thromboembolism (VTE). Parenteral unfractionated heparin, low-molecular-weight heparin, and fondaparinux are available for VTE prophylaxis. Vitamin K antagonists, the only available oral anticoagulants, are widely used in the United States for thromboprophylaxis in joint replacement surgery in spite of being associated with several disadvantages, limiting their effectiveness in the postoperative setting. The oral direct thrombin inhibitor ximelagatran, briefly approved outside the United States for thromboprophylaxis in orthopedic patients, was discontinued due to severe hepatotoxicity concerns. Recently, the oral factor Xa inhibitors rivaroxaban and apixaban have entered late phase development for VTE thromboprophylaxis and treatment and the oral direct thrombin inhibitor dabigatran has received marketing approval from the European Medicines Agency. METHODS Review of clinical studies of the oral anticoagulants in VTE prevention in orthopedic surgery and comparison with large observational registries. RESULTS : Results from Phase II/III studies suggest that new oral anticoagulants may provide an efficacious alternative in VTE prevention in orthopedic surgery. Furthermore, these new oral agents have, so far, shown a good overall safety profile, with no evidence of increased hepatotoxicity. However, comparison with large observational registries reveals differences between real-life patient populations, which make extrapolation of clinical trial data to actual clinical practice difficult. Differences in endpoint definitions also prevent indirect comparison of agents. Specific compliance and postmarketing safety issues (especially liver enzyme monitoring requirements) need to be clarified before these agents are widely accepted into routine clinical practice. CONCLUSIONS Although new oral anticoagulants appear promising, clinical trial results should be viewed with caution until they can be replicated in routine care settings across a broad spectrum of surgical patients.


title: Evaluating a Nurse Training Program in the Emergency Surgery Department Based on the Kirkpatrick's Model and Clinical Demand During the COVID-19 Pandemic.

text: Objective: To analyze the application of Kirkpatrick's model in the nurse training program among the emergency surgery department based on clinical demand during the COVID-19 (coronavirus disease-2019). To provide reference for the training of emergency surgical nurses during the outbreak of COVID-19. Design: Guided by Kirkpatrick's model, 35 nurses in the emergency surgery department were trained according to a program that resulted from the clinical demand during the pandemic. The trainees were observed in terms of their performance at reaction level and learning level. Results: At reaction level, the degree of satisfaction scored by nurses was relatively high, with its total score achieving (18.77 ± 3.09). At learning level, the differences between theoretical and operational scores of tested nurses before and after training proved to be statistically significant (p < 0.001). Conclusion: The application of Kirkpatrick's model based on clinical demand during the COVID-19 confirms to be effective for the training program of nurses in the emergency surgery department. It is also beneficial to improve nurses' knowledge and skills during the pandemic, which serves as a positive influence for clinical reference.


title: Alternative airways for the pediatric emergency department.

text: Securing the pediatric airway in the emergency setting is an uncommon event that is complicated by anatomic, physiologic, and environmental factors. Even more uncommonly, practitioners are faced with the added complication of a difficult airway, and the question of what alternatives to traditional endotracheal intubation are available and most useful may arise. Timely and effective intervention determines the patient's clinical outcome. The purpose of this review was to detail specific alternative airway management strategies and tools for use in the pediatric emergency department.


docid: ywofrosl

title: Middle East respiratory syndrome coronavirus spike protein delivered by modified vaccinia virus Ankara efficiently induces virus-neutralizing antibodies.

text: Middle East respiratory syndrome coronavirus (MERS-CoV) has recently emerged as a causative agent of severe respiratory disease in humans. Here, we constructed recombinant modified vaccinia virus Ankara (MVA) expressing full-length MERS-CoV spike (S) protein (MVA-MERS-S). The genetic stability and growth characteristics of MVA-MERS-S make it a suitable candidate vaccine for clinical testing. Vaccinated mice produced high levels of serum antibodies neutralizing MERS-CoV. Thus, MVA-MERS-S may serve for further development of an emergency vaccine against MERS-CoV.


title: [Thoughts and practice on the treatment of severe and critical new coronavirus pneumonia].

text: Severe and critical coronavirus pneumonia 2019 (COVID-19) often occurs in elder patients with multiple comorbidities, and severe hypoxemia events are an important factor in the deterioration of some cases. The critical type of COVID-19 could progress to acute respiratory distress syndrome and multi-organ dysfunction, which are the most important causes of death. Early start with non-invasive ventilation (NIV) against the possible physiological abnormalities could be helpful to improve prognosis. Close monitoring of oxygenation, reducing patients' oxygen consumption, active psychological intervention, and rapidly dealing with severe hypoxemia events are the key factors for the successful treatment of NIV. In addition, active adjuvant therapy is also important, such as correcting coagulation dysfunction, providing proper nutritional support, accurate volume control, and safe individualized blood glucose monitoring and control.


title: Social marketing interventions for the prevention and control of neglected tropical diseases: A systematic review.

text: BACKGROUND Social marketing is an approach to behavior change that contributes to disease prevention and control. This study aimed to understand how social marketing interventions have addressed neglected tropical diseases (NTDs). It examined the characteristics, breadth of coverage, and outcomes of social marketing interventions focused on the prevention and control of these diseases. METHODOLOGY/PRINCIPAL FINDINGS Studies published in any language between January 1971 and April 2017, targeting at least one of the 17 NTDs prioritized in the World Health Organization (WHO) NTD Roadmap were considered. Included studies had interventions that applied both, at least one core social marketing concept, "social behavioral influence", and one social marketing technique, "integrated intervention mix", described in the Hierarchical Model of Social Marketing. This review is registered with PROSPERO CRD42017063858. Twenty interventions, addressing eight NTDs, met the inclusion criteria. They focused on behaviors related to four of the five WHO public health strategies for NTDs. Most interventions incorporated the concepts "relationship building" and "public / people orientation focus", and the technique "insight-driven segmentation". All the interventions reported changing behavioral determinants such as knowledge, 19 reported behavior change, and four influenced health outcomes. CONCLUSION/SIGNIFICANCE Evidence from this study shows that social marketing has been successfully used to address behaviors related to most of the five public health strategic interventions for NTDs recommended by the WHO. It is suggested that social marketing interventions for the prevention and control of NTDs be grounded on an understanding of the audience and adapted to the contexts intervened. Building stakeholder relationships as early as possible, and involving the publics could help in reaching NTD outcomes. Elements of the intervention mix should be integrated and mutually supportive. Incorporating health education and capacity building, as well as being culturally appropriate, is also relevant. It is recommended that ongoing discussions to formulate the targets and milestones of the new global Roadmap for NTDs integrate social marketing as an approach to overcome these diseases.


Editorial: See One, Do One, Teach One? Paradigm Shift with Three-Dimensional Printing.


COVID-19 epidemic: cocoon the elderly and the vulnerable.


title: Tension-free open hernia repair using an innovative self-gripping semi-resorbable mesh.

text: BACKGROUND Lichtenstein tension-free mesh repair is the most commonly used technique for the open treatment of inguinal hernia. Mesh fixation and the potential risk of associated pain are always a surgical concern. The aim of this study was to report the initial clinical experience using an innovative, partly resorbable mesh with self-gripping properties. METHODS Fifty-two patients (70 hernias) underwent open Lichtenstein hernia repair with Parietene Progrip (Sofradim Production, Trévoux, France-Group Covidien). Patient pain as measured by a visual analogue scale (VAS) was the primary study endpoint. Clinical evaluation, with careful attention to the identification of hernia recurrence, was performed at 1 month and 1 year. The evaluation of fixation precision, quality of fixation and ease of use was assessed by the primary surgeon. RESULTS The mean patient pain was 1.3 (+/-1.4) at discharge, 0.1 (+/-0.4) at 1 month and 0.0 (+/-0.1) (one patient with VAS 1/10) at 1 year, respectively. The mean operative time was 19 +/- 4 min. There was one minor cutaneous infection and no documented recurrence. The quality of the gripping effect was rated very good in 51 (98.1%) of the cases performed. CONCLUSION The use of a novel low-density, macroporous mesh with semi-resorbable self-fixing properties during tension-free repair may be a satisfactory solution to the clinical problems of pain and recurrence following inguinal herniorrhaphy.


title: Treatment of cerebral vasospasm with self-expandable retrievable stents: proof of concept.

text: OBJECTIVE To report our preliminary experience with the use of stent retrievers to cause vasodilation in patients with delayed cerebral vasospasm secondary to subarachnoid hemorrhage. METHODS Four patients from two different high volume neurointerventional centers developed cerebral vasospasm following subarachnoid hemorrhage. In addition to standard techniques for the treatment of cerebral vasospasm, we used commercially available stent retrievers (Solitaire and Capture stent retrievers) to treat the vasospastic segment including M2, M1, A2, and A1. We evaluated the safety of this technique, degree of vasodilation, and longevity of the effect. RESULTS Stent retrievers can be used to safely achieve cerebral vasodilation in the setting of delayed cerebral vasospasm. The effect is long-lasting (>24 hours) and, in our initial experience, carries a low morbidity. We have not experienced any complications using this technique although we have noted that the radial force was not sufficient to cause vasodilation in some instances. The vasospasm did not return in the vessel segments treated with stent angioplasty in any of these cases. In two of our cases stent angioplasty resulted in the reversal of focal neurological symptoms. CONCLUSIONS Stent retrievers can provide long-lasting cerebral vasodilation in patients with delayed cerebral vasospasm.


title: Outcomes of laparoscopic hiatal hernia repair based on surgical specialty: thoracic versus general surgeons.

text: BACKGROUND Hiatal Hernia Repairs (HHR) are performed by both general surgeons (GS) and thoracic surgeons (TS). However, there are limited literature with respect to outcomes of HHR based on specialty training. The objective of this study was to compare the utilization, perioperative outcomes, and cost for HHR performed by GS versus TS. METHODS The Vizient database was used to identify patients who underwent elective laparoscopic HHR between October 2014 and June 2018. Patients were grouped according to surgeon's specialty (GS vs. TS). Patient demographics and outcomes including in-hospital mortality were compared between groups. RESULTS During the study period 13,764 patients underwent HHR by either GS or TS. GS performed 9930 (72%) cases while TS performed 3834 (28%) cases. There was no significant difference between GS versus TS with regard to serious morbidity (1.28% vs. 1.30%, p = 0.97) or mortality (0.10% vs. 0.21%, p = 0.19). The mortality index was 0.24 for GS versus 0.45 for TS. Compared to TS, laparoscopic HHR performed by GS was associated with a shorter LOS (2.57 days vs. 2.72 days, p < 0.001) and lower mean hospital costs ($7139 vs. $8032, p < 0.0001). CONCLUSIONS Within the context of academic centers, laparoscopic HHRs are mostly performed by GS with comparable outcome between general versus thoracic surgeons.


title: Clathrin- and caveolae-independent entry of feline infectious peritonitis virus in monocytes depends on dynamin.

text: Feline infectious peritonitis virus (FIPV), a coronavirus that causes a lethal chronic disease in cats, enters feline monocytes via endocytosis. In this study, the pathway of internalization is characterized by evaluating the effect of chemical inhibitors and/or expression of dominant-negative (DN) proteins on the percentage of internalized virions per cell and infection. Further, co-localization studies were performed to determine the involvement of certain cellular internalization proteins. FIPV is not internalized through a clathrin-mediated pathway, as chlorpromazine, amantadine and DN eps15 did not influence virus uptake and FIPV did not co-localize with clathrin. The caveolae-mediated pathway could be excluded based on the inability of genistein and DN caveolin-1 to inhibit virus uptake and lack of co-localization between FIPV and caveolin-1. Dynamin inhibitory peptide and DN dynamin effectively inhibited virus internalization. The inhibitor strongly reduced uptake to 20.3+/-1.1% of uptake in untreated cells. In the presence of DN dynamin, uptake was 58.7+/-3.9% relative to uptake in untransduced cells. Internalization of FIPV was slightly reduced to 85.0+/-1.4 and 87.4+/-6.1% of internalization in control cells by the sterol-binding drugs nystatin and methyl-beta-cyclodextrin, respectively. Rho GTPases were inhibited by Clostridium difficile toxin B, but no effect was observed. These results were confirmed with infection studies showing that infection was not influenced by chlorpromazine, amantadine and genistein, but was significantly reduced by dynamin inhibition and nystatin. In conclusion, these results indicate that FIPV enters monocytes through a clathrin- and caveolae-independent pathway that strongly depends on dynamin and is slightly sensitive to cholesterol depletion.


title: Trends in COVID-19 outbreak in Tokyo and Osaka from January 25 to May 06, 2020: a joinpoint regression analysis of the outbreak data.

text: We analyzed the trends in the coronavirus disease 2019 (COVID-19) outbreak in Tokyo and Osaka from January 25 to May 06, 2020. To analyze the trends and to identify significant changes in trends we performed a joinpoint regression analysis. Since the last of March, COVID-19 cases soared up in Tokyo (β = 103.51) and Osaka (β = 28.07). During the 2nd and 3rd weeks of April, both Tokyo (β = 157.53) and Osaka (β = 60.96) experienced the peak growth in COVID-19 cases. Since then, with some hope, almost after 14 days of the state of emergency declaration, the cases showed a containment trend but still increasing at a concerning rate in Tokyo (β = 90.66).


title: Mesiolingual root rotation for horizontal mandibular third molar extraction: position classification and surgical simulation.

text: Extracting horizontal mandibular 3rd molars face considerable difficulty due to the large bone and adjacent tooth resistances. This study aims at evaluating the effectiveness of a novel method-mesiolingual root rotation to extract wisdom teeth of this type. In this study, 73 horizontal teeth extracted using piezosurgery were reviewed and classified based on impaction depth: position I, II, III refers to the highest portion of the crown on a level with upper 1/3, middle 1/3, lower 1/3 of the 2rd molar's root. Based on the surgical simulations on their 3D CBCT reconstructions, traditional method(crown distal rotation) and novel method(root mesiolingual rotation) are applied. 79.17% of teeth in position I and 57.89% of teeth in position II were designed using traditional method, 83.33% teeth in position III were designed using the novel method(p < 0.05). The surgeries were performed according to the designs. Two cases in position II using traditional method were found temporary inferior alveolar nerve(IAN) injury; while only one case in position III using novel method got temporary IAN and lingual nerve injury. Our study suggested that root mesiolingual rotation is an effective method to extract the horizontal mandibular 3rd molars, especially the deep impacted ones.


title: Cardiovascular response to short-term fasting in menstrual phases in young women: an observational study.

text: BACKGROUND Menstrual cycle-related symptoms are an important health issue for many women, and some may affect cardiac autonomic regulation. In the present study, we evaluated the cardiovascular and physiological stress response to 12-h short-term fasting in the menstrual phases of healthy young women. METHODS We performed a randomized crossover study. Subjects were seven female university students (age: 22.3 ± 1.0 years). The experiments comprised four sessions: meal intake in the follicular phase, meal intake in the luteal phase, fasting in the follicular phase, and fasting in the luteal phase. All subjects participated in a total of four experimental sessions during two successive phases (follicular and luteal phase in the same menstrual cycle, or luteal phase and follicular phase in the next menstrual cycle) according to a randomized crossover design. R-R intervals were continuously recorded before and after meals, and power spectral analysis of heart rate variability was performed. Other physiological data were obtained before and 20, 40, 60, and 80 min after meal intake or after the corresponding time point of meal intake (fasting in the follicular or luteal phase). RESULTS Heart rate decreased during fasting in the follicular and luteal phases. High frequency power increased during fasting in the follicular and luteal phases. In addition, salivary cortisol concentrations decreased during fasting in the luteal phase. CONCLUSIONS In the present study, short-term fasting resulted in higher parasympathetic activity and lower cortisol levels in the luteal phase in these young women. These results indicate a possibility to produce an anti-stress effect in the luteal phase, which may reduce menstrual symptoms.


title: Neutrophil gelatinase-associated lipocalin: its response to hypoxia and association with acute mountain sickness.

text: Acute Mountain Sickness (AMS) is a common clinical challenge at high altitude (HA). A point-of-care biochemical marker for AMS could have widespread utility. Neutrophil gelatinase-associated lipocalin (NGAL) rises in response to renal injury, inflammation and oxidative stress. We investigated whether NGAL rises with HA and if this rise was related to AMS, hypoxia or exercise. NGAL was assayed in a cohort (n = 22) undertaking 6 hours exercise at near sea-level (SL); a cohort (n = 14) during 3 hours of normobaric hypoxia (FiO2 11.6%) and on two trekking expeditions (n = 52) to over 5000 m. NGAL did not change with exercise at SL or following normobaric hypoxia. During the trekking expeditions NGAL levels (ng/ml, mean ± sd, range) rose significantly (P < 0.001) from 68 ± 14 (60-102) at 1300 m to 183 ± 107 (65-519); 143 ± 66 (60-315) and 150 ± 71 (60-357) at 3400 m, 4270 m and 5150 m respectively. At 5150 m there was a significant difference in NGAL between those with severe AMS (n = 7), mild AMS (n = 16) or no AMS (n = 23): 201 ± 34 versus 171 ± 19 versus 124 ± 12 respectively (P = 0.009 for severe versus no AMS; P = 0.026 for mild versus no AMS). In summary, NGAL rises in response to prolonged hypobaric hypoxia and demonstrates a relationship to the presence and severity of AMS.


title: Epidemiologic approaches to global health.

text: In this introduction to volume 32 of Epidemiologic Reviews, the authors highlight the diversity and complexity of global health concerns, and they frame the 12 articles included in this issue within the diverse topics of research in this emerging and ever-expanding field. The authors emphasize the need for ongoing research related to the methods used in global health and for comprehensive surveillance, and they offer suggestions for future directions in global health research.


title: Reconstruction of the jejunoesophageal anastomosis with a circular mechanical stapler in total laryngopharyngectomy defects.

text: BACKGROUND The aim of this study was to demonstrate the technical feasibility and potential benefits of using a circular mechanical stapler with free jejunal transfer for jejunoesophageal anastomosis in total laryngopharyngectomy reconstruction while comparing the rates of fistula and stricture. METHODS This study was a retrospective review of 12 free jejunal flaps completed with circular mechanical stapler for the jejunoesophageal anastomosis with comparison to 17 jejunal free flaps where all anastomoses were hand sewn. RESULTS In all, 29 patients underwent free jejunal transfer: 12 had jejunal free flap with circular mechanical stapler for jejunoesophageal anastomosis, whereas 17 patients had hand-sewn anastomosis. Corresponding rates of fistula and stricture were 0/12 fistulas and 3/12 strictures in the stapler cohort and 2/17 fistulas with 0/17 strictures in the hand-sewn cohort. No statistically significant difference in rate of fistula was observed between each cohort, whereas a trend toward increased rate of stricture (p = .06) was observed in the stapled anastomosis cohort. CONCLUSIONS Use of circular mechanical stapler appears to be a safe and effective technique at the jejunoesophageal anastomosis for total laryngopharyngeal defects with comparable fistula and stricture rates to grafts that are hand sewn.


title: A pilot study for a prospective, randomized, double-blind trial of the influence of anesthetic depth on long-term outcome.

text: BACKGROUND Deep general anesthesia has been associated with increased mortality in 5 observational studies. The association may be causal or an epiphenomenon due to increased anesthetic sensitivity in high-risk patients. We conducted a pilot study to assess the feasibility of performing a definitive randomized controlled trial. The aims of the study were to determine whether anesthetic depth targeting in a high-risk group was feasible and to document anesthetic doses and arterial blood pressures associated with "deep" and "light" general anesthesia. METHODS ASA physical status III and IV patients, aged ≥60 years, having surgery lasting ≥2 hours, with expected hospital stay ≥2 days, and receiving general anesthesia were randomly allocated to a Bispectral Index (BIS) or spectral entropy (SE) target of 35 ("low" group) or 50 ("high" group). The primary end point was mean BIS or SE. Secondary end points were postanesthesia care unit length of stay and pain scores, quality of recovery score, hospital length of stay, postoperative complications, and death. A composite end point of postoperative complications (pneumonia, myocardial infarction, stroke, pulmonary embolism, heart failure, and death) was determined at 1 year. RESULTS One hundred twenty-five patients were recruited. The mean of the median BIS/SE values for each patient during the maintenance phase of anesthesia in the low and high groups was significantly different: 39 vs 48 (mean difference 8 [95% confidence interval {CI95}, 6 to 10], P < 0.001). There was also a significant difference in mean volatile anesthetic administration (minimum alveolar concentration): 0.98 vs 0.64 (mean difference -0.35 [CI95, -0.44 to -0.26], P < 0.001) and target propofol concentrations: 4.0 vs 3.1 μg/mL (mean difference -0.8 [CI95, -1.2 to -0.3], P = 0.004). Intraoperative mean arterial blood pressures were similar (85 vs 87 mm Hg; mean difference 2 [CI95, -2 to 6], P = 0.86), and there were no differences in short-term recovery characteristics or hospital length of stay. There was a significant difference in the incidence of wound infection at 30 days (13% vs 3%; risk difference -10% [CI95, -21 to -0.1], P = 0.04). At 1 year, the composite rates of complications in the low and high groups were 28% and 17% (risk difference -11 [CI95, -25 to 4], P = 0.15) and mortality rates were 12% and 9%, respectively (risk difference -2 [CI95, -14 to 9], P = 0.70). CONCLUSIONS This pilot study demonstrated that depth of anesthesia targeting with BIS or SE was achievable in a high-risk population with adequate separation of processed electroencephalogram monitor targets. The expected incidence of postoperative complications and mortality occurred. We conclude that a large, multicenter, randomized controlled trial is feasible.


Clinical practice. Acute calculous cholecystitis.


title: Laparoscopic sleeve gastrectomy - 7 years of own experience.

text: INTRODUCTION Laparoscopic sleeve gastrectomy is a procedure frequently chosen by patients and surgeons that carries the risk of serious complications that are difficult to treat. AIM To describe the operations performed by us, considering complications and their management. MATERIAL AND METHODS We performed 565 laparoscopic sleeve gastrectomies. Standard surgical technique was used. A 34 Fr calibration tube was used. An additional reinforcing suture was applied over the staple line. RESULTS There was no need for conversion. In 7.79% of patients, infarcts of the posterior pole of the spleen were observed, whereas 8 patients (1.42%) developed gastric fistulas in the His angle region. In 3 cases, it led to development of an abscess in the posterior splenic pole region and 2 of these developed secondary gastric fistulas of typical location. In total, there were 5 deaths among the patients who had been operated on - 3 due to septic complications in the course of fistula, 1 due to encephalopathy and 1 as a result of myocardial infarction. CONCLUSIONS Sleeve gastrectomy is an effective and safe method of obesity treatment. The causes of the most severe complication - gastric fistula - cannot be established unequivocally. Infarcts of the posterior pole of the spleen, as a potential cause of fistulas, deserve particular attention. In our opinion, primary closure of the fistula by suturing is an inappropriate method of management, whereas the best results are obtained with temporary gastrointestinal tract prosthesis.


title: Bacterial pathogens in wild birds: a review of the frequency and effects of infection.

text: The importance of wild birds as potential vectors of disease has received recent renewed empirical interest, especially regarding human health. Understanding the spread of bacterial pathogens in wild birds may serve as a useful model for examining the spread of other disease organisms, both amongst birds, and from birds to other taxa. Information regarding the normal gastrointestinal bacterial flora is limited for the majority of wild bird species, with the few well-studied examples concentrating on bacteria that are zoonotic and/or relate to avian species of commercial interest. However, most studies are limited by small sample sizes, the frequent absence of longitudinal data, and the constraints of using selective techniques to isolate specific pathogens. The pathogenic genera found in the gut are often those suspected to exist in the birds' habitat, and although correlations are made between bacterial pathogens in the avian gut and those found in their foraging grounds, little is known about the effect of the pathogen on the host, unless the causative organism is lethal. In this review, we provide an overview of the main bacterial pathogens isolated from birds (with particular emphasis on enteropathogenic bacteria) which have the potential to cause disease in both birds and humans, whilst drawing attention to the limitations of traditional detection methods and possible study biases. We consider factors likely to affect the susceptibility of birds to bacterial pathogens, including environmental exposure and heterogeneities within the host population, and present probable avenues of disease transmission amongst birds and from birds to other animal taxa. Our primary aim is to identify gaps in current knowledge and to propose areas for future study.


title: Prefrontal reinstatement of contextual task demand is predicted by separable hippocampal patterns.

text: Goal-directed behavior requires the representation of a task-set that defines the task-relevance of stimuli and guides stimulus-action mappings. Past experience provides one source of knowledge about likely task demands in the present, with learning enabling future predictions about anticipated demands. We examine whether spatial contexts serve to cue retrieval of associated task demands (e.g., context A and B probabilistically cue retrieval of task demands X and Y, respectively), and the role of the hippocampus and dorsolateral prefrontal cortex (dlPFC) in mediating such retrieval. Using 3D virtual environments, we induce context-task demand probabilistic associations and find that learned associations affect goal-directed behavior. Concurrent fMRI data reveal that, upon entering a context, differences between hippocampal representations of contexts (i.e., neural pattern separability) predict proactive retrieval of the probabilistically dominant associated task demand, which is reinstated in dlPFC. These findings reveal how hippocampal-prefrontal interactions support memory-guided cognitive control and adaptive behavior.


title: Thoracoscopic lobectomy in infants less than 10 kg with prenatally diagnosed cystic lung disease.

text: PURPOSE Thoracoscopic lobectomy for congenital cystic lung lesions is an accepted technique in pediatric surgery. Since an increasing number of these lesions are detected prenatally, the safety and efficacy of infant resections have been questioned. We reviewed our experience over a 10-year period to evaluate early resection of these lesions. METHODS From January 2001 to August 2009, 75 patients under 1 year of age and weighing <10 kg underwent thoracoscopic lobectomy at two institutions. Patients carried the following diagnoses: 52 had congenital cystic adenomatoid malformation, 20 had bronchopulmonary sequestration, and 3 had congenital lobar emphysema. All lesions were confirmed after birth by computed tomography scan. Patient age at operation ranged from 4 days to 11 months and patient weight from 3.1 to 10 kg. RESULTS Seventy-four of 75 lobectomies were thoracoscopically completed. There were 16 upper lobectomies, 1 middle lobectomy, and 55 lower lobectomies. Operative time ranged from 45 to 225 minutes. Hospital length of stay ranged from 1 to 5 days. A subset of 26 patients had surgery younger than 3 months of age and <5 kg, despite being asymptomatic. Their operative time averaged 90 minutes, and mean length of hospital stay was 1.5 days. CONCLUSION Thoracoscopic lobectomy is safe for infants <10 kg and avoids the morbidity associated with thoracotomy. Operating early on younger patients may avoid the inflammatory changes associated with both clinically apparent and subclinical infections, even in patients weighing <5 kg. This may make the procedures less technically challenging and may result in lower complication and conversion rates.


title: Transanal single-port microsurgery for rectal tumors: minimal invasive surgery under spinal anesthesia.

text: BACKGROUND Transanal minimally invasive surgery (TAMIS) for rectal tumors has been introduced as an alternative approach to transanal endoscopic microsurgery (TEM). TEM has some limitations, such as the need for special equipment, expensive cost, and steep learning curve. In this study, we address the technical feasibility of TAMIS under spinal anesthesia and its short-term postoperative outcomes. METHODS From July 2011 to September 2012, 25 consecutive patients with middle or upper third rectal masses underwent TAMIS. Tumors were located 6-17 cm from the anal verge. After spinal anesthesia, a single-incision laparoscopic surgery port was inserted into the anal canal. With this access, conventional laparoscopic instruments, including a grasper and monopolar electrocautery and suction device, were used to perform the transanal excision. A hook-type monopolar electrocautery or harmonic scalpel was used for dissection. The defect of the rectum was closed by interrupted sutures. Data concerning demographics, details of operative procedure, postoperative pain, and pathologic results were collected prospectively. To evaluate anal sphincter injury, an endoanal ultrasonography and fecal incontinence severity index survey were performed at 3-6 months after the operation. RESULTS Of the 25 patients, nine had adenocarcinomas, nine had neuroendocrine tumors, three had tubular adenomas with high-grade dysplasia, three had tubular adenomas, one had a tubulovillous adenoma, and one had a gastrointestinal stromal tumor. The median distance from the tumor mass to the anal verge was 9.0 (range 6-17) cm. The median operative time was 45.0 (range 20-120) min. All patients received TAMIS without conversion to laparoscopic resection. There were no intraoperative complications or postoperative morbidity. The median postoperative hospital stay was 3.0 (range 2-7) days. No sphincter injury was detected by endoanal ultrasonography. CONCLUSIONS TAMIS under spinal anesthesia is a safe and feasible technique for resection of middle and upper rectal masses. Spinal anesthesia is adequate for this procedure.


title: Pulmonary and extrapulmonary complications of human rhinovirus infection in critically ill patients.

text: BACKGROUND Human rhinovirus (HRV) is frequently detected in patients with respiratory tract infection. However, the full clinical spectrum of HRV infection in critically ill patients is not well characterized. OBJECTIVE To evaluate the clinical and virological characteristics of critically ill patients with HRV infection. STUDY DESIGN HRV-specific reverse transcription-polymerase chain reaction (RT-PCR) was performed on nasopharyngeal aspirate (NPA) specimens from 294 adult patients who required admission into the intensive care unit (ICU). Clinical characteristics were analyzed. HRV genotyping using the 5'UTR-VP4-VP2 region was performed. RESULTS HRV was detected in NPA specimens of 22 patients (7.5%) by RT-PCR. Dyspnea was the most common presenting symptom (16/22; 72.7%), but seizure also occurred in 5 (22.7%) patients. Exacerbation of underlying disease occurred in 12 (54.5%) patients. Four (18.2%) patients died, and HRV was considered to play a role as the cause of death in 3 patients. Thirteen (59.1%) patients had pneumonia, and the most common radiological finding was consolidation (6/13; 46.2%). Streptococcus pneumoniae was the most common co-pathogen among patients with pneumonia. Among the 9 patients without pneumonia, 3 patients had exacerbation of underlying lung diseases, 3 patients had acute pulmonary edema, 2 patients with diabetes mellitus had acute complications from poor glycemic control, and 1 patient had status epilepticus. HRV-A was the most common species (64.3%), but there was no clear relationship between HRV species and clinical presentation. CONCLUSION Both pulmonary and extrapulmonary complications of HRV were common in critically ill patients.


title: Successful implementation of the american college of surgeons/association of program directors in surgery surgical skills curriculum via a 4-week consecutive simulation rotation.

text: INTRODUCTION Increased patient awareness, duty hour restrictions, escalating costs, and time constraints in the operating room have revolutionized surgery education. Although simulation and skills laboratories are emerging as promising alternatives for skills training, their integration into graduate surgical education is inconsistent, erratic, and often on a voluntary basis. We hypothesize that, by implementing the American College of Surgeons/Association of Program Directors in Surgery Surgical Skills Curriculum in a structured, inanimate setting, we can address some of these concerns. METHODS Sixty junior surgery residents were assigned to the Penn Surgical Simulation and Skills Rotation. The National Surgical Skills Curriculum was implemented using multiple educational tools under faculty supervision. Pretraining and posttraining assessments of technical skills were conducted using validated instruments. Trainee and faculty feedbacks were collected using a structured feedback form. RESULTS Significant global performance improvement was demonstrated using Objective Structured Assessment of Technical Skills score for basic surgical skills (knot tying, wound closure, enterotomy closure, and vascular anastomosis) and Fundamentals of Laparoscopic Surgery skills, P < 0.001. Six trainees were retested on an average of 13.5 months later (range, 8-16 months) and retained more than 75% of their basic surgical skills. DISCUSSION The American College of Surgeons/Association of Program Directors in Surgery National Surgical Skills Curriculum can be implemented in its totality as a 4-week consecutive surgical simulation rotation in an inanimate setting, leading to global enhancement of junior surgical residents' technical skills and contributing to attainment of Accreditation Council for Graduate Medical Education core competency.


title: General anesthesia versus monitored anesthetic care with dexmedetomidine for closed reduction of nasal bone fracture.

text: BACKGROUND Reduction of nasal bone fracture can be performed under general or local anesthesia. The aim of this study was to compare general anesthesia (GA) and monitored anesthetic care (MAC) with dexmedetomidine based on intraoperative vital signs, comfort of patients, surgeons and nurses and the adverse effects after closed reduction of nasal bone fractures. METHODS Sixty patients with American Society of Anesthesiologists physical status I or II were divided into a GA group (n = 30) or MAC group (n = 30). Standard monitorings were applied. In the GA group, general anesthesia was carried out with propofol-sevoflurane-N2O. In the MAC group, dexmedetomidine and local anesthetics were administered for sedation and analgesia. Intraoperative vital signs, postoperative pain scores by visual analog scale and postoperative nausea and vomiting (PONV) were compared between the groups. RESULTS Intraoperatively, systolic blood pressures were significantly higher, and heart rates were lower in the MAC group compared to the GA group. There were no differences between the groups in the patient, nurse and surgeon's satisfaction, postoperative pain scores and incidence of PONV. CONCLUSIONS MAC with dexmedetomidine resulted in comparable satisfaction in the patients, nurses and surgeons compared to general anesthesia. The incidence of postoperative adverse effects and severity of postoperative pain were also similar between the two groups. Therefore, both anesthetic techniques can be used during the reduction of nasal bone fractures based on a patient%s preference and medical condition.